Student Effectiveness Baseline Survey

Attachment L

Student Effectiveness Baseline Survey

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

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)

4. MARK ONE FOR EACH TIME PERIOD

How often have you done one of the following things? Mark how often each thing has ever happened, and then mark how often each thing happened during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

	Ever				During the last 6 months
MARK ONE ANSWER FOR EACH TIME PERIOD	Very often	Sometimes	Not very often	Never	Very often	Sometimes	Not very often	Never
a.a. Rode a bicycle	3	2	1	0	3	2	1	0
b.b. Swam in a pool	3	2	1	0	3	2	1	0

If you have never ridden a bicycle, you would mark “Never” for the Ever time period and “Never” for the During the last 6 months time period.

If you have been swimming in a pool very often, but not during the last 6 months, you would mark “Very often” for the Ever time period and “Never” for the During the last 6 months time period.

QUESTION WITH A SKIP 1. Do you ever eat chocolate? Mark one 1 Yes 0 No→GO to 3 2. Do you always brush your teeth after you eat chocolate? Mark one 1 Yes 0 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.

ID:__________ School:___________

Youth Dating Survey

INSTRUCTIONS: Please mark one answer for each question.

The first few questions are about dating. Teens have told us they think of two different kinds of dating: Group dating is when teens go out in groups but there is some pairing up, and solo dating is when a couple goes out alone.

1. Do your parents or guardian allow you to group date?

₁ Yes

₂ No

2. Do your parents or guardian allow you to solo date?

₁ Yes

₂ No

Here are some dating rules other parents have set for their teens. For each one, please mark whether you have actually been told the rule out loud by an adult family member.

3. Have you actually been told by a parent or guardian. . .

MARK ONE ANSWER FOR EACH	Yes	No
a.a. The time you need to be home from a date?	1	2
b.b. That they need to meet the person before you go out?.	1	2
c.c. That you cannot go to certain places on a date?.	1	2
d.d. That you need to tell them where you are going on the date?	1	2
e.e. That you should call them if something goes wrong on the date?	1	2
f. f. That you should not be physically violent to dates?.	1	2
f. g. That you should tell them if a date hits you?.	1	2

4. Here are some opinions that teens may have about males and females. How strongly do you agree or disagree with the following statements?

MARK ONE ANSWER FOR EACH	Strongly agree	Agree somewhat	Disagree somewhat	Strongly disagree
b.a. In a dating relationship the boy should be smarter than the girl.	3	2	1	0
c.b. Girls are always trying to manipulate boys.	3	2	1	0
d.c. In a dating relationship, the boy and girl should have about equal power.	3	2	1	0
e.d. Swearing is worse for a girl than for a boy.	3	2	1	0
f. e. On a date, the boy should be expected to pay all expenses.	3	2	1	0
f. It is all right for a girl to ask a boy out on a date.	3	2	1	0
g. It is more important for boys than girls to do well in school. .	3	2	1	0
h. Girls should have the same freedom as boys.	3	2	1	0
a.i. Most women can’t be trusted	3	2	1	0
f. j. In general, the father should have greater authority than the mother in making family decisions.	3	2	1	0
k. If both husband and wife have jobs, the husband should do a share of the house-work such as washing dishes and doing the laundry.	3	2	1	0

5. The next questions are about dating relationships. How strongly do you agree or disagree with the following statements?

MARK ONE ANSWER FOR EACH	Strongly agree	Agree somewhat	Disagree somewhat	Strongly disagree
a.a. It is OK for a boy to hit his girlfriend if she did something to make him mad.	3	2	1	0
c.b. It is OK for a boy to hit his girlfriend if she insulted him in front of friends.	3	2	1	0
d.c. It is OK for a boy to force a girl to have sex if he paid for all the expenses of a date.	3	2	1	0
e.d. Girls sometimes deserve to be hit by the boys they date.	3	2	1	0
f. e. A girl who makes her boyfriend jealous on purpose deserves to be hit.	3	2	1	0
f. f. Forcing a dating partner to have sex is never OK.	3	2	1	0
g. Boys sometimes deserve to be hit by the girls they date.	3	2	1	0
h. Sometimes boys have to hit their girlfriends to get them back under control. .	3	2	1	0
i. It is OK for a boy to hit a girl if she hit him first. .	3	2	1	0
j. It is OK for a boy to force a girl to have sex if she got him sexually excited. .	3	2	1	0
k. It is OK for a girl to hit a boy if he hit her first. .	3	2	1	0
l. Teens who are victims of dating violence need to get help from others.	3	2	1	0
m. Violence between dating partners is a personal matter, and people should not interfere.	3	2	1	0
n. Teens who are violent to their dates need to get help from others.	3	2	1	0
o. It is important to try to help a friend who is being abused by a dating partner.	3	2	1	0

6. The next questions are about how you have handled disagreements with people. During the last 6 months, when you had a disagreement with someone, how much of the time did you do the following things?

MARK ONE ANSWER FOR EACH	Most of the time	Some of the time	Not much of the time	Never
a.a. Told the person how I felt	3	2	1	0
b.b. Hung-up the phone on them.	3	2	1	0
c.c. Tried to calm down before I talked to them.	3	2	1	0
d.d. Refused to talk to them about the problem.	3	2	1	0
e.e. Asked lots of questions so that I could get the whole story.	3	2	1	0
f. f. Gave them the silent treatment.	3	2	1	0
f. g. Asked them what they were feeling	3	2	1	0
h. Let them know what was important to me	3	2	1	0
i. Tried to find a solution that suited both of us.	3	2	1	0
j. Stomped off during arguments	3	2	1	0
k. Listened to their side of the story	3	2	1	0
l. Acted like nothing was wrong	3	2	1	0
m. Physically hurt them	3	2	1	0

7. These questions are about what happens when you get mad. During the last 6 months, when you were angry at someone, how often did you do or feel the following things?

MARK ONE ANSWER FOR EACH	Very often	Sometimes	Not very often	Never
a.a. I threw something at the person I was mad at	3	2	1	0
b.b. I asked someone for advice on how to handle it.	3	2	1	0
c.c. I hit the person I was mad at.	3	2	1	0
d.d. I yelled and screamed insults at the person I was mad at.	3	2	1	0
e.e. I told the person why I was angry.	3	2	1	0
f. f. I made nasty comments about the person to others.	3	2	1	0
f. g. I tried to mess up something the person was trying to do	3	2	1	0
h. I had a discussion with the person about it	3	2	1	0
i. I damaged something that belonged to the person. .	3	2	1	0
j. I had thoughts about telling the person off. .	3	2	1	0
k. I tried to calm myself down before I talked to the person.	3	2	1	0
l. I had thoughts about hurting the person..	3	2	1	0
m. I kept it inside. .	3	2	1	0

8. Next, think about what would happen if violence occurred in a dating relationship you were in. How strongly do you agree or disagree with the following statements?

MARK ONE ANSWER FOR EACH	Strongly agree	Agree somewhat	Disagree somewhat	Strongly disagree
a.a. If I hit a dating partner, they would break up with me	3	2	1	0
e.b. If I hit a dating partner, I would be arrested	3	2	1	0
c. If I hit a dating partner, my friends would think I was cool	3	2	1	0
d. If I forced a dating partner to have sex, I would be arrested .	3	2	1	0
e. I would feel ashamed if I used violence against someone I was dating.	3	2	1	0
f. If I used violence against a dating partner, he/she would do exactly what I wanted.	3	2	1	0
g. My friends would be very angry with me if I hit someone I was dating.	3	2	1	0
h. I would feel proud if I used violence against someone I was dating.	3	2	1	0
i. If I frequently hit the person I was dating, I would feel powerful.	3	2	1	0
b.j. When girls say “no” to sex they usually really mean “yes”.	3	2	1	0
c.k. Girls who get drunk at parties or on a date deserve whatever happens to them	3	2	1	0
d.l. Bad things happen to people who are violent to their dating partners.	3	2	1	0
f. m. It is never the girl’s fault if she is raped	3	2	1	0
f. n. A girl who wears sexy clothes is asking to be raped	3	2	1	0
o. Hitting a dating partner is not that big a deal.	3	2	1	0
p. Violence between dating partners improves the relationship	3	2	1	0
q. When a girl wears sexy clothes on a date, it means she wants to have sex	3	2	1	0
r. If a girl agrees to go into a bedroom with a boy she is on a date with, it means she wants to have sex.	3	2	1	0

9. Are there any services in your county for helping teenagers who are victims in abusive and violent dating relationships?

₁ Yes

₂ No

₉₈ I don’t know

10. Are there any services in your county for helping teenagers who are abusive and violent toward the people they date?

₁ Yes

₂ No

₉₈ I don’t know

The next questions are about things that may have happened with someone you were dating or on a date with. For these questions, a “date” includes informal activities like meeting someone at the mall, a park, or at a basketball game, as well as more formal activities like going out to eat or to a movie together.

11. Have you ever been on a date?

₁ Yes

₂ No→GO TO QUESTION 27 ON PAGE 22

12. About how many different people have you been on a date with?

MARK ONE

₁ 1 person

₂ 2 to 3 different people

₃ 4 to 9 different people

₄ 10 or more different people

13. How often has anyone who you have been on a date with done the following things to you? Mark how often each thing has ever happened, and then mark how often each thing happened during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
	Very often	Sometimes	Not very often	Never	Very often	Sometimes	Not very often	Never
a.a. Damaged something that belonged to me	3	2	1	0	3	2	1	0
b.b. Said things to hurt my feelings on purpose.	3	2	1	0	3	2	1	0
c.c. Insulted me in front of others.	3	2	1	0	3	2	1	0
d.d. Threw something at me but missed	3	2	1	0	3	2	1	0
e.e. Would not let me do things with other people	3	2	1	0	3	2	1	0
f. f. Threatened to start dating someone else.	3	2	1	0	3	2	1	0
f. g. Told me I could not talk to someone of the opposite sex	3	2	1	0	3	2	1	0
h. Started to hit me but stopped	3	2	1	0	3	2	1	0
i. Did something just to make me jealous.	3	2	1	0	3	2	1	0
j. Blamed me for bad things they did.	3	2	1	0	3	2	1	0
k. Threatened to hurt me.	3	2	1	0	3	2	1	0
l. Made me describe where I was every minute of the day. .	3	2	1	0	3	2	1	0
m. Brought up something from the past to hurt me.	3	2	1	0	3	2	1	0
n. Put down my looks.	3	2	1	0	3	2	1	0
o. Shared private or embarrassing pictures of me………………………….	3	2	1	0	3	2	1	0

14. How often has anyone who you have been on a date with done the following things to you? Mark how often each thing has ever happened, and then mark how often each thing happened during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
	Very often	Sometimes	Not very often	Never	Very often	Sometimes	Not very often	Never
a.a. Called me names, put me down, or said really mean things to me using a cellphone, email, IM, text, Web chat, or a blog	3	2	1	0	3	2	1	0
b.b. Called my cellphone or sent emails, or text messages when I didn’t want them to just to make me mad.	3	2	1	0	3	2	1	0
c.c. Asked me via cellphone, email, IM, text, or chat to have sex or engage in sexual acts when I didn’t want to	3	2	1	0	3	2	1	0
d.d. Spread rumors about me using a cellphone, email, IM, text, web chat, a blog, or a networking site like MySpace or Facebook	3	2	1	0	3	2	1	0
e.e. Used information posted on a networking site like MySpace or Facebook against me (to harass, put me down, etc.)	3	2	1	0	3	2	1	0
f. f. Made me afraid to not respond to a cellphone call, email, IM, or text because of what they might do	3	2	1	0	3	2	1	0
f. g. Shared private or embarrassing pictures/video of me using a cellphone, email, IM, chat, a blog, or a networking site like MySpace or Facebook	3	2	1	0	3	2	1	0
h. Used a cellphone, email, text messages, or chat to threaten to hurt me physically	3	2	1	0	3	2	1	0

15. How often have you done the following things to someone you have ever had a date with? Mark how often you have ever done this, and then mark how often you have done this during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
	Very often	Sometimes	Not very often	Never	Very often	Sometimes	Not very often	Never
a.a. Damaged something that belonged to them	3	2	1	0	3	2	1	0
b.b. Said things to hurt their feelings on purpose.	3	2	1	0	3	2	1	0
c.c. Insulted them in front of others.	3	2	1	0	3	2	1	0
d.d. Threw something at them but missed	3	2	1	0	3	2	1	0
e.e. Would not let them do things with other people	3	2	1	0	3	2	1	0
f. f. Threatened to start dating someone else.	3	2	1	0	3	2	1	0
f. g. Told them they could not talk to someone of the opposite sex	3	2	1	0	3	2	1	0
h. Started to hit them but stopped	3	2	1	0	3	2	1	0
i. Did something just to make them jealous. .	3	2	1	0	3	2	1	0
j. Blamed them for bad things I did.	3	2	1	0	3	2	1	0
k. Threatened to hurt them.	3	2	1	0	3	2	1	0
l. Made them describe where they were every minute of the day. .	3	2	1	0	3	2	1	0
m. Brought up something from the past to hurt them.	3	2	1	0	3	2	1	0
n. Put down their looks.	3	2	1	0	3	2	1	0
o. Shared private or embarrassing pictures of them……	3	2	1	0	3	2	1	0

16. How often have you done the following things to someone you have ever had a date with? Mark how often you have ever done this, and then mark how often you have done this during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
	Very often	Sometimes	Not very often	Never	Very often	Sometimes	Not very often	Never
a.a. Called them names, put them down, or said really mean things to them using a cellphone, email, IM, text, Web chat, or a blog	3	2	1	0	3	2	1	0
b.b. Called their cellphone or sent emails, or text messages when they didn’t want them to just to make them mad.	3	2	1	0	3	2	1	0
c.c. Asked them via cell phone, email, IM, text, or chat to have sex or engage in sexual acts when they didn’t want to.	3	2	1	0	3	2	1	0
d.d. Spread rumors about them using a cellphone, email, IM, text, web chat, a blog, or a networking site like MySpace or Facebook	3	2	1	0	3	2	1	0
e.e. Used information posted on a networking site like MySpace or Facebook against them (to harass, put them down, etc.)	3	2	1	0	3	2	1	0
f. f. Made them afraid to not respond to a cellphone call, email, IM, or text because of what I might do	3	2	1	0	3	2	1	0
f. g. Shared private or embarrassing pictures/video of them using a cellphone, email, IM, chat, a blog, or a networking site like MySpace or Facebook	3	2	1	0	3	2	1	0
h. Used a cellphone, email, text messages, or chat to threaten to hurt them physically	3	2	1	0	3	2	1	0

17. How often has anyone you have been on a date with done the following things to you? Mark how often each thing ever happened, and then mark how often each thing happened during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
		Yes, on more than one occasion	Yes, on one occasion	No		Yes, on more than one occasion	Yes, on one occasion	No
a.a. Followed or spied on you		2	1	0		2	1	0
b.b. Sent you letters or something written that you did not ask for.		2	1	0		2	1	0
c.c. Made phone calls to you that you did not ask for .		2	1	0		2	1	0
d.d. Stood outside your home, school, or workplace		2	1	0		2	1	0
e.e. Showed up at places you were even though they had no business being there		2	1	0		2	1	0
f. f. Left unwanted items for you to find.		2	1	0		2	1	0
f. g. Tried to communicate in other ways against your will		2	1	0		2	1	0
h. Destroyed or messed up your property on purpose or destroyed something you loved		2	1	0		2	1	0

18. If you answered yes to any of the above, how frightened were you by these things the person did to you? (If you answered no to all of the above, go to Question 20 on page 17.)

MARK ONE ANSWER FOR EACH TIME PERIOD

Ever				During the last 6 months
Very frightened	Somewhat frightened	Just a little frightened	Not really frightened	Very frightened	Somewhat frightened	Just a little frightened	Not really frightened
3	2	1	0	3	2	1	0

19. Did you ever believe you or someone close to you would be seriously harmed when the person was following or harassing you?

MARK ONE ANSWER FOR EACH TIME PERIOD

Ever				During the last 6 months
		Yes	No			Yes	No
		1	2			1	2

20. Below is a list of things that some other boys and girls have reported doing to a dating partner. Mark how often you have ever done each thing to someone you have ever had a date with, and then mark how often you have done each thing during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
		More than once	Once	Never		More than once	Once	Never
a.a. Spied on them		2	1	0		2	1	0
b. Followed them		2	1	0		2	1	0
d.c. Showed up at all of the places that they tended to go		2	1	0		2	1	0
e.d. Went by their house and took something to remember them by		2	1	0		2	1	0
f. e. Wrote, called, or e-mailed to them after being asked not to		2	1	0		2	1	0
f. Stood close to them and touched them without being asked to		2	1	0		2	1	0
g. Tried to scare them into being with you.		2	1	0		2	1	0
h. Made specific threats to hurt their friends if they did not stop seeing them.		2	1	0		2	1	0
i. Made specific threats to damage their property if they did not be with you.		2	1	0		2	1	0
j. Made specific threats to harm their pet if they did not be with you.		2	1	0		2	1	0
k. Made specific threats to harm their family if they did not be with you		2	1	0		2	1	0
l. Took them someplace against their will so that I could talk to them.		2	1	0		2	1	0
m. Broke into their house/apartment		2	1	0		2	1	0

21. How many times has any person who you have been on a date with done the following things to you? Only include it when the dating partner did it to you first. In other words, don’t count it if they did it to you in self-defense. Mark how often each thing ever happened, and then mark how often each thing happened during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
	10 or more times	4 to 9 times	1 to 3 times	Never	10 or more times	4 to 9 times	1 to 3 times	Never
a.a. Scratched me	3	2	1	0	3	2	1	0
b.b. Slapped me.	3	2	1	0	3	2	1	0
c.c. Physically twisted my arm.	3	2	1	0	3	2	1	0
d.d. Slammed me or held me against a wall	3	2	1	0	3	2	1	0
e.e. Kicked me	3	2	1	0	3	2	1	0
f. f. Bent my fingers	3	2	1	0	3	2	1	0
f. g. Bit me	3	2	1	0	3	2	1	0
h. Tried to choke me	3	2	1	0	3	2	1	0
i. Pushed, grabbed, or shoved me.	3	2	1	0	3	2	1	0
j. Dumped me out of a car.	3	2	1	0	3	2	1	0
k. Threw something at me that hit me	3	2	1	0	3	2	1	0
l. Forced me to have sex. .	3	2	1	0	3	2	1	0
m. Forced me to do other sexual things that I did not want to do	3	2	1	0	3	2	1	0
n. Burned me.	3	2	1	0	3	2	1	0
o. Hit me with a fist	3	2	1	0	3	2	1	0
p. Hit me with something hard besides a fist.	3	2	1	0	3	2	1	0
q. Beat me up	3	2	1	0	3	2	1	0
r. Assaulted me with a knife or gun.	3	2	1	0	3	2	1	0

If all of your answers to Question 21 were never, go to Question 24 on page 20. Otherwise, continue with the next questions.

22. Of all the incidents that you marked on Question 21, during how many of these incidents was the other person using alcohol or other drugs when the incident occurred?

MARK ONE

₁ All of the times

₂ Most of the times

₃ Some of the times

₄ None of the times

23. How many of the times were you using alcohol or other drugs when the incidents occurred?

MARK ONE

₁ All of the times

₂ Most of the times

₃ Some of the times

₄ None of the times

24. How many times have you done the following things to a person who you have been on a date with? Only include when you did it to him/her first. In other words, don’t count it if you did it in self-defense. Mark how often each thing ever happened, and then mark how often each thing happened during the last 6 months. Even if you mark “Never” for the Ever time period, you will need to mark an answer for the During the last 6 months time period as well.

MARK ONE ANSWER FOR EACH TIME PERIOD	Ever				During the last 6 months
	10 or more times	4 to 9 times	1 to 3 times	Never	10 or more times	4 to 9 times	1 to 3 times	Never
a.a. Scratched them	3	2	1	0	3	2	1	0
b.b. Slapped them.	3	2	1	0	3	2	1	0
c.c. Physically twisted their arm	3	2	1	0	3	2	1	0
d.d. Slammed or held them against a wall	3	2	1	0	3	2	1	0
e.e. Kicked them	3	2	1	0	3	2	1	0
f. f. Bent their fingers	3	2	1	0	3	2	1	0
f. g. Bit them	3	2	1	0	3	2	1	0
h. Tried to choke them	3	2	1	0	3	2	1	0
i. Pushed, grabbed, or shoved them	3	2	1	0	3	2	1	0
j. Dumped them out of a car	3	2	1	0	3	2	1	0
k. Threw something at them that hit them	3	2	1	0	3	2	1	0
l. Forced them to have sex	3	2	1	0	3	2	1	0
m. Forced them to do other sexual things that they did not want to do	3	2	1	0	3	2	1	0
n. Burned them	3	2	1	0	3	2	1	0
o. Hit them with a fist	3	2	1	0	3	2	1	0
p. Hit them with something hard besides a fist	3	2	1	0	3	2	1	0
q. Beat them up	3	2	1	0	3	2	1	0
r. Assaulted them with a knife or gun	3	2	1	0	3	2	1	0

If all of your answers to Question 24 were NEVER, skip to Question 27 on page 22. Otherwise, continue with Question 25 below.

25. How many different dating partners have you done any of the things you marked on Question 24 to during the last 6 months?

MARK ONE

₁ 1

₂ 2 to 3

₃ 4 to 9

₄ 10 to 14

₅ 15 to 19

₆ 20 or more

26. Of all the times you have done the things you marked on Question 24 to a dating partner, during how many of the times were you using alcohol or other drugs?

MARK ONE

₁ All of the times

₂ Most of the times

₃ Some of the times

₄ None of the times

27. Mark each of the following things you have had at school.

MARK ALL THAT YOU HAVE HAD AT SCHOOL

₁ A play about dating violence

₂ A poster contest about dating violence

₃ A teacher talking about what dating violence is

₄ Someone talking about good ways to resolve conflicts

₅ Instructions on where I can go for help if I am involved in a violent dating relationship

₆ Something called the Safe Dates curriculum

₇ More than 5 class sessions during which dating violence was discussed

₈ None of the above

28. Have you ever participated in any other dating violence prevention program in school, where you learn about dating violence and what to do about it?

₁ Yes

₂ No

29. Have you ever participated in a dating violence prevention program outside of school, where you learn about dating violence and what to do about it?

₁ Yes

₂ No

The next questions are about your health.

30. In general, would you say your health is excellent, very good, good, fair, or poor?

MARK ONE

₁ Excellent

₂ Very good

₃ Good

₄ Fair

₅ Poor

31. The next items are about activities you might do during a typical day. Does your health limit you in these activities? If so, how much?

MMARK ONE ANSWER FOR EACH	Limited a lot	Limited a little	Not limited at all
a.a. First, moderate activities such as moving a table, pushing a vacuum cleaner, or going for a brisk walk	1	2	3
e.b. Climbing a flight of stairs	1	2	3

32. During the past 4 weeks. . . .

MMARK ONE ANSWER FOR EACH	Yes	No
a.a. Have you accomplished less than you would like as a result of your physical health?	1	2
e.b. Were you limited in the regular activities you do as a result of your physical health?	1	2
c. Have you accomplished less than you would like to as a result of any emotional problems, such as feeling depressed or anxious?	1	2

33. During the past 4 weeks, how much did pain interfere with your normal daily activities? Did it interfere not at all, slightly, moderately, quite a bit, or extremely?

MARK ONE

₁ Not at all

₂ Slightly

₃ Moderately

₄ Quite a bit

₅ Extremely

34. The next questions ask about how you feel and how things have been with you during the past 4 weeks. For each question, please give one answer that comes closest to the way you have been feeling. How much time during the past 4 weeks. . . .

MARK ONE ANSWER FOR EACH	All of the time	Most of the time	A good bit of the time	Some of the time	A little of the time	None of the time
a.a. Have you felt calm and peaceful?	1	2	3	4	5	6
b.b. Did you have a lot of energy?.	1	2	3	4	5	6
c.c. Have you felt down?.	1	2	3	4	5	6
d.d. Has your physical health or emotional problems interfered with your social activities like visiting with friends, relatives etc?	1	2	3	4	5	6

35. How tall are you? _____feet _____inches

36. How much do you weigh? _____pounds

37. How do you describe your weight?

MARK ONE

₁ Very underweight

₂ Underweight

₃ About the right weight

₄ Overweight

₅ Very overweight

38. How strongly do you agree or disagree with each of the following statements?

MARK ONE ANSWER FOR EACH	Strongly agree	Agree somewhat	Disagree somewhat	Strongly disagree
a.a. I am satisfied with my weight	3	2	1	0
b.b. Most of the time, I am happy with the way I look.	3	2	1	0
c.c. In the past year, I have been very worried about my health	3	2	1	0
d.d. I wish that I were in better physical condition.	3	2	1	0
e.e. I am uncomfortable with the way my body is developing	3	2	1	0
f. f. I am proud of my body	3	2	1	0
f. g. I am satisfied with my height	3	2	1	0
h. I frequently feel ugly and unattractive	3	2	1	0
i. When others look at me, they must think that I am poorly developed .	3	2	1	0
j. My body is growing about as quickly as I would like it to.	3	2	1	0
k. I feel strong and healthy	3	2	1	0

39. How old are you?

₁ 11 years old

₂ 12 years old

₃ 13 years old

₄ 14 years old

₅ 15 years old

₆ 16 years old

₇ 17 years old

₈ 18 years old

₉ 19 years old

40. What is your sex?

₁ Female

₂ Male

41. Are you Hispanic or Latino?

₁ Yes

₂ No

42. 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___________________)

43. Does your mother, or a woman like a mother, live in your home?

₁ Yes

₂ No→GO TO 45

44. How far in school has she gone?

MARK ONE

₁ Didn’t graduate from high school

₂ Graduated from high school

₃ Vocational or business school

₄ Some college

₅ Graduated from college

₆ More than 4 years of college

₉₈ Don’t know

45. Does your father, or a man like a father, live in your home?

₁ Yes

₂ No→Go to page 27

46. How far in school has he gone?

MARK ONE

₁ Didn’t graduate from high school

₂ Graduated from high school

₃ Vocational or business school

₄ Some college

₅ Graduated from college

₆ More than 4 years of college

₉₈ Don’t know

You have completed the Youth Dating Survey.

Thank you for your participation.