Form 0990-0291 Baseline Survey

Adolescent Family Life Program: Prevention Demonstration Projects

0990-0291Appendix B_Draft Prevention Baseline for grantees_OMB_09-02-08_MK

Baseline survey -Adolescents 9-19Adolescent Family Life Pregnancy Prevention Core Evaluation

OMB: 0990-0291

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ADOLESCENT FAMILY LIFE
PREVENTION PROGRAMS



CORE BASELINE QUESTIONNAIRE























PRIVACY


We want you to know that:


1. Your answers to these questions will help us learn what people your age know, think, and do.


2. You may skip any questions you do not want to answer. But we hope that you will answer as many questions as you can.


3. Your answers will be combined with those of other young people. We will keep your answers private.


PLEASE DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY!













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 0990-0291. The time required to complete this information collection is estimated to average 22 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/OIRM/PRA;

200 Independence Ave., S.W., Suite 531-H; Washington D.C. 20201

Attention: PRA Reports Clearance Officer
















To be completed by project staff:





1. Client ID:








2. Site Number:








M M D D Y Y

3. Today’s Date:








4. Site Name: ___________________________







GENERAL INSTRUCTIONS



  • Read all the answers before marking your choice. If none of the printed answers exactly applies to you, black out the circle beside the answer that best fits.

  • Use a pencil to complete the survey.

  • Completely black out the circle beside your answer choice.

INCORRECT CORRECT

  • If you make a mistake, erase it cleanly and then mark the circle beside your correct answer choice.

  • Do not make any stray marks.

  • PLEASE READ EACH QUESTION CAREFULLY.

Follow these directions for answering each kind of question:

    1. Mark ONE

What is the color of your eyes?

Mark ONE

1 Brown

2 Blue

3 Green

4 Another color

If your eyes are green, you would mark the third circle as shown.





    1. Mark ONE

What is the color of your hair?

Mark ONE

1 Brown

2 Black

3 Blonde

4 Red

5 Some other color (Describe)     Purple    

If your hair is purple, you would mark “Some other color.” Then you would write “purple” in the blank.



GENERAL INSTRUCTIONS (continued)



    1. Mark ALL THAT APPLY

Do you plan to do any of the following next week?

Mark ALL THAT APPLY

1 Rent a video

2 Go to a baseball game

3 Study at a friend’s house

If you plan to rent a video and go to a baseball game, you mark both.





    1. QUESTION WITH A SKIP

  1. Do you ever eat chocolate?

M ark ONE

1 Yes

0 No (SKIP TO 3)

  1. Do you always brush your teeth after you eat chocolate?

Mark ONE

1 Yes

0 No

  1. Did you do any of the following last week?

Mark ALL THAT APPLY

1 Saw a play

2 Went to a movie

3 Attended a sporting event









If you answered “Yes” to Question 1, you go to Question 2. After you answer Question 2, you go to Question 3.


If you answered “No” to Question 1, you skip Question 2. Then you go to Question 3.



ACTIVITIES

The first question asks about activities you may do.

  1. Think about activities that you do after school that are planned or that have adults there. These can be clubs, youth groups, or sports. They can also be lessons or other activities. How often do you do these activities?

Mark ONE

0 0 times per week

1 1 time per week

2 2 times per week

3 3 or more times per week



WHAT YOU THINK

  1. What do you think about each of these statements?


Mark ONE ANSWER FOR EACH

Strongly agree

Agree

Disagree

Strongly disagree

a. I know adults I could talk to about my problems

1

2

3

4

b. I know adults who often cheer me on

1

2

3

4

  1. Here are some things that people your age might say when they think of the future.

In general, do you agree or disagree with each statement?


Mark ONE ANSWER FOR EACH

Agree

Disagree


a. I don’t know what I want out of life

1

0


b. I have a clear picture of what I’d like to be doing in the future

1

0


c. I don’t know what my long-range goals are

1

0

YOUR FAMILY


  1. Who do you live with now?

Mark ALL THAT APPLY

1 Mother (including stepmother, adoptive mother, or foster mother)

2 Father (including stepfather, adoptive father, or foster father)

3 Other adult relative(s)

4 Other adult(s) I am not related to

5 I do not live with any adults

  1. For each of the following, does your family have rules?

    Mark ONE ANSWER FOR EACH

    Yes

    No

    a. The people I hang around with

    1

    0

    b. Dating and going to parties with boys or girls

    1

    0

    c. Telling my parents where I am

    1

    0

    d. What movies or TV shows I can watch

    1

    0

    e. Hanging around with boys or girls when no adults are around

    1

    0

  2. How much do your parents TRY to know…

Mark ONE ANSWER FOR EACH

Try a lot

Try a little

Don’t try

a. Who your friends are?

3

2

1

b. Where you go at night?

3

2

1

c. What you do with your free time?

3

2

1

d. Where you are most afternoons after school?

3

2

1







  1. Please mark which of the following is true for you.

Mark ONE

0 I do not have a mother or someone who is like a mother to me at all. (SKIP TO 10)

1 I have a mother or someone who is like a mother to me (even if she
does not live with me).

  1. Answer the next question about your mother or someone who is like a mother to you.

How close do you feel to her?

Mark ONE

0 Not very close

1 A little close

2 Pretty close

3 Very close

  1. What do you think about these statements? They are about your mother or the person who is like a mother to you. For each, mark how true the statement is:


Mark ONE ANSWER FOR EACH

Mostly true

Sometimes true

Hardly ever true

a. It is easy to talk with her about things that happen in school

1

2

3

b. It is easy to talk with her about things that happen in my life

1

2

3




  1. Please mark which of the following is true for you.

Mark ONE

0 I do not have a father or someone who is like a father to me at all. (SKIP TO 13 ON PAGE 3)

1 I have a father or someone who is like a father to me (even if he does not
live with me).

  1. Answer the next question about your father or someone who is like a father to you.

How close do you feel to him?

Mark ONE

0 Not very close

1 A little close

2 Pretty close

3 Very close

  1. What do you think about these statements? They are about your father or the person who is like a father to you. For each, mark how true the statement is:


Mark ONE ANSWER FOR EACH

Mostly true

Sometimes true

Hardly ever true

a. It is easy to talk with him about things that happen in school

1

2

3

b. It is easy to talk with him about things that happen in my life

1

2

3



  1. How often in the last 3 months have you talked to one or both of your parents about any of these things?

    Mark ONE ANSWER FOR EACH

    Not at all

    1
    time

    2–3
    times

    4 times or more

    a. Dating behavior that is OK

    0

    1

    2

    3

    b. How your mother feels about teen sex

    0

    1

    2

    3

    c. How your father feels about teen sex

    0

    1

    2

    3

    d. How your friends feel about teen sex

    0

    1

    2

    3

    e. Questions about facts about sex

    0

    1

    2

    3

    f. Reasons for not having sex

    0

    1

    2

    3

    g. Things that happen to teens who have sex

    0

    1

    2

    3

    h. Why not having sex is important

    0

    1

    2

    3

    i. Diseases people can get when having sex

    0

    1

    2

    3

    j. How babies are made

    0

    1

    2

    3

    k. What TV, radio, movies, magazines, and/or the Internet say about sex

    0

    1

    2

    3

    l. How your body grows and changes

    0

    1

    2

    3

    m. Peer pressure

    0

    1

    2

    3

    n. Sex in marriage

    0

    1

    2

    3

    o. What other people will say or think about you or your friends

    0

    1

    2

    3

  2. How easy is it for you to talk to your parents about these things?

Mark ONE

0 Never talk to my parents about these things

1 Never easy

2 A little easy

3 Very easy


WHAT YOUNG PEOPLE THINK AND DO

The next questions are about things that some young people think about or do.

Please remember that all of your answers will be kept private.

  1. How many times have you gone out on a date with someone who is at least three years older than you?

Mark ONE

1 Never

2 Once

3 Sometimes (2–10 times)

4 More than 10 times

  1. Young people often feel pressure from other people.

How much pressure have you personally felt to do things you might get in trouble for?

Mark ONE

1 A lot

2 Some

3 Not much

4 None

97 Don’t know

  1. How much would you say that the following statement is true about you?

I can say “No” to activities that I think are wrong.

Mark ONE

1 Very much like me

2 Mostly like me

3 Little like me

4 Not at all like me

97 Don’t know

  1. How often would you say that the following statement is true about you?

I have learned to stay away from people who might get me in trouble.

Mark ONE

1 Almost always

2 Usually

3 Some of the time

4 Almost never

97 Don’t know

  1. Have you ever…

Mark ONE ANSWER FOR EACH

Yes

No

a. Smoked cigarettes?

1

0

b. Drank alcohol, like beer, wine, or liquor?

1

0

c. Used marijuana (pot or hashish)?

1

0



ABOUT YOU

These questions ask about you.

  1. How old are you?

Mark ONE

1 9 years old or younger

2 10 years old

3 11 years old

4 12 years old

5 13 years old

6 14 years old

7 15 years old

8 16 years old

9 17 years old

10 18 years old

11 19 years old or older

  1. Are you a girl or boy?

1 Girl

2 Boy

  1. Are you of Hispanic or Latino origin?

1 Yes

0 No

  1. Mark the circle or circles to describe your race.

Mark ALL THAT APPLY

1 White

2 Black or African American

3 Asian

4 Native Hawaiian or Other Pacific Islander

5 American Indian or Alaska Native

6 Other (Describe_______________________)

MORE QUESTIONS

Some of the following questions use the term “having sex.” We want to be clear on what that means. “Having sex” means vaginal intercourse.

Remember that all your answers will be kept private and will not be shared with anyone.

  1. Think about the future. How important is it for you to not have sex until marriage?

1 Very important

2 Quite important

3 Somewhat important

4 Not too important

5 Not important at all





  1. We would like for you to tell us how having sex as a teen might change a person’s life.

    Would having sex as a teen make it harder for…

    Mark ONE ANSWER FOR EACH

    Yes, much harder

    Yes, somewhat harder

    No, not harder at all

    Haven’t thought about it yet

    1. A person to study and stay in school in the future? ...…..............

    1

    2

    3

    97

    1. A person to have a good marriage and a good family life one day?...….................….................…................…...................…...

    1

    2

    3

    97

    1. A teen to grow, learn to handle feelings, and make moral choices?.….................….................…................….....................

    1

    2

    3

    97

  2. Here are some opinions teens have about sex. Please tell us how much you agree or disagree with each one.

    Mark ONE ANSWER FOR EACH

    Agree
    a lot

    Agree
    a little

    Disagree
    a little

    Disagree
    a lot

    a. It is OK for unmarried teens to have sex if no one gets pregnant..

    1

    2

    3

    4

    b. Only married people should have sex ............................................

    1

    2

    3

    4

    c. No sex is the only sure way to not get pregnant. It is also the only sure way to avoid health problems like diseases people can get when having sex .....................................................................

    1

    2

    3

    4

  3. Here are some more opinions teens have. Please tell us how much you agree or disagree with each one.

    Mark ONE ANSWER FOR EACH

    Strongly
    agree

    Somewhat agree

    Somewhat disagree

    Strongly disagree

    a. It would be OK for teens who have been dating for a long time to have sex

    1

    2

    3

    4

    b. Having a good marriage seems realistic for me

    1

    2

    3

    4

  4. How many of your five closest friends have had sex?

Mark ONE

0 None of them

1 One or two of them

2 Three or four of them

3 All of them

97 Don’t know

  1. How much do you agree with each of these statements?

Mark ONE ANSWER FOR EACH

Agree a lot


Agree
a little


Disagree
a little


Disagree
a lot

a. You would not be able to stay out of settings where you feel like you have to have sex

1

2

3

4

5

6

7

b. You would not be able to say no to sex with someone who wants to have sex with you

1

2

3

4

5

6

7

c. You can avoid doing things that might lead you to have sex when you don't want to

1

2

3

4

5

6

7

d. You can say no to sex even if the other person says they will break up with you if you don’t have sex

1

2

3

4

5

6

7

e. You would not be able to stay away from people who make you feel like you have to have sex

1

2

3

4

5

6

7

f. You can say no to someone who wants you to have sex when you don’t want to

1

2

3

4

5

6

7

WHAT YOU THINK AND DO

Some of the following questions use the term “having sex.” We want to be clear on what that means. “Having sex” means vaginal intercourse.

For the next few questions, we would like for you to think about the future. Please consider how likely the following things are to happen. Remember that all your answers will be kept private.

  1. How likely is it that you will have sex in the next 12 months?

Mark ONE

1 Definitely likely

2 Probably likely

3 Somewhat likely

4 Not very likely

5 Not at all likely

How much do you agree or disagree with the following statements?

  1. I intend to wait until I am older before I have sex with someone.

Mark ONE

1 Strongly agree

2 Agree

3 In the middle

4 Disagree

5 Strongly disagree

  1. I do not intend to wait until I am married before I have sex with someone.

Mark ONE

1 Strongly agree

2 Agree

3 In the middle

4 Disagree

5 Strongly disagree

  1. How likely is it that you will use birth control or pregnancy protection when you have sex?

Mark ONE

1 Definitely likely

2 Probably likely

3 Somewhat likely

4 Not very likely

5 Not at all likely

These questions ask about things you may have done willingly. Willingly means you gave permission or said it was OK. It also means you did it because you wanted to, and not because someone made you. Remember that all your answers will be kept private.

  1. Have you kissed someone on the lips other than a parent or relative?

1 Yes

0 No

  1. Have you tongue kissed or French kissed?

1 Yes

0 No

  1. If you are a boy, have you touched a girl’s chest or breasts?

1 Yes

0 No

99 I’m a girl

  1. If you are a girl, has someone touched your chest or breasts?

1 Yes

0 No

99 I’m a boy

  1. Have you touched someone else’s private parts below the waist under their clothes?

1 Yes

0 No

  1. Has someone touched your private parts below the waist under your clothes?

1 Yes

0 No

  1. Have you ever had sex?

1 Yes

0 No IF NO,
SKIP TO PAGE 9

  1. Think about the first time you had sex. Did you or your partner use...

Mark ALL THAT APPLY

1 Birth control pills

2 Condoms

3 Depo-Provera (injectable birth control)

4 Withdrawal, pulling out

5 Some other method

(Describe_________________________)

0 None of the above

97 Not sure

  1. H ave you had sex during the last 6 months?

1 Yes

0 No



44. Think about the last time you had sex. Did you or your partner use...

Mark ALL THAT APPLY

1 Birth control pills

2 Condoms

3 Depo-Provera (injectable birth control)

4 Withdrawal, pulling out

5 Some other method

(Describe________________________)

0 None of the above

9 7 Not sure











GO TO THE NEXT PAGE

43. During the past 3 months, with how many people did you have sex?

Mark ONE

0 I have had sex, but not during the last 3 months

1 1 person

2 2 people

3 3 people

4 4 people

5 5 people

6 6 or more people























That’s all!

Thank you very much for your time.



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