Program Participants (girls and female adolecents)

Form Approved OMB No. 0990-XXXX

Expiration Date XX/XX/XXXX

Prevention Education Pre-test Survey for Girls (9-11)– Part 1

We are asking you to complete this survey because you are a participant in a program for girls. This survey asks your thoughts, your behaviors and knowledge about health. Your responses will be combined with the responses of other girls to help us learn whether programs like the one that you are in help girls.

Please answer these questions based on what you think and feel, as honestly as possible. Your information will help us learn what parts of the program work best for girls and what can be done better.

Your answers will be kept private. Do not write your name anywhere on the survey. You will be asked to create a special code that you will use on all surveys. GEARS, Inc is the company that will handle all of the surveys. Your answers are confidential. Also, completing this survey is completely voluntary which means that you can choose whether or not you want to fill out the survey. You can also choose not to answer any question on the survey. Choosing not to fill out the survey or answer a question will not affect your participation in the program. Thank you again.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 2 hours per respondent, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:

U.S. Department of Health & Human Services

OS/OIRM/PRA

200 Independence Ave., S.W. Suite 531-H

Washington, D.C. 20201

Attention: PRA Reports Clearance Officer

ID#: ­---- ---- ---- ---- ---- ---- ----
DATE: ­­____________________
Section I – About You!
INSTRUCTIONS: Check the box  next to your answer.
1.	How old are you now? I am _______ years old. What year were you born? _______________
2.	Is at least one of your parents Hispanic or Latino?  Yes  No
3.	Are you Hispanic or Latino?  Yes, I am  No, I am not
4.	What else do you call yourself? (Select all that apply)  American Indian or Alaska Native  Asian or Pacific Islander  Black or African American  White  Other (specify): ___________
5.	What language do your parents or other people who are raising you speak?  Only or mostly English  Only or mostly a language other than English  English and another language the same amount
6.	What languages do you speak where you live now?  Only or mostly English  Only or mostly a language other than English  English and another language about the same amount
7.	Where do you live now?  Home with parents  Foster home  Boarding school  With family members who are not my parents (aunt, uncle, grandparents, cousins)  A shelter with my family  Other (Specify) __________________
8.	Have you moved in the past 6 months?  Yes, I have moved but I’m in the same neighborhood  Yes, I have moved to a new neighborhood  No, I have not moved
9.	In general, is there an adult you can talk to?  Yes  No
10.	How often do you talk to an adult about what you are doing or thinking?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
11.	How often do you do chores (cleaning, laundry, baby sitting, cooking, etc.)?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
12.	How often do you watch TV on schooldays?  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day  I do not watch TV
13.	How often do you spend time on the internet for non educational activities on school days?  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day  I do not spend time on the internet
14.	How often do you spend time texting or talking on the phone for non educational activities on school days?  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day  I do not spend time on the phone
15.	How often do you participate in activities involving members of your own racial or cultural group?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
16.	How often do you take lessons or classes out of school, including this after school program?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
17.	Last summer, how often did you go to a summer program for learning or fun?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
18.	Do you consider yourself a religious or spiritual person?  Yes  No
19.	How often are you supervised or monitored by an adult?  Almost always  Often  Sometimes  Seldom (almost never)  Never
20.	What grade are you in now?  2rd  6th  3th  7th  4th  8th  5th  9th
21.	How often do you feel that the school work you are assigned is useful and important?  Almost always  Often  Sometimes  Seldom (almost never)  Never
22.	How interesting are most of your school subjects to you?  Very interesting  Quite interesting  Fairly interesting  Slightly boring  Very boring
23.	Now thinking back over the past year in school, how often did you enjoy being in school?  Almost always  Often  Sometimes  Seldom (almost never)  Never
24.	Now thinking back over the past year in school, how often did you try to do your best in school?  Almost always  Often  Sometimes  Seldom (almost never)  Never
25.	During the last month, how many whole days of school have you missed because of illness?  None  1 day  2 days  3 days  4 to 5 days  6 to 10 days  11 or more days  Not in school last month
26.	During the last month, how many whole days of school have you missed because you skipped or cut? (To miss school means you did not attend all your classes and you have unexcused absences.)  None  1 day  2 days  3 days  4 to 5 days  6 to 10 days  11 or more days  Not in school last month
27.	During the last month, how many whole days of school have you missed for other reasons?  None  1 day  2 days  3 days  4 to 5 days  6 to 10 days  11 or more days  Not in school last month
28.	Putting all your grades together, what were your grades like last year?  Mostly As  Mostly Bs  Mostly Cs  Mostly Ds  Mostly Fs

About Your Neighborhood.

For each statement, please circle “True” (T) or “False” (F).

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.	T	F
2.	There are plenty of safe places to walk or play outdoors in my neighborhood.	T	F
3.	Every few weeks, some kid in my neighborhood gets beat-up, jumped or robbed.	T	F
4.	Every few weeks, some adult gets beat-up, jumped` or robbed in my neighborhood.	T	F
5.	In my neighborhood, I see signs of racism and prejudice at least once a week.	T	F
6.	I have seen people using or selling drugs in my neighborhood.	T	F
7.	In the morning, or later in the day, I often see drunk people on the street in my neighborhood.	T	F
8.	Most adults in my neighborhood respect the law.	T	F
9.	There are abandoned or boarded up buildings in my neighborhood.	T	F
10.	I feel safe when I walk around my neighborhood by myself.	T	F
11.	The people who live in my neighborhood often damage or steal each other’s property.	T	F
12.	The people who live in my neighborhood always take care of each other and protect each other from crime.	T	F
13.	Almost every day, I see homeless people walking or sitting around in my neighborhood.	T	F
14.	In my neighborhood, the people with the most money are the drug dealers.	T	F
15.	In my neighborhood, there are a lot of poor people who don’t have enough money for food and basic needs.	T	F
16.	For many people in my neighborhood, going to church on Sunday or religious days is an important activity.	T	F
17.	The people in my neighborhood are the best people in the world.	T	F
18.	There gangs in my neighborhood.	T	F
19.	Gang members are troublemakers.	T	F
20.	I have friends that are gang members.	T	F
21.	There are gang members in my school.	T	F
22.	I would like to be a gang member.	T	F
23.	I am a gang member.	T	F
24.	If you are a gang member, when did you join the gang? I joined the gang in ____________________(Month/Year)

How You Solve Problems.

The following questions ask about how often you respond when you have a problem. For each statement check the response that best describes how often you solve problems in this way.

When I have a problem:

		All the time	Most of the time	Some of the time	Almost never	Never
1.	I think about the different things I could do before I do anything.	.	.	.	.	.
2.	I think about the different ways of solving the problem and what good or bad things could happen.	.	.	.	.	.
3.	I get information I need to deal with the problem.	.	.	.	.	.
4.	I compromise (meet halfway or work it out) to get something positive from the situation.	.	.	.	.	.
5.	I think about which of the different ways that I could solve the problem is really the best way.	.	.	.	.	.
6.	I try to listen to the other person, even if I do not agree with him or her.	.	.	.	.	.
7.	I take steps to solve the problem instead of complaining about it to everyone else.	.	.	.	.	.
8.	I give into the other person without giving an opinion.	.	.	.	.	.
9.	I tell the other person what I think no matter how they feel.	.	.	.	.	.
10.	I usually wait until the problem goes away by itself, instead of trying to solve it.	.	.	.	.	.
11.	I like to get everything out in the open so that the problem can be solved as quickly as possible.	.	.	.	.	.

More About You!

For each statement, please circle “Strongly agree” (SA), “Agree” (A), “Neither agree nor disagree” (ND), “Disagree” (DA), or “Strongly disagree” (SDA).

1.	I would tell a friend I think she looks nice, even if I think she shouldn’t go out of the house dressed like that.	SA	A	ND	DA	SDA
2.	I worry that I make others feel bad if I am successful.	SA	A	ND	DA	SDA
3.	I would not change the way I do things in order to please someone else.	SA	A	ND	DA	SDA
4.	I tell my friends what I honestly think even when it is an unpopular idea.	SA	A	ND	DA	SDA
5.	Often I look happy on the outside in order to please others, even if I don’t feel happy on the inside.	SA	A	ND	DA	SDA
6.	I wish I could say what I feel more often than I do.	SA	A	ND	DA	SDA
7.	I feel like it’s my fault when I have disagreements with my friends.	SA	A	ND	DA	SDA
8.	When my friends ignore my feelings, I think that my feelings weren’t very important anyway.	SA	A	ND	DA	SDA
9.	I usually tell my friends when they hurt my feelings.	SA	A	ND	DA	SDA
10.	The way that I can tell that I am a good weight is when I fit into a small size.	SA	A	ND	DA	SDA
11.	I often wish my body were different.	SA	A	ND	DA	SDA
12.	I think that a girl has to be thin to be beautiful.	SA	A	ND	DA	SDA
13.	I think that a girl has to have a light complexion and long hair to be thought of as beautiful.	SA	A	ND	DA	SDA
14.	I am more concerned about how my body looks than how my body feels.	SA	A	ND	DA	SDA
15.	I often feel uncomfortable in my body.	SA	A	ND	DA	SDA
16.	There are times when I have really good feelings in my body.	SA	A	ND	DA	SDA
17.	The way I decide I am at a good weight is when I feel healthy.	SA	A	ND	DA	SDA
18.	On the Whole, I am satisfied with myself.	SA	A	ND	DA	SDA
19.	At times, I think I am no good at all.	SA	A	ND	DA	SDA
20.	I feel that I have a number of good qualities.	SA	A	ND	DA	SDA
21.	I am able to do things as well as most other people.	SA	A	ND	DA	SDA
22.	I feel I do not have much to be proud of.	SA	A	ND	DA	SDA
23.	I certainly feel useless at times.	SA	A	ND	DA	SDA
24.	I feel that I’m a person of worth, at least on an equal plane with others.	SA	A	ND	DA	SDA
25.	I wish I could have more respect for myself.	SA	A	ND	DA	SDA
26.	All in all, I am inclined to feel that I am a failure.	SA	A	ND	DA	SDA
27.	I take a positive attitude toward myself.	SA	A	ND	DA	SDA

Below is a list of the ways you might have felt or acted. Please tell me how much you have felt this way during the past week.

	During the past week…
		Not At All	A Little	Some	A Lot
1.	I was bothered by things that usually don’t bother me.	.	.	.	.
2.	I did not feel like eating; I wasn’t very hungry.	.	.	.	.
3.	I wasn’t able to feel happy, even when my family or friends tried to help me feel better.	.	.	.	.
4.	I felt I was just as good as other kids.	.	.	.	.
5.	I felt like I couldn’t pay attention to what I was doing.	.	.	.	.
6.	I felt down and unhappy.	.	.	.	.
7.	I felt like I was too tired to do things.	.	.	.	.
8.	I felt like something good was going to happen.	.	.	.	.
9.	I felt like things I did before didn’t work out right.	.	.	.	.
10.	I felt scared.	.	.	.	.
11.	I didn’t sleep as well as I usually sleep.	.	.	.	.
12.	I was happy.	.	.	.	.
13.	I was more quiet than usual.	.	.	.	.
14.	I felt lonely, like I didn’t have any friends.	.	.	.	.
15.	I felt like kids I know were not friendly or that they didn’t want to be with me.	.	.	.	.
16.	I had a good time.	.	.	.	.
		Not At All	A Little	Some	A Lot
17.	I felt like crying.	.	.	.	.
18.	I felt sad.	.	.	.	.
19.	I felt that people didn’t like me.	.	.	.	.
20.	It was hard to get started doing things.	.	.	.	.

ID#: ­---- ---- ---- ---- ---- ---- ----

DATE: ­­____________________

Prevention Education Pre-test Survey for Girls (9-11) – Part 2

Section II – Health Knowledge/What You Know.

For each question or statement, please circle “Yes” (Y) or “No” (N).

1.	Can you get HIV by sharing a glass of water with someone who has HIV?	Y	N
2.	Will all pregnant women infected with HIV have babies born with HIV?	Y	N
3.	Can you tell if someone has HIV by looking at them?	Y	N
4.	Is there a vaccine (shot) that can stop people from getting HIV?	Y	N
5.	Can you get HIV by deep kissing (putting their tongue in their partner’s mouth) if their partner has HIV?	Y	N
6.	Will taking a test for HIV one week after having sex tell a person if she or he has HIV?	Y	N
7.	Can you get HIV by sitting in a hot tub or swimming pool with a person who has HIV?	Y	N

Section III– What do you think?

For each statement, please circle “Strongly disagree” (SDA), “Disagree” (D), “Neither agree nor disagree” (ND), “Agree” (A), or “Strongly agree” (SA).

		Strongly disagree	Disagree	Neither Agree or Disagree	Agree	Strongly agree
1.	I think you are safer, and have protection, if you join a gang.	SDA	D	ND	A	SA
2.	I will probably join a gang.	SDA	D	ND	A	SA
3.	Some of my friends at school belong to gangs.	SDA	D	ND	A	SA
4.	I think it’s cool to be in a gang.	SDA	D	ND	A	SA
5.	My friends would think less of me if I join a gang.	SDA	D	ND	A	SA
6.	I believe it is dangerous to join a gang; you will probably end up getting hurt or killed if you belong to a gang.	SDA	D	ND	A	SA
7.	I think being in a gang makes it more likely that you will get into trouble.	SDA	D	ND	A	SA
8.	Some people in my family belong to a gang, or used to belong to a gang.	SDA	D	ND	A	SA
9.	I belong to a gang.	SDA	D	ND	A	SA

Section IV – Your Experiences.

For each statement, please circle how often in the past 3 months you did the following things to solve a problem or conflict with a parent, brother, sister, or friend.

		All the time	Most of the time	Some of the time	Almost never	Never
1.	Discussed an issue calmly.	.	.	.	.	.
2.	Got information to back up your side of things.	.	.	.	.	.
3.	Brought in, or tried to bring in, someone to settle things.	.	.	.	.	.
4.	Insulted or swore at him/her.	.	.	.	.	.
5.	Sulked or refused to talk about an issue.	.	.	.	.	.
6.	Stomped out of the room or house or yard.	.	.	.	.	.
7.	Cried.	.	.	.	.	.
8.	Did or said something to spite him/her.	.	.	.	.	.
9.	Threatened to hit or throw something at him/her.	.	.	.	.	.
10.	Threw or smashed or hit or kicked something.	.	.	.	.	.
11.	Pushed, grabbed or shoved him/her.	.	.	.	.	.
12.	Slapped him/her.	.	.	.	.	.
13.	Kicked, bit, or hit him/her with a fist.	.	.	.	.	.
14.	Hit or tried to hit him/her with something.	.	.	.	.	.
15.	Beat him/her up.	.	.	.	.	.
16.	Choked him/her.	.	.	.	.	.
17.	Threatened him/her with a knife or gun.	.	.	.	.	.
18.	Used a knife or fired a gun.	.	.	.	.	.

Your Behavior.

1.	During the last 30 days, how many times were you in a physical fight?  0 times  1 time  2 or 3 times  4 or 5 times  6 or 7 times  8 or 9 times  10 or 11 times  12 or more times
2.	The last time you were in a physical fight, with whom did you fight?  I have never been in a physical fight  A total stranger  A friend or someone I know  A boyfriend, girlfriend, or date  A parent or another adult family member  Brother(s), sister(s),and/or cousin(s)  Someone not listed above  More than one of the persons listed above
3.	During the last 30 days, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?  0 times  1 time  2 or 3 times  4 or 5 times  6 or more times
4.	During the last 30 days, how many times were you in a physical fight on school property?  0 times  1 time  2 or 3 times  4 of 5 times  6 or 7 times  8 or 9 times  10 or 11 times  12 or more times

Have you ever …

1.	Been bullied?	Yes	No
2.	Run away from home?	Yes	No
3.	Skipped classes without an excuse?	Yes	No
4.	Carried a hidden weapon?	Yes	No
5.	Been loud or rowdy in a public place where somebody complained and you got in trouble?	Yes	No
6.	Made obscene telephone calls, such as calling someone and saying dirty things?	Yes	No
7.	Ridden in a car or motorcycle that was taken without the owner’s permission?	Yes	No
8.	Shoplifted or taken something from a store on purpose (including anything you already told me about)?	Yes	No
9.	Attacked someone with a weapon with the idea of seriously hurting or killing them?	Yes	No
10.	Hit someone with the idea of hurting them.	Yes	No
11.	Been involved in gang or posse (group) fights?	Yes	No
12.	Thrown objects such as rocks or bottles at people (other than what you have already mentioned)?	Yes	No
13.	Sold marijuana, reefer or pot?	Yes	No
14.	Sold hard drugs such as crack, heroin, cocaine, LSD or acid?	Yes	No

Check the box  that best describes how often you do this.

		All of the time	Most of the time	Some of the time	Almost Never	Never
1.	Some kids tell lies about a classmate so that the other kids won’t like the classmate anymore. How often do you do this?	.	.	.	.	.
2.	Some kids try to keep certain people from being in their group when it is time to play or do an activity. How often do you do this?	.	.	.	.	.
3.	When they are mad at someone, some kids get back at the person by not letting the person be in their group anymore. How often do you do this?	.	.	.	.	.
4.	Some kids tell their friends that they will stop liking them unless the friends do what they say. How often do you tell friends this?	.	.	.	.	.
5.	Some kids try to keep others from liking a classmate by saying mean things about the classmate. How often do you do this?	.	.	.	.	.

What do you think?

1.	When is a good age to have sex? _______ years old.
2.	How old do your friends think you should be to have sex? _______ years old.
3.	Do you think you have to have sex to be popular?  Yes  No
4.	Do you think boys have to have sex to be popular?  Yes  No

Your Experience: (Alcohol, Tobacco, and Other Drugs)

Mark the box that applies to you and/or fill out the blank.

1.	How old were you the first time you smoked a cigarette, even one or two puffs?  The first time I smoked a cigarette, I was _______ years old.  I have never smoked a cigarette in my life.
2.	How old were you the first time you had a drink of any alcoholic beverage? (Do not include sips from another person’s drink)  The first time I drank an alcoholic beverage, I was _______ years old.  I have never drunk an alcoholic beverage in my life.
3.	How old were you the first time you used marijuana or hashish, even if it was one or two puffs?  The first time I used marijuana or hashish, I was _______ years old.  I have never used marijuana or hashish in my life.
4.	How old were you the first time you used any inhalant for kicks or to get high?  The first time I used an inhalant for kicks or to get high, I was _______ years old.  I have never used any inhalant for kicks or to get high in my life.

Your Behavior: (Alcohol, Tobacco, and Other Drugs)

1.	How many cigarettes have you smoked during the last 30 days?  Not at all  Less than one cigarette per day  One to five cigarettes per day  About one-half pack per day  About one pack per day  About one and one-half packs per day  Two packs or more per day
2.	How often have you taken smokeless tobacco during the last 30 days?  Not at all  Once or twice  Once to twice per week  Three to five times per week  About once a day  More than once a day
3.	How many times during the last 30 days have you had alcoholic beverages to drink (more than just a few sips)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
4.	How many times during the last 30 days (if any) have you been drunk or very high from drinking alcoholic beverages? (If you choose “0 times” skip to Question #6)  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
5.	How many drinks do you drink at one time?  0 drinks  1 drinks  2 drinks  3 drinks  4 or more
6.	How many times during the last 30 days (if any) have you used marijuana (grass, pot, blunt) or hashish (hash, hash oil)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
7.	During the last 30 days, about how many marijuana cigarettes (joints, reefers), or the equivalent, did you smoke a day, on the average? (If you shared them with other people, count only the amount YOU smoked.)  None  Less than 1 a day  1 a day  2-3 a day  4-6 a day  7-10 a day  11 or more a day
8.	How many times during the last 30 days (if any) have you sniffed glue, or breathed the contents of aerosol spray cans, or inhaled any other gases or sprays in order to get high?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 times or more
	What are you most looking forward to in the program? CHECK YOUR TOP 3 CHOICES  Field trips  Building friendships with other girls.  Learning about my body  Learning how to make good choices for myself  For a new beginning in life  One-on-one time with a caring adult  Feeling better about myself  Having a safe place to go to  Being able to express my feelings  Other (Specify)­­­­­­­­­­­­­­­_________________________

Thank you for your participation!

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