Sexuallly Active Youth Part A Safer Sex

Attachment D

OMB Control No:

Expiration Date:

TPP Replication Study

BASELINE QUESTIONNAIRE

Part A

(Safer Sex Intervention)

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.

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.

Form Approved

OMB No. 0990-

                Exp. Date XX/XX/20XX

GENERAL INSTRUCTIONS

1

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

. 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

Brown

Blue

Green

Another color

2

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.

. EXAMPLE 2: MARK (X) ONE ANSWER and FILL IN THE BLANK

What is the color of your hair?

MARK (X) ONE

Brown

Black

Blond

Red

Some other color PRINT OTHER COLOR purple

3

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

. 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

Rent a movie

Go to a baseball game

Study at a friend’s house

4 . EXAMPLE 4: QUESTION WITH A SKIP

Because you answered “Yes” to question 1, you would continue to question 2 and then question 3.

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

1. Do you ever eat chocolate?

MARK (X) ONE

Yes

No GO TO QUESTION 3

2. Do you always brush your teeth after eating chocolate?

M ARK (X) ONE

Yes

No

3. Did you do any of the following last week?

YOU MAY MARK (X) MORE THAN ONE ANSWER

Went to a play

Went to a movie

Attended a sporting event

5

Fill in the boxes with the correct number. For any number less than 10, put a zero (0) in the first box. For example, if you had eaten 2 chocolate bars in the past 7 days, you would write “0” in the first box and “2” in the second box. If you had eaten 15 chocolate bars, you would write “1” in the first box and “5” in the second box.

. EXAMPLE 5: FILL IN THE NUMBER

In the past seven (7) days, how many chocolate bars have you eaten?

NUMBER OF CHOCOLATE BARS – Your best guess is fine.

6. EXAMPLE 6: MARK (X) ONE ANSWER FOR EACH QUESTION

In the past 12 months, have you done any of the following?

MARK (X) ONE FOR EACH QUESTION

YES

NO

a. Walked a dog on a leash?

b. Played Frisbee?

c. Weeded a garden?

d. Eaten a piece of fresh fruit?

e. Played a piano?

f. 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.

7

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 7: MARK (X) ONE MONTH AND ONE YEAR

In what month and year did you finish elementary school?

M ARK (X) ONE MONTH AND ONE YEAR

Month finished		Year finished
January		2010
February		2009
March		2008
April		2007
May		2006
June		2005
July		2004
August		2003
September		2002
October		2001
November		2000
December		1999

8

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.

. EXAMPLE 8: FOR GIRLS or FOR BOYS

1a. FOR GIRLS Do you want to be a mother someday?

MARK (X) ONE

Yes

No

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

No

Form Approved

OMB No. 0990-

                Exp. Date XX/XX/20XX

SECTION 1: YOU AND YOUR BACKGROUND

1.1. In what month and year were you born?

M ARK (X) ONE MONTH AND ONE YEAR

Month born		Year born
January		2002
February		2001
March		2000
April		1999
May		1998
June		1997
July		1996
August		1995
September		1994
October		1993
November		1992
December		1991

1.2. What grade are you in?

MARK (X) ONE

6th

7th

8th

9th

10th

11th

12th

Not currently in school

1.3

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. 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)

1.7. 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

1.8. 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

1.9. 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

1.10. In the past 12 months, how often did you attend religious services or activities?

MARK (X) ONE

Never

Less than once a month

1-3 times per month

Once a week

More than once a week

1.11. How important is religion in your life?

MARK (X) ONE

Not at all important

Somewhat important

Very important

SECTION 2: YOU AND YOUR FAMILY

2.1. 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

2.2. Thinking about the past month, how often did your parents know who you were going to be with before you went out?

M ARK (X) ONE

Always

Usually

Sometimes

Rarely

Never

I did not go out

2.3. 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

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

M ARK (X) ONE

Yes

No

2.5. 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

2.6. 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

2.7. 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

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. Most of the people my age wait until they are older to have sex.
	b. Most of the people my age are having sex
	c. Most of the people my age who have sex always use condoms

3.2. FOR GIRLS

If you got pregnant now, how would you feel?

M ARK (X) ONE

Very happy

A little happy

Neither happy nor upset

A little upset

Very upset

3.3.

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

3.5. How often do you feel these statements apply to you? MARK (X) ONE FOR EACH QUESTION
	ALWAYS	MOST OF THE TIME	SOMETIMES	RARELY	NEVER
I can ask my partner to use a condom when we have sexual intercourse
I am afraid that my partner would be angry or upset if I asked him to use a condom
If my partner does not want to use condoms, I feel there is little I can do about it
When I get a new partner, I tell him I won’t have sex with him unless we use a condom
I feel my boyfriend would drop me if I didn’t have sex with him
If I asked a guy to use a condom, I feel like he might think I suspect him of having a sexually transmitted disease

3.6. 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?

M ARK (X) ONE

Not at all

A little

A lot

Don’t know GO TO 3.7

3.6a. How confident are you that your answer is correct?

M ARK (X) ONE

Not at all confident

A little confident

Somewhat confident

Very confident

3.7. 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

3.8. 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

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

3.10. 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 3.11

3.10a. How confident are you that your answer is correct?

MARK (X) ONE

Not at all confident

A little confident

Somewhat confident

Very confident

3.11. If birth control pills are used correctly, how much can they decrease the risk of getting HIV, the virus that causes AIDS?

MARK (X) ONE

Not at all

A little

A lot

Don’t know

3.12. If birth control pills are used correctly, how much can they decrease the risk of getting Chlamydia and gonorrhea?

M ARK (X) ONE

Not at all

A little

A lot

Don’t know

3.13. Can you get a sexually transmitted disease, or STD, from having oral sex?

MARK (X) ONE

Yes

No

Don’t know GO TO 3.14

3.13a. How confident are you that your answer is correct?

M ARK (X) ONE

Not at all confident

A little confident

Somewhat confident

Very confident

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

M ARK (X) ONE

Yes, definitely

Yes, probably

No, probably not

No, definitely not

3.15. Do you intend to have sexual intercourse in the next year if you have the chance?

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 or have your partner use a condom?

M ARK (X) ONE

Yes, definitely

Yes, probably

No, probably not

No, definitely not

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

• Birth control pills

• The shot (Depo-Provera)

• The patch

• The ring (NuvaRing)

• IUD (Mirena or Paragard)

• Implants (Implanon)

3.17. 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

3 .18. In the past 3 months, how many TIMES have you gone out on a date?

Zero or None GO TO 3.20

NUMBER OF TIMES – Your best guess is fine.

3 .19. Thinking about these dates in the past 3 months, how many DIFFFERENT PEOPLE did you go out on a date with?

NUMBER OF PEOPLE – Your best guess is fine.

3.20. Have you ever had any of the following: sexual intercourse, oral sex or anal sex?

MARK (X) ONE

Yes

No, definitely not