Formative Research and Tool Development
OMB No. 0920-XXXX
Attachment 3
Partial Model Question Bank
Contact Information:
Vishnu-Priya Sneller MBBS, PhD MSPH,
NCHHSTP OMB Coordinator
National Center for HIV, Viral Hepatitis, STD, and TB Prevention/CDC
1600 Clifton Rd NE, MS E-07
Atlanta, GA 30333
404-718-8548
404-639-3250 (fax)
Qualitative/Exploratory Research
Warm-up Questions
Please tell [me/the group] your first name, and a little about [insert topic]
What do you know about [INSERT TOPIC]?
How would you define, or how would you have others refer to [insert topic]?
What do [you/your friends] think about [INSERT TOPIC]?
Name as many diseases/illnesses that you can think of that can be transmitted or shared through sexual contact.
What are some of the things people can do to prevent getting an STD?
How is [topic] viewed by [people you know/your community]?
Is/are [insert disease] common in [insert population/group]?
Which STDs would you think are the most common among [insert population/group]?
What are some things that may be contributing to [insert problem, disease]?
What do you think about that?
How common do you think [insert contributing factor] is in your community?
Do you think [insert contributing factor] affects how people approach or think about sex? How?
Where do [insert disease] fit in with other things people have to worry about in their lives?
Is [insert disease] more common than [insert disease]?
Who is at risk for [insert disease]?
Do you think [insert population/group] is/are at higher risk of getting [insert disease] than [insert population/group]?
Do you think [insert population/group] are at higher risk of getting [insert disease] or [insert another disease]?
Have you heard that [insert fact]?
What do you think about [insert fact]?
Do you believe [insert fact] to be true?
Practices
Do many people [you know/in your community] practice [insert behavior]?
When/why would people practice [insert behavior]? Probe: Does it depend on [insert scenario/fact]?
What you would do if [INESRT SCENARIO]?
Have you ever talked to a sex partner about whether you or they ever had an STD?
What factors might make a conversation with a partner about [insert topic] easier/harder?
Prevention/Testing/Treatment Services
What have you heard about what it’s like to [insert prevention/testing/treatment-seeking behavior]?
What would you describe as fears or problems to [insert testing/prevention behavior]? Have you heard any concerns from your friends?
If you were in charge of a program to promote [insert prevention/testing behavior], what might you say or do to deal with these fears or problems?
In general, what kinds of things are [you/women/men] looking for in sexual or intimate relationships?
What (benefits) are [you/people] getting out of [insert relationship type]?
How do you weigh the risks and benefits in deciding to have sex?
In relationships, what do you think [insert population/group] expect from their partners in terms of [sex/intimacy/monogamy/protection]?
What do you see as the [man’s/woman’s] role or responsibility in sexual relationships?
Are there certain things that [men/women] should be doing for their partners that they are not?
In thinking about the people you know, what things would you like to see changed or to be different that relate to [relationships/sex]?
1. If someone was being tested for [insert disease], what would people you know think about that person? Why?
Probe: Would it matter what STD they were being tested for?
2. How do people in general feel about someone who has (or has had) [insert disease]?
Probe: Does this differ for men and women with [insert disease]?
Who gets the blame for spreading [insert disease]?
Probe: Do you think views on this are different between men and women? Why is that?
Do people view [insert disease] as being more of a problem among [insert population/group] than among [insert population/group]?
What do [you/your friends/family/people in groups you belong to] think about [insert practice, lifestyle, trend, phenomenon, scenario]? How common is that?
Government Trust
Do you think people trust that they can get the care they need if they have [insert disease]?
How would you compare the [insert preventive, screening or treatment service] that [insert population/group] get, compared to that of [insert population/group]?
How do people feel about the government’s response to [insert public health problem]?
Do you believe the government has your best interest in mind?
What more should the government be doing?
1. When you hear “STDs”, do you think of them as one disease - or as a bunch of separate diseases? Tell me about that.
2. When I first mentioned STDs, were [any of] you also thinking about HIV? In other words, do you view HIV as an STD or as its own separate disease?
3. How are STDs and HIV the same? How are they different?
4. Are there specific STDs that people worry about getting? Which ones?
5. Is it important to make sure that [insert population/group] know(s) that STDs are a threat?
6. What would be a good way to:
Raise awareness that [insert population/group] may be personally at risk?
Motivate [insert population/group] to [insert behavior]?
What type of information would [insert population/group] be most receptive to? For example, should messages emphasize:
the disease (STDs) and health consequences?
the racial differences (disparity)?
healthy sexuality or behaviors?
individual or community empowerment/affirmation?
What, if anything, must change first to enable [insert desired behavior/action/goal]?
When thinking about [insert disease] information, would [you/people you know] prefer to see general information about all STDs combined or each STD separately? Why? What about receiving STD information combined with information about HIV?
Probe: Could we combine STDs that…
Are transmitted the same ways (skin-to-skin vs. fluids)?
Have similar symptoms?
Have similar health consequences?
Can be treated vs. those that are incurable (you have forever)?
When it comes to getting [insert disease] information, who are the people/organizations you are [most/least] likely to trust/listen to?
How would you like to get this information? [Format? Channels?]
When and where would you be most receptive to this information?
1. How does this information make you feel?
2. How would you feel if you saw this kind of information publicized in [insert community]?
3. Is it important to get this information out?
Probe: Why? To whom?
Evaluation
Have you ever heard of a campaign called [insert campaign name]?
If yes, have you ever [insert action] as a result of [insert campaign name]?
In the last six months, do you recall seeing any messages about [insert topic] in/on [insert channel/setting]?
Quantitative Research/Survey Questions
Screening Questions
1. What is your gender? [Read ALL responses. Do not assume]
Male |
Female |
Transgender or Transsexual |
Refused |
2. How old are you? _______________
3 Are you Hispanic/Latina? Yes/No/Don’t know
4. What is the category that best describes your racial/ethnic background?
American Indian/ Alaska Native |
Asian |
African American or Black |
Native Hawaiian/ Other Pacific Islander |
White or Caucasian |
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Would you describe yourself as…
Heterosexual or straight |
Homosexual, gay or same-gender loving |
Bisexual |
Decline |
5. Have you ever had sexual intercourse?
6. Within the past 6 months, have you had sexual intercourse (or sex) with a [man/woman/person]? Yes/No
7. Have you ever had a pelvic exam or Pap test? Yes/No
8. Have you ever gone to a doctor/clinic/other to get birth control?
9. Do you or does anyone else in your immediate family or household work… [READ LIST.]
In marketing research? |
In marketing or advertising? |
In public health or healthcare? |
None |
10. Have you participated in a focus group or interview [on the topic of-INSERT] in the last 6-months?Yes/No
11. What is your current marital status?
Single |
Divorced or Widowed |
Married |
Refuse |
Follow up single with:
in a committed/monogamous relationship
in an open relationship
casually dating one person
casually dating more than one person
not dating anyone at this time
other_________________________________
What grade are you in? ______
What is the highest level of education you have completed?
[READ LIST IF NECESSARY]
Primary or Middle School (grade school) |
Some high school, but not a graduate |
High school graduate (or GED) |
Some college/technical, not graduate |
College graduate or higher |
Refused |
13. What is your yearly household income?
Less than $20,000 |
$20,000-$39,999 |
$40,000-$59,999 |
$60,000-$69,000 |
$70,000-$79,000 |
$80,000 or above |
Don’t know |
14. When was the last time you visited a doctor or nurse for a health checkup (this does not include visits to the dentist, optometrist, or psychologist).
Within last year
1-5 years ago
More than 5 years ago
Don’t remember
15. What type of healthcare provider did you see?
General practitioner/Internist
OB/GYN
Medical specialist other than GYN
Nurse practitioner
Nurse
Other [Record]
16. How many months or years have you lived in the community where you currently live? _______
17. Do you feel like you are a part of the community where you currently live? Yes/No
Which of the following statements best describes your current employment?
Working full-time
Working part-time
Unemployed or laid off
Other [Specify:_________]
Have you ever been in jail or prison?
Yes
No
Do you have a primary care doctor? Yes/No
Do you have health insurance? This includes insurance you may get through an employer, purchase on your own, or get through a government program like Medicaid, Medicare, the military or Veteran’s Administration. Yes/No
22. What language do you speak at home? Please mark ALL that apply
o English
o Spanish
o Another language (What language?__________________________________)
HIV/STD/TB/viral Hepatitis Testing
When you hear the words “Sexually Transmitted Disease” or STD, do you think of HIV
Yes
No
Have you ever been tested for [insert disease]? Yes/No
Where were you tested for [insert disease]?
Clinic
My doctor (private doctor's office)
Emergency room (ER)
Retail clinic (walmart, pharmacy)
home kit
Other
26. Have you ever been told you had [insert disease]? Yes/No
27. Who told you that you had [insert disease]?
health care provider
sex partner
health department
friend
other
When was your last test for [insert disease]?
Less than 6 months ago
7-11 months ago
1-2 years ago
3-5yrs ago
More than 5 yrs ago…………………………………………………………….
29. Which of the following best describes how often you get tested for [insert disease]?
__ I have been tested at least once, but not on a regular basis
__ I test regularly or after any situation where I might have been exposed to [insert disease]
30. Which of these are the main reasons for your last [insert disease] test? Please select one or more of the following reasons.
I just wanted to find out if I had an [insert disease]
I was worried that I was infected
A doctor, nurse or other health care provider recommended that I get tested
The Health Department asked me to
My sex partner asked me to
I found out my sex partner cheated
I had [insert disease] in the past and I needed to get re-tested
I was starting a new relationship
My previous sex partner told me he/she was infected after we had sex
Other reason [SPECIFY: ____________________]
Below is a list of reasons why some people have not been tested for [insert disease]. Which of these are the main reasons why you have not been tested?
I have not been sexually active
I have not had unprotected sex
I am afraid to find out that I have [insert disease]
I don’t want to think about having [insert disease]
I don’t think I am at risk
I don’t like needles
I don’t trust the results to be kept private
I would have to wait too long for the results
I don’t know where to get tested
I trust my sex partner(s)
I would be embarrassed
It is too expensive
I don’t have any symptoms
I know that I don’t have anything
I know that my partner(s) doesn’t have [insert disease]
Some other reason [SPECIFY: ____________________________]
32. If an organization in your community offered you free, confidential [insert disease] testing, would you choose to get tested?
Yes
No
Maybe
33. How likely do you think it would be that others would find out if you or someone you know went to get tested for [insert disease]?
Not very likely
Somewhat likely
Very likely
Knowledge, Attitudes, Beliefs about STDs/HIV
What concerns you about getting [insert disease]? [check all that apply]
Others finding out I have [insert disease] ………………………………
Having a fatal disease (that will kill me)
What it will do to my body (possible health effects)
Having it forever (not being able to cure it)
Not being able to have children
Not being able to have sex
Not being able to live a normal life
Having to tell my partner
Being rejected by partner, family or friends
Other
Nothing
Please indicate how much you agree or disagree with each of the following statements.
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Strongly disagree |
Disagree |
Neither agree nor disagree |
Agree |
Strongly agree |
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What do you personally associate with sex? [circle all that apply]
physical pleasure |
emotional closeness |
feeling good |
feeling strong |
necessary evil |
feeling in control, powerful |
feeling used |
feeling confident |
obligation |
feeling desired |
feeling sexy |
stress relief |
pain |
release |
other |
Please indicate on the following seven point scale how serious you consider each of the following sexually transmitted diseases (STDs) to be. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”
STDs = Sexually Transmitted Disease |
Not Serious 1 |
Somewhat serious 2 |
Very Serious 3 |
Don’t know 4 |
Bacterial Vaginosis (BV) |
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Chancroid |
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Chlamydia (The Clam) |
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Genital herpes |
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Gonorrhea (Dose, Clap, Drip) |
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Hepatitis B (Hep B) |
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HIV (Has the Package, HI-v) |
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Human Papillomavirus (HPV) |
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Pubic lice (Crabs) |
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Syphilis (Syph, Pox, Bad Blood) |
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Trichomoniasis (Trich) |
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Genital Warts |
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Please indicate on the following seven point scale how curable you consider each of the following STDs. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”
STDs = Sexually Transmitted Disease |
Notcurable 1 |
Somewhat curable 2 |
Easily curable 3 |
Don’t know 4 |
Bacterial Vaginosis (BV) |
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Chancroid |
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Chlamydia (The Clam) |
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Genital herpes |
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Gonorrhea (Dose, Clap, Drip) |
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Hepatitis B (Hep B) |
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HIV (Has the Package, HI-v) |
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Human Papillomavirus (HPV) |
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Pubic lice (Crabs) |
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Syphilis (Syph, Pox, Bad Blood) |
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Trichomoniasis (Trich) |
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Genital Warts |
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Please indicate on the following seven point scale to what extent you consider yourself to be at risk for each of the following STDs. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”
STDs = Sexually Transmitted Disease |
Not at all at risk 1 |
Somewhat at risk 2 |
Very much at risk 3 |
Don’t know 4 |
Bacterial Vaginosis (BV) |
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Chancroid |
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Chlamydia (The Clam) |
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Genital herpes |
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Gonorrhea (Dose, Clap, Drip) |
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Hepatitis B (Hep B) |
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HIV (Has the Package, HI-v) |
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Human Papillomavirus (HPV) |
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Pubic lice (Crabs) |
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Syphilis (Syph, Pox, Bad Blood) |
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Trichomoniasis (Trich) |
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Genital Warts |
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Please indicate on the following seven point scale how shameful people consider each of the following STDs to be for those infected. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”
STDs = Sexually Transmitted Disease |
Not at all at risk 1 |
Somewhat at risk 2 |
Very much at risk 3 |
Don’t know 4 |
Bacterial Vaginosis (BV) |
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Chancroid |
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Chlamydia (The Clam) |
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Genital herpes |
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Gonorrhea (Dose, Clap, Drip) |
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Hepatitis B (Hep B) |
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HIV (Has the Package, HI-v) |
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Human Papillomavirus (HPV) |
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Pubic lice (Crabs) |
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Syphilis (Syph, Pox, Bad Blood) |
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Trichomoniasis (Trich) |
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Genital Warts |
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Racism/Homophobia/Discrimination
1. Have you experienced [racist/homophobic/other] attitudes, beliefs or actions in your life?
Yes
No
2. When you feel you’ve been treated unfairly or discriminated against because of being [insert race/ethnicity/sexual orientation,] you… [Please mark all that apply]
Find comfort in your faith/spirituality
Rely on family members to help you deal with it
Shrug it off
Speak up and challenge the person’s actions or beliefs
Talk with friends to help you deal with it
Try to educate them
Get angry
Other:_______________________
Personal Behaviors
1. During the past 6 months, how many people have you had sex with? ________
2. How many of these partners were men? ________
3. How many of these partners were women? ______
Thinking about your partner(s) in the past 6 months, which of the following methods have you used to protect yourself from STDs/HIV? [Mark all that apply, even if you use different methods with different partners]
None
Being faithful to one partner/monogamy
Using condoms
Withdrawal
Getting tested for STDs/HIV on a regular basis
Wash genitals after sex
Urinate after sex
Only have oral sex
Talked to partner(s) to make sure they’ve been tested
Talked to partner to make sure they don’t have an STD
Look at partner to see if they have an STD
Other:________________________
How would you rate your risk of getting infected with [insert disease]?
Very high
High
Average (neither high nor low)
Low
Very low
Undecided/not sure
Have you ever talked to a sex partner about whether you or they ever had [insert disease]?
Yes
No
Never had the need
Have you ever had a discussion with a partner about getting tested for [insert disease]?
Yes
No
Never had the need
Do you currently have a main sex partner—that is, a partner you would call your spouse, significant other, or life partner?
Yes
No
How long have you and your main partner been together? If you and your main partner have been together for less than 1 month, please enter 1 month as your answer.
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Years |
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Months |
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From what you know about your main partner, how would you rate his or her risk of getting infected with [insert disease]?
Very high
High
Average (neither high nor low)
Low
Very low
Undecided/not sure
Not applicable/Refuse to answer
Imagine your doctor told you “you have [insert disease].” Would you be willing to tell your main partner so that you could take steps to protect him/her?
Yes
No
Depends
Imagine that you were diagnosed with [insert disease] and your doctor gave you medicine to give to your main partner. Would you be willing to tell him/her that you were diagnosed with [insert disease] and give him/her the medicine?
Yes
No
Don’t know
Imagine your doctor told you “you have [insert disease].” Would you be willing to tell (all of) your current partner(s) so that you could take steps to protect him/her/them?
Yes
No
Depends
I only have one partner
Imagine that you were diagnosed with [insert disease] and your doctor gave you medicine to give to all of your current partner(s). Would you be willing to tell your partner(s) that you were diagnosed with [insert disease] and give them the medicine?
Yes
No
Don’t know
I only have one partner
15. Who do you talk to when you need advice or guidance about dealing with issues related to your sexual orientation?
-Mother
-Father
-Sibling
-Other relative
-Friend
-Teacher
-Other, please specify
Campaign Evaluation
1) Have you heard of a campaign called [insert name]?
Yes
No
Don't know/not sure
2) If yes, have you done any of the following because of [insert campaign]?
Visited a doctor or health care provider
Talked with a friend about [insert topic]
Texted or called [insert #]
Visited [insert website]
Looked for more information about [insert topic]
Got tested for [insert topic]
Talked with a partner about [insert topic]
Talked with a parent or family member about [insert topic]
Used condoms more often
Got or switched birth control
3) In the last [insert time period], do you recall seeing any messages about [insert topic] on:
Television
YouTube
Social networking sites (facebook, Myspace)
Celebrity websites
Blogs
4) How often do you [watch/listen/visit] [insert TV/radio program or website]?
Never
Less than once a month
Several times a week
Several times a day
5) Have you seen [insert name of ad/program/material]?
No
Not sure
Yes, once
Yes, a few times a week
Yes, at least once a day or more
6) Did [insert name of ad/program/material] help you learn something new about:
Where to go for help or information about sexual issues [y/n]
Sexually transmitted diseases [y/n]
STD testing [y/n]
Where to get tested for STDs [y/n]
Where to vaccinated against STDs [y/n]
How to talk to partners about [insert issue] [y/n]
How to ask for STD testing [y/n]
How to tell someone you don’t want to have sex [y/n]
[insert health topic/issue] [y/n]
Other [y/n]
7) Thinking about [insert name of ad/program/material], please indicate how much you agree or disagree that it:
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Strongly agree
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Somewhat agree |
Neither agree or disagree |
Somewhat Disagree |
Strongly disagree
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Could help change how [insert population/group] think about [insert issue] |
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Really made me think |
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Gets people talking about [insert issues] |
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Made me [insert action] |
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8) How useful did you find [insert name of product]:
Very useful
Somewhat useful
Not at all useful
9) Did you receive [insert material]? y/n
10) Please indicate how much of [insert material] you read? [mark only one]
I have not read it
I glanced at it
I have read all or most of it
I read it and have gone back to re-read a section or look something up.
11) For trustworthy, credible information I go to these sites/dot-coms [check all that apply]:
.com
.edu
.gov
.net
.org
Adolescent Health & Sexuality Questions
Do you have any brothers or sisters who had a baby when they were teenagers?
o No o Yes
Of your 4 closest friends, how many of them have gotten pregnant, gotten someone else pregnant, or had babies?
none
one
two
three
four
How many close friends do you have? ___
During the past 12 months, how many of your close friends have [insert behavior]? ___
In the past [insert time frame], how often did you take part in [insert activity] at school?
o every day
o once or twice a week
o once or twice a month
o never
In the past [insert time frame], how often did you take part in [insert activity] outside of school?
o every day
o once or twice a week
o once or twice a month
o never
What makes it difficult for you to take part in activities at school or in your community? Please mark ALL that apply.
o My family can’t afford it
o I can’t get a ride
o I don’t know any
o I can’t find any that interest me
o It isn’t safe for me to go
o I don’t want to participate
o Something else makes it difficult
(What makes it difficult? _______________________)
o Nothing makes it difficult
Thinking back over Monday through Friday of last week, was there usually a parent, teacher, or other adult with you at the following times?
a. from 3:00 to 5:00 in the afternoon o No o Yes
b. from 5:00 to 7:00 in the evening o No o Yes
On your last report card, what was your grade in [insert subject]?
o A
o B
o C
o D or lower
o Didn’t take this class
Have you ever repeated a grade in school?
o No o Yes
On [weekends/school days], how much time do you spend [insert activity]?
o none
o less than 1 hour
o 1 to 2 hours
o 2 to 3 hours
o more than 3 hours
Please tell us how much you agree or disagree with each of the following statements about your school.
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Agree |
Neither agree nor disagree |
disagree |
I feel close to people at this school. |
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I feel like I am part of this school.
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The teachers at this school treat students fairly.
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I get teased or bullied at this school.
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I feel safe at this school.
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How true do you feel the following statements are about you personally?
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Not at all true |
A little true |
Pretty much true |
Very much true |
I have goals and plans for the future. |
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I plan to graduate from high school.
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I plan to go to college or some other school after high school.
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Health care
Did you see a [doctor/nurse/school nurse] in the past [insert time frame] for any of the following reasons? Please mark yes or no for EACH question.
a. A regular check-up or physical when you weren’t sick or injured o No o Yes
b. Sickness (like a fever or infection) o No o Yes
c. Ongoing illness (like asthma or diabetes) o No o Yes
d. An injury (like a broken bone or cut) o No o Yes
e. A check-up of your vagina or penis
o No o Yes
f. Birth control
o No o Yes
g. A test or treatment for [insert disease] o No o Yes
h. To find out what to do about a pregnancy
oNo oYes
i. Mental health counseling
oNo oYes
j. Information about sex
oNo oYes
k. Information about your health
oNo oYes
l. Something else
Who went with you the last time you saw a doctor or nurse? Please mark only ONE answer.
o One or both of my parents (or guardians)
o Another family member or family friend
o Someone else
o No one else
Your School Nurse
Do you know who your school nurse is? Y/N
Do you know where your school nurse’s office is? Y/N
Have you gone to the school nurse’s office this year? Y/N
Have you ever heard of a vaccine to prevent [insert disease]? Y/N/DK
Have you ever received the vaccine to prevent HPV? Y/N/DK
Do you think [insert fact]? Y/N/DK
Have you ever been taught about [insert health topic] in health class? Y/N
Your Health
How is your health in general?
o Excellent
o Very good
o Good
o Fair
o Poor
Have you ever tried [insert behavior/drug]? Y/N
During [insert time frame], how often do/did you [insert behavior]?
How old were you when you had sexual intercourse for the first time?
o I have never had sexual intercourse
o 10 years old or younger
o 11 years old
o 12 years old
o 13 years old
o 14 years old
o 15 years old or older
The last time you had sexual intercourse, which of the following did you use?
o condoms
o birth control pills, patch, or ring
o birth control shots
o emergency contraception (“morning after pill”, Plan B)
o withdrawal (“pull out”)
o rhythm method (“safe time of the month”)
o something else
o nothing
o I have never had sexual intercourse
Have you ever given or received oral sex?
o Yes, given only
o Yes, received only
o Yes, both
o No
o I don’t know what oral sex is
How likely is it that you will wait to [insert behavior] until you are [married/older/finished high school]?
o I’m sure I won’t wait
o I probably won’t wait
o Even chance (50-50) that I will wait
o I probably will wait
o I’m sure I will wait
How likely are you to have sexual intercourse
a) if you have someone to do it with you?
b) in the next six months?
RESPONSE OPTIONS
o I’m sure it won’t happen
o It probably won’t happen
o Even chance (50-50) that it will happen
o It probably will happen
o I’m sure it will happen
What is the most important reason why you would NOT have sexual intercourse?
Please mark ALL that apply
o Against my religion or morals
o Don’t want to get pregnant
o Don’t want to get a sexually transmitted disease
o Haven’t found the right person yet
o Waiting for the right time
o Other (please explain: ___________________)
Parental Monitoring
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Never
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Rarely |
Sometimes
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Most of the time |
Always |
My parents know where I am after school. |
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If I am going to be home late, I am expected to call my parents to let them know. |
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i tell my parents who I am going to be with before I go out. |
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When I go out at night, my parents know where I am. |
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I talk with my parents about the plans I have with my friends. |
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When I go out, my parents ask me where I am going. |
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i can stay out as late as I want on weekend nights. |
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My parents let me [insert behavior] |
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Family Communication
We have talked about [insert topic].
o Not at all
o Some
o A lot
Whenever we talk about sex, my mother/father [insert action/emotion].
o Not at all
o Some
o A lot
o We have not talked about sex.
How many adults are there in your life, like your parents, grandparents, neighbors or teachers, who really care about you?
o None
o A few
o A lot
How much does your [family member] care about you?
o Not at all
o Some
o A lot
o I don't have this person in my life
How safe do you feel in your neighborhood?
o Very safe
o Pretty safe
o Not at all safe
My family has enough money to afford the kind [insert material/medical need] we need
In the past 6 months:
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Yes |
Sometimes |
No |
1) Were there times when you were very sad? |
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2) Has there been a time when you just weren't interested in anything and felt bored or just sat around most of the time? |
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3) Have you had times when you felt that life was hopeless and that there was nothing good for you in the future? |
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4) Were there times when you were grouchy or irritable, often in a bad mood, so that even little things would make you mad? |
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5) Has there been a time when nothing was fun for you, even things you used to like? |
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6) Have you lost a lot of weight? |
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7) Have you been so down that it was hard for you to do your schoolwork? |
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1.
How often do your parents [insert behavior]?
2. How often do
you rely on your parents for [insert behavior]?
5. How often do
you discuss [insert issue] with your parents?
6.
How often do you give your child praise or encouragement?
7.
How often does your child rely on you for advice and guidance?
9.
How often do you and your child do things together that you both
enjoy?
10. How often does your child discuss personal problems
with you?
Response
options for all: 1) Almost always; 2) Sometimes; 3) Never
Parental conflict: [Y/N response options]
Have both of your parents lived in the same house with you in the past 12 months?
Have other adults lived in the same house with you (for example, your mother and her boyfriend) in the past 12 months?
Do you often see your parents arguing?
When your parents have an argument, do they say mean things to each other? \
Have
your parents ever [insert action] during an argument?
How much do you agree with the following statements? [strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree]
I feel close to people at my school.
I feel like you are a part of my school.
I am happy to be at my school.
The teachers at my school treat students fairly.
I feel safe in my school.
Homework is a waste of time.
I try hard in school.
Education is so important that it's worth putting up with things that I don't like.
In general, I like school.
I don't care what
teachers think of me (it doesn't matter to you what teachers think
about you).
1.
How frequently do you attend religious services, such as attending
church, temple, or prayer-meetings?
1) Never
2) Rarely
(e.g., a few times a year)
3) Often (e.g., about once a month)
4) Very often (e.g., weekly or more often)
2.
How important to you are your religious and spiritual life and
beliefs?
1) Not very
important
2)
Somewhat important
3) Very important
| File Type | application/msword |
| File Title | Exploratory Research |
| Author | alf8 |
| Last Modified By | vbs6 |
| File Modified | 2009-08-06 |
| File Created | 2009-08-06 |