B1 Safer Sex sites and youth who have ever had sex

Attachment F

OMB Control No:

Expiration Date:

TPP Replication Study

BASELINE QUESTIONNAIRE

(Part B1)

For all Safer Sex Participants and for Reducing the Risk and Cuidate! participants who have ever had sex

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

SECTION 4

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 SKIP TO SECTION 5.

Yes CONTINUE.

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?

M ARK (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

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?

M ARK (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

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)

• Implants (Implanon)

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

N one

NUMBER OF TIMES – Your best guess is fine.

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.

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.

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?

M ARK (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.

4.26.

a. To the best of your knowledge, have you ever been pregnant, even if no child was born?

M ARK (X) ONE

Yes

No GO TO 4.27

b. To the best of your knowledge, how many times have you been pregnant?

None

NUMBER OF TIMES

c. Have you ever had a 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?

M ARK (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 GO TO 4.31

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
		YES	NO	DON’T KNOW
	a. Chlamydia
	b. Gonorrhea
	c. Genital herpes
	d. Syphilis
	e. HIV infection or AIDS
	f. Human Papilloma virus, also known as HPV or genital warts
	g. Another sexually transmitted 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?

M ARK (X) ONE

Yes

No

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

M ARK (X) ONE

Yes

No

I have never dated anyone

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?

M ARK (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?

M ARK (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?

M ARK (X) ONE

More than 25 days

5 to 25 days

1 to 4 days

0 (zero) days GO TO 5.8

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

M ARK (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

SECTION 6: FRIENDS, family 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 later 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?

M ARK (X) ONE

A lot of pressure

Some pressure

A little pressure

No pressure

6.4. 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

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

For this last set of questions, we will be asking yourself and your family. You cannot personally be identified by your answers. The information you provide will be combined with the information provided by all the other students completing this survey.

6.6. Now we have some questions about your mother, or the person you think of as your mother. Is this person…?

M ARK (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 6.14

6.7. 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

6.8. Did she graduate from a 4-year college?

MARK (X) ONE

Yes

No

Don’t know

6.9. 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

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

M ARK (X) ONE

Not at all close

A little close

Somewhat close

Very close

6.11. 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

6.12. 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

6.13. 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

6.14. 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 6.22a

6.15. 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?

M ARK (X) ONE

Yes

No

Don’t know

6.16. Did he graduate from a 4-year college?

MARK (X) ONE

Yes

No

Don’t know

6.17. Is he working now?

M ARK (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

6.18. 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

6.19. 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

6.20. 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

6.21. 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

6.22a. 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

6.22b. 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

T he next questions are about where you live and who lives with you.

6.23. Which of the following best describes where you live?

MARK (X) ONE

You live in one home GO TO 6.24

You live in two or more homes, and go back and forth GO TO 6.25

You are homeless (living on the street, in a car or shelter, or staying with friends/relatives)

	6.24. 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
		6.25. 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

6.26a	Thinking about this past summer, did you participate in any Summer Youth Employment Programs?
	(Check one)
	 Yes
	 No  Go To End
	 Don’t know  Go To End

	6.26b	Did you participate in a week-long workshop called Gen.M (Gender Matters)?
		(Check one)
		 Yes
		 No
		 Don’t know

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