1-1-Youth Questionnaire
1-1--Youth Questionnaire.doc
Minority Substance Abuse/HIV Prevention Initiative
1-1-Youth Questionnaire
OMB: 0930-0298
OMB # XXX
Expiration Date: XXX
National Substance Abuse, HIV, and Hepatitis Prevention Initiative
Cohort 6
Youth Baseline Questionnaire First Data Collection Point
TO BE FILLED OUT BY THE LOCAL GRANT SITE DATA COLLECTOR
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RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.
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National Substance Abuse, HIV, and Hepatitis Prevention Initiative
Cohort 6
Youth Baseline Questionnaire
First Data Collection Point
Funding
for data collection supported by the
Center for Substance Abuse
Prevention (CSAP)
Substance Abuse and Mental Health Services
Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
These questions are part of a data collection effort about how to prevent substance abuse, HIV, and hepatitis infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep young people from using drugs and getting infected with HIV and hepatitis.
Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.
We would like you to work fairly quickly, so that you can finish. Please work quietly by yourself. If you have any questions or don’t understand something, let the data collector know.
We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort! Before we begin, let me read the following to you:
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Notice: 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 XXX (expires XXX). The time required to complete this information collection is estimated to average 1 hour per response. Part of this questionnaire has received OMB Approval for CSAP National Outcome Measures. Other questions support performance reporting for the Government Performance Results Act, Performance Assessment Rating Tool, and the CSAP Minority AIDS Initiative. Send all comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857.
INSTRUCTIONS
1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles.
3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth. ___________________________________________________________________________________
MARKING YOUR ANSWERS
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Section One: Facts About You
First, we’d like to ask some questions about you, like how old you are and what grade you are in. We are not going to use this information to identify you, but instead to talk about what different groups of people have to say. For example, what boys have to say, and how that may be different from what girls have to say. Or how 12-year-olds feel about different things, and how that might be different from what 17-year-olds feel. |
1. How would you describe yourself? (Gender)
Male
Female
2. In what year were you born?
1984 1988 1992
1985 1989 1993
1986 1990 1994
1987 1991 1995
3. In what month were you born?
January July
February August
March September
April October
May November
June December
4. On what day of the month were you born?
1 12 22
2 13 23
3 14 24
4 15 25
5 16 26
6 17 27
7 18 28
8 19 29
9 20 30
10 21 31
11
5. Are you Hispanic or Latino?
Yes
No
6. What is your race? (Select one or more)
White
Black or African American
American Indian
Native Hawaiian or Other Pacific Islander
Asian
Alaskan Native
Other
7. How would you describe yourself? (Sexual orientation)
Straight or heterosexual
Bisexual
Gay or lesbian
Unsure
8. What is your primary spoken language?
English
Spanish
Asian (Chinese, Japanese, or other)
American Indian (Apache, Blackfoot, Navajo, or other)
Other
9. How long have you lived in the United States?
Less than a year
1 to 2 years
3 to 4 years
5 or more years
All my life
10. With
whom do you live?
(Mark
all that apply)
Alone
With my mother
With my father
With my brother(s) and/or sister(s)
With my grandparent(s)
With other relatives or guardian(s)
With my spouse or significant other
With my child or my children
With roommates
Other
11. Describe where you live.
In my own home or apartment
In a relative’s home
In a group home
In a foster home
Homeless or in a shelter
Other
What is the highest level of education you have finished, whether or not you received a degree? (Mark only the grades you have completed)
1st grade College freshman
2nd grade College sophomore
3rd grade College junior
4th grade College completion
5th grade Some graduate school, but
6th grade no degree received
7th grade Master’s degree
8th grade Some professional school,
9th grade (such as medical or law
10th grade school) but no degree
11th grade received or doctoral
12th grade program
Doctorate or professional degree
Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Mark one)
More likely
Less likely
Would make no difference
Don’t know or can’t say
During the past 12 months, have you driven a vehicle while you were under the influence of alcohol?
Yes
No
Don’t know or can’t say
Have you ever been suspended from school for drug or alcohol use?
Yes
No
Have you ever been in juvenile detention, jail, or prison for more than 3 days?
Yes
No
If YES to question 16, how long has it been since you last got out of a juvenile detention, jail, or prison?
Never
in juvenile detention, jail, or prison
Less than 30 days
Between 30 days and 1 year
Between 1 and 2 years
Between 2 and 3 years
Between 3 and 4 years
Between 4 and 5 years
More than 5 years
Section Two: Cigarettes, Alcohol, and Drugs
The next two questions ask about how substance use may have affected your personal life, or about how your personal life may have caused you to use substances.
18. During the past 30 days, how stressful have things been for you because of your use of alcohol or drugs?
I
have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
19. During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?
I
have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
The
next two questions are about CIGARETTES
and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products.
20. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Include menthol and regular cigarettes and loose tobacco rolled into cigarettes)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
21. During the past 30 days, on how many days did you use other tobacco products? (Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next two questions are about ALCOHOL.
By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. However, this may not be true for your religious, cultural, or ethnic group. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you consumed alcohol.
22. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
23. During the past 30 days, on how many days have you been drunk or very high from drinking alcoholic beverages?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.
24. During the past 30 days, on how many days did you use marijuana or hashish?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish, which include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or to get high), heroin, crack or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and report on how many days, if any, you used other illegal drugs. |
25. During the past 30 days, on how many days did you use any other illegal drug?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
26. During the past 30 days, on how many days have you sniffed glue or breathed the contents of aerosol spray cans, or inhaled (huffed) any other gases or sprays in order to get high?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
2
Now we would like to ask about your use of several specific drugs.
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
28. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
29. During the past 30 days, on how many days did you inject any drugs? (Count only injections without a doctor’s orders, those you had just to feel good or to get high.)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next few questions ask about the FIRST TIME you used a substance.
Think back whether you have EVER used any substances. If so, tell us your age the FIRST TIME you used the following substances.
|
30. How old were you the first time you smoked part or all of a cigarette? (Include menthol and regular cigarettes and loose tobacco rolled into cigarettes)
I have never smoked part or all of a cigarette
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
31. How old were you the first time you used any other tobacco product? (Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
I have never used any other tobacco products
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
32. How old were you the first time you had a drink of an alcoholic beverage? (Includes beer, wine, wine coolers, malt beverages, and liquor) DO NOT include any time when you only had a sip or two from a drink.
I have never had a drink of an alcoholic beverage
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13
years old or can’t say
33. How old were you the first time you used marijuana or hashish? (Also known as grass, pot, hash, or hash oil)
I have never used marijuana or hashish
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
34. How old were you the first time you used any other illegal drug?
I have never used any other illegal drugs
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
The next few questions ask about YOUR thoughts on someone your age using alcohol, tobacco, and drugs. Please tell us if you approve or disapprove of their actions.
35. How do you feel about someone your age smoking one or more packs of cigarettes a day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
36. How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
37. How do you feel about someone your age trying marijuana or hashish once or twice?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
38. How do you feel about someone your age using marijuana once a month or more?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
39. How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs. |
40. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
41. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
42. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
Section Three: Your Family and Friends
The next few questions ask about your family.
43. Do you have any children?
Yes
No
Don’t know or can’t say
44. If YES to question 43, how many children do you have?
I don’t have any children
1
2
3
4
5 or more children
45. Now, think about the past 12 months through today. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? By PARENTS we mean your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.
Yes
No
Don’t know or can’t say
The next few questions are about your family’s relationships. |
46. I’m available when others in my family want to talk to me.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
47. I listen to what other family members have to say, even when I disagree.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
48. Members of my family ask each other for help.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
49. Members of my family like to spend free time with each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
50. Members of my family feel very close to each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
51. We can easily think of things to do together as a family.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
The next set of questions ask about things your friends may do or think.
How many of your friends do the following:
52. Drink
beer, wine, wine coolers, or hard
liquor (besides a
few sips)?
None
A few
Some
Most
All
53. Get good grades?
None
A few
Some
Most
All
54. Smoke cigarettes?
None
A few
Some
Most
All
55. Get suspended from school or dropped out?
None
A few
Some
Most
All
56. Smoke marijuana or weed?
None
A few
Some
Most
All
57. Sniff glue, gases, or sprays to get high?
None
A few
Some
Most
All
58. Volunteer for community work?
None
A few
Some
Most
All
59. Get arrested?
None
A few
Some
Most
All
60. Get involved in religious activities?
None
A few
Some
Most
All
61. Exercise or play sports?
None
A few
Some
Most
All
62. Are sexually active?
None
A few
Some
Most
All
63. Been
pregnant or got someone
pregnant?
None
A few
Some
Most
All
Section Four: Sexual Behavior
The next set of questions are about SEX and things that are related to sex.
Some of the questions ask about having sex. By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouths.
When a male inserts his penis into his female partner’s vagina, the partners are considered to be having vaginal sex.
When one partner’s mouth touches the other partner’s genitals (penis or vagina) or anus during sex, the partners are considered to be having oral sex.
When a male’s penis is inserted into his male or female partner’s anus, the partners are considered to be having anal sex.
Some questions ask about sexual partners. A sexual partner is someone with whom you have sex, that is, engage in sexual activity.
Some questions refer to protected sex and unprotected sex. Protected sex is when a latex or polyurethane condom (rubber) is used to cover the penis; or a dental dam, or a female condom such as “Reality” is used to cover the vagina; or a dental dam is used to cover the anus. By unprotected sex, we mean vaginal, oral, or anal sex without a barrier such as a latex condom, dental dam, or female condom.
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64. Have you ever had sex (either vaginal, oral, or anal)?
Yes
No
65. How old were you when you had sex for the first time (include vaginal, oral, or anal sex)
I have never had sex
Under 5 years old
Between 5 and 10 years old
Between 11 and 14 years old
Between 15 and 18 years old
Over 18 years old
66. During the last 30 days, have you had sex?
Yes
No
67. If YES to question 66, did you or your partner use a condom?
I did not have sex during the last 30 days
Yes
No
68. During your life, with how many people have you had sex?
0 people
1 person
2 people
3 people
4 people
5 people
6 or more people
69. During the last 3 months, with how many people did you have sex?
0 people
1 person
2 people
3 people
4 people
5 people
6 or more people
The next few questions ask about sexual activity while under the influence of drugs or alcohol. |
70. Think about the last time you had sex. Did you drink alcohol or use drugs before you had sex the last time?
I have never had sex
Yes
No
71. In the last 3 months, have you had sex after getting drunk or high?
Yes
No
72. Have you ever had sex for money, drugs, or other things?
Yes
No
73. In the last 30 days, did you and your boyfriend or girlfriend talk about using condoms?
I do not have a boyfriend or girlfriend
Yes
No
74. In the last 30 days, did you and your boyfriend or girlfriend use condoms during sex?
I did not have sex during the past 30 days
Yes
No
In the next 3 months, how likely are you to...
75. Be sexually active?
Not at all likely
A little likely
Somewhat likely
Very likely
76. Have more than one sexual partner?
Not at all likely
A little likely
Somewhat likely
Very likely
77. To practice safe sex?
Not intending to have any sex during the next 3 months
Not at all likely
A little likely
Somewhat likely
Very likely
Please indicate whether you think each of the following statements about HIV/AIDS is true or false, or if you don’t know.
78. Only people who look sick can spread the HIV/AIDS virus.
True
False
Don’t know
79. Only people who have sex with gay (homosexual) people get HIV/AIDS.
True
False
Don’t know
80. Birth control pills protect women from getting the HIV/AIDS virus.
True
False
Don’t know
81. There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.
True
False
Don’t know
82. There is no cure for AIDS.
True
False
Don’t know
83. Young people under age 18 need their parents’ permission to get an HIV test.
True
False
Don’t know
84. Having another sexually transmitted disease like gonorrhea or herpes increases a person’s risk of becoming infected with HIV.
True
False
Don’t know
85. Sharing intravenous needles increases a person’s risk of becoming infected with HIV.
True
False
Don’t know
86. You
can become infected with HIV by
having unprotected
oral sex.
True
False
Don’t know
87. I can get my boyfriend or girlfriend to use a condom, even if he or she does not want to. (If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)
Strongly agree
Agree
Disagree
Strongly disagree
88. I would be able to say to my boyfriend or girlfriend that we should use a condom. (If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)
Strongly agree
Agree
Disagree
Strongly disagree
89. I could refuse if someone wanted to have sex without a condom.
Strongly agree
Agree
Disagree
Strongly disagree
90. I would be able to say no if a friend offered me a drink of alcohol.
Strongly agree
Agree
Disagree
Strongly disagree
91. I would be able to refuse if a friend offered me drugs, including marijuana.
Strongly agree
Agree
Disagree
Strongly disagree
92. I could say no if someone pressured me to have sex when I did not want to.
Strongly agree
Agree
Disagree
Strongly disagree
Section Five: School
The next few questions ask about how you feel about school. First, we need some background information.
93. Are you enrolled in school?
Yes
No
94. Are you on summer break or vacation?
Yes
No
95. What were your most recent grades in school?
I am not in school
Mostly As
Mostly Bs
Mostly Cs
Mostly Ds
Mostly Fs
96. How often do you feel that the school work you are assigned is meaningful and important?
I am not in school
Almost always
Often
Sometimes
Seldom
Never
97. How interesting are most of your classes to you?
I am not in school
Very interesting
Quite interesting
Fairly interesting
Slightly dull
Very dull
98. How important do you think things you are learning in school are going to be for you later in life?
I am not in school
Very important
Quite important
Fairly important
Slightly important
Not at all important
Now think back over the last year in school...
99. How often did you enjoy being in school?
I was not in school during the last year
Almost always
Often
Sometimes
Seldom
Never
100. How often did you hate being in school?
I was not in school during the last year
Almost always
Often
Sometimes
Seldom
Never
101. How often did you try to do your best in school?
I was not in school during the last year
Almost always
Often
Sometimes
Seldom
Never
Section Six: Social Experiences
The next few questions ask about your ETHNIC GROUP. An ethnic group is a cultural group that has a shared history, similar customs, traditions, and sometimes shared values. For example, Hispanics, African Americans, Native Americans, Asians, and Pacific Islanders are usually considered to be ethnic groups.
102. I have spent time trying to find out more about my ethnic group, such as its history, traditions, and customs.
Strongly agree
Agree
Disagree
Strongly disagree
103. I am active in organizations or social groups that include mostly members of my own ethnic group.
Strongly agree
Agree
Disagree
Strongly disagree
104. I think a lot about how my life is affected by my ethnic group membership.
Strongly agree
Agree
Disagree
Strongly disagree
105a. I have often talked to other people about my ethnic background.
Strongly agree
Agree
Disagree
Strongly disagree
105b. I am interested in learning more about my ethnic background.
Strongly agree
Agree
Disagree
Strongly disagree
106. I participate in cultural practices of my own ethnic group, such as special food, music, or customs.
Strongly agree
Agree
Disagree
Strongly disagree
The next few questions ask about your religious or spiritual beliefs and their role in your daily life.
107. In general, how important are religious or spiritual beliefs in your day-to-day life?
Very important
Fairly important
Not too important
Not at all important
108. When you have problems or difficulties with your school (education), work, family, friends, or personal life, how often do you seek spiritual guidance and support?
Almost always
Often
Sometimes
Rarely
Never
109. How spiritual or religious would you say you are?
Very spiritual or religious
Fairly spiritual or religious
Not too spiritual or religious
Not spiritual or religious at all
Section Seven: Hepatitis Knowledge
Please indicate whether you think each of the following statements about hepatitis is true or false, or if you don’t know.
110. There is a difference between an illness caused by viruses and an illness caused by bacteria.
True
False
Don’t know
111. Hepatitis consists of the inflammation of your liver.
True
False
Don’t know
112. The causes of hepatitis include viruses, bacteria, alcohol and toxins, parasites, and blood transfusions.
True
False
Don’t know
113. Hepatitis (A, B, or C) is not a dangerous disease.
True
False
Don’t know
114. The most common types of hepatitis are hepatitis A, hepatitis B, and hepatitis C.
True
False
Don’t know
115. Hepatitis A is transmitted through contaminated food and water, while B and C are transmitted through exchanging bodily fluids.
True
False
Don’t know
116. The best way to protect yourself from hepatitis is to get immunized (vaccinated).
True
False
Don’t know
117. Hepatitis immunizations (vaccines) are common in the United States and can protect you for a lifetime for certain types of hepatitis.
True
False
Don’t know
Section Eight: Health Care
Teenagers get information about substance abuse, HIV, AIDS, hepatitis, or other health issues from many different sources. The next few questions are about some of these sources.
118. During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention of substance abuse?
Yes
No
Don’t know or can’t say
Please tell us how much you have learned about prevention of substance abuse, HIV, hepatitis, or other health problems from the following sources:
119. Your friends, brothers, or sisters?
A lot
Some
Only a little
Nothing at all
120. Your parents or guardians?
A lot
Some
Only a little
Nothing at all
121. Teachers, school nurses, or classes at school?
A lot
Some
Only a little
Nothing at all
122. A doctor or other health care provider?
A lot
Some
Only a little
Nothing at all
123. Television shows or movies?
A lot
Some
Only a little
Nothing at all
124. Books or pamphlets?
A lot
Some
Only a little
Nothing at all
125. Popular magazines such as Essence, Seventeen, Audrey, Latina Style, Hombre, or YM?
A lot
Some
Only a little
Nothing at all
126. The Internet?
A lot
Some
Only a little
Nothing at all
The next few questions ask about health-related behavior and activities that you have engaged in.
127. In the past 30 days, have you been in any classes or programs where they talked about preventing HIV or AIDS?
Yes
No
128. In the past 30 days, have you been in any classes or programs where they talked about preventing hepatitis?
Yes
No
129. In the past 30 days, have you been in any classes or programs where they talked about prevention of drug and alcohol abuse?
Yes
No
130. Have you ever been tested for the HIV virus that causes AIDS?
Yes
No
131. If YES to question 130, did you receive or go back to get your results?
I have never been tested
Yes
No
132. If you had the opportunity to be tested for HIV, would you?
I have already been tested
Yes
No
Don’t know
133. Have you ever been tested for hepatitis A, B, or C?
Yes
No
134. If YES to question 133, did you receive or go back to get your results?
I have never been tested
Yes
No
135. Have you received the hepatitis A or B vaccination?
Yes
No
Don’t know
The last two questions are about your answers to this survey.
136. How comfortable was it for you to answer the questions in this survey?
Very comfortable
Somewhat uncomfortable
Somewhat comfortable
Very uncomfortable
137. How truthful were you when answering the questions?
Very truthful
Somewhat untruthful
Somewhat truthful
Very untruthful
YOU ARE DONE!
Thank you for your help!
CSAP
HIV 6 Prevention Initiative – 9/2006 Page
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