Instrument 4

Evaluation of Pregnancy Prevention Approaches - Baseline

Instrument 4

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⚠️ Notice: This form may be outdated.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

Document [pdf]

Download: pdf | pdf

EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
SUMMARY TABLE, SITE- SPECIFIC BASELINE SURVEY, AND CONSENT AND
ASSENT FORMS: OHIOHEALTH

The OhioHealth survey instrument is for pregnant and parenting teens 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 OHIOHEALTH BASELINE
SURVEY

OhioHelath #

Concordance #

Items are listed in the order in which they appear on the OhioHealth baseline instrument. The number for the corresponding baseline concordance
item is listed in the “Concordance #” column. Items found on the concordance instrument that are not on the OhioHealth 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
OhioHealth instrument is the same as that on the baseline concordance instrument.
• If an item is specific to the OhioHealth instrument, it is indicated by an “N/A” in the “Concordance #” column and the text is noted in the
“Modifications” column.

1.1a

1.1

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

In what month were you born?
MARK (X) ONE MONTH

1.1b

1.1

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

In what year were you born?
MARK (X) ONE YEAR

1.2

N/A

Baseline Concordance Question Text

Modifications for OhioHelath

Are you currently enrolled in school or studying school subjects
through a program at home, online or somewhere else?
MARK (X) ONE
□
Yes
□
No

OhioHelath #

Concordance #

1.3

1.2

Baseline Concordance Question Text

Modifications for OhioHelath

What grade are you in?
MARK (X) ONE

What is the highest grade in school you completed?
MARK (X) ONE

□
□
□
□
□
□
□
□

1.4

1.11

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

□
□
□
□
□
□
□
□
□
□
□
□

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

6th grade or lower
7th
8th
9th
10th
11th
12th
GED
Community college or vocational school
Four-year college
Your schooling does not have grade levels
Other

Added the option:
Already Done it

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

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

OhioHelath #

Concordance #

Baseline Concordance Question Text

1.5

1.4

Are you Hispanic/Latino?

Modifications for OhioHelath

MARK (X) ONE
□
Yes
□
No
1.6

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

1.7

N/A

What is your country of birth?
MARK (X) ONE

□
□

United States GO TO 1.9
Some other country PRINT OTHER COUNTRY_____________

OhioHelath #

Concordance #

1.8

N/A

Baseline Concordance Question Text

Modifications for OhioHelath
How long have you lived in the United States?
MARK (X) ONE

□
□
□
□

1.9

1.6a

What is the main language you speak at home?

MARK (X) ONE

□
□
□
□

1.10

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
□
□
□
□
□

Less than one year
1 to 5 years
More than 5 years to 10 years
More than 10 years

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

English
Spanish
Somali
Some other language PRINT OTHER
LANGUAGE_______________________

OhioHelath #

Concordance #

1.11

1.8

Baseline Concordance Question Text
How important is religion in your life?
MARK (X) ONE
□
□
□

1.12

Modifications for OhioHelath

Not at all important
Somewhat important
Very important

N/A

What is your religion or faith?
MARK (X) ONE
□
□
□
□
□
□
□
□
□
□
□

Atheist or Agnostic
Buddhist
Hindu
Jewish
Mormon
Muslim
Orthodox (for example Greek or Russian Orthodox)
Protestant
Roman Catholic
Nothing in particular
Other

OhioHelath #

Concordance #

1.13

1.9

Baseline Concordance Question Text

Modifications for OhioHelath

In the past 12 months, have you received any information or learned about any
of the following?

Dropped “how babies are made”.

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

OhioHealth #

Concordance #

Baseline Concordance Question Text

2.1

The next question is about where you live and who lives with you.

Modifications for OhioHealth

Which of the following best describes where you live?
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 2.6

OhioHealth #

Concordance #

Baseline Concordance Question Text

2.2

Who lives with you in your home?

Modifications for OhioHealth
Who lives with you in your home?

MARK ALL THAT APPLY

□
□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□

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
The father of your most recent pregnancy or baby
Your current boyfriend or partner who is not the father of your most
recent pregnancy or baby
One or more parents of the father of your most recent pregnancy or
baby
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

OhioHealth #

Concordance #

Baseline Concordance Question Text

2.3

Who lives with you in each of your homes?

Modifications for OhioHealth
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 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))
□
□
□
□
□
□
□
□
□
□
□
□
□
□

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

OhioHealth #

Concordance #

2.4

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
In the past 30 days, did you or someone who lives with you receive any of the
following types of financial assistance?
MARK (x) YES OR NO FOR EACH QUESTION
Yes, no
a.
b.
c.
d.
e.

2.5

N/A

Social Security Disability
Food stamps, now called SNAP or Supplemental Nutrition Assistance
Program
WIC or The Women, Infants and Children Supplemental Nutrition
Program
Welfare, also called TANF or Temporary Assistance for Needy
Families
Unemployment

In the past 30 days, how many times did you or someone who lives with you…
MARK (X) ONE
Never, Less than once a week, About once a week, More than once a week
a.
b.
c.
d.

Feel sick, in pain or injured but did NOT go for medical help because
of no insurance or no money
Skip a meal because there was no food in the house or money to get
food
Visit a food pantry
Miss school, going to a job, or something else important because
there was no money for gas, a bus, a train, or some other type of
transportation

OhioHealth #

Concordance #

2.6

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
At any time in the past 12 months, has there been a period of time when you
have not had any health insurance at all?
MARK (X) ONE
□
Yes
□
No

2.7

N/A

The next two questions are about your baby’s father.
When you got pregnant, what was your relationship with the baby’s father?
MARK (X) ONE

2.8

N/A

□
Did not know him well or at all
□
Knew him, but not dating
□
Casually dating
□
Seriously dating
□
Engaged or married
□
Other
Currently, what is your relationship with the baby’s father?
MARK (X) ONE
□
□
□
□
□
□
□

No contact
Have contact, but don’t get along
Have contact, get along, not dating
Casual dating
Seriously dating
Engaged or married
Other

OhioHealth #

Concordance #

2.9

2.6

Baseline Concordance Question Text

Modifications for OhioHealth

Now we have some questions about your mother, or the person
you think of as your mother. Is this person…
MARK (X) ONE
□
you
□
□
□
□
□
□
2.12

2.10

2.7

Your biological mother, that is, the woman who gave birth to
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

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

Yes
No
Don’t know

OhioHealth #

Concordance #

2.11

2.9

2.12

2.14

Baseline Concordance Question Text

Modifications for OhioHealth

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

OhioHealth #

Concordance #

2.13

2.15

Baseline Concordance Question Text

Modifications for OhioHealth

The following questions are about the person you marked as your
father or the person you think of as your father.
Did he graduate from high school?
MARK (X) ONE
□
□
□

2.14

2.17

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

OhioHealth #

Concordance #

2.15

2.22a

Baseline Concordance Question Text

Modifications for OhioHealth

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

2.16

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
Don’t know

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

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

OhioHealth #

Concordance #

3.1

3.4

Baseline Concordance Question Text

Modifications for OhioHealth

The next series of questions is about condom use. How strongly do
you agree or disagree that …
MARK (X) ONE FOR EACH
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 sexual partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure

3.2

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

OhioHealth #

Concordance #

3.3

3.6

3.4

3.5

3.7

3.8

Baseline Concordance Question Text

Modifications for OhioHealth

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
The next series of questions is about methods of birth control,
NOT including condoms. How strongly do you agree or disagree
that…
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

OhioHealth #

Concordance #

3.6

3.9

Baseline Concordance Question Text

Modifications for OhioHealth

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

3.7

3.8

3.10

3.11

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

OhioHealth #

Concordance #

3.9

N/A

Baseline Concordance Question Text

Modifications for OhioHealth

The next series of questions is about ALL methods of birth control,
including condoms and birth control pills. How strongly do you
agree or disagree that…

Added

MARK (X) ONE
a.
b.
c.
d.
e.
f.
3.10

Women can trust what doctors and nurses say about birth
control methods
The use of birth control improves a relationship
If a woman uses birth control, her partner will know she
really cares about herself
If a man uses birth control, his partner will know he really
cares about her
If a woman uses birth control, her partner will think she’s
pretty smart
If a man makes sure that one of them is using birth
control, his partner will know he really cares about her

N/A

Before you were in this study, had you ever heard that getting pregnant less
than 18 months after the end of a previous pregnancy increases your risk of
having a preterm baby, that is – a baby born before you reached 37 weeks of
pregnancy?
MARK (X) ONE
□
□

4.1

4.10
Part
B1

Yes
No

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

| NUMBER OF PEOPLE - Your best guess is fine.

OhioHealth #

Concordance #

4.2

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
This question is about types of birth control you have ever used.
For birth control, have you ever used …
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.

4.3

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

Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
Diaphragm
Male vasectomy
Lactational amenorrhea
Female condoms
Fertility awareness
Withdrawal
Spermicide
Other? PRINT OTHER METHOD _________________________

Please think about the 3 months before you found out you were pregnant
with your most recent pregnancy. In those 3 months, how many TIMES did
you have sexual intercourse?
□
None
GO TO 4.8
| | | NUMBER OF TIMES - Your best guess is fine.

OhioHealth #

Concordance #

4.4

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
In the 3 months before you found out you were pregnant, when you had
sexual intercourse how often did you use each of the following types of birth
control?
MARK (X) ONE FOR EACH QUESTION
Never, Sometimes, Always
a.
b.
c.
d.
e.
f.

Condoms
Diaphragm
Female condoms
Fertility awareness
Withdrawal
Spermicide

OhioHealth #

Concordance #

4.5

N/A

Baseline Concordance Question Text

4.6

4.12
Part
B1

Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
Male vasectomy
Lactational amenorrhea
Other PRINT OTHER METHOD __________

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

In those 3 months, how many TIMES did you have sexual intercourse without
using a condom?

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

Concordance #

OhioHealth #
4.7

4.13
Part
B1

Baseline Concordance Question Text

Modifications for OhioHealth

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

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

•
•
•
•
•
•
•

4.8

4.9

4.17
Part
B1

4.18
Part
B1

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

•
•
•
•
•
•
•

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

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

In the 3 months before you found out you were pregnant with your most
recent pregnancy, 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.

Now please think about the past 3 months. In the past 3 months,
how many TIMES have you had oral sex?

In the 3 months before you found out you were pregnant, how many TIMES
have you had oral sex?

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

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

In the 3 months before you found out you were pregnant, how many TIMES
have you had oral sex without using a condom?

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

Concordance #

OhioHealth #
4.10

4.21
Part
B1

Baseline Concordance Question Text

Modifications for OhioHealth

Now please think about the past 3 months. In the past 3 months,
how many TIMES have you had anal sex?

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. In the 3 months
before you found out you were pregnant, how many TIMES have you had anal
sex?

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

□
None
GO TO 4.23
| | | NUMBER OF TIMES - Your best guess is fine.
4.11

4.12

4.22
Part
B1

4.29
Part
B1

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

In the 3 months before you found out you were pregnant, how many TIMES
have you had anal sex without using a condom?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
In the past 12 months, have you been told by a doctor or nurse
that you had a sexually transmitted disease (STD)?

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

MARK (X) ONE
□
□
□

Yes
No
Don’t know

Concordance #

OhioHealth #
4.13

Baseline Concordance Question Text

4.30
Part
B1

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…

Modifications for OhioHealth

Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.
4.14

N/A

4.15

N/A

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:
Including your current or recent pregnancy, how many times have you been
pregnant, even if no child was born?
| | | NUMBER OF TIMES
The next series of questions is about your current or most recent pregnancy.
At the time that you became pregnant the most recent time, did you want to
become pregnant then, did you want to become pregnant later, or did you
not want to become pregnant at all?
MARK (X) ONE
□
□
□

Wanted to become pregnant then
Wanted to become pregnant later
Did not want to become pregnant at all

OhioHealth #

Concordance #

4.16

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
How many weeks along in your pregnancy were you when you went to your
first prenatal visit?
|

4.17

N/A

| WEEKS – Your best guess is fine.

How many weeks along in your pregnancy are you now or were you when
your new baby was born or the pregnancy ended?
|

4.18

| WEEKS – Your best guess is fine.

How did your most recent pregnancy end?
MARK (X) ONE
□
□
□
□
□

4.19

N/A

Live birth or births
Still pregnant GO TO 4.25
Miscarriage GO TO 4.25
Stillbirth GO TO 4.25
Abortion GO TO 4.25

Did you have a c-section delivery, also known as a Caesarean section delivery,
or a vaginal birth, also known as pushing the baby out?
MARK (X) ONE
□
□

C-section
Vaginal birth

OhioHealth #

Concordance #

4.20

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
Was your new baby born full-term, that is after you were 37 weeks pregnant,
or premature, that is before you were 37 weeks pregnant?
MARK (X) ONE
□
□

4.21

N/A

Full-term GO TO 4.25
Premature

Was the delivery of your baby spontaneous, that is – no medicine was used to
cause your baby to be born, or induced, that is – medicine was used to start
labor to cause your baby to be born?
MARK (X) ONE
□
□
□

4.22

N/A

Spontaneous birth – no medicine was used to start labor
Induced because of your own health complications
Induced because of complications involving the baby

How much did your new baby weigh at birth?
|_|_| Pounds |_|_| Ounces

4.23

N/A

How many days was your new baby in the hospital after he or she was born?
□

My new baby is still in the hospital

|_|_| NUMBER OF DAYS

OhioHealth #

Concordance #

4.24

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
How many days was your new baby in the intensive care unit at the hospital
after he or she was born?
□
None
□
My new baby is still in the intensive care unit at the hospital
|_|_| NUMBER OF DAYS

4.25

N/A

Now please think about the time you were pregnant right before your most
recent pregnancy.
At the time that you became pregnant that previous time, did you want to
become pregnant then, did you want to become pregnant later, or did you
not want to become pregnant at all?
MARK (X) ONE
□
I HAVE NEVER BEEN PREGNANT BEFORE THE MOST RECENT TIME GO
TO 5.1
□
Wanted to become pregnant then
□
Wanted to become pregnant later
□
Did not want to become pregnant at all

4.26

N/A

How did that pregnancy end?
MARK (X) ONE
□
□
□
□

Live birth or births
Miscarriage GO TO 5.1
Stillbirth GO TO 5.1
Abortion GO TO 5.1

OhioHealth #

Concordance #

4.27

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
How many weeks were you when your new baby was born?
|

4.28

N/A

| WEEKS – Your best guess is fine.

Did you have a c-section delivery, also known as a Caesarean section delivery,
or a vaginal birth, also known as pushing the baby out?
MARK (X) ONE
□
□

4.29

N/A

C-section
Vaginal birth

Was your baby born full-term, that is after you were 37 weeks pregnant, or
premature, that is before you were 37 weeks pregnant?
MARK (X) ONE
□
□

4.30

N/A

Full-term GO TO 4.31
Premature

Spontaneous birth – no medicine was used to start labor
Induced because of your own health complications
Induced because of complications involving the baby

OhioHealth #

Concordance #

4.31

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
How much did your baby weigh at birth?
|_|_| Pounds |_|_| Ounces

4.32

N/A

How many days was your new baby in the hospital after he or she was born?
|_|_| NUMBER OF DAYS

4.33

N/A

How many days was your new baby in the intensive care unit at the hospital
after he or she was born?
□

None

|_|_| NUMBER OF DAYS
5.1

3.16

Do you intend to have sexual intercourse in the next year?
o
o
o
o

5.2

3.17

Yes, definitely
Yes, probably
No, probably not
No, definitely not GO TO 5.4

If you have sexual intercourse in the next year, do you intend to
use a condom?
o
o
o
o

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

OhioHealth #

Concordance #

5.3

3.18

Baseline Concordance Question Text

Modifications for OhioHealth

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 (Implanaon)

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
5.4

N/A

Do you want to have any more children?
MARK (X) ONE
□
□
□

5.5

N/A

Yes
No GO TO 5.7
Don’t know

How many more children do you want to have?
|_|_| CHILDREN

OhioHealth #

Concordance #

5.6

N/A

Baseline Concordance Question Text

Modifications for OhioHealth
How long do you plan to wait until you become pregnant again?
MARK (X) ONE
□
□
□

5.7

N/A

Less than 6 months after the end of my most recent pregnancy
6 to 18 months after the end of my most recent pregnancy
More than 18 months after the end of my most recent pregnancy

Please think about the next year and a half. Over the next year and a half, will
you be …
MARK (X) ONE
□
□
□
□

5.8

N/A

Trying to get pregnant again
Neither trying to get pregnant nor trying avoid getting pregnant
Trying to avoid getting pregnant
Don’t know

Over the next year and a half, from your partner’s point of view, will he be…
MARK (X) ONE
□
Trying to get you pregnant
□
Neither trying to get you pregnant nor trying to avoid getting you
pregnant
□
Trying to avoid getting you pregnant
□
Don’t know
□
I don’t have a partner right now

Concordance #

OhioHealth #

Baseline Concordance Question Text

Modifications for OhioHealth

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

1.3

1.10

Are you male or female?

Not in site-specific baseline

MARK (X) ONE
□
Male
□
Female
In an average week last month, including weekends, about how many hours did you spend
participating in each of the following?

Not in site-specific baseline

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.

N/A

2.8

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
d. Services or programs at a church, temple, synagogue,
mosque, or other place of worship
e. Working at a paid job
f.
Volunteering
Did she graduate from a 4-year college?

Not in site-specific baseline

MARK (X) ONE
□
□
□

Yes
No
Don’t know

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

2.10

How close do you feel to your mother or the person you think of as a mother?

Modifications for OhioHealth
Not in site-specific baseline

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?

Not in site-specific baseline

MARK (X) ONE
□
□
□
□
N/A

2.12

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

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

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

2.13

How would she feel about you having a baby at this time in your life?

Modifications for OhioHealth
Not in site-specific baseline

MARK (X) ONE
□
□
□
□
□
N/A

2.16

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

Did he graduate from a 4-year college?

Not in site-specific baseline

MARK (X) ONE
□
□
□
N/A

2.18

Yes
No
Don’t know

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

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

2.19

In general, how much do you think he cares about you?

Modifications for OhioHealth
Not in site-specific baseline

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?

Not in site-specific baseline

MARK (X) ONE
□
□
□
□
□
N/A

2.21

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

How would he feel about you having a baby at this time in your life?

Not in site-specific baseline

MARK (X) ONE
□
□
□
□
□

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

OhioHealth #

Concordance #

N/A

2.23

Baseline Concordance Question Text

Modifications for OhioHealth

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?

Not in site-specific baseline

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?

Not in site-specific baseline

MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
□
I did not go out
N/A

2.25

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

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

2.26

If you were going to be home late, would your parents expect you to call?

N/A

2.27

Modifications for OhioHealth

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

Not in site-specific baseline

OhioHealth #

Concordance #

N/A

3.1

Baseline Concordance Question Text

Modifications for OhioHealth

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 . . .

Not in site-specific baseline

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
□
□
□
□
□

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

Not in site-specific baseline

OhioHealth #

Concordance #

N/A

3.2

Baseline Concordance Question Text

Modifications for OhioHealth

FOR BOYS
If you got a female pregnant now, how would you feel?

Not in site-specific baseline

MARK (X) ONE
□
□
□
□
□
N/A

3.3

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

Imagine you are alone with someone you like very much. How likely is it that you could . . .

Not in site-specific baseline

MARK (X) ONE FOR EACH QUESTION
Not at all Likely, a Little likely, Somewhat Likely, Very Likely
a.

N/A

3.5a

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
How confident are you that your answer is correct?

MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

3.9a

How confident are you that your answer is correct?

N/A

3.12

3.12a

N/A

3.13

Not in site-specific baseline

MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
□
□
□

N/A

Modifications for OhioHealth

Yes
No
Don’t know

Not in site-specific baseline

GO TO 3.12
Not in site-specific baseline

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?

Not in site-specific baseline

□ 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.

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

3.15

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

N/A

3.19

3.20

Not in site-specific baseline

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

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

N/A

Modifications for OhioHealth

Not in site-specific baseline

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

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

Not in site-specific baseline

□ 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
N/A

4.1
Part
B1

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?
MARK (X) ONE
□ No STOP AND GO TO PART B2.
□ Yes CONTINUE WITH THIS BOOKLET

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.2
Part
B1

Baseline Concordance Question Text

Modifications for OhioHealth

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

Not in site-specific baseline

Have you ever had sexual intercourse?

N/A

4.3
Part
B1
4.4
Part
B1
4.5
Part
B1

MARK (X) ONE
□
Yes
□
No
GO TO 4.15
The very first time you had sexual intercourse, what month and year was it?

Not in site-specific baseline

MARK (X) ONE MONTH AND ONE YEAR
The very first time you had sexual intercourse, how old were you?

Not in site-specific baseline

4.6
Part
B1

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

The very first time you had sexual intercourse, how old was your partner?

Not in site-specific baseline

MARK (X) ONE
□
□
□
□
□

N/A

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

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.7
Part
B1

Baseline Concordance Question Text

Modifications for OhioHealth

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.

Not in site-specific baseline

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 …

Not in site-specific baseline

MARK (X) ONE FOR EACH ITEM
YES, NO
a.
b.
c.
d.
e.
f.

N/A

4.9
Part
B1

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):

Have you had sexual intercourse more than one time?

Not in site-specific baseline

MARK (X) ONE
□
□

Yes
No

GO TO 4.14

Concordance #

OhioHealth #
N/A

4.14
Part
B1

Baseline Concordance Question Text

Modifications for OhioHealth

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.

Not in site-specific baseline

Have you ever had oral sex?
MARK (X) ONE
□
□
N/A

N/A

Yes
No

Not in site-specific baseline

4.15
Part
B1

The very first time you had oral sex, what month and year was it?

4.16
Part
B1

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

4.19
Part
B1

Have you ever had anal sex?

MARK (X) ONE MONTH AND ONE YEAR

4.20
Part
B1

Not in site-specific baseline

| NUMBER OF PEOPLE - Your best guess is fine.
Not in site-specific baseline

MARK (X) ONE
□
□

N/A

GO TO 4.19

Yes
No

GO TO 4.23

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

| NUMBER OF PEOPLE - Your best guess is fine.

Not in site-specific baseline

N/A

Concordance #

OhioHealth #
N/A

4.23
Part
B1

4.24a
Part
B1

4.24b
Part
B1

Baseline Concordance Question Text

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

Not in site-specific baseline

MARK (X) ONE
□ Yes
□ No
FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual period?

Not in site-specific baseline

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

4.25a
Part
B1

Modifications for OhioHealth

Not in site-specific baseline

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

FOR BOYS ONLY

Not in site-specific baseline

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

Not in site-specific baseline

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

| NUMBER OF YEARS OLD YOU WERE

OhioHealth #

Concordance #

N/A

4.26a

Baseline Concordance Question Text

Modifications for OhioHealth

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

Not in site-specific baseline

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

4.26b

To the best of your knowledge, how many TIMES have you been pregnant or gotten someone
pregnant?

Not in site-specific baseline

□
None
| | | NUMBER OF TIMES
N/A

4.26c

Have you ever had a baby or has anyone you got pregnant actually had the baby?

Not in site-specific baseline

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

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.28
Part
B1

Baseline Concordance Question Text

Modifications for OhioHealth

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?

Not in site-specific baseline

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?

Not in site-specific baseline

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?

Not in site-specific baseline

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 THIS BOOKLET

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.2
Part
B2

Baseline Concordance Question Text

Modifications for OhioHealth

The first two questions in this booklet are about your schooling.

Not in site-specific baseline

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?)

Not in site-specific baseline

MARK (X) ONE MONTH AND ONE YEAR
N/A

4.4
Part
B2

Not in site-specific baseline

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

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.6
Part
B2

Baseline Concordance Question Text

Modifications for OhioHealth
Not in site-specific baseline

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

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.

4.9
Part
B2

Not in site-specific baseline

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

N/A

Not in site-specific baseline

Yes
No

Is your home or any of your homes a group home or halfway house?
□
□

Not in site-specific baseline

Yes
No

Concordance #

OhioHealth #
N/A

4.10
Part
B2

Baseline Concordance Question Text

Modifications for OhioHealth

This question is about who lives with you in your home. If you have more than one home, please
think about your main home.

Not in site-specific baseline

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 . . .

Not in site-specific baseline

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
a.
b.
c.
d.

When you start a project, you finish it
You only work as hard as you have to
You are someone people can count on
When you work, you do a good job

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.13
Part
B2

Baseline Concordance Question Text

Modifications for OhioHealth

Here are some reasons people your age might choose NOT to have sexual intercourse. How
important is each of these reasons to YOU?

Not in site-specific baseline

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.
N/A

N/A

4.14 a
Part
B2

4.14b
Part
B2

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

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.

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.15a
Part
B2

Baseline Concordance Question Text

Modifications for OhioHealth

FOR BOYS ONLY

Not in site-specific baseline

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?

4.17
Part
B2

Not in site-specific baseline

| NUMBER OF YEARS OLD YOU WERE
Not in site-specific baseline

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
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
□
□

Yes
No

Not in site-specific baseline

Concordance #

OhioHealth #
N/A

4.18
Part
B2

Baseline Concordance Question Text

Modifications for OhioHealth

Have you ever been fearful that someone you were dating or having sex with might physically
hurt you?

Not in site-specific baseline

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?

Not in site-specific baseline

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

Not in site-specific baseline

OhioHealth #

Concordance #

N/A

5.1

Baseline Concordance Question Text

Modifications for OhioHealth

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.

Not in site-specific baseline

Have you ever smoked a cigarette?
MARK (X) ONE
□
□
N/A

5.2

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

N/A

5.3

Yes
No GO TO 5.4

Not in site-specific baseline

| 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?

Not in site-specific baseline

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
□
□

Yes
No GO TO 5.8

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

5.5

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

N/A

5.6

Modifications for OhioHealth
Not in site-specific baseline

| 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?

Not in site-specific baseline

MARK (X) ONE
□
□
□
□
N/A

N/A

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

5.7

During the past 30 days, on how many days did you have 5 or more drinks in a row?

Not in site-specific baseline

5.8

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?

Not in site-specific baseline

MARK (X) ONE
□
□

Yes
No GO TO 5.10

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

5.9

During the past 30 days, on how many days did you use marijuana?

N/A

5.10

Modifications for OhioHealth
Not in site-specific baseline

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?

Not in site-specific baseline

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?

Not in site-specific baseline

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

Not in site-specific baseline

OhioHealth #

Concordance #

Baseline Concordance Question Text

N/A

6.1

How many of your friends who are your age think the following things? Your best guess is fine

Modifications for OhioHealth
Not in site-specific baseline

MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know
a.

N/A

6.2

Having sexual intercourse is a good thing for them to do at
their age.
b. It would be okay for them to have sexual intercourse as long
as they used birth control, like a condom.
c. It would be okay for them to have sexual intercourse if they
were dating the same person for a long time
d. They should wait until they are older to have sexual
intercourse.
e. They should wait until marriage to have sexual intercourse.
How many of your friends who are your age have done the following things?

Not in site-specific baseline

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
□
□
□
□

A lot of pressure
Some pressure
A little pressure
No pressure

Not in site-specific baseline

OhioHealth #

Concordance #

N/A

6.4

Baseline Concordance Question Text

Modifications for OhioHealth

People are different in their sexual attraction to other people. Which of the following best
describes you?

Not in site-specific baseline

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?

Not in site-specific baseline

MARK (X) ONE
□
Do not care at all
□
Care a little bit
□
Care somewhat
□
Care very much

OMB Control No:
Expiration Date:

BASELINE QUESTIONNAIRE
Ohio Health
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 – Ohio Health Baseline 06/21/11

EXAMPLE 4: QUESTION WITH A SKIP
1. Do you ever eat chocolate?
Because you answered “Yes” to question 1, you would
continue to question 2 and then question 3.

MARK (X) ONE
X

Yes
GO TO QUESTION 3

If you answered “No” to question 1, you would skip
question 2 and go right to question 3.

2. Do you always brush your teeth after eating chocolate?
MARK (X) ONE

Yes
X

3. Did you do any of the following last week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X

Went to a play

Went to a movie
Attended a sporting event

EXAMPLE 5: FILL IN THE NUMBER
In the past 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
past 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 past 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 – Ohio Health Baseline 06/21/11

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

January
February
March
April
May
June
July
August
September
October
November
December

1.1b. In what year were you born?
MARK (X) ONE YEAR

2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991

PPA Study – Ohio Health Baseline 06/21/11

1.2.

Are you currently enrolled in school or studying school subjects through a program at home, online or
somewhere else?
MARK (X) ONE

Yes
No

1.3.

What is the highest grade in school you completed?
MARK (X) ONE

6th grade or lower
7th
8th
9th
10th
11th
12th
GED
Community college or vocational school
Four-year college
Your schooling does not have grade levels
Other

1.4.

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

ALREADY
DONE IT

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 .......................................................................................................
1.5.

Are you Hispanic / Latino?
MARK (X) ONE

Yes
No

PPA Study – Ohio Health Baseline 06/21/11

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
Some other race PRINT OTHER RACE

1.7.

What is your country of birth?
MARK (X) ONE

United States

GO TO 1.9

Some other country PRINT OTHER COUNTRY

1.8.

How long have you lived in the United States?
MARK (X) ONE

Less than one year
1 to 5 years
More than 5 years to 10 years
More than 10 years

1.9.

What is the main language you speak at home?
MARK (X ONE

English
Spanish
Somali
Some other language PRINT OTHER LANGUAGE

PPA Study – Ohio Health Baseline 06/21/11

1.10. 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
1.11. How important is religion in your life?
MARK (X) ONE

Not at all important
Somewhat important
Very important
1.12. What is your religion or faith?
MARK (X) ONE

Atheist or Agnostic
Buddhist
Hindu
Jewish
Mormon
Muslim
Orthodox (for example Greek or Russian Orthodox)
Protestant
Roman Catholic
Nothing in particular
Other

1.13. In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH

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 diseases, also known as STDs? ..................................................................................
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?....................................................................................................................................

PPA Study – Ohio Health Baseline 06/21/11

SECTION 2: FAMILY
The next questions are about where you live and who lives with you.
2.1. Which of the following best describes where you live?
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, for example living on the street, in
a car or shelter, or staying with friends or relatives
GO TO 2.6

2.2. Who lives with you in your home?
MARK (X) ALL THAT APPLY

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
The father of your most recent pregnancy or baby
Your current boyfriend or partner who is not the father of your most recent pregnancy or baby
One or more parents of the father of your most recent pregnancy or baby
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

AFTER ANSWERING

PPA Study – Ohio Health Baseline 06/21/11

GO TO 2.4

2.3 Who lives with you in each of your homes?
MARK (X) BOTH COLUMNS

Mark (X) everyone you live with in your MAIN home

Mark (X) everyone you live with in your OTHER home(s)

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

The father of your most recent pregnancy or baby

Your current boyfriend or partner who is not the
father of your most recent pregnancy or baby

Your current boyfriend or partner who is not the father of
your most recent pregnancy or baby

One or more parents of the father of your most
recent pregnancy or baby

One or more parents of the father of your most recent
pregnancy or baby

Any aunts, uncles, or other relatives

Any other people you are not related to

You live by yourself

2.4. In the past 30 days, did you or someone who lives with you receive any of the following types of
financial assistance?
MARK (X) YES OR NO FOR EACH QUESTION

YES

a. Social Security Disability .............................................................................................................................
b. Food stamps, now called SNAP or Supplemental Nutrition Assistance Program ......................................
c. WIC or The Women, Infants and Children Supplemental Nutrition Program ..............................................
d. Welfare, also called TANF or Temporary Assistance for Needy Families ...................................................
e. Unemployment .............................................................................................................................................

PPA Study – Ohio Health Baseline 06/21/11

2.5. In the past 30 days, how many times did you or someone who lives with you …
MARK (X) ONE FOR EACH QUESTION

Did not
happen

Less than
once a week

About once
a week

More than
once a week

a. Feel sick, in pain or injured but did NOT go for
medical help because of no insurance or no money? ............................................................................
b. Skip a meal because there was no food in the
house or money to get food? ..................................................................................................................
c.

Visit a food pantry? .................................................................................................................................

d. Miss school, going to a job, or something else
important because there was no money for gas, a
bus, a train, or some other type of transportation? .................................................................................

2.6. At any time in the past 12 months, has there been a period of time when you have not had any
health insurance at all?
MARK (X) ONE

Yes
No

FATHER OF YOUR BABY
2.7. The next two questions are about your baby’s father.
When you got pregnant, what was your relationship with the baby’s father?
MARK (X) ONE

Did not know him well or at all
Knew him, but not dating
Casually dating
Seriously dating
Engaged or married
Other

2.8. Currently, what is your relationship with the baby’s father?
MARK (X) ONE

No contact
Have contact, but don’t get along
Have contact, get along, not dating
Casual dating
Seriously dating
Engaged or married
Other

PPA Study – Ohio Health Baseline 06/21/11

MOTHER
2.9. 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
Don’t have a mother or person I think of as my mother

GO TO 2.12

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

Yes
No
Don’t know

2.11. 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

PPA Study – Ohio Health Baseline 06/21/11

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

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 my father

GO TO 2.15

2.13. The following questions are about the person you marked as your father or the person you think
of as your father.
Did he graduate from high school?
MARK (X) ONE

Yes
No
Don’t know

2.14. 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

PPA Study – Ohio Health Baseline 06/21/11

PARENTS
2.15. The next two questions are about your biological parents.
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

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
Don’t know

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

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

PPA Study – Ohio Health Baseline 06/21/11

SECTION 3: VIEWS AND PERCEPTIONS
3.1. The next series of questions is about condom use. How strongly do you agree or disagree that…
MARK (X) ONE FOR EACH
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? ...........................................................................................................

3.2. 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

3.3. 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

3.4. 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

PPA Study – Ohio Health Baseline 06/21/11

3.5. 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 ................................................................................................................

3.6. The next series of questions is about birth control pills.
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

3.7. 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

3.8. 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

PPA Study – Ohio Health Baseline 06/21/11

3.9. The next series of questions is about ALL methods of birth control, including condoms and birth
control pills. 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. Women can trust what doctors and nurses say
about birth control methods ...........................................................................................................................
b. The use of birth control improves a relationship ............................................................................................
c. If a woman uses birth control, her partner will know
she really cares about herself ........................................................................................................................
d. If a man uses birth control, his partner will know he
really cares about her ....................................................................................................................................
e. If a woman uses birth control, her partner will think
she’s pretty smart ...........................................................................................................................................
f.

If a man makes sure that one of them is using birth
control, his partner will know he really cares about her .................................................................................

3.10. Before you were in this study, had you ever heard that getting pregnant less than 18 months after
the end of a previous pregnancy increases your risk of having a preterm baby, that is – a baby
born before you reached 37 weeks of pregnancy?
MARK (X) ONE

Yes
No

PPA Study – Ohio Health Baseline 06/21/11

SECTION 4: BEHAVIORS AND EXPERIENCES
SEXUAL INTERCOURSE AND BIRTH CONTROL
4.1.

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.
The first question is about sexual intercourse. By sexual intercourse, we mean a male putting his
penis into a female’s vagina.
How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
NUMBER OF PEOPLE – Your best guess is fine.

4.2. This question is about types of birth control you have ever used.
For birth control, have you ever used …
MARK (X) ONE FOR EACH QUESTION

YES

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. Diaphragm? ...................................................................................................................................................
i.

Male vasectomy? ...........................................................................................................................................

Lactational amenorrhea? ...............................................................................................................................

k. Female condoms? .........................................................................................................................................
l.

Fertility awareness? .......................................................................................................................................

m. Withdrawal? ...................................................................................................................................................
n. Spermicide? ...................................................................................................................................................
o. Other? PRINT OTHER METHOD

4.3.

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

Please think about the 3 months before you found out you were pregnant with your most recent
pregnancy. In those 3 months, how many TIMES did you have sexual intercourse?
None

GO TO 4.8

NUMBER OF TIMES – Your best guess is fine.

PPA Study – Ohio Health Baseline 06/21/11

4.4. In the 3 months before you found out you were pregnant, when you had sexual intercourse how
often did you use each of the following types of birth control?
MARK (X) ONE FOR EACH QUESTION

Never
Sometimes
Always
a. Condoms........................................................................................................................................................
b. Diaphragm
c. Female condoms ...........................................................................................................................................
d. Fertility awareness .........................................................................................................................................
e. Withdrawal .....................................................................................................................................................
f.

Spermicide .....................................................................................................................................................

g. Other PRINT OTHER METHOD

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

4.5. In the 3 months before you found out you were pregnant, how much of the time did you use each
of the following types of birth control?
MARK (X) ONE FOR EACH QUESTION

Not at
All

Some of
the Time

All of the
Time

a. Birth control pills .............................................................................................................................................
b. The shot (Depo Provera) ...............................................................................................................................
c. The patch .......................................................................................................................................................
d. The ring (NuvaRing).......................................................................................................................................
e. IUD (Mirena or Paragard) ..............................................................................................................................
f.

Implant (Implanon) .........................................................................................................................................

g. Male vasectomy .............................................................................................................................................
h. Lactational amenorrhea .................................................................................................................................
i.

Other PRINT OTHER METHOD

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

4.6. In those 3 months, how many TIMES did you have sexual intercourse without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

PPA Study – Ohio Health Baseline 06/21/11

4.7. 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 3 months before you found out you were pregnant with your most recent pregnancy, how
many TIMES did you have sexual intercourse without using any of these methods of birth
control?
None
NUMBER OF TIMES – Your best guess is fine.

ORAL AND ANAL SEX
4.8. 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.
In the 3 months before you found out you were pregnant, how many TIMES did you have oral
sex?
None

GO TO 4.10

NUMBER OF TIMES – Your best guess is fine.

4.9. In the 3 months before you found out you were pregnant, how many TIMES did you have oral sex
without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

4.10. Anal sex is when a male puts his penis in someone else’s anus, or their butt. In the 3 months
before you found out you were pregnant, how many TIMES did you have anal sex?
None

GO TO 4.12

NUMBER OF TIMES – Your best guess is fine.

4.11. In the 3 months before you found out you were pregnant, how many TIMES did you have anal sex
without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

PPA Study – Ohio Health Baseline 06/21/11

SEXUALLY TRANSMITTED DISEASES
4.12. Now please think about the past 12 months. In the past 12 months, have you been told by a
doctor or nurse that you had a sexually transmitted disease, also known as an STD?
MARK (X) ONE

Yes
No

4.13. This 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

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? .....................................................................

h. Another sexually transmitted disease (STD)? PRINT OTHER STD

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

PREGNANCY HISTORY
4.14. Including your current or recent pregnancy, how many times have you been pregnant, even if no
child was born?
NUMBER OF TIMES

4.15. The next series of questions is about your current or most recent pregnancy.
At the time that you became pregnant the most recent time, did you want to become pregnant
then, did you want to become pregnant later, or did you not want to become pregnant at all?
MARK (X) ONE

Wanted to become pregnant then
Wanted to become pregnant later
Did not want to become pregnant at all

PPA Study – Ohio Health Baseline 06/21/11

4.16. How many weeks along in your pregnancy were you when you went to your first prenatal visit?
WEEKS – Your best guess is fine

4.17. How many weeks along in your pregnancy are you now or were you when your new baby was
born or the pregnancy ended?
WEEKS

4.18. How did your most recent pregnancy end?
MARK (X) ONE

Live birth or births
Still pregnant

GO TO 4.25

Miscarriage

GO TO 4.25

Stillbirth

GO TO 4.25

Abortion

GO TO 4.25

4.19. Did you have a c-section delivery, also known as a Caesarean section delivery, or a vaginal birth,
also known as pushing the baby out?
MARK (X) ONE

C-section
Vaginal birth

4.20. Was your new baby born full-term, that is after you were 37 weeks pregnant, or premature, that is
before you were 37 weeks pregnant?
MARK (X) ONE

Full-term

GO TO 4.22

Premature

4.21. Was the delivery of your baby spontaneous, that is – no medicine was used to cause your baby
to be born, or induced, that is – medicine was used to start labor to cause your baby to be born?
MARK (X) ONE

Spontaneous birth – no medicine was used to start labor
Induced because of your own health complications
Induced because of complications involving the baby

PPA Study – Ohio Health Baseline 06/21/11

4.22. How much did your new baby weigh at birth?
POUNDS

OUNCES

4.23. How many days was your new baby in the hospital after he or she was born?
MY NEW BABY IS STILL IN THE HOSPITAL
NUMBER OF DAYS

4.24. How many days was your new baby in the intensive care unit at the hospital?
NONE
MY NEW BABY IS STILL IN THE INTENSIVE CARE UNIT AT THE HOSPITAL
NUMBER OF DAYS

PREVIOUS PREGNANCY
4.25. Now please think about the time you were pregnant right before your most recent pregnancy.
At the time that you became pregnant that previous time, did you want to become pregnant then,
did you want to become pregnant later, or did you not want to become pregnant at all?
MARK (X) ONE

I HAVE NEVER BEEN PREGNANT BEFORE THE MOST RECENT TIME

GO TO 5.1

Wanted to become pregnant then
Wanted to become pregnant later
Did not want to become pregnant at all

4.26. How did that pregnancy end?
MARK (X) ONE

Live birth or births
Miscarriage

GO TO 5.1

Stillbirth

GO TO 5.1

Abortion

GO TO 5.1

PPA Study – Ohio Health Baseline 06/21/11

4.27. How many weeks along in your pregnancy were you when your baby was born?
WEEKS

4.28. Did you have a c-section delivery, also known as a Caesarean section delivery, or a vaginal birth,
also known as pushing the baby out?
MARK (X) ONE

C-section
Vaginal birth

4.29. Was your baby born full-term, that is after you were 37 weeks pregnant, or premature, that is
before you were 37 weeks pregnant?
MARK (X) ONE

Full-term

GO TO 4.31

Premature

4.30. Was the delivery of your baby spontaneous, that is – no medicine was used to cause your baby to
be born, or induced, that is – medicine was used to start labor to cause your baby to be born?
MARK (X) ONE

Spontaneous birth – no medicine was used to start labor
Induced because of your own health complications
Induced because of complications involving the baby

4.31. How much did your baby weigh at birth?
POUNDS

OUNCES

4.32. How many days was your baby in the hospital after he or she was born?
NUMBER OF DAYS

4.33. How many days was your baby in the intensive care unit at the hospital?
NONE
NUMBER OF DAYS

PPA Study – Ohio Health Baseline 06/21/11

SECTION 5: PLANNING FOR THE FUTURE
5.1. Again, in this survey, by sexual intercourse, we mean a male putting his penis into a female’s
vagina.
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 5.4

5.2. 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

5.3. 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

PPA Study – Ohio Health Baseline 06/21/11

5.4. Do you want to have any more children?
MARK (X) ONE

Yes
No

GO TO 5.7

Don’t know

5.5. How many more children do you want to have?
CHILDREN

5.6. How long do you plan to wait until you become pregnant again?
Less than 6 months after the end of my most recent pregnancy
6 to 18 months after the end of my most recent pregnancy
More than 18 months after the end of my most recent pregnancy

5.7. Please think about the next year and a half. Over the next year and a half, will you be …
MARK (X) ONE

Trying to get pregnant again
Neither trying to get pregnant nor trying avoid getting pregnant
Trying to avoid getting pregnant
Don’t know

5.8. Over the next year and a half, from your partner’s point of view, will he be…
MARK (X) ONE

Trying to get you pregnant
Neither trying to get you pregnant nor trying to avoid getting you pregnant
Trying to avoid getting you pregnant
Don’t know
I don’t have a partner right now

PPA Study – Ohio Health Baseline 06/21/11

We thank you for
completing this survey!

PPA Study – Ohio Health Baseline 06/21/11

OHIOHEALTH
CONSENT FORM
(Please note that this is a draft of a form that will be submitted to
OhioHealth’s IRB; it has not yet been approved by OhioHealth’s IRB)
TITLE OF STUDY: TEEN OPTIONS TO PREVENT PREGNANCY
PRINCIPAL INVESTIGATOR: NGOZI OSUAGWU, M.D.
OhioHealth, Nationwide Children’s Hospital, and Mathematica Policy Research are a team that
is conducting a clinical trial (a type of research study). Clinical trials include only patients who
choose to take part in the study. This consent form serves two purposes. First, it provides
information on the procedures and risks involved in the clinical trial, so that you can decide if
you want to take part in the study.
Second, this form will ask for your permission to use and release the medical information that we
will get from you during this study. Please take your time to make your decision about taking
part. You may discuss your decision with your friends and family. If you have any questions,
you can ask the study doctor for more explanation.
This study is being sponsored by the U.S. Department of Health and Human Services. The study
is part of a broader national study.
You are being asked to take part in this study because you are 10-19 years old and have had at
least one pregnancy.

WHY IS THIS STUDY BEING DONE?
The purpose of this study is to see if nurse contacts by telephone and transportation assistance
help teenage girls delay a future pregnancy.

WHAT IS INVESTIGATIONAL ABOUT THIS STUDY?
The response of teenage girls to telephone calls from a nurse and transportation assistance is
under study.

HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY?
About 600 teenage girls will take part in this study locally through an OhioHealth hospital or
clinic.

Date

Page 1 of 8

Patient Initials _____

WHAT WILL HAPPEN IN THE STUDY?
Everyone in or out of the study may seek birth control through OhioHealth or outside clinics.
Some outside clinics included Planned Parenthood (1-800-230-7526) or the Ohio State
University Department of Obstetrics and Gynecology (614-293-2913).
You will be “randomized” into one of the study groups described below. Randomization means
that you are put into a group by chance. It is like flipping a coin. A computer will decide which
group you are in. Neither you nor the study doctor will choose what group you will be in. You
will have an equal or one in two chance of being placed in either group.
Group 1
• Will be telephoned roughly 18 times. The calls will roughly happen once per month and
are expected to last about 30-60 minutes each. Sometimes a study nurse may talk to you in
person. During these interactions, the study nurse will talk about different health issues.
These topics may include local health care services and birth control. She may provide
information on birth control and help you problem-solve ways to get it, if you decide to do
so. The conversations with the nurse may be audiorecorded to make sure she is doing her
job correctly.
• Will be eligible for free transportation, if needed, to get to and from appointments
• Will be eligible to obtain services from a mobile clinic
• May be eligible to receive some birth control services at home
Group 2 will not receive any of the phone calls or transportation help mentioned above.
However, Group 2 will still be able to seek birth control from the clinics listed at the beginning
of this section.

HOW LONG WILL I BE IN THE STUDY?
You will be in the study 30 months.
You can stop being a part of this study at any time. However, if you decide to stop being in the
study, please talk to the study doctor (Dr. Ngozi Osuagwu) first. You can still be in the study no
matter what you decide about birth control.

WHAT ARE THE RISKS OF THE STUDY?
Because we are asking about sensitive topics, you may become uncomfortable at times. You
do not have to answer any question that makes you feel uncomfortable.
It is also possible that you may be in an accident if you receive transportation assistance. Please
remember to wear a seat belt and use a car seat for your infant/toddler. These risks are
low, and the seriousness is likely low.
Date

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Patient Initials _____

REPRODUCTIVE RISKS?
This study has no special reproductive risks associated with it.
However, if you decide to use birth control, you should talk to your regular doctor about benefits
and side effects of your selection. If you experience any side effects, do not wait for the study
team to call you. You should call your regular doctor right away to discuss the side effects.
Please note that condoms and not having sex are the only effective birth control methods for
protecting yourself against getting a sexually transmitted infection, including HIV. Remember
that even if you use birth control, you can still get pregnant or catch a disease when you have
sex.
Recent studies suggest that women who are pregnant within 18 months of their last pregnancy are
at increased risk for having a preterm birth. If you become pregnant again, we encourage you to
seek prenatal health care right away. Here is a group that can help you locate this care:
Pregnancy Care Connections (614) 227-9866

ARE THERE BENEFITS TO TAKING PART IN THE STUDY?
This study may or may not have direct benefits to you. You may learn information about birth
control.

WHAT OTHER OPTIONS ARE THERE?
Instead of being in this study, you can:
1. Read about birth control options, effectiveness, and their side effects on your own time.
2. Ask your regular doctor to explain these to you.
You may get birth control even if you do not take part in the study.

WHAT ARE THE COSTS?
Your discussions with the study team are free. The transportation assistance for Group 1 is free.
However, you and/or your insurance company are responsible for any health care services and
birth control you receive.

WHAT IF AN INJURY OCCURS BECAUSE OF THE STUDY TREATMENT?
In the case of injury or illness resulting from this study, emergency medical treatment is
available but will be provided at the usual charge. No funds have been set aside to compensate
you in the event of injury or illness. You or your insurance company will be charged for
continuing medical care and/or hospitalization.
Date

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Patient Initials _____

COMPENSATION?
Everyone from both groups will be asked to complete four surveys. You will be sent gift cards
as follows:
• $10 gift card for completing the survey at the beginning of the study
• $10 gift card for completing the 6 month survey
• $25 gift card for completing the 18 month survey
• $50 gift card for completing the 30 month survey

WHAT INFORMATION WILL BE COLLECTED FROM ME FOR USE IN
THE STUDY?
In the surveys, you will be asked questions about yourself, your family, and your thoughts and
experiences about using birth control. You will be asked about previous and future pregnancies.
In addition, Group 1 will be asked questions about depression and violence as the nurse gets to
know them better. If you are in Group 1, you may also be invited to participate in a focus group
to discuss your experiences with the program.
You will be asked to update the study team on changes in their contact information. You will
also be asked to update the study team on friends and relatives likely to know your whereabouts.
Everyone from both groups will have their OhioHealth medical records looked at by the study
team. The study staff will look for information on births, health care appointments, birth control
use and services, and updated telephone numbers and addresses.
Everyone from both groups will have their names, addresses, and dates of birth passed along to
the Ohio Department of Health to see if they have had future births. Information about each
birth, such as the baby’s weight and how far along you were at delivery, will also be collected.
The above information may identify you by name, address, telephone number, health plan
number, study number, date of birth, dates relating to various medical procedures, your voice, or
other identifying information. You will be asked if we can take a photo of you at the beginning
of the study to help us remember you. You can still be in the study if you do not want your
photo taken.

WHAT ABOUT CONFIDENTIALITY?
As part of OhioHealth’s policy, the research staff has a duty to keep everyone safe. If you say or
do something that poses a threat to your own safety or somebody else, we may be not be able to
keep that information private. If you say or do something that makes us suspect child abuse or

Date

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Patient Initials _____

neglect, we will be required to contact your county’s child protective services agency.
If you give us oral permission, we may have contact with your health care providers to help
coordinate care and communicate your thoughts regarding birth control.
If you sign this form and take part in this study, the study team will be authorized to use the
information described above to carry out the purposes of the research study. The study team will
also be authorized to disclose the information described above to all of the following parties
involved in the research study:
Organizations that may inspect and/or copy your research records for quality assurance and data
analysis include groups such as:
•
•
•
•
•
•
•
•
•
•

Grant/Doctors Hospital Institutional Review Board
U.S. Department of Health and Human Services
The U.S. Food and Drug Administration (FDA) and other government agencies.
The Department of Health and Human Services Office of Human Subject Research
Protections
The Centers for Medicare and Medicaid Services (CMS)
National Government Services (the financial agent for CMS)
The Ohio Department of Health (which has birth certificate data)
Nationwide Children’s Hospital (which is helping us look at study results)
Mathematica Policy Research (an outside company that is helping us look at study
results)
Gary Stofle (a motivational interviewing national trainer—MINT; he will help us
review audiorecordings to make sure that study staff are doing their jobs correctly)

Efforts will be made to keep your personal information confidential. We cannot guarantee
absolute confidentiality. Your personal information may be disclosed if required by law. Once
your information is disclosed to the study sponsors, the IRB or the government agencies
described above, there is a potential that your medical information will be re-disclosed and will
no longer be protected by federal privacy regulations.
Your legal guardian will not have access to any study information collected from you. Your study

number and initials will be used rather than your name as an identifier on your study
questionnaires.

DO I HAVE THE RIGHT TO DECLINE AUTHORIZATION?
You have the right to decline to sign this authorization to use/disclose your medical information.
If you decline, you will not be able to take part in this research study. Except as described
herein, if you decline to sign this authorization, your rights concerning treatment, payment for
services, enrollment in a health plan or eligibility for benefits will not be affected.
Date

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Patient Initials _____

HOW LONG WILL MY AUTHORIZATION REMAIN IN EFFECT?
The authorization for use and disclosure of your information will remain in effect for five years
after study reports have been completed.

CAN I WITHDRAW MY AUTHORIZATION?
You may withdraw your authorization at any time by sending a written request to the Principal
Investigator Dr. Ngozi Osuagwu at the address below:
Department of Community Partnerships
393 E. Town St., Suite 226, Columbus, OH 43215
(614) 566-9989
If you withdraw your authorization:
• Your participation in the study will end
• The study staff will stop collecting your information from or about you
• The study staff will stop using and disclosing your information to those groups
mentioned above.
Your medical information that has already been used and disclosed prior to withdrawing your
authorization remains a part of the research study data.
While the research study is in progress, your access to your study records will be temporarily
suspended. Afterwards, you have the right to see and copy the medical information collected
from you in the course of the study, for as long as that information is maintained by the study
staff and other entities subject to federal privacy regulations.

WHAT ARE MY RIGHTS AS A PARTICIPANT?
Taking part in this study is voluntary. You may choose not to take part or you may leave the
study at any time. Leaving the study will not result in any penalty or loss of benefits to which
you are entitled.

WHOM DO I CALL IF I HAVE QUESTIONS OR PROBLEMS?
For questions about the study or a research-related injury, contact the study doctor, Dr. Ngozi
Osuagwu, MD, 614 566-9989.
For questions about your rights as a research participant, contact Dr. Randall Franz, Chairman of
the OhioHealth Institutional Review Board # 2, which is a group of people who review the
research to protect your rights at (614) 566-5708.
Date

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Patient Initials _____

If you have any questions about the national study or your participation in the study, please call
Melissa Thomas at Mathematica at 1-888-864-6416.
If you have are experiencing mental or emotional crises, you may call Netcare Access at 614276-2273 or 911 or go to the nearest emergency room.
If you are experiencing relationship violence, you may call the Ohio Domestic Violence Network
at 1-800-934-9840 or the National Teen Abuse Helpline at 1-866-331-9474.

Date

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Patient Initials _____

STATEMENT OF CONSENT AND AUTHORIZATION
I hereby freely and voluntarily consent to take part in the research study described above. This
consent is given based on the verbal and written information provided and the understanding that
I am medically and physically qualified to take part in this study. I am free to ask questions at
any time.
I have the option to decline to take part or to withdraw from the study at any time without
incurring any penalty or loss of benefits otherwise available, including medical care at this
institution.
My signature below indicates that I voluntarily agree to take part in this study and that I
authorize the use and disclosure of my information in connection with the study. I will receive a
signed copy of this consent and authorization form.
________________________________
Patient Signature*

__________________
Date

_______
Time

________________________________
Research Coordinator/
Person Obtaining Consent

___________________
Date

_______
Time

________________________________
Investigator Signature

___________________
Date

*If this consent is signed by a legal representative of the patient, check applicable box below explaining your
authority to sign for the patient. For legal representatives acting in the capacity as a parent/guardian to the patient,
attach a copy of documentation giving you the authority to sign this consent form on behalf of the patient.
 Next of Kin
 Parent (patient is a minor)
 Guardian
 Health Care Power of Attorney
 Health Care Proxy or Surrogate
Date
Page X of Y
Patient Initials _____
_______________________________________
_______________________
_________
Signature of Patient’s Legally
Authorized Representative

Date

Time

IF THE PATIENT IS PARTICIPATING BUT UNABLE TO GIVE CONSENT,
INDICATE WHY.
__________________________________________________________________
__________________________________________________________________
Date

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Patient Initials _____

OHIOHEALTH
CHILD ASSENT FORM -- Draft
TITLE OF STUDY: TEEN OPTIONS TO PREVENT PREGNANCY

PRINCIPAL INVESTIGATOR: NGOZI OSUAGWU, M.D.
What is the study about?
We are doing a study to see if we can help girls delay a future pregnancy. You may not
benefit from being in this study but we might learn something that could help others.
You will be assigned to Group 1 or Group 2 by chance, like flipping a coin.
Group 1 will receive phone calls from nurses and transportation assistance to help get
birth control for 18 months. You could be in an accident if you receive transportation
assistance. Please remember to wear a seat belt and you use a car seat for your
child. Group 2 will not receive these phone calls or travel help.
Anyone from either group wishing to get birth control may seek this care through
OhioHealth or outside clinics. These clinics include Planned Parenthood (1-800-2307526) or The Ohio State University Department of Obstetrics and Gynecology (614-2932913). You may get birth control even if you do not take part in the study.
If you decide to use birth control, you should talk to your regular doctor about benefits
and side effects of your choice. If you experience any side effects, do not wait for the
study team to call you. You should call your regular doctor right away to discuss the side
effects.
Condoms and not having sex are the only effective birth control methods for protecting
yourself against getting a sexually transmitted infection, including HIV. Remember that
even if you use birth control, you can still get pregnant or catch a disease if you have sex.
If you become pregnant within 18 months of their last pregnancy, you may be at increased
risk for having a preterm birth. If you become pregnant again, we encourage you to seek
prenatal health care right away. Here is a group that can help you locate this care:
Pregnancy Care Connections (614) 227-9866.
Will I be given anything for being in the study?
You will be sent a gift card for completing interviews. These interviews will occur at the
beginning of the study, at 6 months, at 18 months, and at 30 months.
What kind of questions will I be asked?
You will be asked questions about yourself, your family, and your thoughts and
Date

Page 1 of 2

Patient Initials _____

experiences about using birth control. You will be asked about previous and future
pregnancies. If you are not comfortable with talking about these things, please let us
know. You are free to not answer any question you wish.
The study team will also review your OhioHealth medical records and Ohio Department
of Health birth records.
If you agree to be in the study, we may talk about your experiences with feeling safe or
hurt in your relationships with your partner and others. If you are experiencing dating
violence, you may call the National Teen Abuse Helpline at 1-866-331-9474.
You may be asked about feeling of sadness. If you are experiencing mental or emotional
crises, you may call Netcare at (614) 276-2273 or 9-1-1 or go to the nearest emergency
room.
What about my privacy?
If you say or do something that poses a threat to your own safety or somebody else, we
may not be able to keep that private. If you say something that makes us suspect child
abuse or neglect, we will be required to contact child protection authorities.
May I decide not to be in the study or decide to stop being in the study?
It is up to you to decide if you want to be in this research. You can ask questions to the
study staff at any time.
If you sign your name on the line, it means you want to be in the research. Because you
are under the age of 18, we will need to get permission from your parent/guardian as
well.
If you don’t want to be in the research, don’t sign your name.
Even if you sign your name today, you can still stop being in the research any time. No
one will be upset if you don’t sign your name or if you change your mind later. If you
decide not to finish the study, you can ask us to stop. If you want to stop later on, please
tell your guardian or the person doing this research, Dr. Ngozi Osuagwu by calling 614566-9989.

Your signature

Your age

Date

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Patient Initials _____

OHIOHEALTH
PARENT CONTACT INFORMATION FORM
TITLE OF STUDY: TEEN OPTIONS TO PREVENT PREGNANCY
The following information will be used to contact you and/or the participant in this study in the
future and locate records regarding her participation in this study.
1. What is your name?
______________________________
First

_______________________
Middle

___________________
Last

2. What is your relationship with the person for whom you signed the consent form?
_____________________________________
3. What is your date of birth?
______________________________
Month

_______________________
Day

___________________
Year

4. What is your address?
____________________________________
Street
Apt.
____________________________________
City
______________________________________
State
Zip
5a. What is your main phone number? ___________________________
5b. What type of phone is that? ____Cell ____Home ______Work
6a. What other phone number can you be reached at? _____________________
6b. What type of phone is that? ____Cell ____Home ______Work

_______________________
Middle

___________________
Last

2. What is your relationship with the person for whom you signed the consent form?
_____________________________________
3. What is your date of birth?
______________________________
Month

_______________________
Day

___________________
Year

OHIOHEALTH
CONTACT INFORMATION FORM
TITLE OF STUDY: TEEN OPTIONS TO PREVENT PREGNANCY
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? _____________________________

9. What is your Facebook address, if you have one? ________________________________
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
Staff: Please note respondent’s OhioHealth Medical Record Number from Medical Record
System here.
_______________________

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