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pdfEVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
SUMMARY TABLE, SITE- SPECIFIC BASELINE SURVEY, AND CONSENT AND
ASSENT FORMS: PRINCETON CENTER FOR LEADERSHIP TRAINING (PCLT)
The PCLT survey instrument is divided into three sections:
PART A – FOR ALL YOUTH (this section ends with a question on whether the adolescent has had sex, in
which case the adolescent chooses to continue to either PART B1 or B2)
PART B1 – FOR SEXUALLY-ACTIVE YOUTH
PART B2 – FOR NON-SEXUALLY-ACTIVE YOUTH
SUMMARY OF DIFFERENCES BETWEEN THE BASELINE CONCORDANCE INSTRUMENT AND THE TEEN PEP BASELINE SURVEY
Concordance #
Teen PEP #
Items are listed in the order in which they appear on the Teen PEP baseline instrument. The number for the corresponding
baseline concordance item is listed in the “Concordance #” column. Items in Part A are listed first, followed by items in Section
4, Part B1 (for sexually active respondents), items in Section 4, Part B2 (for non-sexually active respondents) and items in
Sections 5 and 6, Parts B1 and B2 (these sections are the same for sexually active and non-sexually active respondents). Items
found on the concordance instrument that are not on the Teen PEP 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 Teen PEP instrument is the same as that on the baseline concordance instrument.
• If an item is specific to the Teen PEP instrument, it is indicated by an “N/A” in the “Concordance #” column and the text
is noted on the “Modifications” column.
Baseline Concordance Question Text
Modifications for Teen PEP
PART A (Sections 1 – 3): All items in Part A are the same for sexually active and non-sexually active respondents.
1.1
1.1
In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
1
Teen PEP #
Concordance #
1.2
1.2
1.3
1.4
Baseline Concordance Question Text
Modifications for Teen PEP
What grade are you in?
MARK (X) ONE
1.3
□
6th
□
7th
□
8th
□
9th
□
10th
□
11th
□
12th
□
Not currently in school
Are you male or female?
1.4
MARK (X) ONE
□
Male
□
Female
Are you Hispanic/Latino?
MARK (X) ONE
□
Yes
□
No
2
Teen PEP #
Concordance #
Baseline Concordance Question Text
1.5
1.5
What is your race?
Modifications for Teen PEP
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
1.6
1.6
When you are at home or with your family, what language or languages do you usually speak?
YOU MAY MARK (X) MORE THAN ONE ANSWER
□ English
□ Spanish
□ Chinese language such as Mandarin or Cantonese
□ Some other language PRINT OTHER LANGUAGE(S) ____________________________
1.6a
1.6a
What is the main language you speak at home?
□
□
□
□
English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE(S) ____________________________
3
Teen PEP #
Concordance #
1.7
1.7
Baseline Concordance Question Text
In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
□
□
□
□
□
1.8
1.8
1.9
Never
Less than once a month
1-3 times per month
Once a week
More than once a week
How important is religion in your life?
MARK (X) ONE
□
□
□
1.9
Modifications for Teen PEP
Not at all important
Somewhat important
Very important
In the past 12 months, have you any received information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.
Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or whether to use birth control
How to say no to sex
How babies are made
4
Teen PEP #
Concordance #
1.10
1.10
Baseline Concordance Question Text
Modifications for Teen PEP
In an average week last month, including weekends, about how many hours did you spend
participating in each of the following?
MARK (X) ONE FOR EACH QUESTION
Zero Hours Per Week, More Than Zero but Less Than 2 Hours Per Week, 2-5 Hours Per Week,
More Than 5 Hours Per Week
a.
b.
c.
d.
e.
f.
1.11
1.11
Sports-related clubs, teams, or organizations
Lessons, clubs, or performances for art, music, or drama
Other clubs, teams, and organizations, such as academic
clubs, Scouts, chess clubs, or debating teams
Services or programs at a church, temple, synagogue,
mosque, or other place of worship
Working at a paid job
Volunteering
How likely is it that you will do each of the following things?
MARK (X) ONE FOR EACH QUESTION
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
5
Teen PEP #
Concordance #
Baseline Concordance Question Text
2.1
2.1
The next questions are about where you live and who lives with you.
Modifications for Teen PEP
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, or staying with friends/relatives) –
GO TO 2.4
2.2
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
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself
6
Teen PEP #
Concordance #
Baseline Concordance Question Text
2.3
2.3
Who lives with you in each of your homes?
Modifications for Teen PEP
Mark (X) all of the people who live with you in your MAIN home, and then mark (X) all of the
people who live with you in your OTHER homes.
MARK ALL THAT APPLY (List appears for both the MAIN home and the OTHER home(s))
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Your biological mother
Your biological father
A stepmother or adoptive mother
A foster mother
A stepfather or adoptive father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandfathers
Any older brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself
7
Teen PEP #
Concordance #
2.4
2.4
2.5
2.5
Baseline Concordance Question Text
Modifications for Teen PEP
On how many days last week did all the family members who live in your household sit down
together for a meal?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7
On how many days last week did you do something with at least one adult in your family like
play a game, watch a movie, go to a sporting event, or work on something you enjoy doing
together?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7
8
Teen PEP #
Concordance #
2.6
2.6
Baseline Concordance Question Text
Modifications for Teen PEP
Now we have some questions about your mother, or the person you think of as a mother. Is
this person…?
MARK (X) ONE
□
□
□
□
□
□
□
2.7
2.7
Your biological mother, that is, the woman who gave birth to you
Your stepmother or adoptive mother
Your foster mother
Your grandmother
Your aunt or your older sister
Some other adult
Don’t have a mother or person I think of as a mother
GO TO 2.14
The following questions are about the person you marked as your mother or the person you
think of as your mother.
Did she graduate from high school?
MARK (X) ONE
□
□
□
2.8
2.8
Yes
No
Don’t know
Did she graduate from a 4-year college?
MARK (X) ONE
□
□
□
Yes
No
Don’t know
9
Teen PEP #
Concordance #
2.9
2.9
2.10
2.10
Baseline Concordance Question Text
Modifications for Teen PEP
Is she working now?
MARK (X) ONE
□
She is not working at a paid job
□
Yes, she is working part-time or less than 30 hours a week
□
Yes, she is working full-time or at more than one job for 30
hours a week or more
□
Yes, she works, but I don’t know how many hours
□
Don’t know if she is working
How close do you feel to your mother or the person you think of as your mother?
MARK (X) ONE
□
□
□
□
2.11
2.11
Not at all close
A little close
Somewhat close
Very close
In general, how much do you think she cares about you?
MARK (X) ONE
□
□
□
□
Does not care at all
Cares a little bit
Cares somewhat
Cares very much
10
Teen PEP #
Concordance #
2.12
2.12
Baseline Concordance Question Text
Modifications for Teen PEP
Whether you have done this or not, how would she feel about you having sex at this time in
your life?
MARK (X) ONE
□
□
□
□
□
2.13
2.13
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
How would she feel about you having a baby at this time in your life?
MARK (X) ONE
□
□
□
□
□
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
11
Teen PEP #
Concordance #
2.14
2.14
Baseline Concordance Question Text
Modifications for Teen PEP
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
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 my father GO TO 2.22a
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
□
□
□
2.16
2.16
Yes
No
Don’t know
Did he graduate from a 4-year college?
MARK (X) ONE
□
□
□
Yes
No
Don’t know
12
Teen PEP #
Concordance #
Baseline Concordance Question Text
2.17
2.17
Is he working now?
2.18
MARK (X) ONE
□
He is not working at a paid job
□
Yes, he is working part-time or less than 30 hours a week
□
Yes, he is working full-time or at more than one job for 30 hours a week or more
□
Yes, he works, but I don’t know how many hours
□
Don’t know if he is working
How close do you feel to your father or the person you think of as your father?
2.18
Modifications for Teen PEP
MARK (X) ONE
□ Not at all close
□ A little close
□ Somewhat close
□ Very close
2.19
2.19
In general, how much do you think he cares about you?
MARK (X) ONE
□
□
□
□
Does not care at all
Cares a little bit
Cares somewhat
Cares very much
13
Teen PEP #
Concordance #
2.20
2.20
Baseline Concordance Question Text
Modifications for Teen PEP
Whether you have done this or not, how would he feel about you having sex at this time in your
life?
MARK (X) ONE
□
□
□
□
□
2.21
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?
MARK (X) ONE
□
□
□
□
□
2.22a
2.22a
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
Which of the following best describes the relationship between your biological mother and
biological father? If one or both of your biological parents have passed away, please answer
about their relationship when both were alive.
MARK (X) ONE
o
o
o
o
o
They are married to each other
They used to be married to each other, but are now separated
They used to be married to each other, but are now divorced
They have never been married to each other
I don’t know
14
Teen PEP #
Concordance #
Baseline Concordance Question Text
2.22b
2.22b
Do your biological mother and biological father live together now?
Modifications for Teen PEP
MARK (X) ONE
o
o
o
o
2.23
2.23
Yes
No
One or both of my biological parents have passed away
I don’t know
The next questions ask about what your parents know about your activities. By parents, we
mean the parents or guardians you live with most of the time. Thinking about the past month,
how often did your parents know where you were after school?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
15
Teen PEP #
Concordance #
2.24
2.24
Baseline Concordance Question Text
Modifications for Teen PEP
Thinking about the past month, how often did your parents know who you were going to be
with before you went out?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
□
I did not go out
2.25
2.26
2.25
2.26
Thinking about the past month, how often did your parents know where you were when you
went out at night?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
□
I did not go out at night
If you were going to be home late, would your parents expect you to call?
MARK (X) ONE
□
Yes
□
No
16
Teen PEP #
Concordance #
2.27
2.27
Baseline Concordance Question Text
Modifications for Teen PEP
In the past 12 months, how many times have you talked with at least one of your parents or
guardians about . . .
MARK (X) ONE FOR EACH QUESTION
Added:
Never, 1-2 Times, 3-9 Times, 10 or more times
3.1
3.1
a. How things are going with school work or with your grades
b. A personal problem you were having
c. How to have good romantic relationships
d. Strategies for safe dating
e. How to resist pressures to have sex
f.
Avoiding drugs and alcohol
g. Pregnancy or birth
h. Sexually transmitted diseases (also called STDs), HIV, or AIDS
The next series of questions is about your views on sexual intercourse. In this survey, when we
ask about sexual intercourse we mean a male putting his penis into a female’s vagina. How
strongly do you agree or disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.
d.
e.
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
At your age right now, it is okay for you to have sexual intercourse if you use birth control,
like a condom
It is against your values to have sexual intercourse before marriage
17
i. Whether you should be having sex at this time
in your life
Teen PEP #
Concordance #
3.2
3.2
Baseline Concordance Question Text
Modifications for Teen PEP
FOR GIRLS
If you got pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□
3.2
3.2
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
FOR BOYS
If you got someone pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
18
Teen PEP #
Concordance #
Baseline Concordance Question Text
3.3
3.3
Imagine you are alone with someone you like very much. How likely is it that you could . . .
Modifications for Teen PEP
MARK (X) ONE FOR EACH QUESTION
Not at all Likely, a Little Bit likely, Somewhat Likely, Very Likely
a.
3.4
3.4
Stop them if they wanted to touch your chest and you did not want them to do that (FOR
GIRLS)
b. Stop them if they wanted to touch your private parts below the waist, meaning the parts
of the body covered by underwear, and you did not want them to do that
c. Avoid having sexual intercourse if you didn’t want to
The next series of questions is about condom use. How strongly do you agree or disagree that …
MARK (X) ONE FOR EACH QUESTION
Strongly 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
19
Teen PEP #
Concordance #
3.5
3.5
Baseline Concordance Question Text
Modifications for Teen PEP
The next series of questions is about condoms, birth control pills, pregnancy and sexually
transmitted diseases, also known as STDs.
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
3.5a
3.6
3.5a
3.6
GO TO 3.6
How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If a condom is used correctly, how much can it decrease the risk of getting HIV, the virus that
causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
20
Teen PEP #
Concordance #
3.7
3.7
3.8
3.9
Baseline Concordance Question Text
If a condom is used correctly, how much can it decrease the risk of getting Chlamydia and
gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
If birth control pills are used correctly, how much can they decrease the risk of pregnancy?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
3.8a
3.9
3.9a
3.10
Modifications for Teen PEP
GO TO 3.10
How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If birth control pills are used correctly, how much can they decrease the risk of getting HIV, the
virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
21
Teen PEP #
Concordance #
3.10
3.11
3.11
3.8
Baseline Concordance Question Text
Modifications for Teen PEP
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
The next series of questions is about other 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
3.12
3.12
Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
□
□
□
Yes
No
Don’t know
GO TO 3.12
22
Teen PEP #
Concordance #
3.12a
3.12a
3.13
3.13
Baseline Concordance Question Text
Modifications for Teen PEP
How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
In the past 3 months, how many TIMES have you gone out on a date?
□ Zero or None
GO TO 3.15
| | | NUMBER OF TIMES - Your best guess is fine
3.14
3.14
Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you go out
on a date with?
|
3.15
3.16
|
Do you intend to have sexual intercourse in the next year?
o
o
o
o
3.16
3.17
| NUMBER OF PEOPLE - Your best guess is fine.
Yes, definitely
Yes, probably
No, probably not
No, definitely not GO TO QUESTION 3.19
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
23
Teen PEP #
Concordance #
3.17
3.18
Baseline Concordance Question Text
Modifications for Teen PEP
The next question is about your intention to use other methods of birth control, NOT including
condoms:
• Birth control pills
• The shot (Depo Provera)
• The patch
• The ring (NuvaRing)
• IUD (Mirena or Paragard)
• Implants (Implanon)
If you have sexual intercourse in the next year, do you intend to use any of these other
methods of birth control?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not
3.18
3.15
Do you intend to have oral sex in the next year?
MARK (X) ONE
o
o
o
o
Yes, definitely
Yes, probably
No, probably not
No, definitely not
24
Teen PEP #
Concordance #
Baseline Concordance Question Text
3.19
3.19
Do you intend to have sexual intercourse without being married?
Modifications for Teen PEP
MARK (X) ONE
o
o
o
o
3.20
3.20
Yes, definitely
Yes, probably
No, probably not
No, definitely not
Have you ever had sexual intercourse, oral sex, or anal sex?
□ YES: GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
□ NO: GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
PART B1: The items in Section 4, Part B1 are specifically for sexually active respondents. Items in Sections 5 and 6, Part B1 are the same
as the items in Sections 5 and 6, Part B2 (for non-sexually active respondents).
4.1
B1
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?
□ No STOP AND GO TO PART B2
□ Yes CONTINUE WITH THIS BOOKLET.
25
Concordance #
Teen PEP #
4.2
B1
4.2
Part
B1
Baseline Concordance Question Text
Modifications for Teen PEP
The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Have you ever had sexual intercourse?
MARK (X) ONE
□
Yes
□
No
GO TO 4.15
The very first time you had sexual intercourse, what month and year was it?
4.3
B1
4.3
Part
B1
4.4
B1
4.4
Part
B1
The very first time you had sexual intercourse, how old were you?
4.5
B1
4.5
Part
B1
The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE MONTH AND ONE YEAR
|
|
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
MARK (X) ONE
□
□
□
□
□
Three or more years younger than you
A year or two younger than you
The same age as you
A year or two older than you
Three or more years older than you
26
Concordance #
Teen PEP #
4.6
B1
4.6
Part
B1
Baseline Concordance Question Text
The very first time you had sexual intercourse, would you say that it was voluntary or not
voluntary?
MARK (X) ONE
□
□
4.7
B1
4.7
Part
B1
Modifications for Teen PEP
Voluntary
Not voluntary
Birth control methods are something used to reduce the risk of pregnancy, and some can
reduce the risk of sexually transmitted diseases, also called STDs.
The first time you had sexual intercourse, did you or your partner use any type of birth control,
including condoms or any other method?
MARK (X) ONE
□
□
4.8
B1
4.8
Part
B1
Yes
No
GO TO 4.9
The first time you had sexual intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
YES, NO
a.
b.
c.
d.
e.
f.
Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
Nuva ring or the ring
Withdrawal or pulling out
Another method (PRINT OTHER METHOD USED):
27
Concordance #
Teen PEP #
4.9
B1
4.9
Part
B1
4.10
B1
4.10
Part
B1
4.11
B1
4.11
Part
B1
4.12
B1
4.12
Part
B1
Baseline Concordance Question Text
Modifications for Teen PEP
Have you had sexual intercourse more than one time?
MARK (X) ONE
□ Yes
□ No
GO TO 4.14
How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
| | | NUMBER OF PEOPLE - Your best guess is fine.
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.
In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
28
Concordance #
Teen PEP #
4.13
B1
4.13
Part
B1
Baseline Concordance Question Text
Modifications for Teen PEP
The next question is about your use of the following methods of birth control:
•
•
•
•
•
•
•
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
In the past 3 months, how many TIMES have you had sexual intercourse without using any of
these methods of birth control?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
4.14
B1
4.14
Part
B1
Oral sex is when someone puts his or her mouth on another person’s penis or vagina, OR lets
someone else put his or her mouth on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE
□
□
4.15
B1
4.15
Part
B1
Yes
No
GO TO 4.19
The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR
29
Concordance #
Teen PEP #
Baseline Concordance Question Text
Modifications for Teen PEP
4.16
B1
4.16
Part
B1
How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
4.17
B1
4.17
Part
B1
Now please think about the past 3 months. In the past 3 months, how many TIMES have you
had oral sex?
4.18
B1
4.18
Part
B1
In the past 3 months, how many TIMES have you had oral sex without using a condom?
4.19
B1
4.19
Part
B1
|
|
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a
male put his penis in their anus or butt. Have you ever had anal sex?
MARK (X) ONE
□
□
4.20
B1
4.20
Part
B1
| NUMBER OF PEOPLE - Your best guess is fine.
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.
30
Concordance #
Teen PEP #
4.21
B1
Baseline Concordance Question Text
Modifications for Teen PEP
4.21
Part
B1
Now please think about the past 3 months. In the past 3 months, how many TIMES have you
had anal sex?
4.22
B1
4.22
Part
B1
In the past 3 months, how many TIMES have you had anal sex without using a condom?
4.23
B1
4.23
Part
B1
4.24a
B1
4.24a
Part
B1
4.24b
B1
4.24b
Part
B1
□
None
GO TO 4.23
| | | NUMBER OF TIMES - Your best guess is fine.
□
None
| | | NUMBER OF TIMES - Your best guess is fine.
Have you ever had oral sex or anal sex with a person the same sex as you?
MARK (X) ONE
□ Yes
□ No
FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual period?
MARK (X) ONE
□ Yes
□ No GO TO 4.27
FOR GIRLS ONLY- How old were you when you had your first period, that is, your first menstrual
period?
|
|
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
31
Concordance #
Teen PEP #
4.25a
B1
4.25a
Part
B1
Baseline Concordance Question Text
Modifications for Teen PEP
FOR BOYS ONLY
People reach puberty at different ages. Signs of puberty for males include physical changes
such as developing pubic or facial hair, or their voices 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
4.25b
B1
4.25b
Part
B1
FOR BOYS: How old were you when these changes started?
4.26A
B1
4.26a
FOR BOYS AND GIRLS
To the best of your knowledge, have you ever been pregnant or gotten someone pregnant,
even if no child was born?
|
|
| NUMBER OF YEARS OLD YOU WERE
MARK (X) ONE
□ Yes
□
No GO TO 4.27
4.26b
B1
4.26b
To the best of your knowledge, how many TIMES have you been pregnant or gotten someone
pregnant?
□
None
| | | NUMBER OF TIMES
32
Concordance #
4.26c
B1
4.26c
Have you ever had a baby or has anyone you got pregnant actually had the baby?
4.27
B1
4.27
Part
B1
Teen PEP #
Baseline Concordance Question Text
MARK (X) ONE
□
Yes
□
No
□
Don’t know
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
□
□
4.28
B1
4.28
Part
B1
4.29
Part
B1
Yes
No
In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
disease (STD), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE
□
□
4.29
B1
Modifications for Teen PEP
Yes
No
In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted disease (STD)?
MARK (X) ONE
□
□
Yes
No
33
4.31
B1
Concordance #
Teen PEP #
4.30
B1
4.30
Part
B1
4.31
Part
B1
Baseline Concordance Question Text
The next series of questions is about the types of sexually transmitted diseases (STDs) you have
had. In the past 12 months, did you have…
Yes, No, Don’t know
a. Chlamydia
b. Gonorrhea
c. Genital herpes
d. Syphilis
e. HIV infection or AIDS
Human papilloma virus, also called HPV or genital warts
f.
g. Another sexually transmitted disease (STD) PRINT OTHER STD:
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
□
□
4.32
B1
4.32
Part
B1
Modifications for Teen PEP
Yes
No
Have you ever been fearful that someone you were dating or having sex with might physically
hurt you?
MARK (X) ONE
□
□
□
Yes
No
I have never dated anyone
34
Concordance #
Teen PEP #
Baseline Concordance Question Text
Modifications for Teen PEP
PART B2: The items in Section 4, Part B2 are specifically for non-sexually active respondents. Items in Sections 5 and 6, Part B1 are the
same as the items in Sections 5 and 6, Part B2 (for non-sexually active respondents).
4.1
B2
4.1
Part
B2
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
4.2
B2
4.2
Part
B2
□ Yes STOP AND GO TO PART B1
□ No CONTINUE WITH THIS BOOKLET
The first two questions in this booklet are about your schooling.
Do you expect that you will graduate from high school?
MARK (X) ONE
□
□
□
4.3
B2
4.3
Part
B2
Yes
I already graduated from high school
No
GO TO 4.4
In what month and year do you expect to graduate from high school? (If you already graduated,
in what month and year did you graduate from high school?)
MARK (X) ONE MONTH AND ONE YEAR
35
Concordance #
Teen PEP #
4.4
B2
4.4
Part
B2
Baseline Concordance Question Text
Modifications for Teen PEP
The next questions are about where you live.
Modified wording
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?
“In the past 7 days…”
MARK (X) ONE
□
□
4.5
B2
4.6
B2
Yes GO TO 4.11
No
4.5
Part
B2
In how many homes, places, or households do you live: one, two, or three or more?
4.6
Part
B2
Do you consider one of these homes to be your main home?
MARK (X) ONE
□ 1 home
GO TO 4.9
□ 2 homes
□ 3 or more homes
MARK (X) ONE
□ Yes
□ No
36
4.8
B2
4.9
B2
Concordance #
Teen PEP #
4.7
B2
4.7
Part
B2
4.8
Part
B2
4.9
Part
B2
Baseline Concordance Question Text
Modifications for Teen PEP
Thinking about the past 30 days, how many nights did you spend in each home?
FILL IN TWO OR THREE NUMBERS
|
|
| Number of nights at home #1 – Your best guess is fine.
|
|
| Number of nights at home #2 – Your best guess is fine.
|
|
| Number of nights at another home or other homes – Your best guess is fine.
Is there anyone who moves with you from home to home?
MARK (X) ONE
□
□
Yes
No
Is your home or any of your homes a group home or halfway house?
MARK (X) ONE
□
□
Yes
No
37
Concordance #
Teen PEP #
4.10
B2
4.10
Part
B2
Baseline Concordance Question Text
This question is about who lives with you in your home. If you have more than one home,
please think about your main home.
How many people usually live in your home, including all children and anyone who normally
lives there even if they are not there now, like someone who is away traveling or in a hospital?
|
4.11
B2
4.12
B2
4.11
Part
B2
4.12
Part
B2
Modifications for Teen PEP
|
| NUMBER OF PEOPLE
These next few questions are about you and your friends. How strongly do you agree or
disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree
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
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
38
Concordance #
Teen PEP #
4.13
B2
4.13
Part
B2
Baseline Concordance Question Text
Here are some reasons people your age might choose NOT to have sexual intercourse. How
important is each of these reasons to YOU?
MARK (X) ONE FOR EACH QUESTION
Very Important, Somewhat Important, Not Too Important, Not At All Important
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
4.14a
B2
4.14 a
Part
B2
4.14b
B2
4.14b
Part
B2
Modifications for Teen PEP
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 - Have you ever had your period, that is, a menstrual period?
MARK (X) ONE
□ Yes
□ No GO TO 4.16
FOR GIRLS - 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. GO TO 4.16
39
Concordance #
Teen PEP #
4.15a
B2
4.15a
Part
B2
Baseline Concordance Question Text
Modifications for Teen PEP
FOR BOYS ONLY
People reach puberty at different ages. Signs of puberty for males include physical changes
such as developing pubic or facial hair, or their voices 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
4.15b
B2
4.15b
Part
B2
FOR BOYS: How old were you when these changes started?
4.16
B2
4.16
Part
B2
Have you ever done any of the following?
4.17
B2
4.17
Part
B2
|
|
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
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
40
Concordance #
Teen PEP #
4.18
B2
4.18
Part
B2
Baseline Concordance Question Text
Have you ever been fearful that someone you were dating might physically hurt you?
MARK (X) ONE
□
□
□
4.19
B2
4.20
B2
4.19
Part
B2
4.20
Part
B2
Modifications for Teen PEP
Yes
No
I have never dated anyone
In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted diseases, also known as STDs?
MARK (X) ONE
□
Yes
□
No
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
Removed “outside of marriage”:
If you decided to have sexual intercourse, 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
Sections 5 and 6 (Parts B1 and B2) – these items are the same for sexually active and non-sexually active respondents.
41
Teen PEP #
Concordance #
5.1
5.1
Baseline Concordance Question Text
Modifications for Teen PEP
The next questions are about tobacco, alcohol and drugs. Please be as honest as possible, and
remember that everything you tell us will be kept private.
Have you ever smoked a cigarette?
MARK (X) ONE
□
□
5.2
5.2
The very first time you smoked a cigarette, how old were you?
|
5.3
5.3
Yes
No GO TO 5.4
|
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
□
□
□
□
5.4
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
42
Teen PEP #
Concordance #
Baseline Concordance Question Text
5.5
5.5
The very first time you had an alcoholic drink, how old were you?
|
5.6
5.6
|
Modifications for Teen PEP
| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE
□
□
□
□
5.7
5.8
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?
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?
MARK (X) ONE
□
□
Yes
No GO TO 5.10
43
Teen PEP #
Concordance #
Baseline Concordance Question Text
5.9
5.9
During the past 30 days, on how many days did you use marijuana?
5.10
5.10
Modifications for Teen PEP
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used any other type of illegal drug, for example Methamphetamine, speed, PCP,
ecstasy, or any form of cocaine, such as crack?
MARK (X) ONE
□
Yes
□
No
5.11
5.11
Have you ever used any prescription pills or other prescription drugs that were not prescribed
for you?
MARK (X) ONE
□
Yes
□
No
5.12
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
44
Teen PEP #
Concordance #
Baseline Concordance Question Text
6.1
6.1
How many of your friends who are your age think the following things? Your best guess is fine
Modifications for Teen PEP
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know
a.
b.
c.
d.
e.
6.2
6.2
Having sexual intercourse is a good thing for them to do at
their age.
It would be okay for them to have sexual intercourse as long
as they used birth control, like a condom.
It would be okay for them to have sexual intercourse if they
were dating the same person for a long time
They should wait until they are older to have sexual
intercourse.
They should wait until marriage to have sexual intercourse.
How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know
a.
b.
Had sexual intercourse.
Had oral sex.
45
Teen PEP #
Concordance #
6.3
6.3
Baseline Concordance Question Text
Modifications for Teen PEP
In general, how much pressure, if any, do you feel from your friends to have sexual
intercourse?
MARK (X) ONE
□
□
□
□
6.4
6.4
A lot of pressure
Some pressure
A little pressure
No pressure
People are different in their sexual attraction to other people. Which of the following best
describes you?
MARK (X) ONE
□
□
□
□
□
6.5
6.5
I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure
How much do you feel that your friends care about you?
MARK (X) ONE
□
Do not care at all
□
Care a little bit
□
Care somewhat
□
Care very much
46
OMB Control No:
Expiration Date:
BASELINE QUESTIONNAIRE
PART A – Teen Pep
CONFIDENTIALITY
Thank you for your help with this important study. It will help us understand what things are like
for people your age today. Your answers are confidential and everything you say will be kept
private. Your name will not be on the questionnaire. Please answer all questions as well as you
can.
We want you to know that:
1.
We hope that you will answer all the questions, but you may skip any questions you do not
wish to answer.
2.
The answers you give will never be identified as yours. Your responses will be combined
with those of other people your age.
Mathematica Policy Research
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number.
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
If the color of your eyes is brown, you would mark (X)
the first box as shown.
Green
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
3.
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
X
Go to a baseball game
If you plan to rent a movie and go to a baseball game
next week, you would mark (X) both boxes.
Study at a friend’s house
PPA Study – Part A – Teen Pep – 6/23/11
1
4.
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
No
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
No
3. Did you do any of the following last week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X
Went to a play
X
Went to a movie
Attended a sporting event
5.
EXAMPLE 5: FILL IN THE NUMBER
In the last seven (7) days, how many chocolate bars have you eaten?
0
2
NUMBER OF CHOCOLATE BARS – Your best guess is fine.
Fill in the boxes with the correct number. For any number less than 10, put a
zero (0) in the first box. For example, if you had eaten 2 chocolate bars in the
last 7 days, you would write “0” in the first box and “2” in the second box. If
you had eaten 15 chocolate bars, you would write “1” in the first box and “5”
in the second box.
6.
EXAMPLE 6: MARK (X) ONE ANSWER FOR EACH QUESTION
In the last 12 months, have you done any of the following?
MARK (X) ONE FOR EACH QUESTION
a.
b.
c.
d.
e.
f.
YES
NO
Walked a dog on a leash? .......................................................................................................................... X
Played Frisbee? .......................................................................................................................................... X
X
Weeded a garden? .....................................................................................................................................
Eaten a piece of fresh fruit?........................................................................................................................ X
X
Played a piano? ..........................................................................................................................................
X
Watched a movie? ......................................................................................................................................
Mark (x) either “yes” or “no” for each of the six (6) questions
(a–f) by marking (x) one of the of two boxes in each row.
PPA Study – Part A – Teen Pep – 6/23/11
2
7.
EXAMPLE 7: MARK (X) ONE MONTH AND ONE YEAR
In what month and year did you finish elementary school?
MARK (X) ONE MONTH AND ONE YEAR
Month finished
Year finished
January
2010
X
February
X
8.
2009
March
2008
April
2007
May
2006
June
2005
July
2004
August
2003
September
2002
October
2001
November
2000
December
1999
If you finished elementary school in
June of 2009, you would mark (X) the
box next to June and mark (X) the box
next to 2009.
EXAMPLE 8: FOR GIRLS or FOR BOYS
1a. FOR GIRLS Do you want to be a mother someday?
MARK (X) ONE
Yes
No
GO TO 2
1b. FOR BOYS Do you want to be a father someday?
MARK (X) ONE
Yes
No
2.
Do you have any brothers or sisters?
MARK (X) ONE
Yes
Some questions are just for girls and some
questions are just for boys. These
questions are marked with FOR GIRLS or
FOR BOYS. If a question is not marked
specifically FOR GIRLS or FOR BOYS, then
it is a question for everyone to answer.
In the example, if you are a girl, you would
answer 1a (FOR GIRLS), skip 1b (FOR
BOYS), and then answer question 2, for
everyone. If you are a boy, you would skip
1a (FOR GIRLS), answer 1b (FOR BOYS),
and answer question 2, for everyone.
No
PPA Study – Part A – Teen Pep – 6/23/11
3
SECTION 1: YOU AND YOUR BACKGROUND
1.1. In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
Month born
1.2.
Year born
January
2002
February
2001
March
2000
April
1999
May
1998
June
1997
July
1996
August
1995
September
1994
October
1993
November
1992
December
1991
What grade are you in?
MARK (X) ONE
6th
7th
8th
9th
10th
11th
12th
Not currently in school
PPA Study – Part A – Teen Pep – 6/23/11
4
1.3. Are you male or female?
MARK (X) ONE
Male
Female
1.4. Are you Hispanic/Latino?
MARK (X) ONE
Yes
No
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
1.6. When you are at home or with your family, what language or languages do you usually speak?
YOU MAY MARK (X) MORE THAN ONE ANSWER
English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE(S)
1.6a. What is the main language you speak at home?
MARK (X) ONE
English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE(S)
PPA Study – Part A – Teen Pep – 6/23/11
5
1.7. 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
1.8. How important is religion in your life?
MARK (X) ONE
Not at all important
Somewhat important
Very important
1.9. In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Relationships, dating, marriage, or family life ................................................................................................
b. Abstinence from sex ......................................................................................................................................
c. Methods of birth control .................................................................................................................................
d. Where to get birth control ..............................................................................................................................
e. Sexually transmitted 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......................................................................................................................................
h. How babies are made ....................................................................................................................................
PPA Study – Part A – Teen Pep – 6/23/11
6
1.10. In an average week last month, including weekends, about how many hours did you spend
participating in each of the following?
MARK (X) ONE FOR EACH QUESTION
ZERO HOURS
PER WEEK
MORE THAN
ZERO BUT
LESS THAN
2 HOURS
PER WEEK
2-5 HOURS
PER WEEK
MORE THAN
5 HOURS
PER WEEK
a. Sports-related clubs, teams, or organizations ...............................................................................................
b. Lessons, clubs, or performances for art, music,
or drama .........................................................................................................................................................
c. 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 ...................................................................................................................................................
1.11. How likely is it that you will do each of the following things?
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE BIT
LIKELY
SOMEWHAT
LIKELY
VERY LIKELY
a. Graduate from high school ............................................................................................................................
b. Go to a technical or vocational school after high school ...............................................................................
c. Go to college ..................................................................................................................................................
d. Graduate from a 2-year or community college program ................................................................................
e. Graduate from a 4-year college program.......................................................................................................
PPA Study – Part A – Teen Pep – 6/23/11
7
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 (living on the street, in a car or shelter, or staying with friends/relatives)
2.2.
GO TO 2.4
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
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself
AFTER ANSWERING
GO TO 2.4
PPA Study – Part A – Teen Pep – 6/23/11
8
2.3. Who lives with you in each of your homes?
MARK (X) ALL THAT APPLY
MAIN HOME
OTHER HOME(S)
Mark (X) all the people who live with you in your MAIN home
Mark (X) all the people who live with you in your OTHER home(s)
Your biological mother
Your biological mother
Your biological father
Your biological father
A stepmother or adoptive mother
A stepmother or adoptive mother
A foster mother
A foster mother
A stepfather or adoptive father
A stepfather or adoptive father
A foster father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandmothers
Any grandfathers
Any grandfathers
Any older brothers or sisters
Any older brothers or sisters
Any younger brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any aunts, uncles, or other relatives
Any other people you are not related to
Any other people you are not related to
You live by yourself
You live by yourself
2.4. On how many days last week did all the family members who live in your household sit down
together for a meal?
MARK (X) ONE
0
1
2
3
4
5
6
7
PPA Study – Part A – Teen Pep – 6/23/11
9
2.5. On how many days last week did you do something with at least one adult in your family like play
a game, watch a movie, go to a sporting event, or work on something you enjoy doing together?
MARK (X) ONE
0
1
2
3
4
5
6
7
MOTHER
2.6. 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 2.14
2.7. 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
PPA Study – Part A – Teen Pep – 6/23/11
10
2.8. Did she graduate from a 4-year college?
MARK (X) ONE
Yes
No
Don’t know
2.9. 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
2.10. How close do you feel to your mother or the person you think of as your mother?
MARK (X) ONE
Not at all close
A little close
Somewhat close
Very close
2.11. In general, how much do you think she cares about you?
MARK (X) ONE
Does not care at all
Cares a little bit
Cares somewhat
Cares very much
2.12. Whether you have done this or not, how would she feel about you having sex at this time in your
life?
MARK (X) ONE
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
PPA Study – Part A – Teen Pep – 6/23/11
11
2.13. How would she feel about you having a baby at this time in your life?
MARK (X) ONE
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
FATHER
2.14. 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 2.22a
2.15. 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
2.16. Did he graduate from a 4-year college?
MARK (X) ONE
Yes
No
Don’t know
PPA Study – Part A – Teen Pep – 6/23/11
12
2.17. 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
2.18. 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
2.19. In general, how much do you think he cares about you?
MARK (X) ONE
Does not care at all
Cares a little bit
Cares somewhat
Cares very much
2.20. Whether you have done this or not, how would he feel about you having sex at this time in your
life?
MARK (X) ONE
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
PPA Study – Part A – Teen Pep – 6/23/11
13
2.21. How would he feel about you having a baby at this time in your life?
MARK (X) ONE
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
2.22a. 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
I don’t know
2.22b. 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
I don’t know
PPA Study – Part A – Teen Pep – 6/23/11
14
PARENTS
2.23. The next questions ask what your parents know about your activities. By parents, we mean the
parents or guardians you live with most of the time.
Thinking about the past month, how often did your parents know where you were after school?
MARK (X) ONE
Always
Usually
Sometimes
Rarely
Never
2.24. Thinking about the past month, how often did your parents know who you were going to be with
before you went out?
MARK (X) ONE
Always
Usually
Sometimes
Rarely
Never
I did not go out
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
2.26. If you were going to be home late, would your parents expect you to call?
MARK (X) ONE
Yes
No
PPA Study – Part A – Teen Pep – 6/23/11
15
2.27. In the past 12 months, how many TIMES have you talked with at least one of your parents or
guardians about…?
MARK (X) ONE FOR EACH QUESTION
NEVER
1-2
TIMES
3-9
TIMES
10 OR MORE
TIMES
a. How things are going with school work or
with your grades .........................................................................................................................................
b. A personal problem you were having .........................................................................................................
c. How to have good romantic relationships ...................................................................................................
d. Strategies for safe dating ............................................................................................................................
e. How to resist pressures to have sex ...........................................................................................................
f.
Avoiding drugs and alcohol.........................................................................................................................
g. Pregnancy or birth ......................................................................................................................................
h. Sexually transmitted diseases
(also known as STDs), HIV, or AIDS ..........................................................................................................
i.
Whether you should be having sex at this
time in your life ............................................................................................................................................
PPA Study – Part A – Teen Pep – 6/23/11
16
SECTION 3: VIEWS AND PERCEPTIONS
3.1. The next series of questions is about your views on sexual intercourse. In this survey, when we
ask about sexual intercourse, we mean a male putting his penis into a female’s vagina. How
strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
a. Having sexual intercourse is a good thing for
you to do at your age .....................................................................................................................................
b. At your age right now, having sexual intercourse
would create problems...................................................................................................................................
c. At your age right now, not having sexual intercourse
is important for you to be safe and healthy....................................................................................................
d. At your age right now, it is okay for you to have sexual
intercourse if you use birth control, like a condom ........................................................................................
e. It is against your values to have sexual intercourse
before marriage .............................................................................................................................................
3.2. FOR GIRLS
If you got pregnant now, how would you feel?
MARK (X) ONE
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
3.2. FOR BOYS
If you got someone pregnant now, how would you feel?
MARK (X) ONE
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
PPA Study – Part A – Teen Pep – 6/23/11
17
3.3. Imagine you are alone with someone you like very much. How likely is it that you could…?
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE
BIT LIKELY
SOMEWHAT
LIKELY
VERY
LIKELY
a. 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 ......................................................................................
3.4. The next series of questions is about condom use. How strongly do you agree or disagree
that…?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
NEITHER
AGREE
NOR
DISAGREE
DISAGREE
STRONGLY
DISAGREE
a. Condoms should always be used if a
person your age has sexual intercourse ........................................................................................................
b. Condoms are a hassle to use ........................................................................................................................
c. Condoms are pretty easy to get.....................................................................................................................
d. Condoms are important to make sex safer....................................................................................................
e. Using condoms means you don’t trust
your partner....................................................................................................................................................
f.
Using condoms is morally wrong ...................................................................................................................
g. Condoms decrease sexual pleasure .............................................................................................................
PPA Study – Part A – Teen Pep – 6/23/11
18
3.5. The next series of questions is about condoms, birth control pills, pregnancy and sexually
transmitted diseases, also known as STDs.
If a condom is used correctly, how much can it decrease the risk of pregnancy?
MARK (X) ONE
Not at all
A little
A lot
Don’t know
GO TO 3.6
3.5a. How confident are you that your answer is correct?
MARK (X) ONE
Not at all confident
A little confident
Somewhat confident
Very confident
3.6. 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
3.7. 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 – Part A – Teen Pep – 6/23/11
19
3.8. 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
GO TO 3.9
3.8a. How confident are you that your answer is correct?
MARK (X) ONE
Not at all confident
A little confident
Somewhat confident
Very confident
3.9. 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
3.10. 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 – Part A – Teen Pep – 6/23/11
20
3.11. 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
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 ...............................................................................................................
3.12. Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
Yes
No
Don’t know
GO TO 3.13
3.12a. How confident are you that your answer is correct?
MARK (X) ONE
Not at all confident
A little confident
Somewhat confident
Very confident
3.13. In the past 3 months, how many TIMES have you gone out on a date?
Zero or None
GO TO 3.15
NUMBER OF TIMES – Your best guess is fine.
3.14. Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you go out
on a date with?
NUMBER OF PEOPLE – Your best guess is fine.
PPA Study – Part A – Teen Pep – 6/23/11
21
3.15. Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
GO TO 3.18
3.16. If you have sexual intercourse in the next year, do you intend to use a condom?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
3.17. 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 – Part A – Teen Pep – 6/23/11
22
3.18. Do you intend to have oral sex in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
3.19. Do you intend to have sexual intercourse without being married?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
3.20. Have you ever had sexual intercourse, oral sex, or anal sex?
Yes
GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE ENVELOPE
No
GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE ENVELOPE
Complete the correct Part B (B1 or B2),
but not both.
PPA Study – Part A – Teen Pep – 6/23/11
23
Put this booklet back in
the envelope and
Go to Part B1 or Part B2.
PPA Study – Part A – Teen Pep – 6/23/11
24
OMB Control No:
Expiration Date:
BASELINE QUESTIONNAIRE
PART B1 – Teen Pep
Please be sure that you have the correct Part B.
If you answered “Yes” to the last question of Part A, you have the correct version of
Part B. If you answered “No,” please put this version back in your envelope and fill out
Part B2 instead.
Thank you.
Mathematica Policy Research
THE PAPERWORK REDUCTION ACT OF 1995
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reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not
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OMB control number.
PART B
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.
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.
4.2. The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Have you ever had sexual intercourse?
MARK (X) ONE
Yes
No
GO TO 4.14
4.3. The very first time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR
Month of First Sexual
Intercourse
Year of First Sexual
Intercourse
January
2011
February
2010
March
2009
April
2008
May
2007
June
2006
July
2005
August
2004
September
2003
October
2002
November
2001
December
2000 or earlier
PPA Study – Part B1 – Teen Pep – 6/23/11
1
4.4. The very first time you had sexual intercourse, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.
4.5. The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE
Three or more years younger than you
A year or two younger than you
The same age as you
A year or two older than you
Three or more years older than you
4.6. The very first time you had sexual intercourse, would you say that it was voluntary or not
voluntary?
MARK (X) ONE
Voluntary
Not voluntary
4.7. Birth control methods are something used to reduce the risk of pregnancy, and some can reduce
the risk of sexually transmitted diseases, also known as STDs.
The first time you had sexual intercourse, did you or your partner use any type of birth control—
including condoms or any other method?
MARK (X) ONE
Yes
No
GO TO 4.9
4.8. The first time you had sexual intercourse, did you or your partner use…?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Condoms.........................................................................................................................................................
b. Birth control pills or the patch .........................................................................................................................
c. Depo-Provera or other injectable birth control ................................................................................................
d. NuvaRing or the ring .......................................................................................................................................
e. Withdrawal or pulling out ................................................................................................................................
f.
Another method? PRINT OTHER METHOD USED
PPA Study – Part B1 –Teen Pep – 6/23/11
...............................................................................
2
4.9. Have you had sexual intercourse more than one time?
MARK (X) ONE
Yes
No
GO TO 4.14
4.10. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
NUMBER OF PEOPLE – Your best guess is fine.
4.11. 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.
4.12. In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?
None
NUMBER OF TIMES – Your best guess is fine.
4.13. The next question is about your use of the following methods of birth control:
•
•
•
•
•
•
•
Condoms
Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
In the past 3 months, how many TIMES have you had sexual intercourse without using any of
these methods of birth control?
None
NUMBER OF TIMES – Your best guess is fine.
PPA Study – Part B1 –Teen Pep – 6/23/11
3
4.14. Oral sex is when someone puts his or her mouth on another person’s penis or vagina, OR lets
someone else put his or her mouth on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE
Yes
No
GO TO 4.19
4.15. The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND MARK (X) ONE YEAR
Month of First Oral Sex
Year of First Oral Sex
January
2011
February
2010
March
2009
April
2008
May
2007
June
2006
July
2005
August
2004
September
2003
October
2002
November
2001
December
2000 or earlier
4.16. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.
PPA Study – Part B1 –Teen Pep – 6/23/11
4
4.17. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had oral sex?
None
GO TO 4.19
NUMBER OF TIMES – Your best guess is fine.
4.18. In the past 3 months, how many TIMES have you had oral sex without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.
4.19. Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a
male put his penis in their anus or butt.
Have you ever had anal sex?
MARK (X) ONE
Yes
No
GO TO 4.23
4.20. How many DIFFERENT PEOPLE have you ever had anal sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.
4.21. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had anal sex?
None
GO TO 4.23
NUMBER OF TIMES – Your best guess is fine.
4.22. In the past 3 months, how many TIMES have you had anal sex without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.
PPA Study – Part B1 –Teen Pep – 6/23/11
5
4.23. Have you ever had oral sex or anal sex with a person the same sex as you?
MARK (X) ONE
Yes
No
4.24. FOR GIRLS
a. Have you ever had your period, that is, your menstrual period?
MARK (X) ONE
Yes
No
GO TO 4.27
b. 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.
4.25. FOR BOYS
a. People reach puberty at different ages. Signs of puberty for males include physical changes
such as developing pubic or facial hair, or their voices cracking or lowering. Which of the
following best describes these changes for you?
MARK (X) ONE
These changes have not yet started
GO TO 4.27
These changes have barely started
These changes are definitely underway
These changes seem complete
b. How old were you when these changes started?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.
PPA Study – Part B1 –Teen Pep – 6/23/11
6
4.26. FOR BOYS AND GIRLS
a.
To the best of your knowledge, have you ever been pregnant or gotten someone pregnant,
even if no child was born?
MARK (X) ONE
Yes
No
GO TO 4.27
b. To the best of your knowledge, how many TIMES have you been pregnant or gotten someone
pregnant?
None
NUMBER OF TIMES
c.
Have you ever had a baby or has anyone you got pregnant actually had the baby?
MARK (X) ONE
Yes
No
Don’t know
4.27. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted diseases, also known as STDs?
MARK (X) ONE
Yes
No
4.28. In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
disease (STD), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE
Yes
No
4.29. In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted disease (STD)?
MARK (X) ONE
Yes
No
PPA Study – Part B1 –Teen Pep – 6/23/11
7
4.30. The next series of questions is about the types of sexually transmitted diseases (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 .......................................................................
g. Another sexually transmitted disease (STD) PRINT OTHER STD
........................................................
4.31. 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
4.32. Have you ever been fearful that someone you were dating might physically hurt you?
MARK (X) ONE
Yes
No
I have never dated anyone
PPA Study – Part B1 –Teen Pep – 6/23/11
8
SECTION 5: TOBACCO, ALCOHOL AND DRUG USE
5.1. The next questions are about tobacco, alcohol and drugs. Please be as honest as possible, and
remember that everything you tell us will be kept private.
Have you ever smoked a cigarette?
MARK (X) ONE
Yes
No
GO TO 5.4
5.2. The very first time you smoked a cigarette, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.
5.3. During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
5.4. 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
5.5. The very first time you had an alcoholic drink, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.
5.6. During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
PPA Study – Part B1 –Teen Pep – 6/23/11
9
5.7. During the past 30 days, on how many days did you have 5 or more drinks in a row?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
5.8. Have you ever used marijuana, also called weed or pot?
MARK (X) ONE
Yes
No
GO TO 5.10
5.9. During the past 30 days, on how many days did you use marijuana?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
5.10. Have you ever used any other type of illegal drug, for example, Methamphetamine, speed, PCP,
ecstasy or any form of cocaine, such as crack?
MARK (X) ONE
Yes
No
5.11. Have you ever used any prescription pills or other prescription drugs that were not prescribed for
you?
MARK (X) ONE
Yes
No
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
PPA Study – Part B1 –Teen Pep – 6/23/11
10
SECTION 6: FRIENDS AND RELATIONSHIPS
6.1. How many of your friends who are your age think the following things? Your best guess is fine.
MARK (X) ONE FOR EACH
NONE
SOME
HALF
MOST
ALL
DON’T
KNOW
a. 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 ...................................................................................................................................
6.2. How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH
NONE
SOME
HALF
MOST
ALL
DON’T
KNOW
a. Had sexual intercourse ....................................................................................................................................
b. Had oral sex .....................................................................................................................................................
6.3. 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
PPA Study – Part B1 –Teen Pep – 6/23/11
11
6.4. People are different in their sexual attraction to other people. Which of the following best
describes you?
MARK (X) ONE
I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure
6.5. How much do you feel that your friends care about you?
MARK (X) ONE
Do not care at all
Care a little bit
Care somewhat
Care very much
Please put all three parts of the survey back
into the envelope and give the envelope back
to the moderator.
Thank you!
PPA Study – Part B1 –Teen Pep – 6/23/11
12
We thank you for
completing this survey!
PPA Study – Part B1 –Teen Pep – 6/23/11
13
OMB Control No:
Expiration Date:
BASELINE QUESTIONNAIRE
PART B2 – Teen Pep
Please be sure that you have the correct Part B.
If you answered “No” to the last question of Part A, you have the correct version of
Part B. If you answered “Yes,” please put this version back in your envelope and fill
out Part B1 instead.
Thank you.
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.
PART B
4.1. 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
4.2. The first two questions in this booklet are about your schooling.
Do you expect that you will graduate from high school?
MARK (X) ONE
Yes
I already graduated from high school
No
GO TO 4.4
4.3. In what month and year do you expect to graduate from high school? (If you already graduated,
in what month and year did you graduate from high school?)
MARK (X) ONE MONTH AND ONE YEAR
Month of Graduation
Year of Graduation
January
2018 or later
February
2017
March
2016
April
2015
May
2014
June
2013
July
2012
August
2011
September
2010
October
2009
November
2008
December
2007 or earlier
PPA Study – Part B2 – Teen Pep – 6/23/11
1
4.4. The next questions are about where you live.
In the past 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
Yes
GO TO 4.11
No
4.5. 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
4.6. Do you consider one of these homes to be your main home?
MARK (X) ONE
Yes
No
4.7. 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.
4.8. Is there anyone who moves with you from home to home?
MARK (X) ONE
Yes
No
4.9. Is your home or any of your homes a group home or halfway house?
MARK (X) ONE
Yes
No
PPA Study – Part B2 – Teen Pep – 6/23/11
2
4.10. This question is about who lives with you in your home. If you have more than one home, please
think about your main home.
How many people usually live in your home, including all children and anyone who normally lives
there even if they are not there now, like someone who is away traveling or in a hospital?
NUMBER OF PEOPLE
4.11. These next few questions are about you and your friends.
How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
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 ..................................................................................
4.12. How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
a. When you start a project, you finish it ............................................................................................................
b. You only work as hard as you have to ...........................................................................................................
c. You are someone people can count on .........................................................................................................
d. When you do work, you do a good job ..........................................................................................................
PPA Study – Part B2 – Teen Pep – 6/23/11
3
4.13. Here are some reasons people your age might choose NOT to have sexual intercourse. How
important is each of these reasons to YOU?
MARK (X) ONE FOR EACH QUESTION
VERY
IMPORTANT
SOMEWHAT
IMPORTANT
NOT TOO
IMPORTANT
NOT AT ALL
IMPORTANT
a. I don’t want to get a sexually transmitted
disease, also known as an STD ..................................................................................................................
b. I don’t want to disappoint my parents ..........................................................................................................
c. I am too young to have sex..........................................................................................................................
d. My boyfriend or girlfriend doesn’t want
to have sex...................................................................................................................................................
e. I want to wait until I’m married .....................................................................................................................
f.
It is against my personal values ..................................................................................................................
g. I haven’t met the right person yet ................................................................................................................
h. I haven’t had the chance..............................................................................................................................
i.
I don’t want to ..............................................................................................................................................
j.
FOR GIRLS I do not want to get pregnant ..................................................................................................
k. FOR BOYS I do not want to get a girl pregnant ..........................................................................................
4.14. FOR GIRLS
a. Have you ever had your period, that is, a menstrual period?
MARK (X) ONE
Yes
No
GO TO 4.16
b. 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.
PPA Study – Part B2 – Teen Pep – 6/23/11
GO TO 4.16
4
4.15. FOR BOYS
a. People reach puberty at different ages. Signs of puberty for males include physical changes
such as developing pubic or facial hair, or their voices cracking or lowering. Which of the
following best describes these changes for you?
MARK (X) ONE
These changes have not yet started
GO TO 4.16
These changes have barely started
These changes are definitely underway
These changes seem complete
b. How old were you when these changes started?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.
4.16. Have you ever done any of the following?
MARK (X) ONE FOR EACH QUESTION
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 .........................................................................................................
4.17. 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
4.18. Have you ever been fearful that someone you were dating might physically hurt you?
MARK (X) ONE
Yes
No
I have never dated anyone
PPA Study – Part B2 – Teen Pep – 6/23/11
5
4.19. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted diseases, also known as STDs?
MARK (X) ONE
Yes
No
4.20. If you decided to have sexual intercourse, how likely is it that you would use a condom or other
contraceptive method?
MARK (X) ONE
Not at all likely
A little bit likely
Somewhat likely
Very likely
PPA Study – Part B2 – Teen Pep – 6/23/11
6
THIS PAGE IS INTENTIONALLY BLANK
Please continue on the next page with Section 5: Tobacco,
Alcohol and Drug Use.
PPA Study – Part B2 – Teen Pep – 6/23/11
7
SECTION 5: TOBACCO, ALCOHOL AND DRUG USE
5.1. The next questions are about tobacco, alcohol and drugs. Please be as honest as possible, and
remember that everything you tell us will be kept private.
Have you ever smoked a cigarette?
MARK (X) ONE
Yes
No
GO TO 5.4
5.2. The very first time you smoked a cigarette, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.
5.3. During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
5.4. 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
5.5. The very first time you had an alcoholic drink, how old were you?
NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
5.6. During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
PPA Study – Part B2 – Teen Pep – 6/23/11
8
5.7. During the past 30 days, on how many days did you have 5 or more drinks in a row?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
5.8. Have you ever used marijuana, also called weed or pot?
MARK (X) ONE
Yes
No
GO TO 5.10
5.9. During the past 30 days, on how many days did you use marijuana?
MARK (X) ONE
More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days
5.10. Have you ever used any other type of illegal drug, for example, Methamphetamine, speed, PCP,
ecstasy or any form of cocaine, such as crack?
MARK (X) ONE
Yes
No
5.11. Have you ever used any prescription pills or other prescription drugs that were not prescribed for
you?
MARK (X) ONE
Yes
No
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
PPA Study – Part B2 – Teen Pep – 6/23/11
9
SECTION 6: FRIENDS AND RELATIONSHIPS
6.1. How many of your friends who are your age think the following things? Your best guess is fine.
MARK (X) ONE FOR EACH
NONE
SOME
HALF
MOST
ALL
DON’T
KNOW
a. 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 ..............................................................................................................................
6.2. How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH
NONE
SOME
HALF
MOST
ALL
DON’T
KNOW
a. Had sexual intercourse ...................................................................................................................................
b. Had oral sex ....................................................................................................................................................
6.3. 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
PPA Study – Part B2 – Teen Pep – 6/23/11
10
6.4. People are different in their sexual attraction to other people. Which of the following best
describes you?
MARK (X) ONE
I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure
6.5. How much do you feel that your friends care about you?
MARK (X) ONE
Do not care at all
Care a little bit
Care somewhat
Care very much
Please put all three parts of the survey back
into the envelope and give the envelope back
to the moderator.
Thank you!
PPA Study – Part B2 – Teen Pep – 6/23/11
11
We thank you for
completing this survey!
PPA Study – Part B2 – Teen Pep – 6/23/11
12
Dear Parent or Guardian:
Hello! The Administration for Children and Families (ACF) in the U.S. Department of Health
and Human Services (DHHS) is conducting an important study of the effectiveness of ways to
reduce teen pregnancy and sexually transmitted diseases. The Evaluation of Adolescent Pregnancy
Prevention Approaches (PPA) will provide communities like yours with sound scientific findings
on program effectiveness. We are requesting your permission for your child to participate in the
study.
[SCHOOL] is taking part in this study and students, including your child, are invited to
participate. The lead contractor for this research, Mathematica Policy Research, Inc. (Mathematica),
and the local evaluator, Abt Associates, will survey youth on attitudes, beliefs, and activities three
times over the next few years, beginning with a first survey in October. These surveys will ask
about families, friends, communities, and schools, and about attitudes, knowledge and activities in
school and with their peers, including sexual activity, drug use and alcohol use. The study team will
also gather information from participants’ school records, including grades, attendance, and test
scores. The researchers may also invite your child to participate in a focus group to discuss his/her
experiences in the program.
All information collected through the surveys and from school records will be kept strictly
confidential. If you choose to let your child participate, the information from your son/daughter will
be combined with information from other youth to determine the effectiveness of pregnancy
prevention programs. No one outside the study team will ever see the answers your child gives
during the focus group discussion or know whose they were. Names are not kept with the answers
to the surveys. A Certificate of Confidentiality from the National Institutes of Health provides a
strong guarantee that information about your child will not be released to anyone outside the study.
Participation in the study is voluntary. It is important that you let us know whether or not you
will allow your child to be in the study. You or your child can refuse to participate. If you agree that
your child can participate, you or your child can still choose later to stop participating, and your
child can decide to complete only parts of the surveys. But we hope you agree with us that it is
important to learn about effective ways to prevent teen pregnancy through studies like this. Please
complete and sign the attached form, noting whether you consent or do not consent to your child’s
participation, and return it to your child’s teacher within a week.
The only risk to your child connected with the study is that he/she may be uncomfortable
answering some questions in the surveys. If that happens, your child can refuse to answer those
questions.
If you have questions about the PPA study or about your child’s participation, please call
Melissa Thomas, toll-free, at Mathematica at 1-888-864-6416 between the hours of 9 a.m. and 5
p.m. eastern time, Monday through Friday.
Sincerely,
Alan Hershey
Study Director
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES (PPA)
Parent Consent Form
[SCHOOL]/[District] Public Schools
Sponsored by the United States Department of Health and Human Services
I have read the attached information sheet describing the study. By signing this form, I am:
□giving my permission □not giving permission
for my son or daughter, _________________________, to participate in the study.
Print Child’s Name
I understand that, as part of the study, information for all study youth will be collected through
surveys and school records including course grades, attendance, and test scores. I also understand
my child may be invited to participate in a focus group discussion about his/her experiences with
the program. By signing this form, I am giving my permission for this information to be collected
for use in a study conducted by researchers at Mathematica Policy Research, Inc., and Abt
Associates. I further understand that all information on my child will be kept private and used
only for the purposes of the study. If I have questions about my child’s rights as a research
volunteer, I can call Jennifer Stavrakos at Public/Private Ventures, toll-free at 1-800-755-4778.
Parent/Guardian Signature: _________________________________
Date: _______________
Child’s Name: ___________________________ Child’s Date of Birth: _____ / ______ / _____
Month
Day
Year
Please fill in the following information. We will use your contact information only if we need your
help in completing a survey with your child. Thank you.
Parent/Guardian Name: __________________________________________
Street Address: __________________________________
City: ___________________________
Apartment: ____________
Zip Code: ________________
Telephone: (_____) ____ - __________ Home
(_____) ____ - __________ Work
(_____) ____ - __________ Cell
Email: ______________________________
Parents please be aware that under the Protection of Pupil Rights Act. 20 U.S.C. Section 1232(c)(1)(A), you have the right to review a copy of the
questions asked of or materials that will be used with your child. If you would like to do so, you should contact Melissa Thomas toll-free at 1-888864-6416 to obtain a copy of the questions or materials.
WE NEED YOUR ANSWER, WHETHER IT IS YES OR NO.
PLEASE RETURN THIS FORM TO YOUR CHILD’S TEACHER WITHIN A WEEK.
THANK YOU!
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES (PPA)
(Sponsored by the United States Department of Health and Human Services)
An adult at _______________has explained to me the Evaluation of Adolescent Pregnancy Prevention
Approaches (PPA). I was told that I have been selected to be a part of the study and that my
parents/guardians have agreed to my participation. The study was described to me and any questions I
had were answered. I understand I will be asked to complete several questionnaires and that the
information I provide is private and will not be provided to people outside of the study or shown to my
parents or teachers. I also understand that I do not have to answer any questions that make me feel
uncomfortable.
If I have questions about my rights as a research volunteer, I can call Jennifer Stavrakos at Public/Private
Ventures, toll-free at 1-800-755-4778. I understand that participation is voluntary, and I agree to
participate in the study. I understand that I am allowed to stop participating in the study at any time,
without penalty.
______________________
Name
______________________________
Signature
Email:
_________________________________________
Cell phone:
(
) _________ - ______________
Area code
_______________
Date
--------------------------------------------------------------------------------------------------------------I certify that the staff members assigned to explain the study to participants were trained to do so in
terms participants would understand.
_______________________________________
Melissa Thomas
Survey Director
Signature Date
1
Wednesday, May 17, 2011
| File Type | application/pdf |
| Author | MThomas |
| File Modified | 2011-06-29 |
| File Created | 2011-06-29 |