1 Teen Guide Survey

Teen Survival Guide – Feedback Survey

Thank you for taking the time to complete this Survey for the Teen Survival Guide (The Guide). All of your survey answers are anonymous and will help improve future materials for other teens like you!

Before you get started, please ask your mom or dad to read and sign below.

PARENTAL CONSENT

I understand that responses are completely private and that names will not be linked to answers in any way. The purpose of this survey is to gather information that will enable the Office of Women’s Health (OWH) to improve its Women’s Health publications.

By signing below, I am expressing my willingness for ___________________________(name of teen participant) to participate in a survey that will last approximately 15 minutes. I understand that she will be asked her opinions about the format and content of a specific health communication material. The survey will determine how she used the material and the materials potential capacity to impact changes in her knowledge, attitude and behavior around health issues.

I further understand that all paper surveys will be kept under lock and key and all electronic data will be protected by the use of passwords that only the principal investigator and project manager have access to. Identifying information will be kept separate from data. When data is no longer needed, it will be destroyed.

While she may derive some personal benefit from completing the survey, I recognize that this study is not designed to help her personally, but to help the investigator learn more about these materials. I am free to ask questions or have her withdraw from participating at any time and without penalty.

NAME OF TEEN PARTICIPANT:
NAME OF PARENT/GUARDIAN:
DATE:
E-MAIL OF PARENT/GUARDIAN:
ADDRESS OF PARENT/GUARDIAN:

NOTE: IN AN EFFORT TO FURTHER PROTECT YOUR CHILD, PLEASE EXPECT TO RECEIVE A POSTCARD COMFIRMING YOUR CONSENT.

Form Approved

OMB No. 0990-XXXX

Exp. 07-XX-2008

Teen Survival Guide – Feedback Survey

Thank you for taking the time to complete this Survey for the Teen Survival Guide (The Guide). Your survey answers will help improve future materials for other teens like you!

Please answer the following questions about the Teen Survival Guide:

1. How did you receive a copy of the Guide?

 School  Doctor  Nurse

 Community health fair  Workshop  Peer Counselor

 National Women’s Health Information Center

 Other (please specify): ___________________________________________________

2. How much of the Guide did you read?

 Little or none  Less than half  More than half  Almost all or all

3. How much did you like the Guide?

 Not at all  Not very much  Somewhat  Very much

4. How attractive was the format or design of the Guide (i.e. color, pictures, font)?

 Not at all attractive  Not very attractive  Somewhat attractive  Very attractive

5. How useful was the Guide?

 Not at all useful  Not very useful  Somewhat useful  Very useful

6. How does the Guide compare to other health information materials you have read?

 It’s not as good  It’s about the same  It’s better than most  I don’t remember

 I have not received any other teen health information

7. Would you recommend the Guide to a friend or family member?

 No, definitely not  No, probably not  Yes, probably  Yes, definitely

8. I chose to read the Guide because (check all that apply):

 I had specific questions about my health

 I wanted to learn more about my health in general

 An adult at school (teacher, school nurse, counselor, etc.) recommended it

 A health care provider (doctor, nurse, etc.) recommended it

 A friend or family member recommended it

 Other:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/ocio/PRA, 200 Independence Ave., S.W., Suite 531-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. Alice Bettencourt

Please circle the answer to the questions below that best matches your response. When responding to each item, use a scale from 1 (No, Not At All) to 4 (Yes, Definitely).
Did The Guide encourage you to…	No, Not At All			Yes, Definitely
	1	2	3	4
Think more about your health in general.	1	2	3	4
Understand better the importance of your health.	1	2	3	4
Understand better how to take care of yourself.	1	2	3	4
Understand better where you can get health information.	1	2	3	4

How much do you agree or disagree with the following statements about the Teen Survival Guide? Circle the number that best matches your answer.	No, Not at all		Yes, Definitely
	1	2		3	4
I was able to find information quickly.	1	2		3	4
The “Questions From Teens” were helpful.	1	2		3	4
The “Teen Tips” were helpful.	1	2		3	4
The “To Do” activities were helpful.	1	2		3	4
The “Pop Quizzes” were helpful.	1	2		3	4
The Guide influenced me to make healthy choices.	1	2		3	4

Please answer the following questions about the specific topic areas in the Teen Survival Guide. If you check (√) the box in column A, please answer column B. If you do not place a check (√) in Column A, please move on to the next topic (question).
Topic	A. Check (√) the box if you read about any part of this topic	B. Did you learn something NEW?
Reproductive Health (your period, sexually transmitted diseases, and getting general and gynecological health care)		 No	 Yes
General Health (taking care of your hair and skin, sleep needs, being active, nutrition, and eating right)		 No	 Yes
Risky Behaviors (staying tobacco free, alcohol and drugs, living with a substance user, and how to handle the “what-if” situations (personal safety)		 No	 Yes
Emotional Health (self-esteem, body image, emotional ups and downs, relationships, stress, peer pressure, and bullies)		 No	 Yes
Your Future (career and college planning)		 No	 Yes

In the Teen Survival Guide, there were “To Do” Activities and Pop Quizzes. Which of the following activities did you do?	I did this activity	I did not do this activity
Went online to learn how to perform a breast self-exam.
Started a menstrual calendar to keep track of my period.
I printed and kept a copy of the online interactive MyPyramid Plan.
I went to a website to find out what’s inside a cigarette.
I read tips on how to say “no” and deal with peer pressure.
I went online and created a Just4Me log.
I wrote down the things I am grateful for, the people who care about me, and my hopes for the future.
I wrote about when I gave into peer pressure.
I signed a pledge not to bully and to help others who are bullied.
I wrote down the names and numbers of three people who I can call for help or if I feel like talking.
I went online to find out how to get experience in career fields that interest me.
I took one or more of the Pop Quizzes.

Additional Comments

36. Please provide additional comments about the Teen Survival Guide below.

Please answer the following questions about you:
A. How often do you go to the doctor for a physical exam?
 More than once each year			 Every 4-5 years
 Once a year			 I do not regularly visit a doctor
 Every 2-3 years
B. How old are you?
 10 yrs	 12 yrs	 14 yrs			 16 yrs	 18 yrs or older
 11 yrs	 13 yrs	 15 yrs			 17 yrs
Are you Hispanic or Latino? Yes No
D. What is your race? (Check all that apply.)				E. Who do you live with? (Check all that apply.)
 Black/African American				Mother/Stepmother
 White				 Father/Stepfather
 American Indian or Alaska Native				 Brother(s) and/or sister(s)
 Native Hawaiian or other Pacific Islander				 Grandparent(s)
 Asian				 Other relatives or guardian
				 Other (specify):
F. In what city and state do you live? ___________________________ _________ City State

Thank you for taking the time to complete this survey.

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