Instrument 1

Evaluation of Pregnancy Prevention Approaches - Baseline

Instrument 1

OMB: 0970-0360

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0360 can be found here:

2011-08-22 - Revision of a currently approved collection

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EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
SUMMARY TABLE, SITE- SPECIFIC BASELINE SURVEY, AND CONSENT FORM:
CHILDREN’S HOSPITAL LOS ANGELES (CHLA)

The CHLA survey instrument is for adolescent mothers and therefore is not divided into separate parts
for sexually active and non-sexually active youth.

SUMMARY OF DIFFERENCES BETWEEN THE BASELINE CONCORDANCE INSTRUMENT AND THE CHILDREN’S HOSPITAL LOS ANGELES (CHLA) BASELINE SURVEY

CHLA #

Concordance #

Items are listed in the order in which they appear on the CHLA baseline instrument. The number for the corresponding baseline concordance item is listed in the “Concordance
#” column. The CHLA instrument will be administered to adolescent mothers so, there are no separate sections for sexually active and non-sexually active respondents. Items
found on the concordance instrument that are not on the CHLA instrument are listed at the bottom of the table.
• Modifications to an existing baseline concordance item are listed in the “Modifications” column; otherwise, the question text on the CHLA instrument is the same as
that on the baseline concordance instrument.
• If an item is specific to the CHLA instrument, it is indicated by an “N/A” in the “Concordance #” column and the question text is noted in the “Modifications” column.

1.1

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1.2

What grade are you in?

What is the last grade you completed?

MARK (X) ONE

□ 6th
□ 7th
□ 8th
□ 9th
□ 10th
□ 11th
□ 12th
□ Not currently in school

□ Less than 6th grade
□ 7th
□ 8th
□ 9th
□ 10th
□ 11th
□ 12th
□ Completed GED pretest
□ Completed GED
□ Some school after high school

Baseline Concordance Question Text

Modifications for CHLA

CHLA #

Concordance #

1.3

N/A

Baseline Concordance Question Text

Modifications for CHLA
What is your current school status?
MARK (X) ONE

1.4

1.11

□ Enrolled in public or private middle or high school
□ Enrolled in a continuation/alternative school or
court/community school
□ Enrolled in adult education classes
□ Enrolled in technical or vocation school
□ Enrolled in 2-year college
□ Enrolled in 4-year college or university
□ Not currently enrolled in any school or classes
What is the highest level of education you would like to complete?

How likely is it that you will do each of the following things?
MARK (X) ONE

MARK (X) ONE
□ Graduate from high school or obtain a GED
□ Attend technical or vocational school
□ Graduate from a 2-year community college (Associate’s degree)
□ Graduate from a 4-year college (Bachelor’s degree)
□ Obtain a graduate degree (Masters, PhD, MD, etc.)

Not at all likely, A little bit likely, Somewhat likely, Very likely
a.
b.
c.
d.
e.
1.5

Graduate from high school
Go to a technical or vocational school after high school
Go to college
Graduate from a 2-year or community college program
Graduate from a 4-year college program

N/A

Are you currently working?
MARK (X) ONE
□ Yes – full-time
□ Yes – part-time
□ No – but currently looking for a job
□ No – and not currently looking for a job

CHLA #

Concordance #

Baseline Concordance Question Text

1.6

1.4

Are you Hispanic/Latino?

Modifications for CHLA

MARK (X) ONE
□
Yes
□
No
1.7

1.5

What is your race?
YOU MAY MARK (X) MORE THAN ONE ANSWER
□
American Indian or Alaska Native
□
Asian
□
Black or African-American
□
Native Hawaiian or Other Pacific Islander
□
White
□
Some other race PRINT OTHER RACE

1.8

N/A

Are you…
MARK (X) ONE
□ Not currently seeing anyone
□ Casually dating
□ Seriously dating
□ Engaged
□ Married

CHLA #

Concordance #

Baseline Concordance Question Text

1.9

6.2

How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know

How many of your friends who are your age have done the
following things?
MARK (X) ONE FOR EACH
None, Some, Half, Most, All, Don’t Know

a. Had sexual intercourse
b. Had oral sex

1.10

Modifications for CHLA

a.
b.
c.

N/A

Had sexual intercourse
Been pregnant
Been a teen parent

Below is a list of some of the ways you may have felt or behaved.
Please indicate how often you have felt this way during the past
week by checking the appropriate response.
MARK (X) ONE FOR EACH
Rarely or none of the time (Less than 1 day)
Some of or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
a. I felt depressed
b. I felt lonely
c. I had crying spells
d. I felt sad

CHLA #

Concordance #

2.1

2.6

Baseline Concordance Question Text

Modifications for CHLA

Now we have some questions about your mother, or the person you think of
as your mother. Is this person…?

Added “Please specify” after “some other adult”

MARK (X) ONE
□
□
□
□
□
□
□
2.2

Your biological mother, that is, the woman who gave birth to you
Your stepmother or adoptive mother
Your foster mother
Your grandmother
Your aunt or your older sister
Some other adult
Don’t have a mother or person I think of as a mother
GO TO 2.3

N/A

Please answer the questions below about your mother or the
person you think of as your mother that you identified in the
previous question.
How much do you agree with the following statements about your
mother or the person you think of as your mother?
MARK (X) ONE FOR EACH
Strongly disagree, Disagree, Neither disagree or agree, Agree,
Strongly agree
a.
b.
c.
d.

My mother supports me to be a good parent
My mother’s help with the baby is just about right
My mother criticizes the way I take care of my baby
My mother gives me too much help with my baby

CHLA #

Concordance #

2.3

N/A

Baseline Concordance Question Text

Modifications for CHLA
Were any of the following members of your family teen mothers?
MARK (X) ONE FOR EACH
Yes, No
a.
b.
c.

2.4

2.1a

The next questions are about where you live and who lives with you.

Mother
Grandmother
Sister

Added the response option:

Which of the following best describes where you live?

□ You live in a residential program

MARK (X) ONE
□ You live in one home – GO TO 2.2
□ You live in two or more homes and go back and forth – GO TO 2.3
□ You are homeless (living on the street, in a car or shelter, staying with
friends/relatives) – GO
TO 2.4

GO TO 2.7

CHLA #

Concordance #

Baseline Concordance Question Text

2.5

2.2

Who lives with you in your home?

Modifications for CHLA
Modified the response categories:

MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□

MARK (X) ALL THE PEOPLE WHO LIVE WITH YOU
Your biological mother
Your biological father
A stepmother or adoptive mother
A foster mother
A stepfather or adoptive father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandfathers
Any older brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

□Your mother, or the person you think of as your mother
□Your father, or the person you think of as your father
□Any grandmothers
□Any grandfathers
□Any brothers or sisters
□Any aunts, uncles, or other relatives
□Your baby
□The father of your baby
□The parent(s) of the father of your baby
□Your current boyfriend/ partner who isnot the father of your
baby
□Friends or roommates
□You live by yourself

CHLA #

Concordance #

Baseline Concordance Question Text

2.6

2.3

Who lives with you in each of your homes?

Modifications for CHLA
Modified the response categories:

Mark (X) all of the people who live with you in your MAIN home, and then
mark (X) all of the people who live with you in your OTHER homes.

MARK ALL THAT APPLY (List appears for both the MAIN home
and the OTHER home(s))

MARK ALL THAT APPLY (List appears for both the MAIN home and the
OTHER home(s))

□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□
□
2.7

Your biological mother
Your biological father
A stepmother or adoptive mother
A foster mother
A stepfather or adoptive father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandfathers
Any older brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

Your mother, or the person you think of as your mother
Your father, or the person you think of as your father
Any grandmothers
Any grandfathers
Any brothers or sisters
Any aunts, uncles, or other relatives
Your baby
The father of your baby
The parent(s) of the father of your baby
Your current boyfriend/partner who is not the father of your
baby
Friends or roommates
You live by yourself

□
□

N/A

How many times have you moved in the past 6 months?
□
|

None
| NUMBER OF TIMES - Your best guess is fine.

Concordance #

CHLA #

Baseline Concordance Question Text

Modifications for CHLA

4.3
Part
B1

The very first time you had sexual intercourse, what month and year was it?

Added introduction: The next questions are about sexual
intercourse. By sexual intercourse, we mean a male putting his
penis into a female’s vagina.

4.4
Part
B1

The very first time you had sexual intercourse, how old were you?

3.3

4.10
Part
B1

How many DIFFERENT PEOPLE have you ever had sexual intercourse with,
even if only one time?

3.4

N/A

3.1

3.2

MARK (X) ONE MONTH AND ONE YEAR

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

| NUMBER OF PEOPLE - Your best guess is fine.
Now please think about the past 4 weeks. Have you had sexual
intercourse in the past 4 weeks?
MARK (X) ONE

3.5

4.11
Part
B1

Now please think about the past 3 months. In the past 3 months, how many
TIMES have you had sexual intercourse?
□
|

□ Yes
□ No
GO TO 3.10
Modified the reference period to past 4 weeks:
In the past 4 weeks, how many TIMES have you had sexual
intercourse?

None
GO TO 4.14
| | NUMBER OF TIMES - Your best guess is fine.

| NUMBER OF TIMES - Your best guess is fine.

CHLA #

Concordance #

3.6

N/A

Baseline Concordance Question Text

Modifications for CHLA
In the past 4 weeks, have you used any of the following methods
of birth control?
MARK (X) ONE FOR EACH
Yes, No
a. Condoms
b. Birth control pills
c. The shot (Depo-Provera)
d. The patch
e. The ring (NuvaRing)
f. IUD (Mirena or Paragard)
g. Implants (Implanon)
h. Emergency contraception (Plan B)
i. Other (Please specify)

3.7

4.12
Part
B1

In the past 3 months, how many TIMES have you had sexual intercourse
without using a condom?
□
|

Modified the reference period to past 4 weeks:
In the past 4 weeks, how many TIMES have you had sexual
intercourse without using a condom?

None
| | NUMBER OF TIMES - Your best guess is fine.

| NUMBER OF TIMES - Your best guess is fine.

Concordance #

CHLA #
3.8

4.13
Part
B1

Baseline Concordance Question Text

Modifications for CHLA

The next question is about your use of the following methods of birth control:

Modified the reference period to past 4 weeks:

•
•
•
•
•
•
•

The next question is about your use of the following methods of
birth control:

Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)

a.
b.
c.
d.
e.
f.
g.

In the past 3 months, how many TIMES have you had sexual intercourse
without using any of these methods of birth control?
□
|

In the past 4 weeks, how many TIMES have you had sexual
intercourse without using any of these methods of birth control?

None
| NUMBER OF TIMES - Your best guess is fine.

|
3.9

Condoms
Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)

N/A

| NUMBER OF TIMES - Your best guess is fine.

Only ask if said “Yes” to having sex in last 4 weeks AND “No” to
using any birth control during last 4 weeks.
There are different reasons people give for not using
contraception. Please mark ALL of the reasons that are true for
you.
MARK (X) ALL THAT APPLY
□ I just haven’t gotten around to getting anything yet
□ I don’t think I can get pregnant right now
□ My partner doesn’t want me to use contraception
□ I don’t use it because of the side effects for me or my baby
□ Other (please specify):

CHLA #

Concordance #

3.10

6.3

Baseline Concordance Question Text

Modifications for CHLA

In general, how much pressure, if any, do you feel from your friends to have
sexual intercourse?

Modified question to ask about pressure from boyfriend/partner
to have sex without birth control:

MARK (X) ONE

In general, how much pressure, if any, do you feel from your
boyfriend/partner to have sex without birth control?

□
□
□
□

3.11

3.16

A lot of pressure
Some pressure
A little pressure
No pressure

MARK (X) ONE
□ A lot of pressure
□ Some pressure
□ A little pressure
□ No pressure
□ I do not have a boyfriend/partner

Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
o
o
o
o

3.12

3.17

Yes, definitely
Yes, probably
No, probably not
No, definitely not

GO TO 3.19

If you have sexual intercourse in the next year, do you intend to use a
condom?
MARK (X) ONE
o
o
o
o

Yes, definitely
Yes, probably
No, probably not
No, definitely not

CHLA #

Concordance #

3.13

3.18

Baseline Concordance Question Text

Modifications for CHLA

The next question is about your intention to use other methods of birth
control, NOT including condoms:
•
•
•
•
•
•

Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)

If you have sexual intercourse in the next year, do you intend to use any of
these other methods of birth control?
MARK (X) ONE
o
o
o
o

Yes, definitely
Yes, probably
No, probably not
No, definitely not

CHLA #

Concordance #

3.14

N/A

Baseline Concordance Question Text

Modifications for CHLA
Which of the following do you plan on using? (Only ask if answered
Yes to previous question)
MARK (X) ALL THAT APPLY
□ Condoms
□ Oral Contraceptives/birth control pill
□ The shot (Depo-Provera)
□ The patch
□ The ring (NuvaRing)
□ IUD (Mirena or Paragard)
□ Implants (Implanon)
□ Other (Please specify)

3.15

3.8

The next series of questions is about methods of birth control, NOT including
condoms. How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Neither agree nor disagree, Disagree, Strongly disagree
a. Birth control should always be used if a person your age has
sexual intercourse
b. Birth control is a hassle to use
c. Birth control is pretty easy to get
d. Birth control is important to make sex safer
e. Birth control has too many negative side effects
f. Using birth control is morally wrong

Concordance #

CHLA #
3.16

4.14
Part
B1

Baseline Concordance Question Text

Modifications for CHLA

Oral sex is when someone puts his or her mouth on another person’s penis or
vagina, OR lets someone else put his or her mouth on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE
□
□

3.17

4.16
Part
B1

4.17
Part
B1

GO TO 4.19

How many DIFFERENT PEOPLE have you ever had oral sex with, even if only
one time?
|

3.18

Yes
No

| NUMBER OF PEOPLE - Your best guess is fine.

Now please think about the past 3 months.

Modified reference period to past 4 weeks:

In the past 3 months, how many TIMES have you had oral sex?

Now please think about the past 4 weeks. In the past 4 weeks, how
many TIMES have you had oral sex?

□
|

None
GO TO 4.19
| NUMBER OF TIMES - Your best guess is fine.

□
|

None
GO TO 3.21
| NUMBER OF TIMES - Your best guess is fine.

3.20

Concordance #

CHLA #
3.19

4.18
Part
B1

4.19
Part
B1

Baseline Concordance Question Text

Modifications for CHLA

In the past 3 months, how many TIMES have you had oral sex without using a
condom?

Modified reference period to past 4 weeks:

□
|

In the past 4 weeks, how many TIMES have you had oral sex
without using a condom?

None
| NUMBER OF TIMES - Your best guess is fine.

□
|

None
| NUMBER OF TIMES - Your best guess is fine.

Anal sex is when a male puts his penis in someone else’s anus, or their butt,
or someone lets a male put his penis in their anus or butt.
Have you ever had anal sex?
MARK (X) ONE
□
□

3.21

4.20
Part
B1

4.22
Part
B1

GO TO 4.23

How many DIFFERENT PEOPLE have you ever had anal sex with, even if only
one time?
|

3.22

Yes
No

| NUMBER OF PEOPLE - Your best guess is fine.

In the past 3 months, how many TIMES have you had anal sex without using a
condom?
□
|

Modified reference period to past 4 weeks:
Now please think about the past 4 weeks. In the past 4 weeks, how
many TIMES did you have anal sex without using a condom?

None
| | NUMBER OF TIMES - Your best guess is fine.

□
|

None
| NUMBER OF TIMES - Your best guess is fine.

Concordance #

CHLA #
3.23

4.29
Part
B1

Baseline Concordance Question Text

Modifications for CHLA

In the past 12 months, have you been told by a doctor or nurse that you had a
sexually transmitted disease (STD)?

Added introductory statement: These next questions ask about
sexually transmitted diseases, or STDs.

MARK (X) ONE
□
□
3.24

4.30
Part
B1

Yes
No

The next series of questions is about the types of sexually transmitted
diseases or STDs you have had. In the past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION
Yes, No, Don’t know

4.1

4.26b

a. Chlamydia
b. Gonorrhea
c. Genital herpes
d. Syphilis
e. HIV infection or AIDS
Human Papilloma virus, also known as HPV or genital warts
f.
g. Another sexually transmitted disease (STD) PRINT OTHER STD:
To the best of your knowledge, how many times have you been pregnant or
gotten someone pregnant, even if no child was born?
□
|

To the best of your knowledge, how many times have you been
pregnant, even if no child was born?
|

None
| NUMBER OF TIMES

| NUMBER OF TIMES – Your best guess is fine

CHLA #

Concordance #

4.2

N/A

Baseline Concordance Question Text

Modifications for CHLA
When you got pregnant with your baby, were you trying to get
pregnant?
MARK (X) ONE
□
Yes
□
No

4.3

N/A

How likely do you think it is that you will be pregnant again before
your child turns two?
MARK (X) ONE

4.4

□ I am sure I will
□ I probably will
□ There is a 50/50 chance I will
□ I probably will not
□ I am sure I will not
Ideally, when would you want to get pregnant again?

N/A

MARK (X) ONE

4.5

□ Before my baby is 1 year old
□ When my baby is between 1 and 2 years old
□ When my baby is between 2 and 3 years old
□ When my baby is over three years old
□ I don’t know if I want to get pregnant again
□ Unsure

N/A

How old is your baby’s father?
|

| YEARS OLD

CHLA #

Concordance #

4.6

N/A

Baseline Concordance Question Text

Modifications for CHLA
What was your relationship with your baby’s father when you got
pregnant?
MARK (X) ONE
□
□
□
□
□
□
□

4.7

N/A

Did not know him well or at all
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

What is your relationship with your baby’s father now?
MARK (X) ONE
□
□
□
□
□
□
□
□

4.8

N/A

No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

Has your baby’s father had any contact with your child since birth?
MARK (X) ONE
□Yes
□No – GO TO 4.10

CHLA #

Concordance #

4.9

N/A

Baseline Concordance Question Text

Modifications for CHLA
In the past month, how often has your baby’s father spent one or
more hours with your child?
MARK (X) ONE

4.10

□ Every day
□ Almost every day
□ A few times a week
□ About once a week
□ Once or twice
□ Never
Do you currently use child care services other than your family or
friends?

N/A

MARK (X) ONE
□ Yes – Full-time
□ Yes – Part-time
□ No

CHLA #

Concordance #

4.11

N/A

Baseline Concordance Question Text

Modifications for CHLA
In a typical week, how often do each of the following people
provide you with physical support (e.g., childcare, feeding,
changing diapers, bathing) to care for your baby?
MARK (X) ONE FOR EACH
6-7 times a week, 4-5 times a week, 2-3 times a week, 1 day a
week, Rarely or never, Not applicable
a. Baby’s father
b. Your boyfriend or partner who is not the baby’s
father
c. Your parent(s)
d. Your baby’s father’s parent(s)
e. Another relative from your family
f. Another relative from your baby’s father’s family
g. A friend
h. Other (Please specify)

CHLA #

Concordance #

5.1

N/A

Baseline Concordance Question Text

Modifications for CHLA
Please rate yourself on this set of statements, using the 9 point scale
below: (Scale: 1 = Not at all true to 9 =Very true)
MARK (X) ONE FOR EACH
a.
In general, I am focused on preventing negative events in my life
b.
I am anxious that I will fall short of my responsibilities and
obligations
c.
I frequently imagine how I will achieve my hopes and aspirations
d.
I often think about the person I am afraid I might become in the
future
e.
I often think about the person I would ideally like to be in the future
f.
I typically focus on the success I hope to achieve in the future
g.
I often imagine myself experiencing bad things that I fear might
happen to me
h.
I frequently think about how I can prevent failures in my life
i.
I see myself as someone who is primarily striving to reach my “ideal
self” – to fulfill my hopes, wishes, and aspirations
j.
I see myself as someone who is primarily striving to become the self
I “ought” to be – to fulfill my duties, responsibilities, and
obligations
k.
In general, I am focused on achieving positive outcomes in my life
l.
I often imagine myself experiencing good things that I hope will
happen to me
m. Getting pregnant before my baby is 2 will lower my chances of
getting the future I want for myself and my family
n.
Contraception is an important way that I can be a responsible
parent
o.
Focusing on my education and work experience now will help me
achieve a successful future
p.
Having another baby too soon may make it much harder on myself
and my family
q.
I plan to put extra effort into my education or experience to get a
(better) job
r.
I plan to stop doing things that interfere with my job preparation

CHLA #

Concordance #

5.2

N/A

Baseline Concordance Question Text

Modifications for CHLA
For the following statements, indicate to what degree the statement
reflects your own thoughts and feelings using the numbers 1through 6,
with 1 being STRONGLY AGREE and 6 being STRONGLY DISAGREE.
If a statement has more than one part, please indicate your reaction to
the whole statement.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.

I just can’t decide what to do as a parent, there are so many possibilities.
I’ve thought a lot about the kind of mother I want to be, but there’s no
question that I will follow what my “mother” says to do.
My “mom” tells me how to be a parent to my child, and that’s what I do.
I haven’t really decided what kind of mother I want to be. I’m just taking it
day by day.
I’m sure it will be pretty easy to change the kind of mother I am when I’m
ready.
It took me a while to figure it out, but now I know for sure what direction to
move in as a parent.
It took me a while to figure it out, but now I know what kind of mother I
want to be.
I’m still trying to decide how capable I am as a person and what kind of
parenting is right for me.
I just can’t decide what to do for a career. There are so many possibilities.
I might have thought about a lot of different jobs, but there’s really never
been any question since my parents said what they wanted.
My parents decided a long time ago what I should go into for employment
and I am following through with their plans.
It took me awhile to figure it out, but now I know for sure what direction to
move in for a career.
I’m still trying to decide how capable I am as a person and what jobs will be
right for me.
It took me awhile to figure it out, but now I really know what I want for a
career.
When I’m ready, I’m sure it’ll be pretty easy to change or get the kind of job
that’s right for me.
I haven’t chosen the occupation I really want to get into, and I’m just
working at what is available until something better comes along.

CHLA #

Concordance #

5.3a

N/A

Baseline Concordance Question Text

Modifications for CHLA
Who will you be in fifteen years? Each of us has some image or
picture of what we will be like and what we want to avoid being
like in the future. Think about 15 years from now—imagine what
you’ll be like, and what you’ll be doing.
In the lines below, write what you expect you will be like and what
you expect to be doing.
•

•

In the space next to each expected goal, mark No (X) if you are
not currently working on that goal or expectation and mark
Yes(X) if you are currently doing something to get to that
expectation or goal.
For each expected goal that you marked Yes, use the space to
the right to write what you are doing this year to attain that
goal.
1a. In 15 years, I expect to be
____________________________
1b . Am I doing something to be that way?
□ Yes
□ No
1c. (IF YES) What I am doing now to be that way in 15
years? _______________________

CHLA #

Concordance #

5.3b

N/A

Baseline Concordance Question Text

Modifications for CHLA
In addition to expectations and expected goals, we all have images
or pictures of what we don’t want to be like; what we don’t want
to do or want to avoid being. First, think a minute about ways you
would not like to be in 15 years—things you are concerned about
or want to avoid being like.
Write those concerns or selves to-be-avoided in the lines below.
Next to each concern or to-be-avoided self, mark No (X) if you are
not currently working on avoiding that concern or to-be-avoided
self and mark Yes (X) if you are currently doing something so this
will not happen in 15 years.
For each concern or to-be-avoided self that you marked Yes, use
the space at the end of each line to write what you are doing this
year to reduce the chances that this will describe you in 15 years.
1a. In 15 years, I want to avoid
____________________________
1b. Am I doing something to avoid this?
□ Yes
□ No
1c. (IF YES) What I am doing now to avoid being that way in
15 years? ________________

CHLA #

Concordance #

5.4

N/A

Baseline Concordance Question Text

Modifications for CHLA
For each sentence, please think about how you are in most
situations. Rate each statement in a way that describes YOU the
best.
Scale: 0-5 (None of the time – All of the time)
a. I can do what it takes to get the specific work I choose
b. I know how to prepare for the kind of work I want to do
c. When I look into the future, I have a clear picture if what
my work life will be like
d. I have a difficult time identifying my own goals for the next
five years.

DROPPED: The questions listed below are part of the baseline concordance instrument, but are not part of this site-specific baseline
instrument.
N/A

N/A

1.2

1.3

1.6

What grade are you in?
MARK (X) ONE
□
6th
□
7th
□
8th
□
9th
□
10th
□
11th
□
12th
□
Not currently in school
Are you male or female?
MARK (X) ONE
□
Male
□
Female
When you are at home or with your family, what language or languages do
you usually speak?
YOU MAY MARK (X) MORE THAN ONE ANSWER
□ English
□ Spanish
□ Chinese language such as Mandarin or Cantonese
□ Some other language PRINT OTHER LANGUAGE(S)
____________________________

N/A

1.6a

What is the main language you speak at home?
□
□
□
□

English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE(S)
____________________________

N/A

1.7

In the past 12 months, how often did you attend religious services or
activities?
MARK (X) ONE
□
□
□
□
□

N/A

1.8

How important is religion in your life?
MARK (X) ONE
□
□
□

N/A

1.9

Never
Less than once a month
1-3 times per month
Once a week
More than once a week

Not at all important
Somewhat important
Very important

In the past 12 months, have you received information or learned about any of
the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or whether to
use birth control
How to say no to sex
How babies are made

N/A

1.10

In an average week last month, including weekends, about how many hours
did you spend participating in each of the following?
MARK (X) ONE FOR EACH QUESTION
Zero Hours Per Week, More Than Zero but Less Than 2 Hours Per Week, 2-5
Hours Per Week, More Than 5 Hours Per Week
a.
b.
c.
d.
e.
f.

N/A

2.4

2.5

Sports-related clubs, teams, or organizations
Lessons, clubs, or performances for art, music, or drama
Other clubs, teams, and organizations, such as academic
clubs, Scouts, chess clubs, or debating teams
Services or programs at a church, temple, synagogue,
mosque, or other place of worship
Working at a paid job
Volunteering

On how many days last week did all the family members who live in your
household sit down together for a meal?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7
On how many days last week did you do something with at least one adult in
your family like play a game, watch a movie, go to a sporting event, or work
on something you enjoy doing together?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7

N/A

2.7

The following questions are about the person you marked above, that is, your
mother or the person you think of as a mother.
Did she graduate from high school?
MARK (X) ONE
□
□
□

N/A

2.8

Yes
No
Don’t know

Did she graduate from a 4-year college?
MARK (X) ONE
□
□
□

N/A

2.9

N/A

2.10

Yes
No
Don’t know

Is she working now?
MARK (X) ONE
□
She is not working at a paid job
□
Yes, she is working part-time or less than 30 hours a week
□
Yes, she is working full-time or at more than one job for 30
hours a week or more
□
Yes, she works, but I don’t know how many hours
□
Don’t know if she is working
How close do you feel to your mother or the person you think of as a mother?
MARK (X) ONE
□
□
□
□

N/A

2.11

Not at all close
A little close
Somewhat close
Very close

In general, how much do you think she cares about you?
MARK (X) ONE
□ Does not care at all
□ Cares a little bit
□ Cares somewhat
□ Cares very much

N/A

2.12

Whether you have done this or not, how would she feel about you having sex
at this time in your life?
MARK (X) ONE
□
□
□
□
□

N/A

2.13

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

How would she feel about you having a baby at this time in your life?
MARK (X) ONE
□
□
□
□
□

N/A

2.14

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

Next we have some questions about your father, or the person you think of as
a father. Is this person…
MARK (X) ONE
□

N/A

2.15

Your biological father, that is, the man who is genetically
related to you
□
Your stepfather or adoptive father
□
Your foster father
□
Your grandfather
□
Your uncle or your older brother
□
Some other adult
□
Don’t have a father or person I think of as a father GO TO 2.22a
The following questions are about the person you marked above, that is the
person you think of as a father.
Did he graduate from high school?
MARK (X) ONE
□
□
□

Yes
No
Don’t know

N/A

2.16

Did he graduate from a 4-year college?
MARK (X) ONE
□
□
□

N/A

2.17

2.18

2.19

Yes
No
Don’t know

Is he working now?
MARK (X) ONE
□
He is not working at a paid job
□
Yes, he is working part-time or less than 30 hours a week
□
Yes, he is working full-time or at more than one job for 30 hours a week
or more
□
Yes, he works, but I don’t know how many hours
□
Don’t know if he is working
How close do you feel to your father or the person you think of as your
father?
MARK (X) ONE
□ Not at all close
□ A little close
□ Somewhat close
□ Very close
In general, how much do you think he cares about you?
MARK (X) ONE
□
□
□
□

N/A

2.20

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would he feel about you having sex
at this time in your life?
MARK (X) ONE
□
□
□
□
□

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

N/A

2.21

How would he feel about you having a baby at this time in your life?
MARK (X) ONE
□
□
□
□
□

N/A

2.22a

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

Which of the following best describes the relationship between your
biological mother and biological father? If one or both of your biological
parents have passed away, please answer about their relationship when both
were alive.
MARK (X) ONE
o
o
o
o
o

N/A

2.22b

They are married to each other
They used to be married to each other, but are now separated
They used to be married to each other, but are now divorced
They have never been married to each other
I don’t know

Do your biological mother and biological father live together now?
MARK (X) ONE
o
o
o
o

N/A

2.23

Yes
No
One or both of my biological parents have passed away
I don’t know

The next questions ask about what your parents know about your activities.
By parents, we mean the parents or guardians you live with most of the time.
Thinking about the past month, how often did your parents know where you
were after school?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never

N/A

2.24

Thinking about the past month, how often did your parents know who you
were going to be with before you went out?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
□
I did not go out

N/A

2.25

2.26

2.27

Thinking about the past month, how often did your parents know where you
were when you went out at night?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
□
I did not go out at night
If you were going to be home late, would your parents expect you to call?
MARK (X) ONE
□
Yes
□
No
In the past 12 months, how many times have you talked with at least one of
your parents about . . .
MARK (X) ONE FOR EACH QUESTION
Never, 1-2 Times, 3-9 Times, 10 or more times
a.
b.
c.
d.
e.
f.
g.
h.

How things are going with school work or with your grades
A personal problem you were having
How to have good romantic relationships
Strategies for safe dating
How to resist pressures to have sex
Avoiding drugs and alcohol
Pregnancy or birth
Sexually transmitted diseases (also called STDs), HIV, or AIDS

N/A

3.1

The next series of questions is about your views on sexual intercourse. In this
survey, when we ask about sexual intercourse we mean a male putting his
penis into a female’s vagina. How strongly do you agree or disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.

N/A

3.2

Having sexual intercourse is a good thing for you to do at your age
At your age right now, having sexual intercourse would create problems
At your age right now, not having sexual intercourse is important for you
to be safe and healthy
d. At your age right now, it is okay for you to have sexual intercourse if you
use birth control, like a condom
e. It is against your values to have sexual intercourse before marriage
FOR GIRLS
If you got pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□

N/A

3.2

Very happy
A little happy
Neither upset nor happy
A little upset
Very upset

FOR BOYS
If you got a female pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□

Very happy
A little happy
Neither upset nor happy
A little upset
Very upset

N/A

3.3

Imagine you are alone with someone you like very much. How likely is it that
you could . . .
MARK (X) ONE FOR EACH QUESTION
Not at all Likely, a Little likely, Somewhat Likely, Very Likely
a.

N/A

3.4

Stop them if they wanted to touch your chest and you did not want
them to do that (FOR GIRLS)
b. Stop them if they wanted to touch your private parts below the waist,
meaning the parts of the body covered by underwear, and you did not
want them to do that
c. Avoid having sexual intercourse if you didn’t want to
The next series of questions is about condom use. How strongly do you agree
or disagree that …
MARK (X) ONE FOR EACH QUESTION
Strongly approve, Approve, Neither approve nor disapprove, Disapprove,
Strongly disapprove
a. Condoms should always be used if a person your age has
sexual intercourse
b. Condoms are a hassle to use
c. Condoms are pretty easy to get
d. Condoms are important to make sex safer
e. Using condoms means you don’t trust your sexual partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure

N/A

3.5

If a condom is used correctly, how much can it decrease the risk of pregnancy
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

GO TO 3.6

N/A

3.5a

3.6

3.7

3.9

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If a condom is used correctly, how much can it decrease the risk of getting
HIV, the virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
If a condom is used correctly, how much can it decrease the risk of getting
Chlamydia and gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
If birth control pills are used correctly, how much can they decrease the risk
of pregnancy?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

N/A

3.9a

GO TO 3.10

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident

N/A

3.10

3.11

3.12

If birth control pills are used correctly, how much can they decrease the risk
of getting HIV, the virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
If birth control pills are used correctly, how much can they decrease the risk
of getting Chlamydia and gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
□
□
□

N/A

3.12a

N/A

3.13

Yes
No
Don’t know

GO TO 3.12

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
In the past 3 months, how many TIMES have you gone out on a date?
□ Zero or None
GO TO 3.15
| | | NUMBER OF TIMES - Your best guess is fine

N/A

3.14

Thinking about these dates in the past 3 months, how many DIFFERENT
PEOPLE did you go out on a date with?
□
|

Zero or None
| NUMBER OF PEOPLE - Your best guess is fine.

N/A

3.15

Do you intend to have oral sex in the next year?
o
o
o
o

N/A

3.19

Do you intend to have sexual intercourse without being married?
o
o
o
o

N/A

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.20

Have you ever had sexual intercourse, oral sex, or anal sex?

4.1
Part
B1

□ YES: GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
□ NO: GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
The next questions are about your sexual behaviors and experiences. Please
be as honest as possible. Your answers are confidential and everything you
say will be kept private.
Just to confirm, have you ever had sexual intercourse, oral sex, or anal sex?

N/A

4.2
Part
B1

□ No STOP AND GO TO PART B2
□ Yes CONTINUE WITH THISBOOKLET.
The first questions are about sexual intercourse. By sexual intercourse, we
mean a male putting his penis into a female’s vagina.
Have you ever had sexual intercourse?
MARK (X) ONE
□
Yes
□
No
GO TO 4.15

N/A

4.5
Part
B1

4.6
Part
B1

The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE
□
□
□
□
□

The very first time you had sexual intercourse, would you say that it was
voluntary or not voluntary?
MARK (X) ONE
□
□

N/A

4.7
Part
B1

A year or two younger than you
Three or more years younger than you
The same age as you
A year or two older than you
Three or more years older than you

Voluntary
Not voluntary

Birth control methods are something used to reduce the risk of pregnancy,
and some can reduce the risk of sexually transmitted diseases, also called
STDs.
The first time you had sexual intercourse, did you or your partner use any
type of birth control, including condoms or any other method?
MARK (X) ONE
□
□

N/A

4.8
Part
B1

Yes
No

GO TO 4.9

The first time you had sexual intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
YES, NO
a.
b.
c.
d.
e.
f.

Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
Nuva ring or the ring
Withdrawal or pulling out
Another method (PRINT OTHER METHOD USED):

N/A

4.9
Part
B1

4.15
Part
B1
4.21
Part
B1

Have you had sexual intercourse more than one time?
MARK (X) ONE
□ Yes
□ No
GO TO 4.14
The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR
Now please think about the past 3 months. In the past 3 months, how many
TIMES have you had anal sex?
□
|

None
GO TO 4.23
| NUMBER OF TIMES - Your best guess is fine.

4.23
Part
B1

Have you ever had oral sex or anal sex with a person the same sex as you?

4.24a
Part
B1

FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual
period?

4.24b
Part
B1

MARK (X) ONE
□ Yes
□ No

MARK (X) ONE
□ Yes
□ No GO TO 4.27
FOR GIRLS ONLY- How old were you when you had your first period, that is,
your first menstrual period?
|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

N/A

4.25a
Part
B1

FOR BOYS ONLY
People reach puberty at different ages. Signs of puberty for males include
physical changes such as developing pubic or facial hair, or the voice cracking
or lowering. Which of the following best describes these changes for you?
MARK (X) ONE
□ These changes have not yet started
□ These changes have barely started
□ These changes are definitely underway
□ These changes seem complete

N/A

4.25b
Part
B1

FOR BOYS: How old were you when these changes started?

4.26a

To the best of your knowledge, have you ever been pregnant or gotten
someone pregnant, even if no child was born?

| NUMBER OF YEARS OLD YOU WERE

MARK (X) ONE
□ Yes
□
No GO TO 4.27
N/A

4.26c

Have you ever had a baby or has anyone you got pregnant actually had the
baby?
MARK (X) ONE
□
Yes
□
No
□
Don’t know

N/A

4.27
Part
B1

In the past 12 months, have you spoken with a doctor or nurse about having
sex, birth control or sexually transmitted diseases, also known as STDs?
MARK (X) ONE
□
□

Yes
No

N/A

4.28
Part
B1

In the past 12 months, have you been tested by a doctor or nurse for a
sexually transmitted disease (STD), like gonorrhea, Chlamydia, syphilis, or
HIV?
MARK (X) ONE
□
□

N/A

4.31
Part
B1

Yes
No

Have you ever been in a situation where someone touched you in a sexual
way that you did not want, or someone forced you to touch him or her in a
sexual way that you did not want to?
MARK (X) ONE
□
□

N/A

4.32
Part
B1

Yes
No

Have you ever been fearful that someone you were dating or having sex with
might physically hurt you?
MARK (X) ONE

N/A

4.1
Part
B2

□ Yes
□ No
This booklet is for youth who have not had sex. We want to be sure you are in
the correct booklet. We know we asked this before but…
Just to confirm, have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
□ Yes STOP AND GO TO PART B1
□ No CONTINUE WITH THISBOOKLET

N/A

4.2
Part
B2

The first two questions in this booklet are about your schooling.
Do you expect that you will graduate from high school?
MARK (X) ONE
□
□
□

N/A

4.3
Part
B2

Yes
I already graduated from high school
No
GO TO 4.4

In what month and year do you expect to graduate from high school? (If you
already graduated, in what month and year did you graduate from high
school?)
MARK (X) ONE MONTH AND ONE YEAR

N/A

4.4
Part
B2

The next questions are about where you live.
In the last 7 days, did you spend any nights somewhere like a shelter,
someone else’s home, in a car, on the street or in any other temporary
housing because you did not have a regular place to stay?
MARK (X) ONE
□
□

N/A

4.5
Part
B2

Yes GO TO 4.11
No

In how many homes, places, or households do you live: one, two, or three or
more?
MARK (X) ONE
□ 1 home
GO TO 4.9
□ 2 homes
□ 3 or more homes

N/A

4.6
Part
B2

Do you consider one of these homes to be your main home?
MARK (X) ONE
□ Yes
□ No

N/A

4.7
Part
B2

Thinking about the past 30 days, how many nights did you spend in each
home?
FILL IN TWO OR THREE NUMBERS
|

| Number of nights at home #1 – Your best guess is fine.

| Number of nights at home #2 – Your best guess is fine.

N/A

4.8
Part
B2

4.9
Part
B2
4.10
Part
B2

| Number of nights at another home or other homes – Your best
guess is fine.

Is there anyone who moves with you from home to home?
MARK (X) ONE
□
□

Yes
No

Is your home or any of your homes a group home or halfway house?
□ Yes
□ No
This question is about who lives with you in your home. If you have more than
one home, please think about your main home.
How many people usually live in your home, including all children and anyone
who normally lives there even if they are not there now, like someone who is
away traveling or in a hospital?
|

| NUMBER OF PEOPLE

N/A

4.11
Part
B2

These next few questions are about you and your friends. How strongly do
you agree or disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree

N/A

4.12
Part
B2

a. You have friends who will give you good advice
b. You have a friend who cares about you
c. You have a friend you can talk to when you need to
d. You have someone who you can call your best friend
The next series of questions is about effort. How strongly do you agree or
disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree

N/A

4.13
Part
B2

a. When you start a project, you finish it
b. You only work as hard as you have to
c. You are someone people can count on
d. When you work, you do a good job
Here are some reasons people your age might choose NOT to have sexual
intercourse. How important is each of these reasons to YOU?
MARK (X) ONE FOR EACH QUESTION
Very Important, Somewhat Important, Not Too Important, Not At All
Important
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

I don’t want to get a sexually transmitted disease, also known as
an STD
I don’t want to disappoint my parents
I am too young to have sex
My boyfriend or girlfriend doesn’t want to have sex
I want to wait until I’m married
It is against my personal values
I haven’t met the right person yet
I haven’t had the chance
I don’t want to
FOR GIRLS: I do not want to get pregnant
FOR BOYS: I do not want to get a girl pregnant

N/A

4.14 a
Part
B2

4.14b
Part
B2

FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual
period?
MARK (X) ONE
□ Yes
□ No GO TO 4.27
FOR GIRLS ONLY- How old were you when you had your first period, that is,
your first menstrual period?
|

N/A

4.15a
Part
B2

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

N/A

4.15b
Part
B2

FOR BOYS: How old were you when these changes started?

4.16
Part
B2

Have you ever done any of the following with a boy or girl?

| NUMBER OF YEARS OLD YOU WERE

Yes, No
a. Kissed someone on the lips
b. French kissed, that is put your tongue in someone’s mouth while kissing
c. Touched another person’s private parts
d. Let someone touch your private parts

N/A

4.17
Part
B2

Have you ever been in a situation where someone touched you in a sexual
way that you did not want, or someone forced you to touch him or her in a
sexual way that you did not want to?
MARK (X) ONE

N/A

4.18
Part
B2

□ Yes
□ No
Have you ever been fearful that someone you were dating or having sex with
might physically hurt you?
MARK (X) ONE

N/A

4.19
Part
B2

□ Yes
□ No
In the past 12 months, have you spoken with a doctor or nurse about having
sex, birth control or sexually transmitted diseases, also known as STDs?
MARK (X) ONE

N/A

4.20
Part
B2

□
Yes
□
No
If you decided to have sexual intercourse outside of marriage, how likely is it
you would use a condom or other contraceptive method?
MARK (X) ONE
□ Not at all likely
□ A little bit likely
□ Somewhat likely
□ Very likely
□ Don’t plan to have sexual intercourse outside of marriage

N/A

5.1

The next questions are about tobacco, alcohol and drugs. Please be as honest
as possible, and remember that everything you tell us will be kept private.
Have you ever smoked a cigarette?
MARK (X) ONE
□
□

Yes
No GO TO 5.4

N/A

5.2

The very first time you smoked a cigarette, how old were you?
|

N/A

5.3

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

During the past 30 days, on how many days did you smoke one or more
cigarettes?
MARK (X) ONE
□
□
□
□

N/A

5.4

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

Have you ever had an alcoholic drink, such as beer, wine or other liquor, NOT
counting any times you just had a sip?
MARK (X) ONE
□
□

N/A

5.5

The very first time you had an alcoholic drink, how old were you?
|

N/A

5.6

Yes
No GO TO 5.8

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

During the past 30 days, on how many days did you have one or more
alcoholic drink, such as beer, wine or other liquor, NOT counting any times
you just had a sip?
MARK (X) ONE
□
□
□
□

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

N/A

5.7

5.8

During the past 30 days, on how many days did you have 5 or more drinks in a
row?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used marijuana, also called weed or pot?
MARK (X) ONE
□
□

N/A

5.9

5.10

Yes
No GO TO 5.10

During the past 30 days, on how many days did you use marijuana?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used any other type of illegal drug, for example
Methamphetamine, speed, PCP, ecstasy, or any form of cocaine, such as
crack?
MARK (X) ONE
□
Yes
□
No

N/A

5.11

Have you ever used any prescription pills or other prescription drugs that
were not prescribed for you?
MARK (X) ONE
□
Yes
□
No

N/A

5.12

6.1

Have you ever used an inhalant, such as sniffed glue, breathed the contents
of spray cans, or inhaled any paints or solvents to get high?
MARK (X) ONE
□
Yes
□
No
How many of your friends who are your age think the following things? Your
best guess is fine
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know
a.
b.
c.
d.
e.

N/A

6.4

Having sexual intercourse is a good thing for them to do at
their age.
It would be okay for them to have sexual intercourse as long
as they used birth control, like a condom.
It would be okay for them to have sexual intercourse if they
were dating the same person for a long time
They should wait until they are older to have sexual
intercourse.
They should wait until marriage to have sexual intercourse.

People are different in their sexual attraction to other people. Which of the
following best describes you?
MARK (X) ONE
□
□
□
□
□

N/A

6.5

I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure

How much do you feel that your friends care about you?
MARK (X) ONE
□
Do not care at all
□
Care a little bit
□
Care somewhat
□
Care very much

OMB Control No:
Expiration Date:

BASELINE QUESTIONNAIRE
CHLA

CONFIDENTIALITY
Thank you for your help with this important study. It will help us understand what things are like
for people your age today. Your answers are confidential and everything you say will be kept
private. Your name will not be on the questionnaire. Please answer all questions as well as you
can.
We want you to know that:
1.

We hope that you will answer all the questions, but you may skip any questions you do not
wish to answer.

The answers you give will never be identified as yours. Your responses will be combined
with those of other people your age.
Mathematica Policy Research

THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, gathering and maintaining the data needed, 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.

GENERAL INSTRUCTIONS
1.

PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED! USE A PEN OR PENCIL.
PLEASE READ EACH QUESTION CAREFULLY. There are different ways to answer the questions in this
survey. It is important that you follow the instructions when answering each kind of question. Here are
some examples.
EXAMPLE 1: MARK (X) ONE ANSWER
What is the color of your eyes?
MARK (X) ONE
X

Brown
Blue
Green

If the color of your eyes is brown, you would mark (X)
the first box as shown.

Another color
2.

EXAMPLE 2: MARK (X) ONE ANSWER and FILL IN THE BLANK
What is the color of your hair?
MARK (X) ONE

Brown
Black

If the color of your hair is purple, you would mark (X)
the last box and write the word “purple” in the blank as
shown. BE SURE TO WRITE CLEARLY.

Blond
Red
X

Some other color PRINT OTHER COLOR

purple

EXAMPLE 3: YOU MAY MARK (X) MORE THAN ONE ANSWER
Do you plan to do any of the following next week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X

Rent a movie

Go to a baseball game

If you plan to rent a movie and go to a baseball game
next week, you would mark (X) both boxes.

Study at a friend’s house

PPA Study – Part A – CHLA – 6/24/11

EXAMPLE 5: FILL IN THE NUMBER
In the last seven (7) days, how many chocolate bars have you eaten?
0

NUMBER OF CHOCOLATE BARS – Your best guess is fine.
Fill in the boxes with the correct number. For any number less than 10, put a
zero (0) in the first box. For example, if you had eaten 2 chocolate bars in the
last 7 days, you would write “0” in the first box and “2” in the second box. If
you had eaten 15 chocolate bars, you would write “1” in the first box and “5”
in the second box.

EXAMPLE 6: MARK (X) ONE ANSWER FOR EACH QUESTION
In the last 12 months, have you done any of the following?
MARK (X) ONE FOR EACH QUESTION

a.
b.
c.
d.
e.
f.

YES
NO
Walked a dog on a leash ............................................................................................................................ X
Played Frisbee ............................................................................................................................................ X
X
Weeded a garden .......................................................................................................................................
Eaten a piece of fresh fruit.......................................................................................................................... X
X
Played a piano ............................................................................................................................................
X
Watched a movie ........................................................................................................................................
Mark (x) either “yes” or “no” for each of the six (6) questions
(a–f) by marking (x) one of the of two boxes in each row.

PPA Study – Part A – CHLA -6/24/11

EXAMPLE 7: MARK (X) ONE MONTH AND ONE YEAR
In what month and year did you finish elementary school?
MARK (X) ONE MONTH AND ONE YEAR

Month finished

Year finished

January
February

2010
X

2009

March

2008

April

2007

May

2006

June

2005

July

2004

August

2003

September

2002

October

2001

November

2000

December

1999

PPA Study – Part A – CHLA -6/24/11

If you finished elementary school in
June of 2009, you would mark (X) the
box next to June and mark (X) the box
next to 2009.

SECTION 1: YOU AND YOUR BACKGROUND
1.1. In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

Month born

Year born

January

2002

February

2001

March

2000

April

1999

May

1998

June

1997

July

1996

August

1995

September

1994

October

1993

November

1992

December

1991

PPA Study – Part A – CHLA -6/24/11

1.2. What is the last grade you completed?
MARK (X) ONE

Less than 6th grade
7th
8th
9th
10th
11th
12th
Completed GED pretest
Completed GED
Some school after high school

1.3. What is your current school status?
MARK (X) ONE

Enrolled in public or private middle or high school
Enrolled in a continuation/alternative school or court/community school
Enrolled in adult education classes
Enrolled in technical or vocation school
Enrolled in 2-year college
Enrolled in 4-year college or university
Not currently enrolled in any school or classes

1.4. What is the highest level of education you would like to complete?
MARK (X) ONE

Graduate from high school or obtain a GED
Attend technical or vocational school
Graduate from a 2-year community college (Associate’s degree)
Graduate from a 4-year college (Bachelor’s degree)
Obtain a graduate degree (Masters, PhD, MD, etc.)

PPA Study – Part A – CHLA -6/24/11

1.5. Are you currently working?
MARK (X) ONE

Yes – full-time
Yes – part-time
No – but currently looking for a job
No – and not currently looking for a job

1.6. Are you Hispanic/Latino?
MARK (X) ONE

Yes
No

1.7. What is your race?
YOU MAY MARK (X) MORE THAN ONE ANSWER

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some other race (PRINT OTHER RACE)

1.8. Are you…?
MARK (X) ONE

Not currently seeing anyone
Casually dating
Seriously dating
Engaged
Married

PPA Study – Part A – CHLA -6/24/11

1.9. How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH

NONE

SOME

HALF

MOST

ALL

DON’T
KNOW

Had sexual intercourse .....................................................................................................................................

Been pregnant ...................................................................................................................................................

Been a teen parent ............................................................................................................................................

1.10. Below is a list of some of the ways you may have felt or behaved. Please indicate how often you
have felt this way during the past week by checking the appropriate response.
MARK (X) ONE FOR EACH

RARELY OR
NONE OF
THE TIME
(LESS THAN
1 DAY)

SOME OF
OR A LITTLE
OF THE TIME
(1-2 DAYS)

OCCASIONALLY
OR A MODERATE
AMOUNT OF THE
TIME (3-4 DAYS)

MOST OR
ALL OF
THE TIME
(5-7 DAYS)

I felt depressed ..................................................................................................................................................

I felt lonely .........................................................................................................................................................

I had crying spells .............................................................................................................................................

I felt sad .............................................................................................................................................................

PPA Study – Part A – CHLA -6/24/11

SECTION 2: FAMILY
2.1. Now we have some questions about your mother, or the person you think of as your mother.
Is this person…?
MARK (X) ONE

Your biological mother, that is, the woman who gave birth to you
Your stepmother or adoptive mother
Your foster mother
Your grandmother
Your aunt or your older sister
Some other adult (Please specify)
Don’t have a mother or person I think of as my mother

GO TO 2.3

Please answer the questions below about your mother or the person you think of as your mother that
you identified in the previous question.
2.2. How much do you agree with the following statements about your mother or the person you think
of as your mother?
MARK (X) ONE FOR EACH

Strongly
Disagree

Disagree

Neither
Disagree
or Agree

Agree

Strongly
Agree

a. My mother supports me to be a good parent .................................................................................................
b. My mother’s help with the baby is just
about right ......................................................................................................................................................
c. My mother criticizes the way I take care
of my baby .....................................................................................................................................................
d. My mother gives me too much help
with my baby ..................................................................................................................................................

2.3. Were any of the following members of your family teen mothers?
MARK (X) ONE FOR EACH

YES

a. Mother ............................................................................................................................................................
b. Grandmother ..................................................................................................................................................
c. Sister ..............................................................................................................................................................

PPA Study – Part A – CHLA -6/24/11

The next questions are about where you live and who lives with you.
2.4

Which of the following best describes where you live?
MARK (X) ONE

You live in one home

GO TO 2.5

You live in two or more homes, and go back and forth
You live in a residential program

GO TO 2.6

GO TO 2.7

You are homeless (living on the street, in a car or shelter, or staying with friends/relatives)

2.5

GO TO 2.7

Who lives with you in your home?
MARK (X) ALL THE PEOPLE WHO LIVE WITH YOU

AFTER ANSWERING GO TO 2.7

PPA Study – Part A – CHLA -6/24/11

2.6

Who lives with you in each of your homes?
MARK (X) ALL THAT APPLY

MAIN HOME
Mark (X) all the people who live with you in your MAIN home

OTHER HOME(S)
Mark (X) all the people who live with you in your OTHER home(s)

Your mother, or the person you think of as your mother

Your father, or the person you think of as your father

Any grandmothers

Any grandfathers

Any brothers or sisters

Any aunts, uncles, or other relatives

Your baby

The father of your baby

The parent(s) of the father of your baby

Your current boyfriend/partner who is not the father of
your baby

Friends or roommates

You live by yourself

2.7. How many times have you moved in the past 6 months?
None
NUMBER OF TIMES – Your best guess is fine.

PPA Study – Part A – CHLA -6/24/11

SECTION 3: BEHAVIORS
3.1. The next questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
The very first time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

Month of First Sexual
Intercourse

Year of First Sexual
Intercourse

January

2011

February

2010

March

2009

April

2008

May

2007

June

2006

July

2005

August

2004

September

2003

October

2002

November

2001

December

2000 or earlier

3.2. The very first time you had sexual intercourse, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.

3.3. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
NUMBER OF PEOPLE – Your best guess is fine.

PPA Study – Part A – CHLA -6/24/11

3.4. Now please think about the past 4 weeks. Have you had sexual intercourse in the past 4 weeks?
MARK (X) ONE

Yes
GO TO 3.10

3.5. In the past 4 weeks, how many TIMES have you had sexual intercourse?
None
NUMBER OF TIMES – Your best guess is fine.

3.6. In the past 4 weeks, have you used any of the following methods of birth control?
MARK (X) ONE FOR EACH

Yes
No
a. Condoms...............................................................................................
b. Birth control pills ...................................................................................
c. The shot (Depo-Provera) ......................................................................
d. The patch ..............................................................................................
e. The ring (NuvaRing) .............................................................................
f.

IUD (Mirena or Paragard) .....................................................................

g. Implant (Implanon) ................................................................................
h. Emergency contraception (Plan B) .......................................................
i.

Other (Please specify) ..........................................................................

3.7. In the past 4 weeks, how many TIMES have you had sexual intercourse without using a condom?
NUMBER OF TIMES – Your best guess is fine.

PPA Study – Part A – CHLA -6/24/11

3.8. The next question is about your use of the following methods of birth control:
•
•
•
•
•
•
•

Condoms
Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)

In the past 4 weeks, how many TIMES have you had sexual intercourse without using any of
these methods of birth control?
NUMBER OF TIMES – Your best guess is fine.

Only ask if said “Yes” to having sex in last 4 weeks AND “No” to using any birth control during last
4 weeks.
3.9. There are different reasons people give for not using contraception. Please mark ALL of the
reasons that are true for you.
MARK (X) ALL THAT APPLY

I just haven’t gotten around to getting anything yet
I don’t think I can get pregnant right now
My partner doesn’t want me to use contraception
I don’t use it because of the side effects for me or my baby
Other (Please specify)

3.10. In general, how much pressure, if any, do you feel from your boyfriend/partner to have sex
without birth control?
MARK (X) ONE

A lot of pressure
Some pressure
A little pressure
No pressure
I do not have a boyfriend/partner

PPA Study – Part A – CHLA -6/24/11

3.11. Do you intend to have sexual intercourse in the next year?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

GO TO 3.15

3.12. If you have sexual intercourse in the next year, do you intend to use a condom?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.13. The next question is about your intention to use other methods of birth control, NOT including
condoms:
•
•
•
•
•
•

Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)

If you have sexual intercourse in the next year, do you intend to use any of these other methods
of birth control?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

PPA Study – Part A – CHLA -6/24/11

3.14. Which of the following do you plan on using? (Only ask if answered Yes to previous question.)
MARK (X) ALL THAT APPLY

Condoms
Oral Contraceptives/birth control pill
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
Other (Please specify)

3.15. The next question is about methods of birth control, NOT including condoms. How strongly do
you agree or disagree that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Birth control should always be used if a
person your age has sexual intercourse ........................................................................................................
b. Birth control is a hassle to use .......................................................................................................................
c. Birth control is pretty easy to get ...................................................................................................................
d. Birth control is important to make sex safer ..................................................................................................
e. Birth control has too many negative
side effects .....................................................................................................................................................
f.

Using birth control is morally wrong ...............................................................................................................

3.16. Oral sex is when someone puts his or her mouth on another person’s penis or vagina, OR lets
someone else put his or her mouth on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE

Yes
No

GO TO 3.20

3.17. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.

PPA Study – Part A – CHLA -6/24/11

3.18. Now please think about the past 4 weeks. In the past 4 weeks, how many TIMES have you had
oral sex?
GO TO 3.21

None

NUMBER OF TIMES – Your best guess is fine.

3.19. In the past 4 weeks, how many TIMES did you have oral sex without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

3.20. Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a
male put his penis in their anus or butt.
Have you ever had anal sex?
MARK (X) ONE

Yes
GO TO 3.23

3.21. How many DIFFERENT PEOPLE have you ever had anal sex with, even if only one time?
NUMBER OF TIMES – Your best guess is fine.

3.22. Now please think about the past 4 weeks. In the past 4 weeks, how many TIMES did you have
anal sex without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

3.23. These next questions ask about sexually transmitted diseases, or STDs. In the past 12 months,
have you been told by a doctor or nurse that you had a sexually transmitted disease (STD)?
MARK (X) ONE

Yes
No

PPA Study – Part A – CHLA -6/24/11

3.24. In the past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION

DON’T
YES
NO
KNOW
a. Chlamydia ......................................................................................................................................................
b. Gonorrhea ......................................................................................................................................................
c. Genital herpes ...............................................................................................................................................
d. Syphilis...........................................................................................................................................................
e. HIV infection or AIDS .....................................................................................................................................
f.

Human Papilloma virus, also known as HPV or genital warts .......................................................................

g. Another sexually transmitted disease (STD) PRINT OTHER STD

PPA Study – Part A – CHLA -6/24/11

.........................................................

SECTION 4: PREGNANCY AND RELATIONSHIP WITH BABY’S FATHER
The next questions ask about your pregnancy and your relationship with your baby’s father.
4.1. To the best of your knowledge, how many times have you ever been pregnant, even if no child
was born?
NUMBER OF TIMES – Your best guess is fine.

4.2. When you got pregnant with your baby, were you trying to get pregnant?
MARK (X) ONE

Yes
No

4.3. How likely do you think it is that you will be pregnant again before your child turns two?
MARK (X) ONE

I am sure I will
I probably will
There is a 50/50 chance I will
I probably will not
I am sure I will not

4.4. Ideally, when would you want to get pregnant again?
MARK (X) ONE

Before my baby is 1 year old
When my baby is between 1 and 2 years old
When my baby is between 2 and 3 years old
When my baby is over three years old
I don’t know if I want to get pregnant again
Unsure

4.5. How old is your baby’s father?
YEARS OLD

PPA Study – Part A – CHLA -6/24/11

4.6. What was your relationship with your baby’s father when you got pregnant?
MARK (X) ONE

Did not know him well or at all
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

4.7. What is your relationship with your baby’s father now?
MARK (X) ONE

No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

4.8. Has your baby’s father had any contact with your child since birth?
MARK (X) ONE

Yes
No

GO TO 4.10

4.9. In the past month, how often has your baby’s father spent one or more hours with your child?
MARK (X) ONE

Every day
Almost every day
A few times a week
About once a week
Once or twice
Never

PPA Study – Part A – CHLA -6/24/11

4.10. Do you currently use child care services other than your family or friends?
MARK (X) ONE

Yes – Full-time
Yes – Part-time
No

4.11. In a typical week, how often do each of the following people provide you with physical support
(e.g., childcare, feeding, changing diapers, bathing) to care for your baby?
MARK (X) ONE FOR EACH

6-7 times
a week

4-5 times
a week

2-3
times a
week

1 day a
week

Rarely or
never

Not
Applicable

a. Baby’s father .....................................................................................................................................................
b. Your boyfriend or partner who is not
the baby’s father ...............................................................................................................................................
c. Your parent(s) ...................................................................................................................................................
d. Your baby’s father’s parent(s)...........................................................................................................................
e. Another relative from your family ......................................................................................................................
f.

Another relative from your
baby’s father’s family ........................................................................................................................................

g. A friend..............................................................................................................................................................
h. Other (Please specify) ......................................................................................................................................

PPA Study – Part A – CHLA -6/24/11

SECTION 5: ATTITUDES
5.1. Please rate yourself on this set of statements, using the 9 point scale below.
MARK (X) ONE FOR EACH

Not at
All
True
1

Very
True
9

a. In general, I am focused on preventing
negative events in my life ..........................................................................................................................................................................
b. I am anxious that I will fall short of my
responsibilities and obligations ..................................................................................................................................................................
c. I frequently imagine how I will
achieve my hopes and aspirations ............................................................................................................................................................
d. I often think about the person I am
afraid I might become in the future ............................................................................................................................................................
e. I often think about the person I
would ideally like to be in the future ...........................................................................................................................................................
f. I typically focus on the success I
hope to achieve in the future .....................................................................................................................................................................
g. I often imagine myself experiencing bad
things that I fear might happen to me ........................................................................................................................................................
h. I frequently think about how I can
prevent failures in my life ...........................................................................................................................................................................
i. I see myself as someone who is
primarily striving to reach my “ideal
self”—to fulfill my hopes, wishes,
and aspirations ..........................................................................................................................................................................................
j. I see myself as someone who is
primarily striving to become the self
I “ought” to be – to fulfill my duties,
responsibilities, and obligations .................................................................................................................................................................
k. In general, I am focused on achieving
positive outcomes in my life .......................................................................................................................................................................
l. I often imagine myself experiencing good
things that I hope will happen to me ..........................................................................................................................................................
m. Getting pregnant before my baby is 2
will lower my chances of getting the
future I want for myself and my family .......................................................................................................................................................
n. Contraception is an important way
that I can be a responsible parent .............................................................................................................................................................
o. Focusing on my education and work
experience now will help me achieve
a successful future .....................................................................................................................................................................................
p. Having another baby too soon may make
it much harder on myself and my family ....................................................................................................................................................
q. I plan to put extra effort into my
education or experience to get a
(better) job .................................................................................................................................................................................................
r. I plan to stop doing things that
interfere with my job preparation ...............................................................................................................................................................

PPA Study – Part A – CHLA -6/24/11

5.2. For the following statements, indicate to what degree the statement reflects your own thoughts
and feelings using the numbers 1 through 6, with 1 being STRONGLY AGREE and 6 being
STRONGLY DISAGREE. If a statement has more than one part, please indicate your reaction to
the whole statement.
MARK (X) ONE FOR EACH
STRONGLY
AGREE
1

STRONGLY
DISAGREE
6

a. I just can’t decide what to do as a parent, there are so
many possibilities ....................................................................................................................................................................................
b. I’ve thought a lot about the kind of mother I want to be,
but there’s no question that I will follow what my “mother”
says to do ...............................................................................................................................................................................................
c. My “mom” tells me how to be a parent to my child, and
that’s what I do ........................................................................................................................................................................................
d. I haven’t really decided what kind of mother I want to be.
I’m just taking it day by day .....................................................................................................................................................................
e. I’m sure it will be pretty easy to change the kind of mother
I am when I’m ready ...............................................................................................................................................................................
f. It took me awhile to figure it out, but now I know for sure
what direction to move in as a parent .....................................................................................................................................................
g. It took me a while to figure it out, but now I know what
kind of mother I want to be .....................................................................................................................................................................
h. I’m still trying to decide how capable I am as a person
and what kind of parenting is right for me ...............................................................................................................................................
i. I just can’t decide what to do for a career. There are so
many possibilities ....................................................................................................................................................................................
j. I might have thought about a lot of different jobs, but
there’s really never been any question since my
parents said what they wanted ...............................................................................................................................................................
k. My parents decided a long time ago what I should go
into for employment and I am following through with
their plans ...............................................................................................................................................................................................
l. It took me a while to figure it out, but now I know for
sure what direction to move in for a career.............................................................................................................................................
m. I’m still trying to decide how capable I am as a person
and what jobs will be right for me ...........................................................................................................................................................
n. It took me a while to figure it out, but now I really know
what I want for a career ..........................................................................................................................................................................
o. When I’m ready, I’m sure it’ll be pretty easy to change
or get the kind of job that’s right for me ..................................................................................................................................................
p. I haven’t chosen the occupation I really want to get
into, and I’m just working at what is available until
something better comes along ................................................................................................................................................................

PPA Study – Part A – CHLA -6/24/11

5.3a. Who will you be in fifteen years? Each of us has some image or picture of what we will be like
and what we want to avoid being like in the future. Think about 15 years from now—imagine what
you’ll be like, and what you’ll be doing.
Possible Selves Questionnaire
•

In the lines below, write what you expect you will be like and what you expect to be doing.

•

For each expected goal that you marked Yes, use the space to the right to write what you are doing
this year to attain that goal.

EXAMPLE:
In 15 years, I expect to be…

Am I am doing
something now
about this?
No

What I am doing now is…

Yes

(P1)

a cosmetologist

(s1) practice hair braiding on my friends and little sister

(P2)

a home owner

(s2) getting my GED

In 15 years, I expect to be…

Am I doing
something to be
that way?
Yes

(IF YES) What I am doing now
to be that way in 15 years?

(P1)

(s1)

(P2)

(s2)

(P3)

(s3)

(P4)

(s4)

PPA Study – Part A – CHLA -6/24/11

5.3b. In addition to expectations and expected goals, we all have images or pictures of what we don’t
want to be like; what we don’t want to do or want to avoid being. First, think a minute about ways
you would not like to be in 15 years—things you are concerned about or want to avoid being like.
•

Write those concerns or selves to-be-avoided in the lines below.

•

Next to each concern or to-be-avoided self, mark No (X) if you are not currently working on avoiding
that concern or to-be-avoided self and mark Yes (X) if you are currently doing something so this will
not happen in 15 years.

•

For each concern or to-be-avoided self that you marked Yes, use the space at the end of each line to
write what you are doing this year to reduce the chances that this will describe you in 15 years.

EXAMPLE:
Next year, I want to avoid…

Am I doing
something to
avoid this?
No

(P5)

Unemployed

(P6)

In debt_____

In 15 years, I want to avoid…

Yes
X

(IF YES) What I am doing now to avoid being that way
next year?

(s5) finding out how to get some part time job experience
(s6) __________________________________________
Am I doing
something to
avoid this?
Yes

(IF YES) What I am doing
now to avoid being that
way in 15 years?

(P5)

(s5)

(P6)

(s6)

(P7)

(s7)

(P8)

(s8)

PPA Study – Part A – CHLA -6/24/11

5.4. For each sentence, please think about how you are in most situations. Rate each statement in a
way that describes YOU the best.
MARK (X) ONE FOR EACH

None of
the
Time
0

All of
the
Time
5

a. I can do what it takes to get the specific
work I choose ....................................................................................................................................................
b. I know how to prepare for the kind of work
I want to do .......................................................................................................................................................
c. When I look into the future, I have a clear
picture if what my work life will be like ..............................................................................................................
d. I have a difficult time identifying my own
goals for the next five years ..............................................................................................................................

PPA Study – Part A – CHLA -6/24/11

Children’s Hospital Los Angeles
CONSENT/ASSENT TO PARTICIPATE IN A RESEARCH STUDY
AIM (Adult Identity Mentoring) for Teen Moms
Funded by the Office of Adolescent Health (OAH), U.S.Department of Health and
Human Services
Teen Participant Form-DRAFT

Subject’s Name: _______________________________________________________
CHLA#:__________________________________ Birth Date: _________________

INTRODUCTION
Children’s Hospital Los Angeles, Mathematica Policy Research, and ETR Associates are
conducting an important study on behalf of the U.S. Department of Health and Human
Services (DHHS) on ways to reduce teen pregnancy and sexually transmitted diseases.
The Evaluation of Adolescent Pregnancy Prevention Approaches (PPA) will provide
communities like yours with clear information on program effectiveness. You are being
asked to take part in this study because you are a teen parent between 15 and 19 years
old. If you agree to take part in this study, you would work with a case manager to
complete a computer survey three times over the next 2 years, and possibly participate in
the AIM for Teen Moms program. You may also be invited to participate in a focus group
discussion about your experience with AIM for Teen Moms. About 1400 teen mothers
will be part of this study. Participants will be selected at random to either attend the AIM
for Teen Moms sessions or to continue receiving their existing services as usual. Taking
part in this study is completely voluntary. Please read the information below and ask us
any questions before you decide if you will participate.
PURPOSE OF THE STUDY
The purpose of this study is to understand if a special program, AIM for Teen Moms, can
help teen parents avoid getting pregnant again. We want to understand how teen parents
can be motivated and confident for their future.
PROCEDURES
If you agree to take part in this study, we will ask you to do the following things:
First, we will ask you to complete a survey on the computer about teen parenting. The
survey asks questions about yourself, your activities, your thoughts about the future, and
pregnancy prevention.

Page 1 of 5

Second, you will be randomly assigned to either receive the AIM for Teen Moms program
along with other services you may be receiving, or have your usual case management
sessions (if applicable).
Third, your case manager will ask you to take a survey on the computer two more times
over the next two years. This will happen after 12 months and 24 months. If you are not
meeting with your case manager when it is time for a survey, we will contact you. Your
case manager will find a time to give you the survey in your home or another place you
pick. If this is not possible, we may have you complete the survey online on a computer,
over the phone, or on paper.
POTENTIAL RISK AND DISCOMFORTS
You may feel uncomfortable answering some of the questions on the survey. You can
refuse to answer any questions.
ANTICIPATED BENEFITS TO SUBJECTS
You may not personally benefit from taking part in this study. However, taking part will
help us understand the needs of teen parents.
EXPECTED BENEFITS TO SOCIETY
The results of the study may help health educators understand how to provide services for
pregnant and parenting teens.
ALTERNATIVES TO PARTICIPATION
If you decide not to be part of the study you can still receive case management from
Project NATEEN or El Nido Family Centers. You may decide at any time not to take part
in this study and still receive your services.
PAYMENT FOR PARTICIPATION
You will get a $20 gift card for finishing the first and second surveys. You will get a $25
gift card for the third survey.
FINANCIAL OBLIGATION
The surveys will take place during your regular case management time (if you are
currently receiving case management services) or at a prescheduled time of your
convenience. You are responsible for the normal costs of these visits, such as time off
from work, bus fare, and babysitter fees. There will be no other costs to you to take part
in this study. If you need to complete the survey online, over the telephone, or on paper,
we will give you toll-free access and/or postage-paid mailing.
EMERGENCY CARE AND COMPENSATION FOR INJURY
The researchers and CHLA cannot give financial compensation or pay for treatment if
you are injured as a result of taking part in research.
PRIVACY AND CONFIDENTIALITY

Page 2 of 5

Members of the research team and your case manager will know that you are in the study.
All the results will be confidential. Your name will not be attached to your answers on
the survey and none of the information you provide during the research will be shared
with others without your written permission. The only exception is to protect your rights
or welfare (for example, if you are injured and need emergency care) or if required by
law (for example, child abuse).
PARTICIPATION AND WITHDRAWAL
Taking part in this research is VOLUNTARY. Your decision to take part or not take part
will have no affect on your services from AFLP, Cal Learn, Project NATEEN, and/or El
Nido Family Centers. If you decide to take part, but later decide to stop, there will be no
affect on your services.
INDENTIFICATION OF INVESTIGATORS
If you have a research related injury, please immediately contact one of the people listed
below. If questions are not an emergency, you can get better information by calling Mona
Desai than by calling Adolescent Medicine.
Daytime; Monday through Friday, 8:00 am until 4:30 pm call Mona Desai at (323) 3612390.
Evenings, nights, weekends, or holidays call the hospital number (323) 660-2450 and ask
for the Adolescent Medicine service doctor on call.
If you have questions about your rights as a research subject in this study, you can call
the Committee on Clinical Investigations (I.R.B.: Institutional Review Board) at (323)
361-2265.
FINANCIAL INTEREST OF THE INVESTIGATOR
If your health care provider is working on this study she/he is interested in both your
health care and this research. You do not have to take part in a research study led by your
health care provider.
RIGHTS OF RESEARCH SUBJECTS
You may stop being part of this study at any time without penalty. You are not giving up
any legal claims or rights by being part of this research study. If you have questions about
your rights as a research subject, you may contact the CHLA Office for Protection of
Human Subjects at (323) 361-2265. You may also contact Jennifer Stavrakos at
Public/Private Ventures, toll-free at 1-800-755-4778.
If you have questions about the study, please call Melissa Thomas, toll-free at
Mathematica at 1-888-864-6416 between the hours of 9 a.m and 5 p.m., eastern time,
Monday through Friday.

Page 3 of 5

SIGNATURE OF PARTICIPANT
Your signature(s) below means:
 You have read this document and understand what it means;
 You have had a chance to ask questions and have had these questions answered to
your satisfaction;
 You consent to take part in this study; and
 You will be given a copy of the signed permission form and of the Experimental
Subject’s Bill of Rights.
_____________________________________
Name of Participant
_____________________________________
Signature of Participant

__________________
Date

SIGNATURE OF CONSENTER
I have explained the study to the participant and have answered all of their questions. I
believe that they understand all of the information described in this document and freely
give assent/consent/permission to participate.
________________________________________
Name of Consenter
_________________________________
Signature of Consenter

______________________________
Date (must be the same as participant)

 CHECK THAT THE BILL OF RIGHTS AND SIGNED HIPAA AUTHORIZATION IS
OBTAINED.

SIGNATURE OF WITNESS (if applicable)
My signature as witness indicates that the participant voluntarily signed this consent form
in my presence.
___________________________
Name of Witness
___________________________
Signature of Witness

________________________________________
Date (must be the same date as participant)

Page 4 of 5

SIGNATURE OF INTERPRETER (if applicable)
______________________
Name of Interpreter
____________________
Signature of Interpreter

_____________________________________
Date (must be the same date as participant)

Routing of signed copies of the consent/permission form:
1) Place in the teen’s Project NATEEN, or El Nido Family Centers case management
record
2) Place in the Principal Investigator's research file (original)

Page 5 of 5

CHLA

CONTACT INFORMATION FORM
The following information will be used to contact you in the future and locate records regarding
your participation in this study. We will ask you for updated information should anything change
for you during the study.
1. What is your name?
______________________________
First

_______________________
Middle

___________________
Last

_______________________
Day

___________________
Year

2. What is your date of birth?
______________________________
Month
3. How old are you? ___________
4. What is your social security number? _______ - _______ - _________ (optional)
5. What is your address?
____________________________________
Street
Apt.
____________________________________
City
______________________________________
State
Zip
6a. What is your main phone number? ___________________________
6b. What type of phone is that? ____Cell ____Home ______Work
7a. What other phone number can you be reached at? _____________________
7b. What type of phone is that? ____Cell ____Home ______Work
8. What is your main email address? _____________________________

10. What is the name of someone who will know how we can contact you if we cannot reach
you? __________________________________________
11. What is the relationship between you and the person you named above? _____________
12. What is that person’s address?
____________________________________
Street
Apt.
____________________________________
City
______________________________________
State
Zip
14a. What is this person’s main phone number? ___________________________
14b. What type of phone is that? ____Cell ____Home ______Work
15a. What other phone number can this person be reached at? _____________________
15b. What type of phone is that? ____Cell ____Home ______Work

File Type	application/pdf
Author	MThomas
File Modified	2011-07-01
File Created	2011-07-01