1st and 2nd Student Mid-Implementation Survey

Attachment N

2^nd 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 2. 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:________________)	6. About how often have you missed this class during the last month of school? Mark one 1 Never 2 Sometimes 3 Often 4 Always

safe dates student survey

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.

MMARK 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 describe how gender stereotypes can affect how a person acts with a dating partner	1	2	3	4	5	6	7	99
Safe Dates classes provide important information that is needed by students in this school	1	2	3	4	5	6	7	99
My teacher showed a lot of interest in the topic of dating violence	1	2	3	4	5	6	7	99
I will not stay in a dating relationship that involves verbal abuse such as yelling or name-calling	1	2	3	4	5	6	7	99
Students in this class actively participated in Safe Dates classroom activities.	1	2	3	4	5	6	7	99
It is wrong to abuse a dating partner in any way	1	2	3	4	5	6	7	99
I was very interested in the material presented in the Safe Dates program	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
In the future, I will never verbally abuse my dating partner by doing things like name-calling	1	2	3	4	5	6	7	99

MMARK ONE ANSWER FOR EACH		Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
I can name eight communication skills that can be used to resolve conflict.		1	2	3	4	5	6	7	99
It was easy to understand the information about dating violence presented in this class.		1	2	3	4	5	6	7	99
There was plenty of time in class to carry out Safe Dates classroom activities		1	2	3	4	5	6	7	99
I actively participated in Safe Dates classroom activities		1	2	3	4	5	6	7	99
I will not stay in a dating relationship that involves physical abuse of any kind such as hitting		1	2	3	4	5	6	7	99
I enjoyed the Safe Dates program about dating violence		1	2	3	4	5	6	7	99
The Safe Dates unit is a good addition to this class		1	2	3	4	5	6	7	99
There’s no excuse for allowing a dating partner to abuse you any way		1	2	3	4	5	6	7	99
I actively participated in Safe Dates classroom discussions		1	2	3	4	5	6	7	99
Safe Dates is a good addition to this school’s health programming		1	2	3	4	5	6	7	99
I can identify situations that trigger anger (hot buttons) for me		1	2	3	4	5	6	7	99
Reducing dating violence among students was the main goal of the Safe Dates program		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
I will not stay in a dating relationship that involves emotional abuse such as threats		1	2	3	4	5	6	7	99
Students seemed interested in the material presented in the Safe Dates program ….		1	2	3	4	5	6	7	99
I can explain why the victim of a sexual assault is never to blame for the assault.		1	2	3	4	5	6	7	99
MMARK ONE ANSWER FOR EACH		Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
It is a mistake to date someone who abuses you in any way.		1	2	3	4	5	6	7	99
Students asked a lot of questions during Safe Dates classes.		1	2	3	4	5	6	7	99
When we had discussions about dating violence we often ran out of time.		1	2	3	4	5	6	7	99
I know why gender stereotyping can be harmful.		1	2	3	4	5	6	7	99
I will not stay in a dating relationship in which my partner does not respect my boundaries		1	2	3	4	5	6	7	99
There’s no excuse for abusing a dating partner in any way.		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 know how to use the eight communication skills taught in Safe Dates		1	2	3	4	5	6	7	99
Students actively participated in Safe Dates classroom discussions and activities		1	2	3	4	5	6	7	99
In the future, I will never physically abuse my dating partner by doing things like hitting		1	2	3	4	5	6	7	99
I can describe signals that show that I’m angry – both physical and psychological signals		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
We had to skip some Safe Dates lessons because of scheduling problems		1	2	3	4	5	6	7	99
Students seemed interested in Safe Dates classroom activities		1	2	3	4	5	6	7	99
I can understand “no” cues correctly ….		1	2	3	4	5	6	7	99
This school’s decision to offer the Safe Dates program was a good decision.		1	2	3	4	5	6	7	99
MMARK ONE ANSWER FOR EACH		Strongly disagree	Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
I can describe some non-violent responses to make if a dating partner does not communicate in a way that is fair and equal.		1	2	3	4	5	6	7	99
The information was presented in class about dating violence was easy for most students to follow.		1	2	3	4	5	6	7	99
Safe Dates fits well with the health programs at this school.		1	2	3	4	5	6	7	99
I asked a lot of questions during Safe Dates classes.		1	2	3	4	5	6	7	99
There was plenty of time in class to finish classroom discussions about dating violence		1	2	3	4	5	6	7	99
In the future, I will always respect the boundaries of my dating partner		1	2	3	4	5	6	7	99
The Safe Dates program will help students avoid dating violence.		1	2	3	4	5	6	7	99
I can identify a variety of non-violent ways to respond to anger		1	2	3	4	5	6	7	99
My teacher talked about the importance of taking a program about reducing dating violence		1	2	3	4	5	6	7	99
The way information was presented in this class made it comfortable to talk about dating violence		1	2	3	4	5	6	7	99
I can clearly communicate my sexual boundaries to a dating partner		1	2	3	4	5	6	7	99
I recognize that it is my choice about how I respond to anger from others		1	2	3	4	5	6	7	99
My teacher said that it was important to cover all of the lessons in the Safe Dates program		1	2	3	4	5	6	7	99
I really liked the Safe Dates program		1	2	3	4	5	6	7	99
I can describe some dating tips that will lower my chance of being a victim of a sexual assault		1	2	3	4	5	6	7	99
MMARK ONE ANSWER FOR EACH	Strongly disagree		Disagree	Disagree somewhat	Neither agree nor disagree	Agree somewhat	Agree	Strongly agree	Don’t know
We often ran out of time when we did Safe Dates classroom activities ….	1		2	3	4	5	6	7	99
I can describe some dating tips that will lower the chance that I will assault my dating partner.	1		2	3	4	5	6	7	99
In the future, I will never emotionally abuse my dating partners by doing things like making threats.	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
I was very interested in Safe Dates classroom activities.	1		2	3	4	5	6	7	99
The way classroom activities were done in this class made it comfortable to take part in them.	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.

.

MMARK 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
Positive and negative images of relationships are learned from TV, parents, etc	1	2	3	4	5	6	7
Good communication can help equalize power in dating relationships ….	1	2	3	4	5	6	7
Anger is always controllable.	1	2	3	4	5	6	7
Sometimes abuse is deserved.	1	2	3	4	5	6	7
Sexual assault is any forced sexual activity without a partner’s consent.	1	2	3	4	5	6	7
Gender stereotypes influence our images of dating relationships.	1	2	3	4	5	6	7
In relationships that are already abusive, communication skills may not help	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
A person can control his/her anger much easier if they know their “hot buttons”.	1	2	3	4	5	6	7
Forced sex is a crime	1	2	3	4	5	6	7
Students need to be aware of whether others are treating them based on gender stereotypes	1	2	3	4	5	6	7

MMARK 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 never abuse boys	1	2	3	4	5	6	7
It’s easier to control your anger if you know your anger cues ….	1	2	3	4	5	6	7
It’s important to be aware of how your expectations of a dating partner are influenced by gender stereotypes.	1	2	3	4	5	6	7
Some cases of dating violence should NOT be reported.	1	2	3	4	5	6	7
Controlling anger is easier if you have some planned responses to anger.	1	2	3	4	5	6	7
Forced sex is not okay for any reason.	1	2	3	4	5	6	7
In some states, hitting your dating partner is okay; in others states, it’s not okay	1	2	3	4	5	6	7
Yelling is likely to be an effective approach for calming-down a violent partner	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 FOR EACH
Possible Safe Dates Classroom Activity	Occurred?	Possible Safe Dates Classroom Activity	Occurred?
89. We created a list of where teens get their images of what dating relationships should be like.	1 Yes 2 No	97. We talked about situations where abuse was deserved.	1 Yes 2 No
90. We acted out the LaToya and Marcus story.	1 Yes 2 No	98. We wrote lists of positive, non-violent responses to situations we identified.	1 Yes 2 No
91. We identified our “hot buttons” – things that make us angry.	1 Yes 2 No	99. We read the “Chris and Alex” story.	1 Yes 2 No
92. We wrote song lyrics about dating abuse.	1 Yes 2 No	100. We watched a movie on self-defense techniques.	1 Yes 2 No
93. We did a scavenger hunt to find dating tips.	1 Yes 2 No	101. We did an activity called the “fishbowl”.	1 Yes 2 No
94. We paired up to brainstorm about gender stereotyping.	1 Yes 2 No	102. We role-played communication skills in small groups.	1 Yes 2 No
95. We played Dating Monopoly.	1 Yes 2 No	103. We took a quiz about sexual assault.	1 Yes 2 No
96. My teacher defined sexual assault.	1 Yes 2 No	104. We brainstormed explanations for why either Lisa or Matt could be blamed for a scenario we read about.	1 Yes 2 No

105. 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 106

₂ NO (I have not taken quizzes and/or tests related to the Safe Dates program.) → GO TO PAGE 15

₉₉ DON’T KNOW (I am not sure whether I took quizzes and/or tests related to the Safe Dates program.) → GO TO PAGE 15

106. 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

107. 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!