“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”
Attachment 1e. ACASI Survey-Youth
Form Approved
OMB No. 0920-0840
Expiration Date 01/31/2013
“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”
ACASI Survey-Youth
Public reporting burden of this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)
[ALL NOTES FOR THE ACASI PROGRAMMER ARE IN BRACKETS]
ADOLESCENT ASSESSMENT
[PLEASE ADD “NOT APPLICABLE,” “REFUSE TO ANSWER,” AND “I DON’T KNOW/DO NOT REMEMBER OPTIONS FOR ALL QUESTIONS]
[PLEASE ADD PROMPTS ON A SEPARATE SCREEN FROM THE QUESTIONS]
Benet-Martinez Acculturation Scale
(Benet-Martinez, 2006)
Sex: __ Male __ Female
Age: ____ years
Do you consider yourself Latino-a/Hispanic?
YES___; NO____
If you consider yourself Latino and your ethnicity is mixed, indicate approximate percentage or fractions _____
Your Race: Check all that apply (If your race is mixed, indicate approximate percentages or fractions)
__Asian
__African-American
__American Indian or Alaskan Native
__Native Hawaiian or Pacific Islander
__White
Your country of birth:________ [PLEASE ADD 15 SPACES FOR RESPONSE]
Father's country of birth:________ [PLEASE ADD 15 SPACES FOR RESPONSE]
Father’s ethnicity is __________________________ PLEASE ADD 30 SPACES FOR RESPONSE]
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND INDICATE ANSWER OPTIONS WHERE 1=“LITTLE KNOWLEDGE” TO 6=“PERFECTLY FLUENT”]
[SKIP OUT FOR AFRICAN AMERICAN PARTICIANTS, SECTION A]
PROMPT:
The following questions are about your language use. Please rank your answers from 1 to 6 where 1=little knowledge to 6=perfectly fluent.
A. LANGUAGE USE little knowledge perfectly fluent
1. Rate your overall English language ability(1-6)
2. Rate your overall Spanish language ability(1-6)
3. How much do you use/have you used English to speak with your mother?(1-6)
4. How much do you use/have you used Spanish to speak with your mother?(1-6)
5. How much do you use/have used English to speak with your father?(1-6)
6. How much do you use/have used Spanish to speak with your father?(1-6)
7. How much did you use English in general during childhood and adolescence?(1-6)
8. How much did you use Spanish in general during childhood and adolescence?(1-6)
9. How much have you used English in general as an adult?(1-6)
10 How much have you used Spanish in general as an adult?(1-6)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND INDICATE ANSWER OPTIONS WHERE 1= “NOT AT ALL” TO 6= “ALL THE TIME”]
PROMPT:
The following questions are about your media preferences. Please rank your answers from 1 to 6 where 1=not at all to 6=all the time.
B. MEDIA PREFERENCE [Wording for Latinos. Programmer input appropriate changes for African American participants]
1. How often do you read Anglo (i.e. in English) newspapers/magazines?(1-6)
2. How often do you read Latino newspapers/magazines?(1-6)
3. How often do you watch Anglo (i.e. in English) shows on TV?(1-6)
4. How often do you watch Latino shows on TV?(1-6)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND INDICATE ANSWER OPTIONS WHERE 1= “STRONGLY AGREE” TO 6= “STRONGLY DISAGREE”]
PROMPT:
We would like to ask you about your cultural identity, that is, the culture(s) you feel you belong to, the culture(s) you share your beliefs and values with. Please tell us how much you agree or disagree with the statements below by circling the appropriate number. Please rate BOTH statements where 1=strongly agree to 6=strongly disagree.
C. CULTURAL IDENTITY
We would like to ask you about your cultural identity, that is, the culture(s) you feel you belong to, the culture(s) you share your beliefs and values with. Please tell us how much you agree or disagree with the statements below by circling the appropriate number. Please rate BOTH statements!
I feel North-American (US):(1-6)
I feel Latino-a:(1-6)
[INCLUDE ALL QUESTIONS FROM THIS SCALE]
PROMPT LATINOS:
As a Latino-a living in the United States, you have been exposed to two cultures: Latino and North American cultures. Thus you could be described as a bi-cultural individual. Please think how much the Latino and North-American cultures feel as SEPARATE or COMBINED cultures for you. Next, read the statements below, think about their meaning carefully, and choose the one that best describes your particular experience. Very important: Choose ONE statement and only one (if both are more or less true, choose the one that is most true to you).
PROMPT AFRICAN AMERICAN:
As an African American/Black person living in the United States, you have been exposed to two cultures: African American and North American or White cultures. Thus you could be described as a bi-cultural individual. Please think how much the African American and North-American cultures feel as SEPARATE or COMBINED cultures for you. Next, read the statements below, think about their meaning carefully, and choose the one that best describes your particular experience. Very important: Choose ONE statement and only one (if both are more or less true, choose the one that is most true to you).
D. WAYS OF BALANCING CULTURES
1. I combine both cultures (e.g., I feel a mixture of North-American and Latino-a most of the time)
2. I keep both cultures separate (e.g., Most of the time I feel North-American in some places and Latino in others)
1. I don't feel caught between the two cultures
2. I feel caught (i.e., conflicted) between two cultures (e.g., I usually feel like I must choose between being North-American OR Latino-a)
1. I feel Latino-a-North American" (i.e., a mixture of all of these)
2. I feel Latino-a in North America
1. I feel as part of a combined culture
2. I feel as someone moving between the two cultures
Acculturation (Adolescents)
[INCLUDE ALL QUESTIONS FROM THIS SCALE USE “MOSTLY PEOPLE WHO ARE NOT (RESPONDANT’S ETHNICITY)” “MOSTLY PEOPLE WHO ARE (RESPONDANT’S ETHNICITY)” “ABOUT HALF THE PEOPLE WHO ARE (RESPONDANT’S ETHNICITY)” “NEITHER”AS ANSWER OPTIONS]
***The Acculturation, Habits, and Interests Multicultural Scale for Adolescents Acculturation Scale
PROMPT:
The following questions are about what your preferences.
[WORDING FOR LATINOS]
1. I am most comfortable being with people from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
2. My best friends are from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
3. The people I fit in with best are from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
4. My favorite music is from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
5. My favorite TV shows are from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
6. The holidays I celebrate are from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
7. The food I eat at home is from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
8. The way I do things and the way I think about things are from [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ??]
[INCLUDE ALL QUESTIONS FROM THIS SCALE]
[SKIP AFRICAN AMERICAN PARTICIPANTS]
PROMPT:
The following questions are about your language preferences.
In general, what language(s) do you speak?
1. English only
2. Mixture of English and Spanish
3. Mixture of English and Other
Specify Other [LANGUAGE] [PLEASE ADD 15 SPACES FOR RESPONSE]
4. Spanish only
[SKIP AFRICAN AMERICAN PARTICIPANTS]
What language do you usually speak with your parents?
1. Only/mostly English
2. Only/mostly [PROGRAM LANGUAGE]
3. Both
[SKIP AFRICAN AMERICAN PARTICIPANTS]
What language do you usually speak with your friends?
1. Only/mostly English
2. Only/mostly [PROGRAM LANGUAGE]
3. Both
What ethnicity are your close friends? Are they:
1. All [PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ]
2. Mostly PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ]
3. About half PROGRAM RESPONDANT’S ETHNICITY FROM QUESTION ] and half from different groups
4. Mostly from different groups
5. All from different ethnic groups than you
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY AGREE,” “SOMEWHAT AGREE,” “STRONGLY DISAGREE” AND “SOMEWHAT DISAGREE” AS ANSWERS OPTIONS]
Ethnic Identity
***The Multigroup Ethnic Identity Measure
PROMPT:
The following statements are about different ethnic groups, including your own. Please indicate how much you agree or disagree.
In terms of ethnic group, I consider myself to be_________________________________.[PROGRAM 30 SPACES FOR RESPONSE]
1. I have spent time trying to find out more about my own ethnic group, such as its history, traditions and customs.
2. I am active in organizations or social groups that include mostly members of my own ethnic group.
3. I have a clear sense of my ethnic background and what it means for me.
4. I like meeting and getting to know people from ethnic groups other than my own.
5. I think a lot about how my life will be affected by my ethnic group membership.
6. I am happy that I am a member of the group I belong to.
7. I sometimes feel it would be better if different ethnic groups didn’t try to mix together.
8. I am not very clear about the role of my ethnicity in my life.
9. I often spend time with people from ethnic groups other than my own.
10. I really have not spent much time trying to learn more about the culture and history of my ethnic group.
11. I have a strong sense of belonging to my own ethnic group.
12. I understand pretty well what my ethnic group membership means to me, in terms of how to relate to my own group and other groups.
13. In order to learn more about my ethnic background, I have often talked to other people about my ethnic group.
14. I have a lot of pride in my ethnic group and its accomplishments.
15. I don’t try to become friends with people from other ethnic groups.
16. I participate in cultural practices of my own group, such as special food, music and customs.
17. I am involved in activities with people from other ethnic groups.
18. I feel a strong attachment towards my own ethnic group.
19. I enjoy being around people from ethnic groups other than my own.
20. I feel good about my cultural or ethnic background.
[PROGRAM SCALE BELOW FOR MOTHERS: USE A SEPARATE SET OF QUESTIONS TO ADDRESS COMMUNICATION WITH FATHER OR MALE CAREGIVER. USE SKIP PATTERN IF CHILD DOES NOT HAVE MALE CAREGIVER. USE “STRONGLY AGREE,” “SOMEWHAT AGREE,” “SOMEWHAT DISAGREE” AND “STRONGLY DISAGREE” AS ANSWERS OPTIONS]
***Parent-Adolescent Communication About Sex (Adolescent and Caregiver)
Miller, B.C., Norton, M.C., Fan, X., & Christopherson, C.R. (1998). Pubertal development, parent communication, and sexual values in relation to adolescent sexual behaviors. Journal of Early Adolescence, 18, 27-52.
PROMPT:
The following statements are about your mother and/or female caregiver. Please tell us how much you agree or disagree.
MOTHER/FEMALE CAREGIVER WORDING:
1. I can go to my mother when I have concerns or questions about sex.
2. If I talk openly with my mother about sex, she will think I might be interested in experimenting with sex. R
3. I really don't want to talk to my mother about sex. R
4. I feel when my mother talks about sex she holds back information. R
5. When my mother talks to me about sex, she understands me and cares about my feelings.
PROMPT:
The following statements are about your father and/or male caregiver. Please tell us how much you agree or disagree.
FATHER/MALE CAREGIVER WORDING:
1. I can go to my father when I have concerns or questions about sex.
2. If I talk openly with my father about sex, he will think I might be interested in experimenting with sex. R
3. I really don't want to talk to my father about sex. R
4. I feel when my father talks about sex he holds back information. R
5. When my father talks to me about sex, he understands me and cares about my feelings.
Note: Items followed by an R should be reversed when coding.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY DISAGREE,” “DISAGREE,” “NEUTRAL” “AGREE” AND “STRONGLY AGREE” AS ANSWERS OPTIONS]
***Parent/adolescent communication about sex.
PROMPT:
The following statements are about what you mother or female caregiver may or may not have told you about sex and birth control. Please tell us how much you disagree or agree.
1. I would be embarrassed talking to my mother about sex and birth control.
2. My mother would not want to answer my questions about sex and birth control.
3. My mother would only lecture me if I tried to talk to her about sex and birth control.
4. I don’t need to talk to my mother about sex and birth control; I know what I need to know.
5. My mother doesn’t know enough for me to want to talk with her about sex and birth control.
6. My mother would not be honest with me if I talked with her about sex and birth control.
7. My mother is too old to be able to relate to me about sex and birth control.
8. I would only make my mother suspicious of me if I tried to talk to her about sex and birth control.
9. It would be difficult to find a convenient time and place to talk to my mother about sex and birth control.
10. My mother is just too busy to talk to me about sex and birth control.
11. My mother would ask me too many personal questions if I tried to talk with her about sex and birth control.
12. My mother doesn’t want to hear what I have to say when it comes to sex and birth control.
13. My mother and I would only argue if we were to talk about sex and birth control.
14. My mother would be embarrassed talking to me about sex and birth control.
15. I would have a difficult time being honest about my behavior with my mother if we were to talk about sex and birth control.
16. My mother would get angry if I tried to talk to her about sex and birth control.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “NEVER” “RARELY” “SOMETIMES” “MOST OF THE TIME” “ALWAYS” AS ANSWERS OPTIONS]
***Parental Monitoring Assessment (PMA)
PROMPT:
The following statements are about how well your parents are aware of your activities. Please indicate how often this applies to you.
1. My parents know where I am after school.
2. If I am going to be home late, I am expected to call my parent(s) to let them know.
3. I tell my parent(s) who I am going to be with before I go out.
4. When I go out at night, my parent(s) know where I am.
5. I talk with my parent(s) about the plans I have with my friends.
6. When I go out, my parent(s) ask me where I am going.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY AGREE,” “AGREE,” “DISAGREE” AND “STRONGLY DISAGREE” AS ANSWERS OPTIONS]
***General Parent-adolescent communication
PROMPT:
The following statements are about how you and your parents communicate with each other. Please tell us how much you agree or disagree.
a. My parent(s)/guardian(s) and I can talk about almost anything.
b. My parent(s)/guardian(s) sometimes don’t listen to me.
c. I can tell my parent(s)/guardian(s) how I feel about everything.
d. I am satisfied with how my parent(s)/guardian(s) and I talk together.
e. I am careful about what I say to my parent(s)/guardian(s).
f. When I ask a question, I get honest answers from my parent(s)/guardian(s).
g. There are topics I avoid discussing with my parent(s)/guardian(s).
h. My parent(s)/guardian(s) know how to talk to me
i. I find it easy to discuss problems with my parent(s)/guardian(s).
j. It is easy to discuss all my true feelings with my parent(s) parent(s)/guardian(s)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY AGREE,” “AGREE,” “DISAGREE” AND “STRONGLY DISAGREE” AS ANSWERS OPTIONS]
***Parental Social Support and Family Cohesion (Adolescent)
SOCIAL SUPPORT SCALE ANESHENSEL
PROMPT:
Now we’d like to ask you some questions about your relationship with your mom. Please tell us how much you agree or disagree.
1. Understand(s) when I tell her things.
2. Show(s) me I can trust her.
3. Doesn’t pay enough attention to me.
4. Care(s) about my feelings.
5. Really understand(s) me.
6. Make(s) me feel wanted.
7. Make(s) me feel good about myself.
8. Know(s) the real me.
9. Understand(s) my feelings.
10. Is there when I need her.
11. Like(s) to spend time with me.
12. Really listen(s) to me.
13. Let(s) me know she cares about me.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “NOT AT ALL TRUE” “A LITTLE TRUE” PRETTY MUCH TRUE” AND “VERY MUCH TRUE” AS ANSWERS OPTIONS]
***CHKS Resiliency scales below.
California Healthy Kids Survey ©2007 CA Dept. of Ed.
Version M10 - Fall 2007
Middle School Questionnaire
Module B: Supplemental Resilience and Youth Development
PROMPT:
Please tell us how true you feel these statements are about you personally?
1. I have goals and plans for the future.
2. I plan to graduate from high school.
3. I plan to go to college or some other school after high school.
4. I know where to go for help with a problem.
5. I try to work out problems by talking or writing about them.
6. I can work out my problems.
7. I can do most things if I try.
8. I can work with someone who has different opinions than mine.
9. There are many things that I do well.
10. I feel bad when someone gets their feelings hurt.
11. I try to understand what other people go through.
12. When I need help, I find someone to talk with.
13. I enjoy working together with other students my age.
14. I stand up for myself without putting others down.
15. I try to understand how other people feel and think.
16. There is a purpose to my life.
17. I understand my moods and feelings.
18. I understand why I do what I do.
PROMPT:
Please tell us how true these statements about your FRIENDS?
I have a friend about my own age ...
19. who really cares about me.
20. who talks with me about my problems.
21. who helps me when I’m having a hard time.
My friends….
22. get into a lot of trouble.
23. get into a lot of trouble.
24. try to do what is right.
25. do well in school.
PROMPT:
Please tell us how true these statements are about your HOME or the ADULTS WITH WHOM YOU LIVE?
In my home, there is a parent or some other adult ...
26. who expects me to follow the rules.
27. who is interested in my school work.
28. who believes that I will be a success.
29. who talks with me about my problems.
30. who always wants me to do my best.
31. who listens to me when I have something to say.
At home ...
32. I do fun things or go fun places with my parents or other adults.
33. I do things that make a difference.
34. I help make decisions with my family
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “TRUE’ AND “FALSE” AS ANSWER OPTIONS]
***Neighborhood Environment (Adolescent and Caregiver)
PROMPT:
The following statements are about your neighborhood. Please tell us how much each applies to you.
1. Within walking distance of my house there is a park or playground where I like to walk and enjoy myself, playing sports or games.
2. There are plenty of safe places to walk or play outdoors in my neighborhood.
3. Every few weeks, some kid in my neighborhood gets beat-up or mugged.
4. Every few weeks, some adult gets beat-up or mugged in my neighborhood.
5. In my neighborhood, I see signs of racism and prejudice at least once a week.
6. In my neighborhood, many yards and alleys have broken bottles and trash lying around.
7. I have seen people using or selling drugs in my neighborhood.
8. In the morning or later in the day, I often see drunk people on the street in my neighborhood.
9. Most adults in my neighborhood respect the law.
10. There are abandoned or boarded-up buildings in my neighborhood.
11. I feel safe when I walk around my neighborhood by myself.
12. The people who live in my neighborhood often damage or steal each other’s property.
13. The people who live in my neighborhood always take care of each other and protect each other from crime.
14. Almost everyday I see homeless people walking or sitting around in my neighborhood.
15. In my neighborhood, the people with the most money are the drug dealers.
16. In my neighborhood, there are a lot of poor people who don’t have enough money for food and basic needs.
17. For many people in my neighborhood, going to church on Sunday or religious days is a very important activity.
18. The people who live in my neighborhood are the best people in the world.
***Adolescent Health Behavior (Adolescent)
2007 YRBS
PROMPT:
The following questions are about you. Please be honest.
1. How tall are you without your shoes on? [PROGRAM TO SEPARATE FIELDS ONE FOR FEET AND ONE FOR INCHES]
2. How much do you weigh without your shoes on? [PROGRAM 3 SPACES FOR RESPONSE]
PROMPT:
The following questions are about safety.
3. When you rode a bicycle during the past 12 months, how often did you wear a helmet?
A. I did not ride a bicycle during the past 12 months
B. Never wore a helmet
C. Rarely wore a helmet
D. Sometimes wore a helmet
E. Most of the time wore a helmet
F. Always wore a helmet
4. How often do you wear a seat belt when riding in a car driven by someone else?
A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always
5. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
6. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
PROMPT:
The following questions ask about violence-related behaviors.
7. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?
[PROGRAM SKIP PATTERN]
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
8. During the past 30 days, on how many days did you carry a gun?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
9. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club on school property?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
10. During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
11. During the past 12 months, how many times has someone threatened or injured you with a weapon such as a gun, knife, or club on school property?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
12. During the past 12 months, how many times has someone stolen or deliberately damaged your property such as your car, clothing, or books on school property?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
13. During the past 12 months, how many times were you in a physical fight?
[PROGRAM SKIP PATTERN]
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
14. During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
15. During the past 12 months, how many times were you in a physical fight on school property?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
16. During the past 12 months, did your boyfriend or girlfriend ever hit, slap, or physically hurt you on purpose?
A. Yes
B. No
17. Have you ever been physically forced to have sexual intercourse when you did not want to?
A. Yes
B. No
PROMPT:
The next questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life.
18. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?
A. Yes
B. No
19. During the past 12 months, did you ever seriously consider attempting suicide?
A. Yes
B. No
20. During the past 12 months, did you make a plan about how you would attempt suicide?
A. Yes
B. No
IN ORDER TO HAVE A COMPLETE PICTURE ABOUT ACTION AND NOT JUST IDEATION I THINK WE SHOULD INCLUDE THE FOLLOWING TWO QUESTIONS…..
21. During the past 12 months, how many times did you actually attempt suicide?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
22. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
A. I did not attempt suicide during the past 12 months
A. Yes
B. No
PROMPT:
The following questions ask about tobacco use.
23. Have you ever tried cigarette smoking, even one or two puffs?
A. Yes
B. No
[PROGRAM SKIP PATTERN FOR SMOKING]
24. How old were you when you smoked a whole cigarette for the first time?
A. I have never smoked a whole cigarette
B. 8 years old or younger
C. 9 or 10 years old
D. 11 or 12 years old
E. 13 or 14 years old
F. 15 or 16 years old
G. 17 years old or older
25. During the past 30 days, on how many days did you smoke cigarettes?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
26. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
A. I did not smoke cigarettes during the past 30 days
B. Less than 1 cigarette per day
C. 1 cigarette per day
D. 2 to 5 cigarettes per day
E. 6 t o10 cigarettes per day
F. 11 t o20 cigarettes per day
G. More than 20 cigarettes per day
27. During the past 30 days, how did you usually get your own cigarettes? (Select only one response.)
A. I did not smoke cigarettes during the past 30 days
B. I bought them in a store such as a convenience store, supermarket, discount store, or gas station
C. I bought them from a vending machine
D. I gave someone else money to buy them for me
E. I borrowed (or bummed) them from someone else
F. A person 18 years old or older gave them to me
G. I took them from a store or family member
H. I got them some other way
28. During the past 30 days, on how many days did you smoke cigarettes on school property?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
29. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
A. Yes
B. No
30. During the past 12 months, did you ever try to quit smoking cigarettes?
A. I did not smoke during the past 12 months
B. Yes
C. No
31. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
32. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip on school property?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
33. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
PROMPT:
The following questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.
34. During your life, on how many days have you had at least one drink of alcohol?
[PROGRAM SKIP PATTERN FOR ALCOHOL USE]
A. 0 days
B. 1 or 2 days
C. 3 to 9 days
D. 10 to 19 days
E. 20 to 39 days
F. 40 to 99 days
G. 100 or more days
35. How old were you when you had your first drink of alcohol other than a few sips?
A. I have never had a drink of alcohol other than a few sips
B. 8 years old or younger
C. 9 or 10 years old
D. 11 or 12 years old
E. 13 or 14 years old
F. 15 or 16 years old
G. 17 years old or older
36. During the past 30 days, on how many days did you have at least one drink of alcohol?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
37. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
38. During the past 30 days, how did you usually get the alcohol you drank?
A. I did not drink alcohol during the past 30 days
B. I bought them in a store such as a convenience store, supermarket, discount store, or gas station
C. I bought it at a restaurant, bar, or club
D. I bought it at a public event such as a concert or sporting event
E. I gave someone else money to buy it for me
F. Someone gave it to me
G. I took it from a store or family member
H. I got them some other way
39. During the past 30 days, on how many days did you have at least one drink of alcohol on school property?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
PROMPT:
The following questions ask about marijuana use. Marijuana also is called grass or pot.
40. During your life, how many times have you used marijuana?
[PROGRAM SKIP PATTERN]
A. 0 days
B. 1 or 2 days
C. 3 to 9 days
D. 10 to 19 days
E. 20 to 39 days
F. 40 to 99 days
G. 100 or more days
41. How old were you when you tried marijuana for the first time?
A. I have never tried marijuana
B. 8 years old or younger
C. 9 or 10 years old
D. 11 or 12 years old
E. 13 or 14 years old
F. 15 or 16 years old
G. 17 years old or older
42. During the past 30 days, how many times did you use marijuana?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
43. During the past 30 days, how many times did you use marijuana on school property?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
PROMPT:
The following questions ask about other drugs that you may or may not have used.
44. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?
[PROGRAM SKIP PATTERN]
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
45. During the past 30 days, how many times did you use any form of cocaine, including powder, crack, or freebase?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
FOR THE NEXT DRUG QUESTIONS, WHY ARE WE NOT INTERESTED IN THE PAST 30 DAY USE?
46. During your life, how many times have you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
47. During your life, how many times have you used heroin (also called smack, junk, or China White)?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
48. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
49. During your life, how many times have you used ecstasy (also called MDMA)?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
50. During your life, how many times have you taken steroid pills or shots without a doctor's prescription?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
51. During your life, how many times have you used a needle to inject any illegal drug into your body?
A. 0 times
B. 1 time
C. 2 or more times
WHY TAKE THIS QUESTION OUT?
52. During the past 12 months, has anyone offered, sold, or given you an illegal drug on school property?
A. Yes
B. No
PROMPT:
The following questions ask about sexual behavior. Where sexual intercourse means having a male put his penis in a female’s vagina.
53. Have you ever had sexual intercourse?
A. Yes
B. No [PROGRAM SKIP PATTERN]
54. How old were you when you had sexual intercourse for the first time?
A. I have never had sexual intercourse
B. 11 years old or younger
C. 12 years old
D. 13 years old
E. 14 years old
F. 15 years old
G. 16 years old
H. 17 years old or older
55. During your life, with how many people have you had sexual intercourse?
A. 1 person
B. 2 people
C. 3 people
D. 4 people
E. 5 people
F. 6 or more people
56. During the past 3 months, with how many people did you have sexual intercourse?
B. I have had sexual intercourse, but not during the past 3 months
A. 1 person
B. 2 people
C. 3 people
D. 4 people
E. 5 people
F. 6 or more people
57. Did you drink alcohol or use drugs before you had sexual intercourse the last time?
A. Yes
B. No
58. The last time you had sexual intercourse, did you or your partner use a condom?
A. Yes
B. No
59. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? (Select only one response.)
WHAT IF THEY USED BOTH THE PILL OR DEPO AND CONDOMS AT THE SAME TIME TO BE EXTRA CAREFUL AND ISN’T THAT WHAT TEENS ARE ADVISED TO DO??? MAYBE WE SHOULD PUT THIS AS AN OPTION…
A. No method was used to prevent pregnancy
B. Birth control pills
C. Condoms
D. Depo-Provera (injectable birth control)
E. Withdrawal
F. Some other method
G. Not sure
-Have you ever been tested for a sexually transmitted infection/disease?
A. Yes
B. No
-Have you ever tested positive for a sexually transmitted infection/disease?
A. Yes
B. No
-Have you ever been pregnant? [PROGRAMMER CHANGE WORDING FOR MALES]
A. Yes
B. No
PROMPT:
The following questions ask about body weight.
60. How do you describe your weight?
A. Very underweight
B. Slightly underweight
C. About the right weight
D. Slightly overweight
E. Very overweight
61. Which of the following are you trying to do about your weight?
A. Lose weight
B. Gain weight
C. Stay the same weight
D. I am not trying to do anything about my weight
62. During the past 30 days, did you exercise to lose weight or to keep from gaining weight?
A. Yes
B. No
63. During the past 30 days, did you eat less food, fewer calories, or foods low in fat to
lose weight or to keep from gaining weight?
A. Yes
B. No
64. During the past 30 days, did you go without eating for 24 hours or more (also called
fasting) to lose weight or to keep from gaining weight?
A. Yes
B. No
PROMPT:
The following questions ask about food you ate or drank during the past 7 days. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.
67. During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.)
A. I did not drink 100% fruit juice during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
68. During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)
A. I did not eat fruit during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
69. During the past 7 days, how many times did you eat green salad?
A. I did not eat green salad during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
70. During the past 7 days, how many times did you eat potatoes? (Do not count French fries, fried potatoes, or potato chips.)
A. I did not eat potatoes during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
71. During the past 7 days, how many times did you eat carrots?
A. I did not eat carrots during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
72. During the past 7 days, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots.)
A. I did not eat other vegetables during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
73. During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop.)
A. I did not drink soda or pop during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
74. During the past 7 days, how many glasses of milk did you drink? (Include the milk you drank in a glass or cup, from a carton, or with cereal. Count the half pint of milk served at school as equal to one glass.)
A. I did not drink milk during the past 7 days
B. 1 to 3 glasses during the past 7 days
C. 4 to 6 glasses during the past 7 days
D. 1 glass per day
E. 2 glasses per day
F. 3 glasses per day
G. 4 or more glasses per day
PROMPT:
The following questions ask about physical activity.
75. During the past 7 days, on how many days were you physically active for a total of at
least 60 minutes per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
G. 6 days
H. 7 days
76. On an average school day, how many hours do you watch TV?
A. I do not watch TV on an average school day
B. Less than 1 hour per day
C. 1 hour per day
D. 2 hours per day
E. 3 hours per day
F. 4 hours per day
G. 5 or more hours per day
77. On an average school day, how many hours do you play video or computer games or use a computer for something that is not school work? (Include activities such as Nintendo, Game Boy, PlayStation, Xbox, computer games, and the Internet.)
A. I do not play video or computer games or use a computer for something that is not school work
B. Less than 1 hour per day
C. 1 hour per day
D. 2 hours per day
E. 3 hours per day
F. 4 hours per day
G. 5 or more hours per day
78. In an average week when you are in school, on how many days do you go to physical education (PE) classes?
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
79. During the past 12 months, on how many sports teams did you play? (Include any teams run by your school or community groups.)
A. 0 teams
B. 1 team
C. 2 teams
D. 3 or more teams
PROMPT:
The following questions ask about other health-related topics.
80. Have you ever been taught about AIDS or HIV infection in school?
A. Yes
B. No
C. Not sure
***Teaming African American Parents with Survival Skills (T.A.A.P.S.S.)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “YES” AND “NO” AS ANSWER OPTIONS]
PROMPT:
The following questions are about what your parents have told you about sex.
[PROGRAM FOR LIFETIME AND LAST THREE MONTHS]
1. In the past 3 months, did you and your guardian(s)/parent(s) talk about sexual intercourse?
2. In the past 3 months, did you and your guardian(s)/parent(s) talk about birth control?
3. In the past 3 months, did you and your guardian(s)/parent(s) talk about condoms?
4. In the past 3 months, did you and your guardian(s)/parent(s) talk about how to protect yourself from sexually transmitted diseases (STDs) such as Acquired Immune Deficiency Syndrome (AIDS)?
5. In the past 3 months, did you and your guardian(s)/parent(s) talk about teen pregnancy?
6. In the past 3 months, did you and your guardian(s)/parent(s) talk about not having sex until you were older?
7. In the past 3 months, did you and your guardian(s)/parent(s) talk about how to handle pressure from friends to have sex?
8. In the past 3 months, did you and your guardian(s)/parent(s) talk about how to handle pressure from partners to have sex?
9. In the past 3 months, did you and your guardian(s)/parent(s) talk about drugs?
10. In the past 3 months, did you and your guardian(s)/parent(s) talk about alcohol?
11. In the past 3 months, did you and your guardian(s)/parent(s) talk about abstaining from sex/not having sex?
[INCLUDE ALL QUESTIONS FROM THIS SCALE]
PROMPT:
The following questions are about sexual activities you may or may not engage in during the next year. Please tell us how likely you are to engage in these activities.
29) During the NEXT YEAR, how likely is it that if you have VAGINAL intercourse, you will use a CONDOM?
Very
likely
Sort
of likely
Sort of unlikely
Very unlikely
There is no
chance that I will have vaginal intercourse in the next year
30) During the NEXT YEAR, how likely is it that you will have VAGINAL intercourse.
Very
likely
Sort
of likely
Sort of unlikely
Very unlikely
There is no
chance that I will have vaginal intercourse in the next year
PROMPT:
The following statements are about what your parents may have told you about sex.
20) The following topics have come up when I talk to my mother or father about sex. Please indicate all that apply.
I was informed that I shouldn’t engage in any sexual behavior.
I was informed that I should only go so far sexually for right now.
I was told that I should wait to have sex until I was married.
I was told that it is better to wait to have sex until married but no one told me not to have sex.
I was asked if I was having sex.
I was given information on condoms.
I was given information on birth control other than condoms.
I was given warnings about sexually transmitted diseases.
I was given warnings about HIV or AIDS.
We talked about heavy petting (touching a boy or girl on his/her private parts).
We talked about oral sex.
We talked about French kissing or kissing with the tongue.
We talked about dating and/or relationships.
We talked about my orientation (whether I was attracted to boys or girls).
PROMPT:
The following question is about your sexual orientation.
31) Which sexual orientation best describes you?
100%
heterosexual/straight (attracted only to females)
Mostly
heterosexual/straight
Bisexual (equally attracted to males and
females)
Mostly
homosexual/gay
100% homosexual/gay (attracted only to males)
Not
sure
PROMPT:
The following questions are about condom use.
34) When you have sexual intercourse, how often do you use a condom?
Always
Almost always
Sometimes
Almost never
Never
I have not had sexual intercourse [SKIP TO ??]
35) Did you use a condom the last time you had sex?
Yes
No
36) Did you use a condom the first time you had sex?
Yes
No
37) How often do you use a condom when you have oral sex?
Always
Almost always
Sometimes
Almost never
Never
I have not had oral sex [SKIP TO ??]
38) Did you use a condom the last time you had oral sex?
Yes
No
39) Did you use a condom the first time you had oral sex?
Yes
No
PROMPT:
The following questions are about your school experience.
9) What kind of grades do you get?
Mostly A’s
Mostly A’s and B’s
Mostly B’s
Mostly B’s and C’s
Mostly C’s
Mostly C’s and D’s
Mostly D’s
Mostly D’s and F’s
10) How far do you think you will go in school?
Won’t finish high school
Will graduate from high school
Will go to trade, technical or vocational school after high school
Will attend a 2 year community college
Will attend a 4 year university or college
Will go to a post graduate or professional school (like business, medicine, or law)
PROMPT:
The following questions are about your religion or spirituality.
11) How often do you attend religious services?
About once a week, sometimes more
Once or twice a month
Less than once a month
A few times a year
Once a year or less
12) How important is God in your life?
Not important
A little important
Pretty important
Very important
PROMPT:
The following questions are about your knowledge about HIV/AIDS.
67. Do you think you are at risk of getting HIV/AIDS?
YES [SKIP TO ??]
NO [SKIP TO ??]
REFUSED [SKIP TO ??]
DON’T KNOW [SKIP TO ??]
68. IF YES: Why do you think that you are at risk of getting HIV/AIDS? What other reason? (check all that apply)
SEX W/ INFECTED PERSON 1 0
SHARED DRUG NEEDLES 1 0
PARTNER W/ STD COULD HAVE AIDS 1 0
MULTIPLE SEX PARTNERS 1 0
HEMOPHILIAC/SURGERY/MEDICAL 1 0
HOMOSEXUAL SEX 1 0
UNPROTECTED SEX 1 0
UNKNOWN HIV STATUS 1 0
ANYONE CAN GET IT 1 0
DON’T KNOW 1 0
OTHER:_______________________ 1 0
69. IF NO: Why do you think you’re not at risk of getting AIDS? What other reason? (check all that apply).
MONOGAMOUS 1 0
NO SEX WITH INFECTED PERSON 1 0
ONLY HAVE HETEROSEXUAL SEX 1 0
NO SEXUAL CONTACT 1 0
PROTECTED SEX 1 0
HIV TESTED/NEGATIVE 1 0
NO IV DRUG/NEEDLE USE 1 0
NO BLOOD TRANSFUSION 1 0
AM HEALTHY/DON’T FEEL SICK 1 0
DON’T KNOW 1 0
OTHER: SPECIFY_____________________ 1 0
[INCLUDE ALL QUESTIONS IN SCALE AND USE “0=CANNOT DO AT ALL”, “5=MODERATELY CERTAIN CAN DO”, “10=CERTAIN CAN DO” AS ANSWER OPTIONS.
PROMPT:
The following statements are about your ability to limit substance use. Please rank your ability where 0=Cannot do at all, 5=Moderately certain can do, 10=Certain can do.
Self-Efficacy for Limiting Substance Use
1.
I can tell my friends that I don't want to use alcohol.
2. I can
tell my friends that I don't want to use drugs.
3. I can hang
out with friends who are drunk, even if I stay sober.
4. I can
hang out with friends who are high on drugs, even if I don't get
high.
5. I can date people who drink alcohol, even if I'm trying
not to.
6. I can date people who use drugs, even if I'm trying
not to.
This ends the questionnaire. Thank you very much for your time and cooperation. Your answers are very important to us and will remain confidential.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lnw8 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |