1st and 2nd Student Mid-Implementation Survey

Attachment M

1^st Student

Mid-Implementation

Survey

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

Public Reporting burden of this collection of information is estimated at 25 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).

Survey information

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 helping the CDC to learn how to make this program available to students across the country.

Privacy

Your answers on this survey will be kept private: you will NOT put your name on this survey. School personnel will not know the answers of any individual student. You will be asked to give some information about yourself, like your age and sex. Your completed survey, which you will seal in an envelope, will be given directly to the researcher team.

Voluntary

Participation in this survey is voluntary: you can choose not to participate. If you participate, you can skip any questions you do not want to answer.

general instructions

This is the second of four surveys you will be asked to complete. It should take about 25 minutes, and you will complete it in class. Some questions are similar to the others, but this is to help us interpret the results of the survey.

This is an opinion survey. It is not a test. There are no “right” or “wrong” answers. Answer the questions quickly, based on what you know or what you think. It’s best not to think to much or worry about each question. Use the “don’t know” option as needed, like when you don’t understand a question.

Questions may be on both sides of the survey pages. So be sure to check both sides of each page. When you have completed the survey, please seal it in the envelope provided.

Thank you in advance for your participation!

General Instructions

• Read all the answers before marking your choice. If none of the printed answers exactly applies to you, black out the box beside the answer that best fits.

• Use a pencil to complete the survey.

• Completely black out in the box beside your answer choice.

INCORRECT CORRECT

 

• If you make an error, erase it cleanly and then mark the box beside your correct answer choice.

• Do not make any stray marks.

• PLEASE READ EACH QUESTION CAREFULLY.

Follow the directions for responding to each kind of question. These are:

MARK ONE What is the color of your eyes? Mark one 1 Brown 2 Blue 3 Green 4 Another color	If the color of your eyes is green, you would mark the third box as shown.
MARK ONE What is the color of your hair? Mark one 1 Brown 2 Black 3 Blonde 4 Red 5 Some other color (Describe) _____Purple_____	If your hair is purple, you would mark “Some other color.” Then you would write “purple” in the blank.
MARK ONE OR MORE Do you plan to do any of the following next week? Mark one or more 1 Rent a video 2 Go to a baseball game 3 Study at a friend’s house	If you plan to rent a video and go to a baseball game, you mark both.

General Instructions (continued)

QUESTION WITH A SKIP 1. Do you ever eat chocolate? Mark one 1 Yes 2 No → GO TO 3 Do you always brush your teeth after you eat chocolate? Mark one 1 Yes 2 No 3. Did you do any of the following last week? Mark one or more 1 Saw a play 2 Went to a movie 3 Attended a sporting event

If you answered “Yes,” you go to Question 2. After you answer Question 2, you go to Question 3. If you answered “No” to Question 1, you skip Question 2. Then you go to Question 3.

Safe Dates Student Survey

School: __________________________ Class Period: _______________

Teacher: _________________________ Date: ______________________

The following background information is requested so that we can describe who responds to the survey. Please keep in mind that all of your answers will be kept private and in no way be will traced to you.

Please mark the information that best describes you.

1. Your gender: Mark one 1 Female 2 Male	4. Your grade: Mark one 1 9 2 10 3 11 4 12
2. Are you Hispanic or Latino? Mark one 1 Yes 2 No	5. When you think about your most recent report card, what grade best describes your overall performance? Mark one 1 A 2 B 3 C 4 D 5 F
3. What is your race? Mark one or more 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or Other Pacific Islander 5 American Indian or Alaska Native 6 Other (Describe:________________)	About how often have you missed this class during the last month of school? Mark one 1 Never 2 Sometimes 3 Often 4 Always

INSTRUCTIONS: Please indicate how much you agree or disagree with each of the statements in this survey that relate to our recent classes about the topic of preventing dating violence.

These classes about dating violence are part of a program called “Safe Dates”. So when the term “Safe Dates” is mentioned in this survey, it is referring to those classes.

If you are unsure about the answer to a question, mark “Don’t know”. Please note that “don’t know” is a useful and important response.

Mark the response option that most closely reflects your response to each statement.

MARK ONE ANSWER FOR EACH	Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
Offering the Safe Dates program is a good idea for this school	1	2	3	4	5	6	7	99
I can name the things that are most important to me in a dating relationship….	1	2	3	4	5	6	7	99
The Safe Dates program provides important information to students at this school.	1	2	3	4	5	6	7	99
Offering the Safe Dates program will make the students at this school safer.	1	2	3	4	5	6	7	99
I can name the warning signs that a person is a victim or a perpetrator of dating abuse.	1	2	3	4	5	6	7	99
The way Safe Dates classroom activities are done in this class makes it comfortable for me to take part in them…………………..	1	2	3	4	5	6	7	99
I have enjoyed the Safe Dates program	1	2	3	4	5	6	7	99
The Safe Dates program is a good addition to this class	1	2	3	4	5	6	7	99
The Safe Dates program is a good addition to this school’s health programs.	1	2	3	4	5	6	7	99
I can identify red flags that tell me a friend might be abusive to his or her dating partner	1	2	3	4	5	6	7	99
I hope the school continues to offer the Safe Dates program in the future	1	2	3	4	5	6	7	99

MARK ONE ANSWER FOR EACH	Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
Students in this class seem interested in the material presented in the Safe Dates program	1	2	3	4	5	6	7	99
I can name the bad things that can happen from being in an abusive relationship ….	1	2	3	4	5	6	7	99
Students in this class ask a lot of questions during Safe Dates classes	1	2	3	4	5	6	7	99
This teacher is one of the best I’ve ever had	1	2	3	4	5	6	7	99
I can identify red flags that tell me a friend might be a victim of dating abuse.	1	2	3	4	5	6	7	99
Students in this school need to learn about ways to prevent dating violence	1	2	3	4	5	6	7	99
I could confront a friend who is abusive in a dating relationship	1	2	3	4	5	6	7	99
I am very interested in the material presented in the Safe Dates program	1	2	3	4	5	6	7	99
This school has strong rules and programs for preventing violence involving students	1	2	3	4	5	6	7	99
Students in this class seem interested in Safe Dates classroom activities	1	2	3	4	5	6	7	99
I can recognize the difficulty and fear a friend in an abusive relationship may have in reaching out for help	1	2	3	4	5	6	7	99
The school’s decision to offer the Safe Dates program is a good decision	1	2	3	4	5	6	7	99
I really like this teacher	1	2	3	4	5	6	7	99
I actively participated in Safe Dates classroom discussions….	1	2	3	4	5	6	7	99
It is easy to understand the information about dating violence presented in this class.	1	2	3	4	5	6	7	99
Safe Dates fits well with other programs at this school.	1	2	3	4	5	6	7	99
MARK ONE ANSWER FOR EACH	Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
I understand why the decision to leave an abusive relationship can be a hard one.	1	2	3	4	5	6	7	99
The way information is presented in this class makes it comfortable for me to talk about dating violence.	1	2	3	4	5	6	7	99
I can identify actions that are caring and supportive in relationships	1	2	3	4	5	6	7	99
I actively participate in Safe Dates classroom activities	1	2	3	4	5	6	7	99
This school’s rules and programs for preventing violence seem to work very well.	1	2	3	4	5	6	7	99
I can describe a few different ways to support a friend who is a victim of dating abuse	1	2	3	4	5	6	7	99
The information presented in this class about dating violence is easy for most students to follow	1	2	3	4	5	6	7	99
I can describe how I want to be treated by a dating partner	1	2	3	4	5	6	7	99
I can identify abusive behaviors when I see them	1	2	3	4	5	6	7	99
I ask a lot of questions during Safe Dates classes	1	2	3	4	5	6	7	99
Violence of any kind such as fighting, bullying and yelling is not allowed at this school	1	2	3	4	5	6	7	99
Dating violence is likely to decrease among students who take the Safe Dates program	1	2	3	4	5	6	7	99
Students in this class actively participate in Safe Dates classroom activities	1	2	3	4	5	6	7	99
I can describe how dating abuse can be used to control others ….	1	2	3	4	5	6	7	99
I am very interested in Safe Dates classroom activities.	1	2	3	4	5	6	7	99
This school puts a lot of effort into preventing violence of any kind among students.	1	2	3	4	5	6	7	99

MARK ONE ANSWER FOR EACH	Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
The Safe Dates program will help students who take it to avoid dating violence in the future.	1	2	3	4	5	6	7	99
I can define physically and emotionally abusive behaviors.	1	2	3	4	5	6	7	99
So far, I like the Safe Dates program	1	2	3	4	5	6	7	99
This teacher is one of my favorites	1	2	3	4	5	6	7	99
This school does a good job preventing fighting and other forms of violence.	1	2	3	4	5	6	7	99
The Safe Dates program should be a regular part of this school’s health program	1	2	3	4	5	6	7	99
I can identify harmful dating behaviors	1	2	3	4	5	6	7	99
Students who behave violently are not allowed to stay at this school	1	2	3	4	5	6	7	99
Students in this class take an active part in Safe Dates classroom discussions	1	2	3	4	5	6	7	99

PLEASE GO ON TO THE NEXT PAGE.

WHICH OF THESE POINTS WERE EMPHASIZED BY YOUR TEACHER?

INSTRUCTIONS:

There were many different points your teacher may have emphasized in the course of teaching Safe Dates lessons. Please read the following list of points that may or may not have been made by your teacher while teaching these lessons related to the topic of dating violence.

Please indicate on the scale below how certain you are about whether or not the specific point was made by your teacher.

Mark the response option that most closely reflects your response to each statement.

MARK ONE ANSWER FOR EACH	Completely certain point was NOT made	Certain point was NOT made	Somewhat certain point was NOT made	Don’t know if that point was made	Somewhat certain point WAS made	Certain point WAS made	Completely certain point WAS made
We all have choices about how we are to be treated	1	2	3	4	5	6	7
Everyone needs to know how to deal with a violent dating relationship ….	1	2	3	4	5	6	7
There are many different reasons for why people abuse others.	1	2	3	4	5	6	7
Sometimes abuse is deserved.	1	2	3	4	5	6	7
Students in abusive relationships should tell someone they trust.	1	2	3	4	5	6	7
Students need to take a firm stand against dating abuse.	1	2	3	4	5	6	7
We all have a choice about how we treat others	1	2	3	4	5	6	7
Hitting back can be an effective way to stop physical abuse	1	2	3	4	5	6	7
Students must make it clear to others about how they expect to be treated.	1	2	3	4	5	6	7
Abusive behaviors have serious short and long term consequences	1	2	3	4	5	6	7
Since abuse can isolate victims, students need to stay connected to or reconnect with family and friends	1	2	3	4	5	6	7

MARK ONE ANSWER FOR EACH	Completely certain point was NOT made	Certain point was NOT made	Somewhat certain point was NOT made	Don’t know if that point was made	Somewhat certain point WAS made	Certain point WAS made	Completely certain point WAS made
Girls rarely abuse boys	1	2	3	4	5	6	7
Students must tell people who are abusive that it is not an OK thing to do ….	1	2	3	4	5	6	7
Students have the power to decide how they will be treated and how they will treat others.	1	2	3	4	5	6	7
Some cases of dating violence should not be reported.	1	2	3	4	5	6	7
There are some clear signs of abuse.	1	2	3	4	5	6	7
It’s important to support people who are victims of abuse.	1	2	3	4	5	6	7
Violence and abuse is a choice	1	2	3	4	5	6	7
Yelling is likely to be an effective approach for calming-down a violent partner because it gets their attention	1	2	3	4	5	6	7

WHICH OF THESE ACTIVITIES DEFINITELY HAPPENED IN YOUR CLASS?

INSTRUCTIONS: There were many different classroom activities your teacher could choose from in the course of teaching Safe Dates classes. We are interested in which activities your teacher decided to carry out.

Please read the list shown below of possible classroom activities. Indicate whether each activity actually occurred in your class.

Mark “yes” if you’re absolutely sure it occurred. Otherwise, please mark “no”.

MARK ONE ANSWER FOR EACH
Possible Safe Dates Classroom Activity	Occurred?	Possible Safe Dates Classroom Activity	Occurred?
78. We played Dating Bingo.	1 Yes 2 No	86. We role-played stories of dating abuse.	1 Yes 2 No
79. We created a list of harmful physical and emotional behaviors dating partners might do.	1 Yes 2 No	87. We reviewed the “Friends Wheel” and 6 ways to help a friend who is being abused.	1 Yes 2 No
80. We had small group discussions about the short term consequences for victims and perpetrators of dating abuse.	1 Yes 2 No	88. We read stories that helped us figure out why people abuse others.	1 Yes 2 No
81. We went out on practice dates.	1 Yes 2 No	89. We designed outfits for girls to wear on dates.	1 Yes 2 No
82. The class created a list of how we “want to be treated”.	1 Yes 2 No	90. We filled out a handout about “Ways I want to be treated by a dating partner”.	1 Yes 2 No
83. We role-played a scenario in which we moved from the “I want to stay” side of the room to the “I want to leave” side of the room.	1 Yes 2 No	91. We posted “red flags” that let us know that a person may be abusive or may be a victim of abuse.	1 Yes 2 No
84. We filled out a handout on “The 5 signs that show you are not ready to date”.	1 Yes 2 No	92. We role-played how to respond to an abusive friend.	1 Yes 2 No
85. We read a scenario and learned “red flags” that indicated a character in the story was being abusive.	1 Yes 2 No	93. We wrote a short paper in class about our past dating experiences.	1 Yes 2 No

94. Have you taken any tests or quizzes about the information covered in the Safe Dates program?

Mark one

₁ YES (I have taken quizzes and/or tests related to the Safe Dates program.) → GO TO 95

₂ NO (I have not taken quizzes and/or tests related to the Safe Dates program.) → GO TO PAGE 14

₉₉ DON’T KNOW (I am not sure whether I took quizzes and/or tests related to the Safe Dates

program.) → GO TO PAGE 14

95. About how many quizzes and/or tests did you take?

Mark one

₁ 1

₂ 2

₃ 3

₄ 4

₅ 5 or more quizzes and/or tests

₉₉ Don’t know

96. What grade best reflects your performance?

Mark one

₁ A

₂ B

₃ C

₄ D

₅ F

You have completed this survey.

Thank you for your participation!