Principle, Prevention Coordinator and Teacher Baseline Survey

Attachment V

Baseline Teacher Survey

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

Public Reporting burden of this collection of information is estimated at 15 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 many 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 NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

Baseline Teacher Survey

Purpose

The Centers for Disease Control and Prevention (CDC) thank you for your willingness to participate in our study of the Safe Dates program. You are taking a leading role in allowing the CDC to gather some important information aimed at making this program more accessible to high school students across the nation.

Your perspective is very important to us.

Because of your unique role in the school, your opinions and impressions are particularly important to us. This is the first of three brief surveys you will receive. It is expected to take about 15 minutes to complete. We know your time is precious so we’ve limited our questions to those considered the most important.

We are seeking your first impressions and reactions.

Please provide responses based on what you know or what you think. Feel free to use the ‘don’t know’ option as needed. There are no “right” or “wrong” answers.

We recommend that you work quickly without puzzling or worrying about individual questions. We are aware that some questions may appear to be repetitive but it is necessary to ask a variety of questions to obtain reliable and accurate information about the topics addressed in the questionnaire.

Privacy:

All answers you provide will be kept private. Findings will be summarized in aggregated form to protect the identity of participating individuals and schools.

Please complete your survey within 2 business days.

Feedback:

In addition to a variety of incentives that your school is receiving in exchange for participating in this study, your school also will receive an executive summary of findings from the study.

Background Information: Please provide the following information so that we can: (a) match your answers to this survey with those on follow-up surveys; (b) describe study participants; and (c) group responses according to title, school, etc. The information you provide will be kept private.

1. Your title: _______________________	7. Years working in education: ________ yrs.
2. Duration of a typical class period at this school: _______ minutes.	8. Your gender: _____male ______ female
3. Number of times per week students attend this class (circle 1) : 1 2 3 4 5	9. Highest degree earned (check 1):
	_____ Associates _____ Bachelors
	_____ Masters _______ PhD or EdD 10. Major associated w/ highest degree (check 1) :
4. On average, about how many students are in your health class(es)? _____ students	_____ P.E. _____ Health ______ Recreation _____ Other (please explain below)
5. Time in current job: ______yrs.______ mos.	11. Primary subject you teach (Check 1): ____ Health _____ P.E. ______ Wellness _____ Other (please explain below)
6. Tenure at this school: ______yrs. _____mos.

12.	Which of the following options best describes how the Safe Dates (SD) course is likely to be incorporated into your school's broader health or prevention curriculum? ____ SD will be taught as an independent course in the health or prevention curriculum ____ SD lessons will be an intact module within a course in the health or prevention curriculum ____ SD lessons will be interspersed among other lessons in the broader curriculum ____ Other (please explain: ______________________________________________)
The Safe Dates curriculum is designed to be taught in the form of nine, 50-minute lessons. Based on your overall curriculum plans for this academic year, please estimate a likely kickoff date and a likely completion date for teaching the 9- session Safe Dates curriculum.
13.	Your estimated kick-off date for the Safe Dates Curriculum: _____ month ______ year
14.	Your estimated completion date for the Safe Dates Curriculum: _____ month _____ year
15.	Thinking back to the last time you taught a health or wellness class, which of the following best describes the methods you employed in your teaching? (Choose one only) _______ Primarily lecture _______ Mostly lecture with some in-class activities (e.g., discussion, exercises, role-play) _______ Half lecture and half in-class activities (e.g., discussion, exercises, role-play) _______ Mostly activities (e.g., discussion, exercises, role-play)with some lecture _______ Primarily activities (e.g., discussion, exercises, role-play.) _______ Other: (please explain: ______________________________________________)

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

	This school is very willing to implement new prevention programs that have been developed by researchers	____
	Offering the Safe Dates curriculum is a very good idea for this school	____
	The Safe Dates curriculum must be implemented in a precise and prescribed manner in order to be effective…	____
	The advantages of implementing the Safe Dates curriculum at this school will far outweigh any disadvantages	____
	This school can deal with any difficulties that might interfere with teaching the Safe Dates curriculum as it is prescribed	____
	The Safe Dates curriculum addresses a need that is already being addressed by an existing program at this school	____
	Scientific evidence indicates the Safe Dates course is effective in reducing dating violence	____
	I first heard about the Safe Dates curriculum when our school decided to participate in this study	____
	Implementing Safe Dates will address an important unmet need of our student body	____
	The Safe Dates course will contribute to the safety of the students who take it	____
	This school's involvement in implementing Safe Dates is voluntary	____
	Teachers who will be teaching Safe Dates were actively involved in the school's decision to participate in this study	____
	Top administrators at this school don't really seem to care whether or not we implement Safe Dates.	____
	The Safe Dates curriculum will be complicated to implement correctly	____
	I will have the final say about which Safe Dates lessons to cover in my class	____
	Offering the Safe Dates curriculum will help this school meet some of its strategic goals	____
	This school has strong rules and programs for preventing violence involving students	____
	Research-based prevention programs typically don’t work well in most school settings	____
	The school's decision to offer the Safe Dates curriculum is a good decision	____
	Adaptations can be made in how the Safe Dates course is taught without jeopardizing its effectiveness	____
	Overall, implementing the Safe Dates curriculum is likely to be advantageous to this school	____
	I strongly support including Safe Dates in this school's health curriculum	____
	If unforeseen scheduling conflicts arise, the Safe Dates curriculum can still be delivered as intended.	____

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

	There is strong scientific evidence suggesting the Safe Dates course reduces violence between dating partners	_______
	I had heard about the Safe Dates program before this school decided to participate in the study related to Safe Dates	_______
	Safe Dates will be an important addition to the school's health curriculum	_______
	The incidence of dating violence will decrease among students who participate in the Safe Dates program	_______
	The implementation of the Safe Dates curriculum at this school is mandated by a higher authority	_______
	School administrators rather than teachers made the decision to participate in this study involving Safe Dates	_______
	Top administrators at this school seem committed to including Safe Dates in our health and/or prevention curriculum	_______
	It will be easy to prepare teachers to implement the Safe Dates curriculum as recommended by experts.	_______
	I will be able to decide whether or not to cover all or only some of the lessons included in the Safe Dates curriculum	_______
	The Safe Dates curriculum fits well with the strategic goals of this school	_______
	The Safe Dates curriculum is very similar to a course we already offer at this school	_______
	This school puts a lot of effort into preventing violence of any kind among students	_______
	Teachers at this school know more than academic researchers about what makes a prevention program effective	_______
	The Safe Dates program is likely to be a valuable addition to this school's health/prevention curriculum	_______
	Some components of the Safe Dates curriculum have to be implemented as prescribed but others do not.	_______
	Implementing the Safe Dates curriculum will have more benefits than drawbacks for this school	_______
	Quite frankly, I really don’t care if we implement Safe Dates at this school	_______
	We are prepared to see that the Safe Dates curriculum is delivered as intended regardless of the obstacles that might arise	_______
	The Safe Dates curriculum will enhance this school's existing health and prevention programming	_______
	There is convincing scientific evidence which suggests that the Safe Dates course reduces dating violence	_______

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

	This school is highly motivated to implement the Safe Dates program	_____
	The Safe Dates program will provide students with knowledge and strategies to reduce the incidence of dating violence in the future	_____
	It is my decision about whether or not to teach the Safe Dates course	_____
	Teachers who will be teaching Safe Dates were actively involved in making the decision to participate in this study (related to the Safe Dates program)	_____
	Top administrators at this school are committed to ensuring that the Safe Dates course is part of the health/prevention curriculum	_____
	The existing violence-prevention policies, strategies and programs, etc. at this school are very effective	_____
	There are one or more reasons why it will be difficult for teachers to implement the Safe Dates curriculum at this school.	_____
	It will be necessary for me to teach every lesson included in the Safe Dates curriculum	_____
	Violence of any kind such as fighting, bullying and yelling is not allowed at this school……………………	_____
	Teaching Safe Dates exactly as it was developed by experts is critical to getting expected results	_____
	This school can deal with any “bumps in the road” that may arise in the process of delivering the Safe Dates curriculum	_____
	The Safe Dates curriculum will complement existing health and prevention programming at this school.	_____
	I will have the choice about whether or not to teach the Safe Dates course	_____
	This school's rules and programs for preventing violence seem to work very well	_____
	Teachers who will be teaching Safe Dates were consulted in arriving at the decision to participate in this study (related to the Safe Dates program	_____
	It will be easy to implement the Safe Dates curriculum correctly on a consistent basis	_____
	This school does a good job preventing fighting and other forms of violence involving students	_____
	I am committed to seeing that the Safe Dates curriculum is taught at this school	_____
	This school’s policies, programs and approaches related to violence prevention are well-suited to our needs	_____
	The Safe Dates course will have lifelong benefits for the students who take it	_____
	Students who behave violently are not allowed to stay at this school	_____

INSTRUCTIONS: The Safe Dates curriculum addresses the topic of dating violence and recommends approaches for reducing its occurrence. Whether or not you have had the chance to review the Safe Dates Teacher Manual/Curriculum guide, please carefully read each statement and indicate how much confidence you have that you could accomplish each of these tasks using the 5-point shown below. If you “Don’t Know,” please enter “0”.

No confidence at all	Very little confidence	Some confidence	A lot of confidence	Complete confidence		Don’t Know
1	2	3	4	5		0

HOW MUCH CONFIDENCE DO YOU HAVE THAT YOU CAN:

	Teach the 9 lessons in the Safe Dates curriculum after reading the teacher manual/curriculum guide	____
	See to it that the recommended Safe Dates student poster contest is implemented for students in your class	____
	See to it that the recommended Safe Dates student play is performed by (or for) students in your class	____
	Persuade students in your Safe Dates class to actively participate in role-playing exercises	____
	Persuade students in your Safe Dates class to work together as a group on Safe Dates group exercises	____
	Persuade students in your class to participate in classroom discussions about the topic of dating violence	____
	Teach the lessons in the Safe Dates curriculum in strict accordance with the curriculum guide	____
	Implement the activities in the Safe Dates curriculum in strict accordance with the curriculum guide	____
	Comfortably present information to your students about preventing sexual violence	____