Attachment C
Baseline Instrument
Outcome Evaluation of “Teenage Pregnancy Prevention: Integrating Services, Programs, and Strategies Through Community-Wide Initiatives”
Household Baseline Survey
July 6, 2011
PRIVACY Thank you for your help with this important study. It will help us to understand what things are like for people your age today. Your answers will be kept private to the extent allowed by law. 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.
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THE PAPERWORK REDUCTION ACT OF 1995 Public reporting burden for this collection of information is estimated to average 45 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
[A recording of verbal instructions will be played for each respondent following their assent.] While each question is read to you, you will be shown several answer choices on the screen. Select the answer that you think is best. If you need to have the question read again, click on the Hear Question Again button. Once you have selected your answer, click Next. Once you move to the next question you cannot go back to a previous question. If you need help at any time, click on the Help button. |
SECTION 1: YOU AND YOUR BACKGROUND
In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
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Are you male or female?
MARK (X) ONE
Male
Female
Are you Hispanic or Latino?
MARK (X) ONE
Yes
No
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
Other (Specify___________________________)
1.5. When you are at home or with your family, what language or languages do you usually speak? [GO TO 1.6 if only one language is spoken.]
YOU MAY MARK (X) MORE THAN ONE ANSWER
English
Spanish
Chinese language such as Mandarin or Cantonese
Other (Print other languages ____________________________)
1.5.1. What is the main language you speak at home?
MARK (X) ONE
English
Spanish
Chinese language such as Mandarin or Cantonese
Other (Print other language ____________________________)
1.6. Have you graduated from high school?
MARK (X) ONE
Yes [GO TO 1.6.2]
No [GO TO 1.6.1]
1.6.1. What grade are you in?
MARK (X) ONE
7th
8th
9th
10th
11th
12th
Not currently in school
1.6.2. Are you attending or have you attended college? [Will be programmed with 1.6, not relevant if answered “No” to 1.6]
MARK (X) ONE
Yes, a 4-year college or university
Yes, a 2-year technical school or community college
No, but currently enrolled in a trade school (e.g., beauty or automotive school)
Not currently in school
1.6.3. Are you employed at a paying job?
MARK (X) ONE
Yes, full-time (usually more than 30 hours per week)
Yes, part-time (usually less than 30 hours per week)
Not currently employed at a paying job
1.7. In the last 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 an average week last month, including weekends, about how many hours did you spend participating in each of the following?
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MARK (X) ONE FOR EACH QUESTION |
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ZERO HOURS PER WEEK |
LESS THAN 2 HOURS PER WEEK |
2–5 HOURS PER WEEK |
MORE THAN 5 HOURS PER WEEK |
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a. Sports-related clubs, teams, or organizations |
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b. Lessons, clubs, or performances for art, music, or drama |
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c. Other clubs, teams, and organizations, such as academic clubs, Scouts, chess clubs, or debating teams |
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d. Services or programs at a church, temple, synagogue, mosque, or other place of worship |
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e. Working at a paid job [Can be programmed for skip on basis of employment question in 1.6.3.] |
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f. Volunteering |
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1.10. How likely is it that you will do each of the following things? [Program to ask on basis of responses to 1.6 series.]
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MARK (X) ONE FOR EACH QUESTION |
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NOT AT ALL LIKELY |
A LITTLE BIT LIKELY |
SOMEWHAT LIKELY |
VERY LIKELY |
a. Graduate from high school |
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b. Go to a technical or vocational school after high school |
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c. Go to college |
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d. Graduate from a 2-year or community college program |
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e. Graduate from a 4-year college program |
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The next questions are about where you live and who lives with you.
1.11. Which of the following best describes where you live?
MARK (X) ONE
You live in one home
You live in two or more homes
You are homeless (living on the street, in a car or shelter, or staying with friends/relatives) [GO TO 2.1]
1.11.1. Who lives with you in your home or homes? If you live in one home, fill out Column A. If you live in two or more homes, fill out Columns B and C.
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You Live in One Home |
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You Live in Two or More Homes |
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Column A Mark (X) all the people who live with you in your home |
Column B Mark (X) all the people who live with you in your MAIN home |
Column C Mark (X) all the people who live with you in your OTHER home(s) |
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SECTION 2: YOUR EXPOSURE TO PREVENTION MESSAGES AND INFORMATION
2.1. In the last 12 months, have you had any classes, special programs, or instruction:
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MARK (X) ONE FOR EACH QUESTION |
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YES |
NO |
a. About relationships, dating, marriage, or family life? |
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b. About abstinence from sex? |
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c. About methods of birth control? |
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d. About where to get birth control? |
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e. About sexually transmitted diseases, also known as STDs? |
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f. About how to talk to your partner about whether to have sex or whether to use birth control? |
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g. About alcohol or drug use? |
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h. About physical development and reproduction? |
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i. About refusal skills, such as how to say no to sex, or how to resist peer pressure? |
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2.1.1. [If yes to any item in 2.1:]
For
the items above that you marked yes, did you learn about that type of
information in a class or program that occurred over multiple days?
MARK (X) ONE
Yes
No
2.1.2. [If yes to 2.1.1:]
What was
the name of the program or programs?
MARK (X) ONE
Name of program/programs: _______________________________
The program(s) didn’t have a name
I don’t remember the name of the program(s)
2.2. In the last 12 months, have you:
[For each of the following, response options will be tailored to the content and mode of campaign undertaken by the grantee in the target community.]
CHECK ALL THAT APPLY
Seen any television commercials [that provide pregnancy prevention information or advertise pregnancy prevention services]?
Heard any radio commercials [that provide pregnancy prevention information or advertise pregnancy prevention services]?
Seen any billboards [that provide pregnancy prevention information or advertise pregnancy prevention services]?
Seen any flyers or posters [that provide pregnancy prevention information or advertise pregnancy prevention service]?
Seen any brochures [that advertise pregnancy prevention services – referral guides]?
[Been provided information about pregnancy prevention services or information] through an online social network (such as Facebook or Twitter)
[Been provided information about pregnancy prevention or services] through a website?
[Been provided information about pregnancy prevention or pregnancy prevention services] by text message?
Been to any events (e.g., health fair, sporting event, etc.) where [information on pregnancy prevention or pregnancy prevention services] was provided?
2.3. In the last 12 months, have you discussed pregnancy prevention with:
CHECK ALL THAT APPLY
Your mother or father?
A doctor or nurse?
A teacher or school counselor?
Another adult
A friend
I have not talked about these issues with anyone
2.4. If you were concerned about preventing pregnancy, is there a place in your community that could provide you with information or other assistance (such birth control or a prescription for birth control)?
MARK (X) ONE
Yes
No [GO TO 2.5]
2.4.1. Given what you know about this place, how likely would it be that you would go there to access information or other assistance?
MARK (X) ONE
1 = Not at all likely
2 = A little likely
3 = Moderately likely
4 = Mostly likely
5 = Extremely likely
2.4.2. How much would the following issues affect your decision to get information or other assistance about pregnancy prevention?
MARK (X) ONE IN EACH COLUMN
Cost or Money |
Confidentiality or Privacy |
Transportation |
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2.5. Have you ever received any of these services from a medical provider or clinic?
CHECK ALL THAT APPLY
Counseling or information about birth control
Counseling or information about an Intrauterine Device (IUD)
Counseling or information about Implanon® (a hormone-release device placed under the skin on your arm)
Counseling or information about emergency contraception, also known as “Plan B” or “Preven” or the “morning-after pill”
Counseling or information about sexually transmitted diseases (STDs)
I have never received any of these services [GO TO 3.1]
[If yes to any of the above:]
2.5.1. Where did you receive your services?
CHECK ALL THAT APPLY
Family planning clinic (a clinic that focuses on reproductive health and provides birth control and STD testing)
School or school-based clinic
Gynecologist’s office
Other doctor’s office such as your primary care physician or family doctor
Hospital emergency room, urgent care center, or walk-in facility
Some other place (Specify:_______________________________)
2.5.2. Where did you hear about the service?
CHECK ALL THAT APPLY
Your mother or father?
A doctor or nurse?
A teacher or school counselor?
Another adult?
A friend?
A TV advertisement
A radio advertisement
A poster or flyer
A brochure
A billboard
A website
A text message
An online social network site such as Facebook or Twitter
Other (Specify:_______________)
2.6. In the last 12 months, have you received any of these services from a medical provider or clinic?
CHECK ALL THAT APPLY
Counseling or information about birth control
Counseling or information about an Intrauterine Device (IUD)
Counseling or information about Implanon® (a hormone-release device placed under the skin on your arm)
Counseling or information about emergency contraception, also known as “Plan B” or “Preven” or the “morning-after pill”
Counseling or information about sexually transmitted diseases (STDs)
I have not received any of these services in the last 12 months [GO TO 3.1]
[If yes to any of the above:]
2.6.1. Where did you receive your services?
CHECK ALL THAT APPLY
Family planning clinic (a clinic that focuses on reproductive health and provides birth control and STD testing)
School or school-based clinic
Gynecologist’s office
Other doctor’s office such as your primary care physician or family doctor
Hospital emergency room, urgent care center, or walk-in facility
Some other place (Specify:_______________________________)
2.6.2. Where did you hear about the service?
CHECK ALL THAT APPLY
Your mother or father?
A doctor or nurse?
A teacher or school counselor?
Another adult?
A friend?
A TV advertisement
A radio advertisement
A poster or flyer
A brochure
A billboard
A website
A text message
An online social network site such as Facebook or Twitter
Other (Specify:_______________)
SECTION 3: FAMILY
The following questions are about your family and those who you think of as your family.
3.1. On how many days last week did all the family members who live in your household sit down together for a meal? [Program to skip if inappropriate on basis of response to 1.11.1.]
MARK (X) ONE
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3.2. On how many days last week did you do something with at least one adult in your family such as play a game, watch a movie, go to a sporting event, or work on something you enjoy doing together?
MARK (X) ONE
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MOTHER
3.3. Now we have some questions about your mother, or the person you think of as a 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?
Some other adult?
Don’t have a mother or person I think of as a mother [GO TO 3.11]
The following questions are about the person you marked as your mother or the person you think of as your mother.
3.4. Did she graduate from high school?
MARK (X) ONE
Yes
No
Don’t know
3.5. Did she graduate from a 4-year college?
MARK (X) ONE
Yes
No
Don’t know
3.6. 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
3.7. How close do you feel to your mother or the person you think of as a mother?
MARK (X) ONE
Not at all close
A little close
Somewhat close
Very close
3.8. 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
3.9. 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 |
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3.10. Whether you have done this or not, 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 |
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FATHER
3.11. Next we have some questions about your father, or the person you think of as a 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?
Some other adult?
Don’t have a father or person I think of as a father [GO TO 3.21]
The following questions are about the person you marked as your father or the person you think of as your father.
3.12. Did he graduate from high school?
MARK (X) ONE
Yes
No
Don’t know
3.13. Did he graduate from a 4-year college?
MARK (X) ONE
Yes
No
Don’t know
3.14. Is he working now?
MARK (X) ONE
He is not working at a paid job
Yes, he is working part-time or less than 30 hours a week
Yes, he is working full-time or at more than one job for 30 hours a week or more
Yes, he works, but I don’t know how many hours
Don’t know if he is working
3.15. 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
3.16. 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
3.17. 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 |
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3.18. Whether you have done this or not, 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 |
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3.19. My mother and father are:
MARK (X) ONE
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3.20. Do your mother and father live together?
MARK (X) ONE
Yes
No
Don’t know
PARENTS
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.
3.21. Thinking about the last month, how often did your parents know where you were after school?
MARK (X) ONE
Always
Usually
Sometimes
Rarely
Never
3.22. Thinking about the last 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
Did not go out
3.23. Thinking about the last month, how often did your parents know where you were when you went out at night?
MARK (X) ONE
Always
Usually
Sometimes
Rarely
Never
Did not go out at night
3.24. If you were going to be home late, would your parents expect you to call?
MARK (X) ONE
Yes
No
3.25. In the last 12 months, how many times have you talked with at least one of your parents or guardians about:
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MARK (X) ONE FOR EACH QUESTION |
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NEVER |
1–2 |
3–9 |
10 OR MORE TIMES |
a. How things are going with school work or with your grades? |
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b. A personal problem you were having? |
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c. How to have good romantic relationships? |
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d. Strategies for safe dating? |
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e. How to resist pressures to have sex? |
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f. Avoiding drugs and alcohol? |
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g. Avoiding pregnancy or birth? |
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h. Avoiding sexually transmitted diseases, also called STDs, HIV, or AIDS? |
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The next two questions are about your biological parents.
3.26.1. About how old was your biological mother when she had her first child?
MARK (X) ONE
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3.26.2. About how old was your biological father when his first child was born?
MARK (X) ONE
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SECTION 4: VIEWS AND PERCEPTIONS
These questions are your views and perceptions around sexual behaviors. Please be as honest as possible, and remember that everything you tell us will be kept private.
The next series of questions is about your views on sexual intercourse. In this survey, when we ask about sexual intercourse, we mean vaginal sex—when a male inserts his penis into a female’s vagina.
4.1. How strongly do you agree or disagree that:
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MARK (X) ONE FOR EACH QUESTION |
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STRONGLY AGREE |
AGREE |
DISAGREE |
STRONGLY DISAGREE |
a. Having sexual intercourse is a good thing for you to do at your age? |
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b. At your age right now, having sexual intercourse would create problems? |
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c. At your age right now, not having sexual intercourse is important for you to be safe and healthy? |
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d. At your age right now, it is okay for you to have sexual intercourse if you use birth control, like a condom? |
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e. It is against your values to have sexual intercourse before marriage? |
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4.2.1 FOR GIRLS ONLY:
If you got pregnant now, how would you feel?
MARK (X) ONE
VERY UPSET |
A LITTLE UPSET |
NEITHER UPSET NOR PLEASED |
A LITTLE PLEASED |
VERY PLEASED |
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4.2.2 FOR BOYS ONLY:
If you got a female pregnant now, how would you feel?
MARK (X) ONE
VERY UPSET |
A LITTLE UPSET |
NEITHER UPSET NOR PLEASED |
A LITTLE PLEASED |
VERY PLEASED |
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4.3. Imagine you are alone with someone you like very much. How likely is it that you could:
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MARK (X) ONE FOR EACH QUESTION |
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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? [Should be programmed for girls only.] |
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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? |
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c. Avoid having sexual intercourse if you didn’t want to? |
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4.4. The next series of questions is about condom use. How strongly do you agree or disagree that:
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MARK (X) ONE FOR EACH QUESTION |
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STRONGLY AGREE |
AGREE |
NEITHER AGREE NOR DISAGREE |
DISAGREE |
STRONGLY DISAGREE |
a. Condoms should always be used if a person your age has sexual intercourse? |
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b. Condoms are a hassle to use? |
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c. Condoms are pretty easy to get? |
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d. Condoms are important to make sexual intercourse safer? |
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e. Using condoms means you don’t trust your sexual partner? |
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f. Using condoms is morally wrong? |
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g. Condoms decrease sexual pleasure? |
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h. Condoms and other birth control methods should be used together (at the same time)? |
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The next series of questions is about condoms, birth control pills, pregnancy, and sexually transmitted diseases, also called STDs.
4.5. If a condom is used correctly, how much can it decrease the risk of pregnancy?
MARK (X) ONE
Not at all
A little
A lot
Don’t know [GO TO 4.6]
4.5.1. How confident are you that your answer is correct?
MARK (X) ONE
Not at all confident
A little confident
Somewhat confident
Very confident
4.6. 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
4.7. 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
4.7.1. The next series of questions is about other forms of birth control, not including condoms. How strongly do you agree or disagree that:
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MARK (X) ONE FOR EACH QUESTION |
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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? |
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b. Birth control is a hassle to use? |
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c. Birth control is pretty easy to get? |
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d. Birth control is important to make sexual intercourse safer? |
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e. Birth control has too many negative side effects? |
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f. Using birth control is morally wrong? |
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4.8. 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 4.9]
4.8.1. How confident are you that your answer is correct?
MARK (X) ONE
Not at all confident
A little confident
Somewhat confident
Very confident
4.9. 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
4.10. 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
4.11. Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
Yes
No
Don’t know [GO TO 4.12]
4.11.1. How confident are you that your answer is correct?
MARK (X) ONE
Not at all confident
A little confident
Somewhat confident
Very confident
4.12. In the last 3 months, how many times have you gone out on a date?
Zero or none [GO TO 4.14]
| | | Number of times (your best guess is fine)
4.13. Thinking about these dates in the last 3 months, how many different people did you go out on a date with?
| | | Number of people (your best guess is fine)
4.14. Do you intend to have oral sex in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
4.15. 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 4.18]
4.16. 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
The next question is about your intention to use effective methods of birth control. By effective
methods, we mean the following:
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
Diaphragm/cervical cap
4.17. If you have sexual intercourse in the next year, do you intend to use any of these methods of birth control?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
4.18. Think about whether you will have sexual intercourse without being married. Which statement is most true for you?
MARK (X) ONE
You will not have sexual intercourse unless you are married
You probably will not have sexual intercourse unless you are married
You probably will have sexual intercourse without being married
You will have sexual intercourse without being married
SECTION 5: TOBACCO, ALCOHOL, AND DRUG USE
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.
5.1. 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 (your best guess is fine)
5.3. During the last 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
More than 25 days
5–25 days
1–4 days
0 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 (your best guess is fine)
5.6. During the last 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
5–25 days
1–4 days
0 days
5.7. [For boys only] During the last 30 days, on how many days did you have five or more drinks in 2 hours?
MARK (X) ONE
More than 25 days
5–25 days
1–4 days
0 days
5.7.1 [For girls only] During the last 30 days, on how many days did you have four or more drinks in 2 hours?
MARK (X) ONE
More than 25 days
5–25 days
1–4 days
0 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 last 30 days, on how many days did you use marijuana?
MARK (X) ONE
More than 25 days
5–25 days
1–4 days
0 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
5.10.1 During the last 30 days, on how many days did you use an illegal drug other than marijuana?
MARK (X) ONE
More than 25 days
5–25 days
1–4 days
0 days
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
SECTION 6: FRIENDS AND RELATIONSHIPS
6.1 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
6.2. How many of your friends who are your age think the following things? (Your best guess is fine.)
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NONE |
SOME |
HALF |
MOST |
ALL |
DON’T KNOW |
a. Having sexual intercourse is a good thing for them to do at their age. |
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b. It would be okay for them to have sexual intercourse as long as they used birth control, like a condom. |
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c. It would be okay for them to have sexual intercourse if they were dating the same person for a long time. |
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d. They should wait until they are older to have sexual intercourse. |
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e. They should wait until marriage to have sexual intercourse. |
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6.3. How many of your friends who are your age have done the following things?
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MARK (X) ONE FOR EACH QUESTION |
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NONE |
SOME |
HALF |
MOST |
ALL |
DON’T KNOW |
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a. Had sexual intercourse |
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b. Had oral sex |
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c. Had anal sex |
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6.4. Here are some reasons people your age might choose NOT to have sexual intercourse. How important is each of these reasons to you? B2
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MARK (X) ONE FOR EACH QUESTION |
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VERY IMPORTANT |
SOMEWHAT IMPORTANT |
NOT TOO IMPORTANT |
NOT AT ALL IMPORTANT |
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a. (GIRLS ONLY) I do not want to get pregnant. |
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b. (BOYS ONLY) I do not want to get a girl pregnant. |
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c. I don’t want to get a sexually transmitted disease, that is, an STD. |
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d. I don’t want to disappoint my parents. |
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e. Having sex would interfere with my progress in school. |
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f. I am too young to have sex. |
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g. My boyfriend or girlfriend doesn’t want to have sex. |
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h. I want to wait until I’m married. |
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i. It is against my personal values. |
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j. I haven’t met the right person yet. |
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k. It would interfere with my future goals. |
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l. I haven’t had the chance. |
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m. I don’t want to. |
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6.5. In general, how much pressure, if any, do you feel from your friends (not your boyfriend or girlfriend) to have sexual intercourse?
MARK (X) ONE
A lot of pressure
Some pressure
A little pressure
No pressure at all
6.5.1 In general, how much pressure, if any, do you feel from your boyfriend or girlfriend to have sexual intercourse?
MARK (X) ONE
A lot of pressure
Some pressure
A little pressure
No pressure at all
6.6. 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
6.7. 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
6.8. People are different in their sexual attraction to other people. Which of the following best describes your feelings?
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
SECTION 7: DEVELOPMENT, BEHAVIORS, AND EXPERIENCES
The next questions are about your physical growth and maturation.
7.0.1. FOR GIRLS ONLY:
a. Have
you ever had your period, that is, your menstrual period?
MARK (X) ONE
Yes
No [GO TO 7.1]
b. How old were you when you had your first period, that is, your first menstrual period? |
| | | Number of years old (your best guess is fine)
7.0.2. FOR BOYS ONLY:
a. People reach puberty at different ages. Signs of puberty for males include physical changes such as developing pubic or facial hair, or the voice cracking or lowering. Which of the following best describes these changes for you?
MARK (X) ONE
These changes have not yet started [GO TO 7.1]
These changes have barely started
These changes are definitely under way
These changes seem complete
b. How old were you when these changes started?
| | | Number of years old (your best guess is fine)
The next section is about your sexual behaviors and experiences. Please be as honest as possible. Everything you say will be kept private.
7.1. Have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
No [STOP]
Yes [CONTINUE]
7.2. The first questions are about sexual intercourse. Remember that by sexual intercourse, we mean when a male puts his penis into a female’s vagina. Have you ever had sexual intercourse?
MARK (X) ONE
Yes
No [GO TO 7.7, and will also skip out of other questions specific to sexual intercourse]
7.3. 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 |
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Year
of First Sexual |
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7.4. The very first time you had sexual intercourse, how old were you?
| | | Number of years old (your best guess is fine)
7.5. 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
7.6. The very first time you had sexual intercourse, would you say that it was voluntary or not voluntary?
MARK (X) ONE
Voluntary
Not voluntary
The next section is about medical services that you may have received.
7.7. Have you ever received any of these services from a medical provider or clinic?
CHECK ALL THAT APPLY
A method of birth control or a prescription for a method
A checkup or medical test related to using a birth control method
Emergency contraception, also known as “Plan B” or “Preven” or the “morning after pill,” or a prescription for it?
A pregnancy test?
Testing or treatment for a sexually transmitted diseases (STDs)
I have never received any of these services [GO TO 7.13]
[If yes to any of the above:]
7.8. Where did you receive your services?
CHECK ALL THAT APPLY
Family planning clinic (a clinic that focuses on reproductive health and provides birth control and STD testing)
School or school-based clinic
Gynecologist’s office
Other doctor’s office such as your primary care physician or family doctor
Hospital emergency room, urgent care center, or walk-in facility
Some other place (Specify:_______________________________)
7.9. Where did you hear about the service?
CHECK ALL THAT APPLY
Your mother or father?
A doctor or nurse?
A teacher or school counselor?
Another adult?
A friend?
A TV advertisement
A radio advertisement
A poster or flyer
A brochure
A billboard
A website
A text message
An online social network site such as Facebook or Twitter
Other (Specify:_______________)
7.10. In the last 12 months, have your received any of these services from a medical provider or clinic?
CHECK ALL THAT APPLY
A method of birth control or a prescription for a method
A checkup or medical test related to using a birth control method
Emergency contraception, also known as “Plan B” or “Preven” or the “morning after pill,” or a prescription for it?
A pregnancy test?
I have not received any of these services in the last 12 months [GO TO 7.13]
[If yes to any of the above:]
7.11. Where did you receive your services?
CHECK ALL THAT APPLY
Family planning clinic (a clinic that focuses on reproductive health and provides birth control and STD testing)
School or school-based clinic
Gynecologist’s office
Other doctor’s office such as your primary care physician or family doctor
Hospital emergency room, urgent care center, or walk-in facility
Some other place (Specify:_______________________________)
7.12. Where did you hear about the service?
CHECK ALL THAT APPLY
Your mother or father?
A doctor or nurse?
A teacher or school counselor?
Another adult?
A friend?
A TV advertisement
A radio advertisement
A poster or flyer
A brochure
A billboard
A website
A text message
An online social network site such as Facebook or Twitter
Other (Specify:_______________)
The next series of questions is about your sexual behaviors and experiences, and use of birth control.
7.13. 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?
MARK (X) ONE
Yes
No [GO TO 7.15]
7.14. The first time you had sexual intercourse, did you or your partner use:
CHECK ALL THAT APPLY |
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7.15. Have you had sexual intercourse more than one time?
MARK (X) ONE
Yes
No [GO TO 7.17]
7.16. How many different people have you ever had sexual intercourse with, even if only one time?
| | | Number of people (your best guess is fine)
7.17. Now please think about the last 12 months. In the last 12 months have you had sexual intercourse? [We’ll use a calendar prompt for all of this section for 12- and 3-month recall.]
MARK (X) ONE
Yes
No [GO TO 7.31]
7.18. How many different people have you had sexual intercourse with in the last 12 months, even if only one time?
| | | Number of people (your best guess is fine)
7.19. How many times have you had sexual intercourse in the last 12 months?
| | | Number of times (your best guess is fine)
7.20. When you have had sexual intercourse in the last 12 months, how often have you used a condom?
MARK (X) ONE
Every time
Most of the time
About half of the time
Some of the time
None of the time
The next question is about your use of effective methods of birth control. By effective methods, we
mean the following:
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
Diaphragm/cervical cap
7.21. When you have had sexual intercourse in the last 12 months, how often have you used any of these methods of birth control?
MARK (X) ONE
Every time
Most of the time
About half of the time
Some of the time
None of the time
7.22. In the last 12 months, which of the following methods of birth control have you or your partner used?
CHECK ALL THAT APPLY
Condoms
Diaphragm/cervical cap
Birth control pills or the patch
NuvaRing® or the ring
Depo-Provera or other injectable birth control
Intrauterine device (IUD)
Implanon® (a hormone-release device placed under the skin on your arm)
Another method (__________________________________)
[7.23 will be programmed to only appear for those with “condoms” and another method selected in
7.22.]
7.23. When you had sexual intercourse in the last 12 months, how often did you use a condom at the same time you used (fill in the other effective method(s) they used based on response to 7.22])?
MARK (X) ONE
Every time
Most of the time
About half of the time
Some of the time
None of the time
7.24. In the last 12 months, did you use emergency contraception, also known as “Plan B” or “Preven” or the “morning after pill”?
MARK (X) ONE
Yes
No
7.25. Now please think about the last 3 months. In the last 3 months have you had sexual intercourse? [We’ll use a calendar prompt for all of this section for 12- and 3-month recall.]
MARK (X) ONE
Yes
No [GO TO 7.31]
7.26. How many different people have you had sexual intercourse with in the last 3 months, even if only one time?
| | | Number of people (your best guess is fine)
7.27. In the last 3 months, how many times have you had sexual intercourse?
| | | Number of times (your best guess is fine)
7.28. In the last 3 months, how many times have you had sexual intercourse with a condom?
| | | Number of times (your best guess is fine)
The next questions are about your use of effective methods of birth control. By effective methods, we
mean the following:
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
Diaphragm/cervical cap
7.29. In the last 3 months, how many times have you had sexual intercourse using any of these methods of birth control?
| | | Number of times (your best guess is fine)
7.30. In the last 3 months, which of the following methods of birth control have you or your partner used?
CHECK ALL THAT APPLY
Condoms
Diaphragm/cervical cap
Birth control pills or the patch
NuvaRing® or the ring
Depo-Provera or other injectable birth control
Intrauterine device (IUD)
Implanon® (a hormone-release device placed under the skin on your arm)
Another method (__________________________________)
7.31. Now, please think about the last time you had sexual intercourse. Did you use birth control?
MARK (X) ONE
Yes
No [GO TO 7.33]
7.32. Please describe the type of birth control used the last time you had sexual intercourse.
CHECK ALL THAT APPLY |
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7.33. Again, think about the last time you had sexual intercourse. Were you drunk or high?
MARK (X) ONE
Yes
No
7.34. 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 7.39]
7.35. The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR
Month of First Oral Sex |
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Year of First Oral Sex |
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7.36. How many different people have you ever had oral sex with, even if only one time? |
| | | Number of people (your best guess is fine)
7.37. Now, please think about the last 3 months. In the last 3 months, how many times have you had oral sex? |
None [GO TO 7.39]
| | | Number of times (your best guess is fine)
7.38. In the last 3 months, how many times did you have oral sex while using a condom?
None
| | | Number of times (your best guess is fine)
7.39. 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 7.43]
7.40. How many different people have you ever had anal sex with, even if only one time?
MARK (X) ONE
| | | Number of people (your best guess is fine)
7.41. Now, please think about the last 3 months. In the last 3 months, how many times have you had anal sex? B1
None [GO TO 7.43]
| | | Number of times (your best guess is fine)
7.42. In the last 3 months, how many times did you have anal sex while using a condom?
None
| | | Number of times (your best guess is fine)
7.43. 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:
7.44. To the best of your knowledge, have you ever been pregnant, even if no child was born?
MARK (X) ONE
Yes
No [GO TO 7.52]
7.45. To the best of your knowledge, how many times have you been pregnant? (If you are or think you are pregnant now, include that in your count.)
| | | Number of times (your best guess is fine)
7.46. Have you ever had a baby?
MARK (X) ONE
Yes
No
FOR GIRLS ONLY:
7.47. To the best of your knowledge, are you pregnant now?
MARK (X) ONE
Yes [GO TO 7.52]
No [GO TO 7.52]
Don’t know
7.48. Do you think you are probably pregnant or not?
MARK (X) ONE
Probably yes
Probably no
FOR BOYS ONLY:
7.49. To the best of your knowledge, have you ever gotten someone pregnant, even if no child was born?
MARK (X) ONE
Yes
No [GO TO 7.52]
7.50. To the best of your knowledge, how many times have you gotten someone pregnant?
| | | Number of times (your best guess is fine)
7.51. Has anyone you got pregnant had the baby?
MARK (X) ONE
Yes
No
Don’t Know
7.52. In the last 12 months, have you spoken with a doctor or nurse about having sex, birth control, or sexually transmitted diseases, also known as STDs?
MARK (X) ONE
Yes
No
7.53. In the last 12 months, have you been tested by a doctor or nurse for a sexually transmitted disease (STD), such as gonorrhea, chlamydia, syphilis, or HIV?
MARK (X) ONE
Yes
No
7.54. In the last 12 months, have you been told by a doctor or nurse that you had a sexually transmitted disease (STD)?
MARK (X) ONE
Yes
No
7.55. The next series of questions is about the types of sexually transmitted diseases (STDs) you have had. In the last 12 months, did you have:
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MARK (X) ONE FOR EACH QUESTION |
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YES |
NO |
DON’T KNOW |
a. Chlamydia? |
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b. Gonorrhea? |
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c. Genital herpes? |
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d. Syphilis? |
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e. HIV infection or AIDS? |
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f. Human papilloma virus, also known as HPV or genital warts? |
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g. Another sexually transmitted disease (STD)? |
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Thank you for completing this survey. |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |