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pdfATTACHMENT D
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
FOLLOW- UP INSTRUMENT: OKLAHOMA INSTITUTE FOR CHILD ADVOCACY
(OICA)
The OICA survey instrument is not divided into separate parts for sexually active and non-sexually active
youth.
Form approved
OMB No. 0990-0382
Exp. Date: xx/xx/20xx
FOLLOW-UP QUESTIONNAIRE
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
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0382. The time
required to complete this information collection is estimated to average 36 minutes per response, including the time to review
instructions and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA,
200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
TODAY’S DATE (MONTH/DAY/YEAR): _______________
SECTION 1: DEMOGRAPHICS
1.1. Are you male or female?
MARK (X) ONE
Male
Female
1.2. What is the last grade you completed?
MARK (X) ONE
6th
7th
8th
9th
10th
11th
12th
1.3. How old were you when you entered the foster care system?
MARK (X) ONE
<1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
1
1.4. Do you currently live in a group home?
MARK (X) ONE
Yes
No
1.5. In what month and year did you start living in this group home?
I am not currently living in a group home
MARK (X) ONE MONTH AND ONE YEAR
Month started living in this
group home
Year started living in this
group home
January
2008
February
2009
March
2010
April
2011
May
2012
June
2013
July
2014
August
2015
September
October
November
December
1.6. Are you Hispanic/Latino?
MARK (X) ONE
Yes
No
2
1.7
What is your race?
SELECT ONE OR MORE
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
1.8. What is the second letter of your first
name?
1.9. What is the last letter of your first name?
MARK (X) ONE
MARK (X) ONE
A
N
A
N
B
O
B
O
C
P
C
P
D
Q
D
Q
E
R
E
R
F
S
F
S
G
T
G
T
H
U
H
U
I
V
I
V
J
W
J
W
K
X
K
X
L
Y
L
Y
M
Z
M
Z
3
1.10. In which month were you
born?
MARK (X) ONE
1.11. On which day were you
born?
MARK (X) ONE
1.12. In which year were you
born?
MARK (X) ONE
January
1
17
1991
February
2
18
1992
March
3
19
1993
April
4
20
1994
May
5
21
1995
June
6
22
1996
July
7
23
1997
August
8
24
1998
September
9
25
1999
October
10
26
2000
November
11
27
2001
December
12
28
13
29
14
30
15
31
16
1.13. How likely is it that you will do each of the following?
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE
BIT LIKELY
SOMEWHAT
LIKELY
VERY
LIKELY
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.......................................................................................................
4
1.14. 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 infections, also known as STIs .....................................................................................
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 ....................................................................................................................................
1.15. Thinking about the past 12 months, how many times did you get information on relationships, abstinence,
birth control, or sexually transmitted diseases at each of the following places?
MARK (X) ONE FOR EACH
NEVER
1-3 TIMES
4-9 TIMES
10 OR MORE TIMES
a. School class ............................................................................................................................................
b. Church, synagogue, mosque, or religious
classes outside of school ........................................................................................................................
c.
Community center, youth organization, or
after-school activity .................................................................................................................................
d. Doctor, nurse, or clinic ............................................................................................................................
e. Friends ....................................................................................................................................................
f.
Parents and other relatives or family members ......................................................................................
g. Internet and media ..................................................................................................................................
h. Other
LIST OTHER SOURCE
...................................................................................................
1.16. Thinking about the past 12 months, where did you get information on relationships, abstinence, birth
control, or sexually transmitted diseases that was very helpful to you?
SELECT ONE OR MORE
School class
Church, synagogue, mosque or religious classes outside of school
Community center, youth organization, or after-school activity
Doctor, nurse, or clinic
Friends
Parents and other relatives or family members
Internet and media
Other
5
SECTION 2: KNOWLEDGE
These next questions ask about the body, sexually transmitted infections (STIs), and methods of
protection.
2.1. The body part of the female body where a baby grows during pregnancy is the:
MARK (X) ONE
Cervix
Uterus
Vagina
Ovary
Don’t know
2.2. The part of the male’s body that produces sperm is the:
MARK (X) ONE
Testicles
Urethra
Penis
Prostate
Don’t know
2.3. When is it possible for a female to become pregnant?
MARK (X) ONE
The first time she has sex
When she is ovulating
When her partner withdraws (pulls out) before ejaculating
All of the above
Don’t know
2.4. Of the following statements about methods of protection, which one is false?
MARK (X) ONE
You can get them with a prescription from a doctor
You can buy them at a local store in the drug or pharmacy section
Some require a prescription and others do not, depending on the type of method
You must have your parent’s/guardian’s permission to get them if you are under age 18
Don’t know
6
2.5. Please mark whether each statement is true, false, or you don’t know.
MARK (X) ONE FOR EACH QUESTION
TRUE
FALSE
DON’T
KNOW
a. A sexually active girl can become pregnant if she forgets to take
her birth control pills for several days in a row ............................................................................................
b. Using a condom can help prevent HIV ........................................................................................................
c. A condom can be used more than once ......................................................................................................
d. If a condom is used, a young man should be careful how he
pulls out........................................................................................................................................................
e. If a young couple has had unprotected sex a few times and a
pregnancy did not occur, then they do not have to worry about
her getting pregnant .....................................................................................................................................
f.
HIV destroys the immune system’s ability to fight off infections
and diseases ................................................................................................................................................
g. You cannot tell if a person has HIV by looking at them ...............................................................................
h. HIV is the only sexually transmitted infection that is incurable ....................................................................
i.
All sexually active individuals are at risk for getting HIV .............................................................................
j.
Latex condoms are 100% effective in preventing pregnancy
and STIs (including HIV) ..............................................................................................................................
k. All sexually transmitted infections (STIs) can be cured ..............................................................................
l.
You can get the same sexually transmitted infection (STI) twice ...............................................................
m. You can get a sexually transmitted infection (STI) from having oral sex ...................................................
7
2.6. Which of the following methods of protection offers the most protection against HIV and other
STIs?
MARK (X) ONE
Depo-Provera (the shot)
Vaginal film
Condom (rubber)
Birth control pill
Don’t know
2.7. What is the safest and most effective method for avoiding pregnancy and sexually transmitted
infections (STIs)?
MARK (X) ONE
Birth control pill
Condom (rubber)
Depo-Provera (the shot)
Abstinence (not having sex)
Don’t know
2.8. Which one of the following methods listed below do you think is most effective for preventing
pregnancy?
MARK (X) ONE
Condom (rubber)
Depo-Provera (the shot)
Rhythm (safe period by calendar)
Patch (Ortho evra)
Birth control pill
Withdrawal method
Don’t know
2.9. Which one of the following methods listed below do you think is least effective for preventing
pregnancy?
MARK (X) ONE
Condom (rubber)
Depo-Provera (the shot)
Rhythm (safe period by calendar)
Patch (Ortho evra)
Birth control pill
Withdrawal method
Don’t know
8
SECTION 3: ATTITUDES AND SELF-EFFICACY
The following questions are about your views on sex and protection.
3.1. Two people having vaginal intercourse should use some method of protection if they are not
ready for a child.
MARK (X) ONE
Strongly agree
Agree
Disagree
Strongly disagree
3.2. Using a method of protection is very important.
MARK (X) ONE
Strongly agree
Agree
Disagree
Strongly disagree
3.3. The next questions are about condom use. How strongly do you agree or disagree that…
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
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.
Condoms are morally wrong ..........................................................................................................................
g. Condoms decrease sexual pleasure .............................................................................................................
h. Condoms make sex less exciting ..................................................................................................................
9
3.4.
The next questions are 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
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 ...............................................................................................................
3.5. Please tell us how sure or unsure you are that you could do the following things:
MARK (X) ONE FOR EACH QUESTION
VERY
SURE
SOMEWHAT
SURE
SOMEWHAT
UNSURE
VERY
UNSURE
a. Find a place in your community to obtain
methods of protection from pregnancy and STIs ..........................................................................................
b. Tell your partner your feelings about what
you do and do not want to do sexually ..........................................................................................................
c. Say “no” if your partner puts pressure on you
to be involved sexually, and you do not want
to be involved sexually...................................................................................................................................
d. Talk with your partner about methods of
protection if you have sex with him/her ........................................................................................................
e. Insist on using a method of protection if you
have sex and want to use a method of
protection ......................................................................................................................................................
f.
Stop and use a method of protection once
you are turned on ..........................................................................................................................................
g. Plan ahead to have some method of protection
available .........................................................................................................................................................
h. Resist having sex with your partner if he/she
did not want to use a method of protection ...................................................................................................
10
3.6. The next questions are about your views on sexual intercourse. In this question, 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...........................................................................................................................
11
SECTION 4: BEHAVIOR AND INTENTIONS
NOTE: The following questions are about behaviors. Questions on this survey only mean behaviors
that you choose to participate in - do not count behaviors you were forced to do against your will.
SEXUAL INTERCOURSE
4.1. These 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
4.2. Have you had sexual intercourse more than one time?
MARK (X) ONE
I have never had sexual intercourse
Yes
No
4.3. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
I have never had sexual intercourse
NUMBER OF PEOPLE – Your best guess is fine.
4.4. These next few questions ask about the first time you had sexual intercourse. The very first time
you had sexual intercourse, how old were you?
I have never had sexual intercourse
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old or older
12
4.5. Birth control methods are something used to reduce the risk of pregnancy, and some can reduce
the risk of sexually transmitted infections, also known as STIs.
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
I have never had sexual intercourse
Yes
No
4.6. The first time you had sexual intercourse, did you or your partner use…?
MARK (X) ONE FOR EACH QUESTION
I have never had sexual intercourse
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
................................................................................
4.7. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had sexual intercourse?
None
NUMBER OF TIMES – Your best guess is fine.
4.8. In the past 3 months, how many TIMES have you had sexual intercourse without you or your
partner using a condom?
None
NUMBER OF TIMES – Your best guess is fine.
13
4.9. 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.
4.10. In the past 3 months, with how many people have you had sex?
MARK (X) ONE
I have not had sex in the past 3 months
1 person
2 people
3 people
4 people
5 people
6 or more people
4.11. The next few questions are about your intentions for the next year.
Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
14
4.12. If you have sexual intercourse in the next year, do you intend to use (or have your partner use) a
condom?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
4.13. The next question is about your intention to use the following methods of birth control:
•
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 (or have your partner use)
any of these methods of birth control?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
PREGNANCY
4.14. To the best of your knowledge, have you ever been pregnant or gotten anyone pregnant, even if
no child was born? Be sure to answer ‘yes’ if you are currently pregnant or had any pregnancy
that ended in a birth, an abortion, stillbirth, miscarriage, or live birth after which the baby died.
MARK (X) ONE
Yes
No
4.15. Have you been pregnant or gotten someone pregnant during the past 3 months? Be sure to
answer ‘yes’ if you are currently pregnant or had any pregnancy that ended in a birth, an
abortion, stillbirth, miscarriage, or live birth after which the baby died.
MARK (X) ONE
Yes
No
15
4.16. To the best of your knowledge, how many times have you been pregnant or gotten someone
pregnant?
None
NUMBER OF TIMES PREGNANT
4.17. Have you ever had a baby or has anyone you got pregnant had the baby?
MARK (X) ONE
I have never been pregnant or gotten anyone pregnant
Yes
No
Don’t know
4.18. When you or your partner got pregnant, were you trying to become pregnant?
MARK (X) ONE
I have never been pregnant or gotten anyone pregnant
Yes
No
4.19. If you got pregnant now or 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
16
ORAL SEX
4.20. The next questions are about oral sex. 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
4.21. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
I have never had oral sex
NUMBER OF PEOPLE – Your best guess is fine.
4.22. Now think about the first time you had oral sex. The very first time you had oral sex, how old were
you?
MARK (X) ONE
I have never had oral sex
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old or older
4.23. Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
oral sex?
None
NUMBER OF TIMES – Your best guess is fine.
4.24. Do you intend to have oral sex in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
17
SEX – VAGINAL, ORAL, AND ANAL SEX
The next few questions ask about sex. By sex, we mean ALL types of sex – including vaginal,
oral, and anal sex.
4.25. Have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
Yes
No
4.26. These next few questions ask about the last time you had sex (sexual intercourse, oral sex or
anal sex). The last time you had sex did you or your partner use a method of protection?
MARK (X) ONE
I have never had sex
Yes
No
4.27. The last time you had sex did you or your partner use a condom?
MARK (X) ONE
I have never had sex
Yes
No
4.28. The last time you had sex, did you or your partner use the following methods to prevent
pregnancy or STIs?
MARK (X) ONE FOR EACH QUESTION
I have never had sex
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.
Not sure .........................................................................................................................................................
g. Another method PRINT OTHER METHOD USED
................................................................................
________________________________________________________________
18
4.29. Which one of these statements best describes you now?
MARK (X) ONE
I have not had sex and am not even thinking about having sex
I have not had sex, however I am thinking about having sex
I have not had sex, but I am seriously thinking about having sex in the near future
I have had sex in the past but I am not having sex now
I am currently having sex
4.30. Which of the following categories best describes your use of methods of protection now? Please
choose just one category.
MARK (X) ONE
I do not use any methods of protection because I am not sexually active
I do not use a method of protection
I do not use any methods of protection, but am considering using a method of protection
I use a method of protection sometimes, but I am thinking about using a method of protection every time I have
sex
I use a method of protection every time, but it has been less than 6 months since I started using a method of
protection every time
I use a method of protection every time, and it has been more than 6 months since I started using a method of
protection every time
19
SEXUALLY TRANSMITTED INFECTIONS (STIs)
The next questions ask about sexually transmitted infections (STIs.)
4.31. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted infections, also known as STIs?
MARK (X) ONE
Yes
No
4.32. In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
infection (STI), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE
Yes
No
4.33. In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted infection (STI)?
MARK (X) ONE
Yes
No
4.34. This question is about the types of sexually transmitted infections (STIs) you have had. In the
past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION
I have not had an STI in the last 12 months
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 infection (STI) PRINT OTHER STI.................................................................
_________________________________________________________
20
SECTION 5: POWER THROUGH CHOICES
5.1. Were you in the POWER Through Choices program at any previous time?
MARK (X) ONE
Yes
No
For the next few questions, please think about POWER Through Choices and how it may have
influenced you.
5.2. Would you say that being in this program has made you more likely or less likely to have sexual
intercourse in the next year?
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
5.3. If you were to have sexual intercourse in the next year, would you say that being in POWER
Through Choices has made you more likely or less likely to use (or ask your partner to use) a
condom?
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
21
5.4. If you were to have sexual intercourse in the next year, would you say that being in POWER
Through Choices has made you more likely or less likely to use (or ask your partner to use) any
of the these methods of birth control?
•
Condoms
•
Birth control pills
•
The shot (Depo Provera)
•
The patch
•
The ring (NuvaRing)
•
IUD (Mirena or Paragard)
•
Implants (Implanon)
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
5.5. Would you say that being in POWER Through Choices has made you more likely or less likely to
abstain from sexual intercourse in the next year (abstaining means choosing not to have sex)?
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
5.6. How helpful do you feel the material presented in POWER Through Choices has been to you
personally?
MARK (X) ONE
Extremely helpful
Very helpful
Neutral
Not very helpful
Not helpful at all
22
5.7. Compared to other teachers you have had, how would you rate the instructor who presented the
POWER Through Choices program?
MARK (X) ONE
Outstanding
Above average
Average
Below average
Poor
23
| File Type | application/pdf |
| Author | MThomas |
| File Modified | 2012-03-27 |
| File Created | 2012-03-27 |