Download:
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pdfThe OICA survey instrument is for foster care youth and is not divided into separate parts for sexually
active and non-sexually active youth.
SUMMARY OF DIFFERENCES BETWEEN THE BASELINE CONCORDANCE INSTRUMENT AND THE OICA BASELINE SURVEY
OICA #
Concordance #
Items are listed in the order in which they appear on the OICA baseline instrument. The number for the corresponding baseline concordance item is listed in the
“Concordance #” column. The OICA instrument will be read aloud to youth in foster care homes. There are no separate sections for sexually active and nonsexually active respondents. Items found on the concordance instrument that are not on the OICA 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 OICA instrument is
the same as that on the baseline concordance instrument.
If an item is specific to the OICA instrument, it is indicated by an “N/A” in the “Concordance #” column and the question text is noted on the
“Modifications” column.
Baseline Concordance Question Text
1.1
1.3
Are you male or female?
1.2
1.2
Modifications for OICA
MARK (X) ONE
□
Male
□
Female
What grade are you in?
MARK (X) ONE
□
□
□
□
□
□
□
□
What is the last grade you completed?
MARK (X) ONE
□
□
□
□
□
□
□
6th
7th
8th
9th
10th
11th
12th
Not currently in school
1
6th
7th
8th
9th
10th
11th
12th
OICA #
Concordance #
1.3
N/A
1.4
N/A
1.5
1.4
Baseline Concordance Question Text
Modifications for OICA
How old were you when you entered the foster care system?
MARK (X) ONE
□ <1 year old
□ 1 year old
□ 2 years old
□ 3 years old
□ 4 years old
□ 5 years old
□ 6 years old
□ 7 years old
□ 8 years old
□ 9 years old
□ 10 years old
□ 11 years old
□ 12 years old
□ 13 years old
□ 14 years old
□ 15 years old
□ 16 years old
□ 17 years old
□ 18 years old
In what month and year did you start living in this group home?
MARK (X) ONE MONTH AND ONE YEAR
Are you Hispanic/Latino?
MARK (X) ONE
□
Yes
□
No
2
OICA #
Concordance #
Baseline Concordance Question Text
1.6
1.5
What is your race?
Modifications for OICA
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
1.7
N/A
What is the second letter of your first name?
MARK (X) ONE
1.8
N/A
What is the last letter of your first name?
MARK (X) ONE
1.9
1.1
1.10
N/A
In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
In which month were you born?
MARK (X) ONE
On which day were you born?
MARK (X) ONE
3
OICA #
Concordance #
1.11
1.1
In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
1.12
1.11
How likely is it that you will do each of the following things?
MARK (X) ONE
Baseline Concordance Question Text
Modifications for OICA
In which year were you born?
MARK (X) ONE
Not at all likely, A little bit likely, Somewhat likely, Very likely
1.13
1.9
a. Graduate from high school
b. Go to a technical or vocational school after high school
c. Go to college
d. Graduate from a 2-year or community college program
e. Graduate from a 4-year college program
In the past 12 months, have you received any information or learned
about any of the following?
Refers to STIs and sexually transmitted infections instead of STDs and
sexually transmitted diseases.
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
4
OICA #
Concordance #
2.1
N/A
Baseline Concordance Question Text
Modifications for OICA
The next questions ask about the body, sexually transmitted infections
(STIs), and methods of protection.
The body part of the female body where a baby grows during
pregnancy is the:
2.2
□ Cervix
□ Uterus
□ Vagina
□ Ovary
The part of the male’s body that produces sperm is the:
N/A
MARK (X) ONE
2.3
□ Testicles
□ Urethra
□ Penis
□ Prostate
When is it possible for a female to become pregnant?
MARK (X) ONE
N/A
□
□
□
□
5
The first time she has sex
When she is ovulating
When her partner withdraws (pulls out) before ejaculating
All of the above
OICA #
Concordance #
2.4
N/A
Baseline Concordance Question Text
Modifications for OICA
Of the following statements about methods of protection, which one is
false?
MARK (X) ONE
□ You can get them with a prescription from a doctor
□ You can buy them at a local store in the drug or pharmacy section
□ Some require a prescription and others do not, depending on the
type of method
□ You must have your parent’s/guardian’s permission to get them if
you are under age 18
6
OICA #
Concordance #
2.5
N/A
Baseline Concordance Question Text
Modifications for OICA
Please mark whether each statement is true, false, or you don’t know.
MARK (X) ONE FOR EACH QUESTION
True, False, Don’t Know
a.
A sexually active girl can become pregnant if she forgets to take
her birth control pills for several days in a row
b. Using a condom can help prevent HIV
c. A condom can be used more than once
d. If a condom is used, a young man should be careful how he
pulls out
e. If a young couple has had unprotected sex a few times and a
pregnancy did not occur, then they do not have to worry about
her getting pregnant
f. HIV destroys the immune system’s ability to fight off infections
and diseases
g. You cannot tell if a person has HIV by looking at them
h. HIV is the only sexually transmitted infection that is incurable
i.
All sexually active individuals are at risk for getting HIV
j.
Latex condoms are 100% effective in preventing pregnancy
and STIs (including HIV)
k. All sexually transmitted infections (STIs) can be cured
l. You can get the same sexually transmitted infection (STI) twice
m. You can get a sexually transmitted infection (STI) from having
oral sex
7
OICA Baseline #
Concordance #
2.6
N/A
Baseline Concordance Question Text
Modifications for OICA
Which of the following methods of protection offers the most
protection against HIV and other STIs?
MARK (X) ONE
2.7
□ Depo-Provera (the shot)
□ Vaginal film
□ Condom (rubber)
□ Birth control pill
What is the safest and most effective method for avoiding pregnancy
and sexually transmitted infections (STIs)?
N/A
MARK (X) ONE
2.8
□ Birth control pill
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Abstinence (not having sex)
Which one of the following methods listed below do you think is most
effective for preventing pregnancy?
N/A
MARK (X) ONE
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Rhythm (safe period by calendar)
□ Patch (Ortho evra)
□ Birth control pill
□ Withdrawal method
8
OICA Baseline #
Concordance #
2.9
N/A
3.1
Baseline Concordance Question Text
Modifications for OICA
Which one of the following methods listed below do you think is
least effective for preventing pregnancy?
MARK (X) ONE
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Rhythm (safe period by calendar)
□ Patch (Ortho evra)
□ Birth control pill
□ Withdrawal method
The following questions are about your views on sex and protection.
N/A
Two people having vaginal intercourse should use some method of
protection if they are not ready for a child.
MARK (X) ONE
3.2
□ Strongly agree
□ Agree
□ Disagree
□ Strongly disagree
Using a method of protection is very important.
N/A
MARK (X) ONE
□ Strongly agree
□ Agree
□ Disagree
□ Strongly disagree
9
OICA Baseline #
Concordance #
3.3
3.4
Baseline Concordance Question Text
Modifications for OICA
The next series of questions is about condom use. How strongly do you
agree or disagree that …
Added:
h. Condoms make sex less exciting
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Neither agree nor disagree, Disagree, Strongly
disagree
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 partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure
10
OICA Baseline #
Concordance #
3.4
3.8
Baseline Concordance Question Text
Modifications for OICA
The next series of questions is about other 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
11
OICA Baseline #
Concordance #
3.5
N/A
Baseline Concordance Question Text
Modifications for OICA
Please tell us how sure or unsure you are that you could do the
following things:
MARK (X) ONE FOR EACH QUESTION
a. Find a place in your community to obtain methods of protection
b. Tell your partner your feelings about what you do and do not want
to do sexually
c. Say “no” if your partner puts pressure on you to be involved sexually,
and you do not want that
d. Talk with your partner about methods of protection if you have sex
with him/her
e. Insist on using a method of protection if you have sex and want to
use a method of protection
f. Stop and use a method of protection once you are turned on
g. Plan ahead to have some method of protection available
h. Resist having sex with your partner if he/she did not want to use a
method of protection
12
OICA Baseline #
Concordance #
3.6
3.1
Baseline Concordance Question Text
Modifications for OICA
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.
4.1
4.2
Part
B1
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
c. 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
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?
4.2
4.9
Part
B1
MARK (X) ONE
□
Yes
□
No
Have you had sexual intercourse more than one time?
Added the option:
MARK (X) ONE
□
□
□
Yes
No
GO TO 4.14
13
I have never had sexual intercourse
Concordance #
OICA Baseline #
4.3
4.10
Part
B1
Baseline Concordance Question Text
Modifications for OICA
How many DIFFERENT PEOPLE have you ever had sexual intercourse with,
even if only one time?
Added the option:
□
|
4.4
4.4
Part
B1
|
| NUMBER OF PEOPLE - Your best guess is fine.
The very first time you had sexual intercourse, how old were you?
|
|
I have never had sexual intercourse
These next few questions ask about the first time you had sexual
intercourse. The very first time you had sexual intercourse, how old
were you?
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
□I have never had sexual intercourse
□ 9 years old
□10 years old
□11 years old
□12 years old
□13 years old
□14 years old
□15 years old
□16 years old
□17 years old
□18 years old
14
Concordance #
OICA Baseline #
4.5
Baseline Concordance Question Text
Modifications for OICA
4.7
Part
B1
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.
Question refers to STIs and sexually transmitted infections instead of
STDs and sexually transmitted diseases.
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
□
□
4.6
4.8
Part
B1
Yes
No
Added the option:
□
MARK (X) ONE FOR EACH ITEM
YES, NO
4.7
4.11
Part
B1
I have never had sexual intercourse
GO TO 4.9
The first time you had sexual intercourse, did you or your partner use …
a.
b.
c.
d.
e.
f.
Added the option:
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):
Now please think about the past 3 months. In the past 3 months, how
many TIMES have you had sexual intercourse?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
15
I have never had sexual intercourse
Concordance #
OICA Baseline #
4.8
4.12
Part
B1
Baseline Concordance Question Text
Modifications for OICA
In the past 3 months, how many TIMES have you had sexual intercourse
without using a condom?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
4.9
4.13
Part
B1
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)
In the past 3 months, 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.
4.10
3.16
Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
o
o
o
o
Yes, definitely
Yes, probably
No, probably not
No, definitely not
16
OICA Baseline #
Concordance #
4.11
3.17
Baseline Concordance Question Text
Modifications for OICA
If you have sexual intercourse in the next year, do you intend to use a
condom?
MARK (X) ONE
o
o
o
o
4.12
3.18
Yes, definitely
Yes, probably
No, probably not
No, definitely not
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?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not
17
OICA Baseline #
Concordance #
4.13
4.26a
Baseline Concordance Question Text
Modifications for OICA
To the best of your knowledge, have you ever been pregnant or gotten
someone pregnant, even if no child was born?
Added: Be sure to answer ‘yes’ if you are currently pregnant or had any
pregnancy that ended in a birth, an abortion, stillbirth, miscarriage, or
live birth after which the baby died.
MARK (X) ONE
□ Yes
□
No
4.14
N/A
Have you been pregnant or gotten someone pregnant during the past 3
months? Be sure to answer ‘yes’ if you are currently pregnant or had
any pregnancy that ended in a birth, an abortion, stillbirth, miscarriage,
or live birth after which the baby died.
MARK (X) ONE
□ Yes
□
No
4.15
4.26b
To the best of your knowledge, how many TIMES have you been
pregnant or gotten someone pregnant?
□
None
| | | NUMBER OF TIMES
4.16
4.26c
Have you ever had a baby or has anyone you got pregnant actually had
the baby?
Added the option:
□ I have never been pregnant or gotten anyone pregnant
MARK (X) ONE
□
Yes
□
No
□
Don’t know
18
OICA Baseline #
Concordance #
4.17
N/A
Baseline Concordance Question Text
Modifications for OICA
When you or your partner got pregnant, were you trying to become
pregnant?
MARK (X) ONE
□ I have never been pregnant or gotten anyone pregnant
□ Yes
□ No
4.18
3.2
for
girls;
3.2
for
boys
FOR GIRLS
If you got pregnant now, how would you feel?
If you got pregnant now or got someone pregnant now, how would
you feel?
FOR BOYS
If you got someone pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□
MARK (X) ONE
□
□
□
□
□
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
19
Very happy
A little happy
Neither upset nor happy
A little upset
Very upset
Concordance #
OICA Baseline #
4.19
Baseline Concordance Question Text
4.14
Part
B1
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.
Modifications for OICA
Have you ever had oral sex?
MARK (X) ONE
□
□
4.20
4.16
Part
B1
Yes
No
How many DIFFERENT PEOPLE have you ever had oral sex with, even if
only one time?
Added the option:
□ I have never had oral sex
|
|
| NUMBER OF PEOPLE - Your best guess is fine.
20
Concordance #
OICA Baseline #
4.21
4.15
Part
B1
Baseline Concordance Question Text
Modifications for OICA
The very first time you had oral sex, what month and year was it?
Now think about the first time you had oral sex. The very first time you
had oral sex, how old were you?
MARK (X) ONE
MARK (X) ONE MONTH AND ONE YEAR
□I have never had oral sex
□ 9 years old
□10 years old
□11 years old
□12 years old
□13 years old
□14 years old
□15 years old
□16 years old
□17 years old
□18 years old
4.22
4.17
Part
B1
Now please think about the past 3 months. In the past 3 months, how
many TIMES have you had oral sex?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
4.23
3.15
Do you intend to have oral sex in the next year?
o
o
o
o
Yes, definitely
Yes, probably
No, probably not
No, definitely not
21
OICA Baseline #
Concordance #
Baseline Concordance Question Text
4.24
3.20
Have you ever had sexual intercourse, oral sex, or anal sex?
Modifications for OICA
Added the following as introduction:
The next few questions ask about sex. By sex, we mean ALL types of
sex – including vaginal, oral, and anal sex.
MARK (X) ONE
□Yes
□No
4.25
N/A
These next few questions ask about the last time you had sex (sexual
intercourse, oral sex or anal sex).
The last time you had sex did you or your partner use a method of
protection?
MARK (X) ONE
□ I have never had sex
□ Yes
□ No
4.26
N/A
The last time you had sex did you or your partner use a condom?
MARK (X) ONE
□ I have never had sex
□ Yes
□ No
22
OICA Baseline #
Concordance #
4.27
N/A
Baseline Concordance Question Text
Modifications for OICA
The last time you had sex, did you or your partner use the following
methods to prevent pregnancy or STIs?
MARK (X) ONE FOR EACH QUESTION
□ I have never had sex
a.
b.
c.
d.
e.
f.
g.
4.28
N/A
Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
NuvaRing or the ring
Withdrawal or pulling out
Not sure
Another method (PRINT OTHER METHOD USED):
Which one of these statements best describes you now?
MARK (X) ONE
□
□
□
23
□
I have not had sex and am not even thinking about having sex
I have not had sex, however I am thinking about having sex
I have not had sex, but I am seriously thinking about having sex in
the near future
I have had sex in the past but I am not having sex now
□
I am currently having sex
OICA Baseline #
Concordance #
4.29
N/A
Baseline Concordance Question Text
Modifications for OICA
Which of the following categories best describes your use of methods
of protection now? Please choose just one category.
MARK (X) ONE
□ I do not use any methods of protection because I am not sexually
active
□ I do not use a method of protection
□ I do not use any methods of protection, but am considering using a
method of protection
□ I use a method of protection sometimes, but I am thinking about
using a method of protection every time I have sex
□ I use a method of protection every time, but it has been less than 6
months since I started using a method of protection every time
□ I use a method of protection every time, and it has been more than 6
months since I started using a method of protection every time
4.30
4.27
Part
B1
In the past 12 months, have you spoken with a doctor or nurse about sex,
birth control or sexually transmitted diseases, also known as STDs?
MARK (X) ONE
□
□
Yes
No
24
Question refers to STIs and sexually transmitted infections instead of
STDs and sexually transmitted diseases.
Concordance #
OICA Baseline #
4.31
Baseline Concordance Question Text
Modifications for OICA
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?
Question refers to STIs and sexually transmitted infections instead of
STDs and sexually transmitted diseases.
MARK (X) ONE
□
□
4.32
4.29
Part
B1
Yes
No
In the past 12 months, have you been told by a doctor or nurse that you
had a sexually transmitted disease (STD)?
Question refers to STIs and sexually transmitted infections instead of
STDs and sexually transmitted diseases.
MARK (X) ONE
□
□
□
4.33
4.30
Part
B1
Yes
No
Don’t know
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…
Question refers to STIs and sexually transmitted infections instead of
STDs and sexually transmitted diseases.
Added the option:
Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.
□ I have not had an STI in the past 12 months
Chlamydia
Gonorrhea
Genital herpes
Syphilis
HIV infection or AIDS
Human papilloma virus, also called HPV or genital warts
Another sexually transmitted disease (STD) PRINT OTHER STD:
25
OICA Baseline #
Concordance #
4.34
N/A
Baseline Concordance Question Text
Modifications for OICA
Were you in the POWER Through Choices program at any previous
time?
MARK (X) ONE
□
□
26
Yes
No
DROPPED: The questions listed below are part of the baseline concordance instrument, but are not part of this site-specific baseline
instrument.
N/A
1.6
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?
□
□
□
□
N/A
1.7
English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE(S) ____________________________
In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
□
□
□
□
□
Never
Less than once a month
1-3 times per month
Once a week
More than once a week
27
N/A
1.8
How important is religion in your life?
MARK (X) ONE
□
□
□
N/A
1.10
Not at all important
Somewhat important
Very important
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
2.1
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
The next question is about where you live and who lives with you.
Which of the following best describes where you live?
□ 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
N/A
2.2
Who lives with you in your home?
MARK ALL THAT APPLY
□
Your biological mother
28
□
□
□
□
□
□
□
□
□
□
□
□
□
N/A
2.3
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
Who lives with you in each of your homes?
Mark all of the people who live with you in your MAIN home, and then mark 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))
□
□
□
□
□
□
□
□
□
□
□
□
□
□
N/A
2.4
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
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
29
N/A
N/A
2.5
2.6
□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
Now we have some questions about your mother, or the person you think of as a mother. Is this
person…
MARK (X) ONE
□
□
□
□
□
□
□
N/A
2.7
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 2.14
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?
30
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
31
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
32
□
N/A
2.16
Don’t know
Did he graduate from a 4-year college?
MARK (X) ONE
□
□
□
N/A
N/A
Yes
No
Don’t know
2.17
Is he working now?
2.18
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
N/A
2.19
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
33
□ 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
2.22
a
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
2.22
b
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
34
□
□
□
□
N/A
2.24
Usually
Sometimes
Rarely
Never
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
N/A
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.
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
35
N/A
3.3
f.
Avoiding drugs and alcohol
g. Pregnancy or birth
h. Sexually transmitted diseases (also called STDs), HIV, or AIDS
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
3.5
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
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
N/A
N/A
N/A
3.5a
3.6
3.7
GO TO 3.6
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
36
N/A
3.9
□
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
N/A
N/A
N/A
3.9a
3.10
3.11
3.12
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
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
□
□
□
Yes
No
Don’t know
GO TO 3.12
37
N/A
3.12
a
N/A
3.13
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
3.19
Do you intend to have sexual intercourse without being married?
o
o
o
o
N/A
N/A
3.20
4.1
Part
B1
Yes, definitely
Yes, probably
No, probably not
No, definitely not
Have you ever had sexual intercourse, oral sex, or anal sex?
□ 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?
□ No STOP AND GO TO PART B2
□ Yes CONTINUE WITH THIS BOOKLET.
38
N/A
N/A
4.3
Part
B1
The very first time you had sexual intercourse, what month and year was it?
4.5
Part
B1
The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE MONTH AND ONE YEAR
MARK (X) ONE
□
□
□
□
□
N/A
4.6
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
The very first time you had sexual intercourse, would you say that it was voluntary or not
voluntary?
MARK (X) ONE
1 □ Voluntary
2 □ Not voluntary
N/A
N/A
4.18
Part
B1
4.19
Part
B1
In the past 3 months, how many TIMES have you had oral sex without using a condom?
□
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
□
□
N/A
N/A
Yes
No
GO TO 4.23
4.20
Part
B1
How many DIFFERENT PEOPLE have you ever had anal sex with, even if only one time?
4.21
Part
Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
anal sex?
|
|
| NUMBER OF PEOPLE - Your best guess is fine.
39
B1
□
None
GO TO 4.23
| | | NUMBER OF TIMES - Your best guess is fine.
N/A
N/A
N/A
N/A
N/A
4.22
Part
B1
4.23
Part
B1
4.24
a
Part
B1
4.24
b
Part
B1
4.25
Part
B1
In the past 3 months, how many TIMES have you had anal sex without using a condom?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
Have you ever had oral sex or anal sex with a person the same sex as you?
MARK (X) ONE
□ Yes
□ No
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?
|
|
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
FOR BOYS ONLY
a
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
4.25
b
Part
FOR BOYS: How old were you when these changes started?
|
|
| NUMBER OF YEARS OLD YOU WERE
40
N/A
B1
4.31
Part
B1
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
N/A
4.2
Part
B2
□ Yes STOP AND GO TO PART B1
□ No CONTINUE WITH THIS BOOKLET
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
41
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
N/A
4.7
Part
B2
4.8
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.
|
|
| 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
□
□
N/A
4.9
Part
Yes
No
Is your home or any of your homes a group home or halfway house?
42
B2
N/A
4.10
Part
B2
□ 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?
|
N/A
4.11
Part
B2
|
| NUMBER OF PEOPLE
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
N/A
4.12
Part
B2
4.13
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
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.
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
43
g.
h.
i.
j.
k.
N/A
N/A
N/A
4.14
a
Part
B2
4.14
b
Part
B2
4.15
Part
B2
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
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?
|
|
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
FOR BOYS ONLY
a
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
N/A
4.15
b
Part
B2
4.16
Part
B2
FOR BOYS: How old were you when these changes started?
|
|
| NUMBER OF YEARS OLD YOU WERE
Have you ever done any of the following with a boy or girl?
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
44
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
□
□
N/A
5.2
Yes
No GO TO 5.4
The very first time you smoked a cigarette, how old were you?
45
|
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
□
□
□
□
N/A
5.7
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
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
46
N/A
5.8
Have you ever used marijuana, also called weed or pot?
MARK (X) ONE
□
□
N/A
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
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
47
N/A
6.1
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
6.2
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.
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
N/A
6.3
a. Have had sexual intercourse.
b. Have had oral sex.
In general, how much pressure, if any, do you feel from your friends to have sexual intercourse?
MARK (X) ONE
□
□
□
□
N/A
6.4
A lot of pressure
Some pressure
A little pressure
No pressure
People are different in their sexual attraction to other people. Which of the following best
describes you?
MARK (X) ONE
□
□
□
□
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
48
□
N/A
6.5
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
49
OMB Control No:
Expiration Date:
BASELINE QUESTIONNAIRE
OICA
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.
2.
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.
PPA Study – OICA – 06/20/11
1
SECTION 1: DEMOGRAPHICS
1.1. Are you male or female?
MARK (X) ONE
Male
Female
1.2. What is the last grade you completed?
MARK (X) ONE
6th
7th
8th
9th
10th
11th
12th
1.3. How old were you when you entered the foster care system?
MARK (X) ONE
<1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
1.4. In what month and year did you start living in this group home?
MARK (X) ONE MONTH AND ONE YEAR
Month started living in this
group home
Year started living in this
group home
January
2008
February
2009
March
2010
April
2011
May
2012
June
2013
July
2014
August
September
October
November
December
1.5. Are you Hispanic/Latino?
MARK (X) ONE
Yes
No
1.6
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 or Caucasian
Some other race (Print other race )
1.7. What is the second letter of your first
name?
1.8. What is the last letter of your first name?
MARK (X) ONE
MARK (X) ONE
A
N
A
N
B
O
B
O
C
P
C
P
D
Q
D
Q
E
R
E
R
F
S
F
S
G
T
G
T
H
U
H
U
I
V
I
V
J
W
J
W
K
X
K
X
L
Y
L
Y
M
Z
M
Z
1.9. In which month were you
born?
MARK (X) ONE
1.10. On which day were you
born?
MARK (X) ONE
1.11. In which year were you
born?
MARK (X) ONE
January
1
17
1991
February
2
18
1992
March
3
19
1993
April
4
20
1994
May
5
21
1995
June
6
22
1996
July
7
23
1997
August
8
24
1998
September
9
25
1999
October
10
26
2000
November
11
27
2001
December
12
28
13
29
14
30
15
31
16
1.12. How likely is it that you will do each of the following?
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE
BIT LIKELY
SOMEWHAT
LIKELY
VERY
LIKELY
a. Graduate from high school ............................................................................................................................
b. Go to a technical or vocational school after high school ...............................................................................
c. Go to college ..................................................................................................................................................
d. Graduate from a 2-year or community college program ................................................................................
e. Graduate from a 4-year college program.......................................................................................................
1.13. In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Relationships, dating, marriage, or family life ................................................................................................
b. Abstinence from sex ......................................................................................................................................
c. Methods of birth control .................................................................................................................................
d. Where to get birth control ..............................................................................................................................
e. Sexually transmitted infections, also known as STIs .....................................................................................
f.
How to talk to your partner about whether to have sex or whether to use birth control ................................
g. How to say no to sex......................................................................................................................................
h. How babies are made ....................................................................................................................................
SECTION 2: KNOWLEDGE
These next questions ask about the body, sexually transmitted infections (STIs), and methods of
protection.
2.1. The body part of the female body where a baby grows during pregnancy is the:
MARK (X) ONE
Cervix
Uterus
Vagina
Ovary
2.2. The part of the male’s body that produces sperm is the:
MARK (X) ONE
Testicles
Urethra
Penis
Prostate
2.3. When is it possible for a female to become pregnant?
MARK (X) ONE
The first time she has sex
When she is ovulating
When her partner withdraws (pulls out) before ejaculating
All of the above
2.4. Of the following statements about methods of protection, which one is false?
MARK (X) ONE
You can get them with a prescription from a doctor
You can buy them at a local store in the drug or pharmacy section
Some require a prescription and others do not, depending on the type of method
You must have your parent’s/guardian’s permission to get them if you are under age 18
2.5. Please mark whether each statement is true, false, or you don’t know.
MARK (X) ONE FOR EACH QUESTION
TRUE
FALSE
DON’T
KNOW
a. A sexually active girl can become pregnant if she forgets to take
her birth control pills for several days in a row .................................................................................................
b. Using a condom can help prevent HIV .............................................................................................................
c. A condom can be used more than once ...........................................................................................................
d. If a condom is used, a young man should be careful how he
pulls out.............................................................................................................................................................
e. If a young couple has had unprotected sex a few times and a
pregnancy did not occur, then they do not have to worry about
her getting pregnant ..........................................................................................................................................
f.
HIV destroys the immune system’s ability to fight off infections
and diseases .....................................................................................................................................................
g. You cannot tell if a person has HIV by looking at them ....................................................................................
h. HIV is the only sexually transmitted infection that is incurable .........................................................................
i.
All sexually active individuals are at risk for getting HIV ..................................................................................
j.
Latex condoms are 100% effective in preventing pregnancy
and STIs (including HIV) ...................................................................................................................................
k. All sexually transmitted infections (STIs) can be cured ...................................................................................
l.
You can get the same sexually transmitted infection (STI) twice ....................................................................
m. You can get a sexually transmitted infection (STI) from having oral sex ........................................................
2.6. Which of the following methods of protection offers the most protection against HIV and other
STIs?
MARK (X) ONE
Depo-Provera (the shot)
Vaginal film
Condom (rubber)
Birth control pill
2.7. What is the safest and most effective method for avoiding pregnancy and sexually transmitted
infections (STIs)?
MARK (X) ONE
Birth control pill
Condom (rubber)
Depo-Provera (the shot)
Abstinence (not having sex)
2.8. Which one of the following methods listed below do you think is most effective for preventing
pregnancy?
MARK (X) ONE
Condom (rubber)
Depo-Provera (the shot)
Rhythm (safe period by calendar)
Patch (Ortho evra)
Birth control pill
Withdrawal method
2.9. Which one of the following methods listed below do you think is least effective for preventing
pregnancy?
MARK (X) ONE
Condom (rubber)
Depo-Provera (the shot)
Rhythm (safe period by calendar)
Patch (Ortho evra)
Birth control pill
Withdrawal method
SECTION 3: ATTITUDES AND SELF-EFFICACY
The following questions are about your views on sex and protection.
3.1. Two people having vaginal intercourse should use some method of protection if they are not
ready for a child.
MARK (X) ONE
Strongly agree
Agree
Disagree
Strongly disagree
3.2. Using a method of protection is very important.
MARK (X) ONE
Strongly agree
Agree
Disagree
Strongly disagree
3.3. The next questions are about condom use. 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. 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 partner....................................................................................................................................................
f.
Condoms are morally wrong ..........................................................................................................................
g. Condoms decrease sexual pleasure .............................................................................................................
h. Condoms make sex less exciting ..................................................................................................................
3.4.
The next questions are about other 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 ...............................................................................................................
3.5. Please tell us how sure or unsure you are that you could do the following things:
MARK (X) ONE FOR EACH QUESTION
VERY SURE
SOMEWHAT
SURE
SOMEWHAT
UNSURE
VERY
UNSURE
a. Find a place in your community to obtain
methods of protection from pregnancy and STIs ..........................................................................................
b. Tell your partner your feelings about what
you do and do not want to do sexually ..........................................................................................................
c. Say “no” if your partner puts pressure on you
to be involved sexually, and you do not want
to be involved sexually...................................................................................................................................
d. Talk with your partner about methods of
protection if you have sex with him/her ........................................................................................................
e. Insist on using a method of protection if you
have sex and want to use a method of
protection ......................................................................................................................................................
f.
Stop and use a method of protection once
you are turned on ..........................................................................................................................................
g. Plan ahead to have some method of protection
available .........................................................................................................................................................
h. Resist having sex with your partner if he/she
did not want to use a method of protection ...................................................................................................
3.6. The next questions are 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. Having sexual intercourse is a good
thing for you to do at your age .......................................................................................................................
b. At your age right now, having sexual
intercourse would create problems ................................................................................................................
c. 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...........................................................................................................................
SECTION 4: BEHAVIOR AND INTENTIONS
NOTE: The following questions are about behaviors. Questions on this survey only mean behaviors
that you choose to participate in - do not count behaviors you were forced to do against your will.
SEXUAL INTERCOURSE
4.1. These 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
4.2. Have you had sexual intercourse more than one time?
MARK (X) ONE
I have never had sexual intercourse
Yes
No
4.3. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
I have never had sexual intercourse
NUMBER OF PEOPLE – Your best guess is fine.
4.4. These next few questions ask about the first time you had sexual intercourse. The very first time
you had sexual intercourse, how old were you?
I have never had sexual intercourse
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
4.5. Birth control methods are something used to reduce the risk of pregnancy, and some can reduce
the risk of sexually transmitted infections, also known as STIs.
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
I have never had sexual intercourse
Yes
No
4.6. The first time you had sexual intercourse, did you or your partner use…?
MARK (X) ONE FOR EACH QUESTION
I have never had sexual intercourse
YES
NO
a. Condoms........................................................................................................................................................
b. Birth control pills or the patch ........................................................................................................................
c. Depo-Provera or other injectable birth control ...............................................................................................
d. NuvaRing or the ring ......................................................................................................................................
e. Withdrawal or pulling out ...............................................................................................................................
f.
Another method PRINT OTHER METHOD USED
................................................................................
4.7. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had sexual intercourse?
None
NUMBER OF TIMES – Your best guess is fine.
4.8. In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?
None
NUMBER OF TIMES – Your best guess is fine.
4.9. 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 3 months, 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.
4.10. The next few questions are about your intentions for the next year.
Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
4.11. 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
4.12. 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
Yes, definitely
Yes, probably
No, probably not
No, definitely not
PREGNANCY
4.13. To the best of your knowledge, have you ever been pregnant or gotten anyone pregnant, even if
no child was born? Be sure to answer ‘yes’ if you are currently pregnant or had any pregnancy
that ended in a birth, an abortion, stillbirth, miscarriage, or live birth after which the baby died.
MARK (X) ONE
Yes
No
4.14. Have you been pregnant or gotten someone pregnant during the past 3 months? Be sure to
answer ‘yes’ if you are currently pregnant or had any pregnancy that ended in a birth, an
abortion, stillbirth, miscarriage, or live birth after which the baby died.
MARK (X) ONE
Yes
No
4.15. To the best of your knowledge, how many times have you been pregnant or gotten someone
pregnant?
None
NUMBER OF TIMES PREGNANT
4.16. Have you ever had a baby or has anyone you got pregnant had the baby?
MARK (X) ONE
I have never been pregnant or gotten anyone pregnant
Yes
No
Don’t know
4.17. When you or your partner got pregnant, were you trying to become pregnant?
MARK (X) ONE
I have never been pregnant or gotten anyone pregnant
Yes
No
4.18. If you got pregnant now or got someone pregnant now, how would you feel?
MARK (X) ONE
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
ORAL SEX
4.19. The next questions are about oral sex. 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
4.20. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
I have never had oral sex
NUMBER OF PEOPLE – Your best guess is fine.
4.21. Now think about the first time you had oral sex. The very first time you had oral sex, how old were
you?
MARK (X) ONE
I have never had oral sex
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
4.22. Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
oral sex?
None
NUMBER OF TIMES – Your best guess is fine.
4.23. Do you intend to have oral sex in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
SEX – VAGINAL, ORAL, AND ANAL SEX
The next few questions ask about sex. By sex, we mean ALL types of sex – including vaginal,
oral, and anal sex.
4.24. Have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
Yes
No
4.25. These next few questions ask about the last time you had sex (sexual intercourse, oral sex or
anal sex). The last time you had sex did you or your partner use a method of protection?
MARK (X) ONE
I have never had sex
Yes
No
4.26. The last time you had sex did you or your partner use a condom?
MARK (X) ONE
I have never had sex
Yes
No
4.27. The last time you had sex, did you or your partner use the following methods to prevent
pregnancy or STIs?
MARK (X) ONE FOR EACH QUESTION
I have never had sex
YES
NO
a. Condoms........................................................................................................................................................
b. Birth control pills or the patch ........................................................................................................................
c. Depo-Provera or other injectable birth control ...............................................................................................
d. NuvaRing or the ring ......................................................................................................................................
e. Withdrawal or pulling out ...............................................................................................................................
f.
Not sure ........................................................................................................................................................
g. Another method PRINT OTHER METHOD USED
................................................................................
4.28. Which one of these statements best describes you now?
MARK (X) ONE
I have not had sex and am not even thinking about having sex
I have not had sex, however I am thinking about having sex
I have not had sex, but I am seriously thinking about having sex in the near future
I have had sex in the past but I am not having sex now
I am currently having sex
4.29. Which of the following categories best describes your use of methods of protection now? Please
choose just one category.
MARK (X) ONE
I do not use any methods of protection because I am not sexually active
I do not use a method of protection
I do not use any methods of protection, but am considering using a method of protection
I use a method of protection sometimes, but I am thinking about using a method of protection every time I have
sex
I use a method of protection every time, but it has been less than 6 months since I started using a method of
protection every time
I use a method of protection every time, and it has been more than 6 months since I started using a method of
protection every time
SEXUALLY TRANSMITTED INFECTIONS (STIs)
The next questions ask about sexually transmitted infections (STIs.)
4.30. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted infections, also known as STIs?
MARK (X) ONE
Yes
No
4.31. In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
infection (STI), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE
Yes
No
4.32. In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted infection (STI)?
MARK (X) ONE
Yes
No
4.33. This question is about the types of sexually transmitted infections (STIs) you have had. In the
past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION
I have not had an STI in the last 12 months
YES
NO
DON’T
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 infection (STI) PRINT OTHER STI.................................................................
4.34. Were you in the POWER Through Choices program at any previous time?
MARK (X) ONE
Yes
No
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Consent Version, Date
IRB No: __________
Consent Form
University of Oklahoma Health Sciences Center (OUHSC)
Oklahoma (Tulsa/Oklahoma counties)
California (Bakersfield/Kern counties)
Illinois (Chicago metro area/Cook county)
Maryland (Baltimore/Montgomery counties)
For the Evaluation of the Power Through Choices Project.
as part of the national Evaluation of Adolescent Pregnancy Prevention Approaches
(PPA). Conducted by Mathematica Policy Research, Inc.
Sponsored by the U.S. Department of Health and Human Services (DHHS)
Roy F. Oman, Ph.D., Principal Investigator
If you are a Legally Authorized Representative consenting for a minor child, all
references to “you” are applicable to the minor child.
This is a research study. Research studies involve only individuals who choose to
participate. Please take your time to make your decision. Discuss this with your family
and friends.
Why Have I Been Asked To Participate In This Study? You are being asked to take
part in this trial/study because you live in a group care foster home and you are 14 to 18
years of age.
Why Is This Study Being Done? The purpose of this study is to determine if the Powers
Through Choices program is effective in protecting youth who live in a group care foster
home from pregnancy and sexually transmitted infections
How Many People Will Take Part In The Study? About 1600 people will take part in
this study nationwide. About 6 to 20 of these individuals will participate at this location.
What Is Involved In The Study? The foster care group home that you live in will be
randomized to receive either the Powers Through Choices curriculum or to usual care.
Randomization means that you are put in a group by chance. Your foster care home has
an equal or 50/50 chance, like the flip of a coin, of being assigned to the group that
receives the Powers Through Choices curriculum or to usual care. A computer program at
the study sponsor will make this random assignment.
If your foster care group home is assigned to the Powers Through Choices intervention
you will be expected to participate in ten instructional sessions that teach youth how to
avoid sexual risk behaviors, pregnancy, and sexually transmitted infections. Each
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instructional session lasts about 1 1/2 hours and the entire 10 sessions will be completed
in about 2 ½ months or earlier. The instructional sessions are about topics such as human
anatomy/reproductive health, increasing communication skills, avoiding sexually
transmitted infections/HIV, and preventing pregnancy through the use of contraception.
If your foster care group home is assigned to usual care then you will not be asked to
participate in an intervention that is part of the study. You are able to participate in any
program or instruction that might be offered to you.
All youth in the study, regardless if they are in a group care home randomized to the
Powers Through Choices program or to usual care, will be asked to a complete
questionnaire at the beginning of the study; and also complete a questionnaire at three,
six, and 12 months after the Powers Through Choices program is over.
Completing the questionnaire will take about one hour. The questionnaire has questions
to determine your age, sex, and race. Other questions will ask about your attitudes,
knowledge, intentions, and behavior regarding sexual activity, STIs, contraceptive use,
and abstaining from sexual activity. You will answer the questions by filling in bubbles
on a paper form. No one will know how you answered the questions because you will not
put your name on the answer sheet. Instead you will put a code name on the answer sheet.
If you are in a group home assigned to the Power Through Choices Program, you may
also be invited to participate in a short focus group discussion about your experience with
the intervention.
How Long Will I Be In The Study? You will be in the study for about one year. You
can stop participating in this study at any time. However, if you decide to stop
participating in the study, we encourage you to talk to the researcher and your regular
doctor first.
What Are The Risks of The Study? You may feel embarrassed or uncomfortable when
answering very personal questions. If at any time during this study we are informed of any sexual
or child abuse, we will be required by law to report it.
Are There Benefits to Taking Part in The Study? If you are in a foster care group
home that receives the Powers Through Choices program you will learn how to protect
yourself from pregnancy or from getting someone pregnant and you will learn how to
protect yourself from sexually transmitted infections.
What Other Options Are There? You may choose not to participate in the study.
What About Confidentiality? Efforts will be made to keep your personal information
confidential. You will not be identifiable by name or description in any reports or
publications about this study. We cannot guarantee absolute confidentiality. Your
personal information may be disclosed if required by law. You will be asked to sign a
separate authorization form for use or sharing of your protected health information.
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There are organizations that may inspect and/or copy your research records for quality
assurance and data analysis. These organizations include our partners and sponsors: the
US Department of Health and Human Services (DHHS), Mathematica Policy Research,
and the OUHSC Institutional Review Board. A Certificate of Confidentiality from the
National Institutes of Health provides a strong guarantee that information about your
child will not be released to anyone outside the study.
What Are the Costs? There is no cost to you for participating in this study.
Will I Be Paid For Participating in This Study? You will be paid up to $100 for
participating in the study.
What Are My Rights As a Participant? Taking part in this study is voluntary. You may
choose not to participate. Refusal to participate will involve no penalty or loss of benefits
to which you are otherwise entitled. If you agree to participate and then decide against it,
you can withdraw for any reason and leave the study at any time without penalty or loss
of benefits, to which you are otherwise entitled.
You have the right to access the medical information that has been collected about you as
a part of this research study. However, you may not have access to this medical
information until the entire research study has completely finished and you consent to
this temporary restriction.
Whom Do I Call If I have Questions or Problems?
If you have questions, concerns, or complaints about the study or have a research-related
injury, contact the Roy Oman, Ph.D. at (405) 271-2017 ext. 46752. If you cannot reach
the Investigator or wish to speak to someone other than the investigator, contact the
OUHSC Director, Office of Human Research Participant Protection at 405-271-2045, or
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.
.
For questions about your rights as a research participant, contact the OUHSC Director,
Office of Human Research Participant Protection at 405-271-2045 or Jennifer Stavrakos
at Public/Private Ventures, toll-free at 1-800-755-4778.
Signature: By signing this form, you are agreeing to participate in this research study
under the conditions described. You have not given up any of your legal rights or
released any individual or entity from liability for negligence. You have been given an
opportunity to ask questions. You will be given a copy of this consent document.
I agree to participate in this study:
_________________________________
Legally Authorized Representative
_______________________ _________
Printed Name
Date
_________________________________
PARTICIPANT SIGNATURE
_______________________ _________
Printed Name
Date
Page 3 of 4
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_________________________________
SIGNATURE OF PERSON
OBTAINING CONSENT
_______________________ _________
Printed Name
Date
IRB Office Version Date: 09/08/2010
Page 4 of 4
| File Type | application/pdf |
| Author | MThomas |
| File Modified | 2011-06-29 |
| File Created | 2011-06-29 |