Att E - Completion and Follow up Survey

Completion and Follow Up Survey (12- and 18-month)

Expect Respect Support Group Survey

Form Approved

OMB No. 0920-0861

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 (0920-0861).

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
2. School Code 3. Facilitator Code
4. Date 5. Age ______________ 6. Post and Follow-up Survey
1 Post		2 Follow-up 1	3 Follow-up 2

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
Yelled at others when they annoyed you	0	1	2	3
Had fights with others to show who was on top	0	1	2	3
Reacted angrily when provoked by others	0	1	2	3
Taken things from other students	0	1	2	3
Gotten angry when frustrated	0	1	2	3
Damaged something for fun	0	1	2	3
Had temper tantrums	0	1	2	3
Damaged things because you felt mad	0	1	2	3
Had a gang fight to be cool	0	1	2	3
Hurt others to win a game	0	1	2	3
Become angry or mad when you don’t get your way	0	1	2	3
Used physical force to get others to do what you want	0	1	2	3
Gotten angry or mad when you lost a game	0	1	2	3
Gotten angry when others threatened you	0	1	2	3
Used force to obtain money or things from others	0	1	2	3
Felt better after hitting or yelling at someone	0	1	2	3
Threatened or bullied someone	0	1	2	3
Made obscene phone calls for fun	0	1	2	3
Hit others to defend yourself	0	1	2	3
Gotten others to gang up on someone else	0	1	2	3
Carried a weapon to use in a fight	0	1	2	3
Gotten angry or mad or hit others when teased	0	1	2	3
Yelled at others so they would do things for you	0	1	2	3

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
Take charge of everything that goes on.	0			1		2		3
Tell your dating partner to spend all their time with you and drop other friends.	0			1		2		3
Check up or spy on your dating partner.	0			1		2		3
Put your partner down and call him/her mean names.	0			1		2		3
Make your partner dress a certain way.	0			1		2		3
Constantly send text messages.	0			1		2		3
Ignore your partner when you are unhappy with him/her.	0			1		2		3
Try to find out where your partner is every minute.	0			1		2		3
Slap, push, or shove your partner.	0			1		2		3
Forward private emails or photos to other people.	0			1		2		3
Act jealous if your partner talks to other people.	0			1		2		3
Kiss your partner when they say “No.”	0			1		2		3
Tell your partner that to show their love they should have sex with you.	0			1		2		3
How strongly do you agree or disagree with each statement?		Strongly agree	Agree somewhat		Disagree somewhat		Strongly disagree
It is OK for a boy to hit his girlfriend if she does something to make him mad.		0	1		2		3
It is OK for a boy to hit his girlfriend if she insults him in front of friends.		0	1		2		3
Girls sometimes deserve to be hit by the boys they date.		0	1		2		3
A girl who makes her boyfriend jealous on purpose deserves to be hit.		0	1		2		3
Boys sometimes deserve to be hit by the girls they date.		0	1		2		3
Sometimes boys have to hit their girlfriends to get them to do what they want them to do.		0	1		2		3
It is OK for a boy to hit a girl if she hits him first.		0	1		2		3
It is OK for a girl to hit a boy if he hits her first.		0	1		2		3

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 132 (page 13). If YES, continue with the next questions.					1 Yes			2 No
59. How many people have you dated in the past 3 months? 1 1	2 2 - 3		3 4 - 7		4 More than 7 people
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		Rarely		Some- times	Often
I let my partner know what was important to me.		0		1		2	3
I said “no” when I was uncomfortable with what was going on.		0		1		2	3
I calmed myself down before talking when I was mad.		0		1		2	3
I talked to my partner about how I really felt.		0		1		2	3
I tried to keep my partner from spending time with other people.		0		1		2	3
My partner tried to keep me from spending time with other people.		0		1		2	3
I put my partner down.		0		1		2	3
My partner put me down.		0		1		2	3
I asked my partner what he/she was feeling.		0		1		2	3
I offered a solution that would make us both happy.		0		1		2	3
I scratched or slapped my partner.		0		1		2	3
My partner scratched or slapped me.		0		1		2	3
I listened to my partner’s side of the story.		0		1		2	3
I called my partner bitch, slut, ho, player or gay.		0		1		2	3
My partner called me bitch, slut, ho, player or gay.		0		1		2	3
I made fun of my partner in front of others.		0		1		2	3
My partner made fun of me in front of others.		0		1		2	3
I checked where my partner was and who he/she was hanging out with.		0		1		2	3
My partner checked where I was and who I was hanging out with.		0		1		2	3
I let my partner know what I wanted.		0		1		2	3
I did not let my partner do things with other people.		0		1		2	3
My partner did not let me do things with other people.		0		1		2	3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I threatened to end the relationship if my partner didn’t do what I wanted.	0	1	2	3
My partner threatened to end the relationship if I didn’t do what he/she wanted.	0	1	2	3
I showed nude or almost nude pictures/ video of my partner to others.	0	1	2	3
My partner showed nude or almost nude pictures/ video of me to others.	0	1	2	3
I threatened to hurt or hit my partner.	0	1	2	3
My partner threatened to hurt or hit me.	0	1	2	3
I told my partner when I was angry and why.	0	1	2	3
I told my partner that he/she should touch me in a sexual way to prove their love.	0	1	2	3
My partner told me that I should touch him/her in a sexual way to prove my love.	0	1	2	3
I yelled and screamed at my partner.	0	1	2	3
My partner yelled and screamed at me.	0	1	2	3
I spread sexual rumors about my partner.	0	1	2	3
My partner spread sexual rumors about me.	0	1	2	3
I made nasty comments about my partner to others.	0	1	2	3
My partner made nasty comments about me to others.	0	1	2	3
I hit my partner with a fist or a hard object.	0	1	2	3
My partner hit me with a fist or a hard object.	0	1	2	3
I pressured my partner to engage in a sexual act.	0	1	2	3
My partner pressured me to engage in a sexual act.	0	1	2	3
I showed up at my partner’s home, school or work or waited for him/her even when my partner didn’t want me to.	0	1	2	3
My partner showed up at my home, school or work or waited for me even when I didn’t want him/her to.	0	1	2	3
I twisted my partner’s arm or bent his/her fingers.	0	1	2	3
My partner twisted my arm or bent my fingers.	0	1	2	3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never		Rarely		Some- times	Often
I grabbed or touched my partner’s private parts without his/her consent.	0		1		2	3
My partner grabbed or touched my private parts without my consent.	0		1		2	3
I repeatedly used cell phone, text messaging, or e-mail to check up on my partner and to see where he/she was.	0		1		2	3
My partner repeatedly used cell phone, text messaging, or e-mail to check up on me and to see where I was.	0		1		2	3
I forced my partner to kiss me.	0		1		2	3
My partner forced me to kiss him/her.	0		1		2	3
I pushed, shoved, or kicked my partner.	0		1		2	3
My partner pushed, shoved or kicked me.	0		1		2	3
I got my partner drunk or high to get him/her to do something sexual.	0		1		2	3
My partner got me drunk or high to get me to do something sexual.	0		1		2	3
I used e-mails, text messaging, web chat, blog Facebook, MySpace or Twitter to spread rumors about my partner.	0		1		2	3
My partner used e-mails, text messaging, web chat, blog Facebook, MySpace or Twitter to spread rumors about me.	0		1		2	3
I beat my partner up.	0		1		2	3
My partner beat me up.	0		1		2	3
I was afraid of my partner.	0		1		2	3
My partner was afraid of me.	0		1		2	3
I used physical force to protect or defend myself.	0		1		2	3
I had a bruise or small cut.	0	1		2		3
My partner had a bruise or small cut.	0	1		2		3
I felt physical pain that still hurt the next day.	0	1		2		3
My partner felt physical pain that still hurt the next day.	0	1		2		3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I went to a doctor or nurse because of an injury.	0	1	2	3
My partner went to a doctor or nurse because of an injury.	0	1	2	3
I felt unsafe.	0	1	2	3
My partner felt unsafe.	0	1	2	3
I worried that I could get hurt physically.	0	1	2	3
I worried that I could hurt my partner physically.	0	1	2	3

Part 5: About You

132. What grade are you in?
	1 6th	2 7th		3 8th		4 9th	5 10th	6 11th		7 12th
133. Are you?
	1 Female		2 Male		3 Transgender
134. What were your grades for the last semester or grading period you completed? (Mark one.) 1 mostly A’s 2 mostly B’s 3 mostly C’s 4 mostly D’s 5 some A’s, some B’s and some C’s
135. Which of the following best describes you? (Mark one.)
	1 American Indian or Alaska Native					5 Native Hawaiian or Other Pacific Islander
	2 Asian					6 White
	3 Black or African American					7 Other
	4 Hispanic or Latino					8 Multiracial
136. 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): __________________________________________________

How much has group helped you?	Not at all	Somewhat	Very much
Communicate your thoughts and feelings	1	2	3
Increase your personal safety	1	2	3
Learn healthy ways to cope with problems	1	2	3
Feel supported	1	2	3
Stand up for yourself	1	2	3
Increase your understanding of abusive and respectful relationships	1	2	3
Increase your skills for healthy relationships	1	2	3
Know how to help a friend in an abusive relationship	1	2	3
Feel more comfortable to discuss and report hurtful things that happen in your relationships, such as put downs or hitting.	1	2	3
Become aware of abusive behaviors in others	1	2	3
Speak up when you see abusive or harassing behavior in others.	1	2	3
Become aware of abusive behaviors that you may be using toward others	1	2	3
Feel confident that you can have healthy relationships	1	2	3

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.

In the past 3 months, did these things happen more often, the same or less often than before you started Expect Respect.	More often than before	Same as before	Less often than before	Never happened in the past or now
I put down, controlled or threatened a dating partner.	0	1	2	3
My partner put me down, controlled or threatened me.	0	1	2	3
I scratched, slapped, kicked or otherwise physically hurt a dating partner.	0	1	2	3
My partner scratched, slapped, kicked or otherwise physically hurt me.	0	1	2	3
I pressured a dating partner to do something sexual when he/she didn’t want to.	0	1	2	3
A dating partner pressured me to do something sexual when I didn’t want to.	0	1	2	3

Thank you for your hard work in answering these questions.

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