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Completion and Follow Up Survey (12- and 18-month) |
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Expect Respect Support Group Survey |
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OMB No. __0920-xxxx0861
Exp. Date: 08/31/2013
Public
Reporting burden of this collection
of information is estimated at 60 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 may 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-xxxx0861).
Completion and Follow-Up Survey
Instructions
We would like to ask you a few questions about your relationships. This is not a test, so there are no right or wrong answers.
Please read the directions and questions carefully and answer the questions as honestly as you can. The Expect Respect Facilitator will assist you if you need help.
Your answers are completely confidential. School personnel will not see your questionnaire. Your name will not appear on the survey.
By answering the questions you help us to understand what is important to teens like you and how we can improve programs for teens.
To be completed by SafePlace staff
1. SafePlace ID |
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2. School Code
3. Facilitator Code
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4. Date
5. Age ______________
6. Post and Follow-up Survey
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Part 1: Are the following statements true for you?
7. I always speak out when someone is being harassed.
1 False
2True
8. I sometimes feel upset when I don’t get my way.
1 False
2True
9. I like to gossip sometimes.
1 False
2True
10. I’m always a good listener.
1 False
2True
11. I’m always willing to admit it when I make a mistake.
1 False
2True
12. I am always nice with people.
1 False
2True
13. I have never hurt someone’s feelings on purpose.
1 False
2True
Part 2: Dealing with Anger
Most of us feel angry sometimes. Do not spend a lot of time thinking about the questions – just give your first response.
In the past 3 months, how often have you … |
Never |
Rarely |
Sometimes |
Often |
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Part 3: Your Opinion
Is it OKAY if you do these things in a dating relationship? |
Definitely not okay |
Probably not okay |
Probably okay |
Definitely okay |
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How strongly do you agree or disagree with each statement? |
Strongly agree |
Agree somewhat |
Disagree somewhat |
Strongly disagree |
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Part 4: Relationships
By dating we’re talking about having a boyfriend or a girlfriend, going out or hanging out in a romantic way, or hooking up with one person. This can be a relationship of any length.
58. Have you dated in the past 3 months? If NO, skip to question 136 (page 12). If YES, continue with the next questions. |
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59. How many people have you dated in the past 3 months?
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When you answer the following questions, please think about all the dating relationship(s) you’ve had in the past 3 months.
By dating partner we’re talking about a boyfriend or girlfriend, someone you go out with or hang out with in a romantic way, or someone you hook up with.
In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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Part 5: About You
132. What grade are you in? |
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133. Are you? |
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134. What were your grades for the last semester or grading period you completed? (Mark one.)
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135. Which of the following best describes you? (Mark one.) |
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136. Have you participated in any of the following activities in the past 12 months? (Mark all that apply.)
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How much has group helped you?
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Not at all |
Somewhat |
Very much |
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Think about what your dating relationships were like before you started this program and think about your dating relationships in the past 3 months.
Only answer these questions if you were dating before you started this program and if you were also dating in the past 3 months.
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In the past 3 months, did these things happen more often, the same or less often than before you started Expect Respect.
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More often than before
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Same as before |
Less often than before |
Never happened in the past or now |
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Part 1: About You
6. What grade are you in? |
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7. Are you? |
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9. Which of the following best describes you? (Mark one.) |
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10. Have you participated in any of the following activities in the past 12 months? (Mark all that apply.) 1 I have participated in Expect Respect Support Groups. 2 I have participated in a leadership group to prevent bullying, sexual harassment and dating violence. 3 I have participated in a poster, poetry or other contest about dating violence and healthy relationships. 4 We have talked about dating violence and healthy relationships in class. 5 We have talked about dating violence and healthy relationships in my after-school program. 6 I have seen a theater performance about bullying, sexual harassment and dating violence. 7 I have participated in an assembly about bullying, sexual harassment and dating violence. 8 I have seen posters and handouts in my school about dating violence. 9 I talk to my parents about how to have good relationships. 10 I have talked to my friends about healthy relationships. 11 I have gotten information about healthy relationships in other ways (please list): __________________________________________________
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April
2010 Compiled and adapted by SafePlace.
Please,
contact SafePlace before using this survey and for information about
sources. (512) 356 1623 or (512) 356 1628.
Are the following statements true for you?
11. I always speak out when someone is being harassed.
1 False
2True
12. I sometimes feel upset when I don’t get my way.
1 False
2True
13. I like to gossip sometimes.
1 False
2True
14. I’m always a good listener.
1 False
2True
15. I’m always willing to admit it when I make a mistake.
1 False
2True
16. I am always nice with people.
1 False
2True
17. I have never hurt someone’s feelings on purpose.
1 False
2True
Part 2: Relationships
By dating we’re talking about having a boyfriend or a girlfriend, going out or hanging out in a romantic way, or hooking up with one person. This can be a relationship of any length.
18. Have you dated in the past 3 months? If NO, skip to question 96 (page 10). If YES, continue with the next questions. |
1 Yes |
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19. How many people have you dated in the past 3 months? |
1 1 |
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20. How often did you and this dating partner spend time together in the past 3 months?
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1 About once a month |
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1 Never, we were usually with other friends |
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22. Who do you feel had more power in this dating relationship in the past 3 months?
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1 I had more power |
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23. How physically affectionate were you and your partner in the past 3 months? |
1 Not much, we mostly held hands |
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When you answer the following questions, please think about all the dating relationship(s) you’ve had in the past 3 months.
By dating partner we’re talking about a boyfriend or girlfriend, someone you go out with or hang out with in a romantic way, or someone you hook up with.
In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
I let my partner know what was important to me. |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
I tried to keep my partner from spending time with other people. |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
I hit my partner with a fist or a hard object. |
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In the past 3 months, how often did the following things happen in your dating relationship(s)?
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Rarely |
Some- times |
Often |
I was afraid of my partner. |
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In the past 3 months, how often did the following things happen in your dating relationship(s)?
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Never |
Rarely |
Some- times |
Often |
I spread sexual rumors about my partner. |
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Part 3: Dealing with Anger
Most of us feel angry sometimes. Do not spend a lot of time thinking about the questions – just give your first response.
In the past 3 months, how often have you … |
Never |
Rarely |
Sometimes |
Often |
Yelled at others when they annoyed you |
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Part 4: Your Opinion
Is it OKAY if you do these things in a dating relationship? |
Definitely not okay |
Probably not okay |
Probably okay |
Definitely okay |
Take charge of everything that goes on. |
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How strongly do you agree or disagree with each statement? |
Strongly agree |
Agree somewhat |
Disagree somewhat |
Strongly disagree |
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Thank you for your hard work in answering these questions.
File Type | application/msword |
File Title | Completion and Follow Up Survey (12- and 18-month) |
Author | User |
Last Modified By | its7 |
File Modified | 2011-03-24 |
File Created | 2011-03-04 |