Form 2 Student Outcome Survey Mid-Term

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Attachment F:

Student Outcome Survey Mid-Term

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student name:

Student ID number:

Classroom ID number:

School ID number:

Program Year:

Survey Iteration:

Survey Date:

Evaluation of CDC’s Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Student Survey (Mid-term)

Instructions

• Use a pencil or blue or black pen.

• Fill bubbles completely. Like this: 

• Do not mark answers with ’s or ’s.

1. Birth date: Month: ___________ Day: ________Year:________

2. Sex: 3. What is your current grade?

 Male  6^th

 Female  7^th

 8^th

4. What is your race? You may mark one or more races, as appropriate:

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

5. Are you Hispanic or Latino?

 Yes

 No

6. Think about the grown-ups that live in your house. Mark the circle for each grown-up that lives in your house.

 Mother	 Foster Mother/Guardian	 Aunt
 Father	 Foster Father/Guardian	 Uncle
 Stepmother/Father's Girlfriend	 Grandmother	 Other relatives or friends
 Stepfather/Mother's Boyfriend	 Grandfather

Strengths and Difficulties Questionnaire (Prosocial and Emotional Symptoms Subscales)

For each item, please mark the circle for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of how things have been for you in the last six months.

	Not True	Somewhat True	Certainly True
a. I try to be nice to other people. I care about their feelings			
b. I get a lot of headaches, stomach-aches, or sickness			
c. I usually share with others, for example, CD’s, games, food			
g. I worry a lot			
I am helpful if someone is hurt, upset, or feeling ill			
k. I am often unhappy, depressed, or tearful			
m. I am nervous in new situations. I easily lose confidence			
n. I am kind to younger children			
q. I often offer to help others (parents, teachers, children)			
t. I have many fears; I am easily scared			

Resilience Factors (Adapted from LONGSCAN)

The next few questions are about whether or not you have adults you can count on – to encourage you, or help you with any serious problems that come up.

2a. Could you go to a parent or to another relative (not a parent) with a serious problem?

 No

 Yes

Dating History Questionnaire (Furman & Wehner, 1992)

The next questions ask about “dating.” By “dating,” we mean spending time with someone you are seeing or going out with. Examples of this might include hanging out at the mall, in the neighborhood, or at home or going somewhere together like the movies, a game, or a party. It doesn't have to be a formal date or something you planned in advance and it may be with a small group. The term "date" includes both one-time dates and time together as part of long-term relationships.

1. Have you ever DATED someone, including, for example, someone you spent time with or someone you are/were seeing or going out with?

 No

 Yes

2. Do your parents allow you to date?

 No

 Yes

3. Do your parents know where you are when you are out on a date?

 No

 Yes

4. What was the length of your longest dating relationship?

 1 date

 1 week

 More than 1 week and less than one month

 1 to 6 months

 More than 6 months and less than a year

 1 year or more

5. Have you ever dated someone who is a different age than yourself?

 1-year difference

 2-year difference

 More than 3 years difference in age

** If you haven’t started dating, go on to page <# (conflict resolution style items)> **

(If you have started dating, please complete this page)

10. How many different people have you dated or been seeing since you began dating?

 0	 4	 8
 1	 5	 9
 2	 6	 10 or more
 3	 7

The Conflict in Adolescent Dating Relationships Inventory (Modified)

The following questions ask you about things that may have happened with a boyfriend/girlfriend (past or present).

If you haven’t started dating, fill in this bubble  and move onto the next page.

If you have started dating (even one date), fill in the bubbles below that are your best estimates of how often these things have ever happened with someone you were dating. As a guide, use the following scale:

Never: this has never happened in your relationships

Seldom: this has happened only 1-2 times in your relationships

Sometimes: this has happened about 3-5 times in your relationships

Often: this has happened 6 times or more in your relationships

		Never	Seldom	Sometimes	Often
1.	I touched him/her sexually when he/she didn’t want me to.				
	He/she touched me sexually when I didn’t want him/her to.				
2.	I tried to turn his/her friends against him/her.				
	He/she tried to turn my friends against me.				
3.	I did something to make him/her feel jealous.				
	He/she did something to make me feel jealous.				
4.	I destroyed or threatened to destroy something he/she valued.				
	He/she destroyed or threatened to destroy something I valued.				
		Never	Seldom	Sometimes	Often
5.	I brought up something bad he/she had done in the past.				
	He/she brought up something bad I had done in the past.				
6.	I threw something at him/her.				
	He/she threw something at me.				
7.	I said things just to make him/her angry.				
	He/she said things just to make me angry.				
8.	I spoke to him/her in a hostile or mean tone of voice.				
	He/she spoke to me in a hostile or mean tone of voice.				
9.	I forced him/her to have sex when he/she didn’t want to.				
	He/she forced me to have sex when I didn’t want to.				
		Never	Seldom	Sometimes	Often
10.	I threatened him/her in an attempt to have sex with him/her.				
	He/she threatened me in an attempt to have sex with me.				
11.	I insulted him/her with put-downs.				
	He/she insulted me with put-downs.				
12.	I kissed him/her when he/she didn’t want me to.				
	He/she kissed me when I didn’t want him/her to.				
13.	I said things to his/her friends about him/her/her to turn them against him/her/her.				
	He/she said things to my friends about me to turn them against me.				
15.	I ridiculed or made fun of him/her/her in front of others.				
	He/she ridiculed or made fun of me in front of others.				
16.	I kept track of who he/she was with and where he/she was.				
	He/she kept track of who I was with and where I was.				
17.	I blamed him/her/her for the problem.				
	He/she blamed me for the problem.				
18.	I kicked, hit, or punched him/her/her.				
	He/she kicked, hit, or punched me				
19.	I accused him/her of flirting with another girl/guy				
	He/she accused me of flirting with another girl/guy.				
20.	I deliberately tried to frighten him/her.				
	He/she deliberately tried to frighten me.				
		Never	Seldom	Sometimes	Often
21.	I ridiculed or made fun of him/her/her in front of others.				
	He/she ridiculed or made fun of me in front of others.				
22.	I slapped him/her or pulled his/her hair.				
	He/she slapped me or pulled my hair.				
23.	I threatened to hurt him/her.				
	He/she threatened to hurt me.				
24.	I threatened to end the relationship.				
	He/she threatened to end the relationship.				
25.	I threatened to hit him/her or throw something at him/her.				
	He/she threatened to hit me or throw something at me.				
		Never	Seldom	Sometimes	Often
27.	I pushed, shoved, or shook him/her				
	He/she pushed, shoved, or shook me.				
28.	I spread rumors about him/her				
	He/she spread rumors about me.				
24.	I threatened him/her with a knife or gun (including waving or pointing a knife).				
	He/she threatened me with a knife or gun (including waving or pointing a knife).				
25.	I choked him/her.				
	He/she choked me.				
26.	I used a knife or fired a gun.				
	He/she used a knife or fired a gun.				
		Never	Seldom	Sometimes	Often
30.	I scratched him/her and/or bent his/her fingers.				
	He/she scratched me and/or bent my fingers.				
31.	I burned him/her.				
	He/she burned me.				
32.	I bit him/her.				
	He/she bit me.				

[following source: Supporting Healthy Marriage Study]

Please indicate how often each of the following statements was true of you in the last month.  Would you say never, sometimes, usually, or always?		Never	Sometimes	Usually	Always
	My {boyfriend/girlfriend} is honest and truthful with me.				
	My {boyfriend/girlfriend} and I are good at working out our differences.				
	When I have a serious disagreement with my {boyfriend/girlfriend}, we discuss it respectfully.				
	My {boyfriend/girlfriend} and I work as a team.				
	I enjoy spending time with my {boyfriend/girlfriend}.				

Conflict Resolution Styles Inventory (Kurdek, 1994)

The following questions refer to times when you and the person you are dating have disagreements. We want you to answer these questions about a dating partner if you have one now or have had one in the last 4 months. But if you do not have a current or recent (in the last 4 months) boyfriend or girlfriend, please think about a close friend, either a boy or a girl.

Please remember that by “dating,” we mean spending time with someone you are seeing or going out with. Examples of this might include hanging out at the mall, in the neighborhood, or at home or going somewhere together like the movies, a game, or a party. It doesn't have to be a formal date or something you planned in advance and it may be with a small group. The term "date" includes both one-time dates and time together as part of long-term relationships.

The person I am thinking about when filling out this questionnaire has these initials: ___________ and was born in this month: ____________. This person is:

 a current or recent (in the last 4 months) boy/girlfriend
(please select if you have dated anyone in the last 4 months)

OR

 a close friend (only if you have not dated anyone in the last 4 months)

Using the scale below, rate how frequently you use each of the styles to deal with arguments or disagreements with the person you are thinking about.

1 2 3 4 5

Never Always

How often do YOU use these styles…		1	2	3	4	5
1.	Launching personal attacks					
2.	Focusing on the problem at hand.					
3.	Remaining silent for long periods of time					
4.	Not being willing to stick up for myself					
5.	Exploding and getting out of control					
6.	Sitting down and discussing differences constructively.					
7.	Reaching a limit, shutting down, and refusing to talk any further.					
8.	Being too compliant.					
9.	Getting carried away and saying things that aren’t meant.					
10.	Finding alternatives that are acceptable to each of us.					
11.	Tuning the other person out.					
12.	Not defending my position.					
13.	Throwing insults and digs.					
14.	Negotiating and compromising.					
15.	Withdrawing, acting distant, and not interested.					
16.	Giving in with little attempt to present my side of the issue.					

Alabama Parenting Questionnaire (APQ; Child Form)

From the list below, choose the adult in your home who is the main person who takes care of you.

 Mom

 Dad

 Grandmother

 Grandfather

 Step-mom

 Step-dad

 Older sister

 Older brother

 Aunt

 Uncle

 Foster mom

 Foster dad

 Other adult

The statements below are about this person who mainly takes care of you. (In the statements, to keep things simple, we call this person you selected above “parent” even though they may have a different relationship to you.)

Please rate each item as to how often it TYPICALLY occurs in your home.		Never	Almost Never	Sometimes	Often	Always
2.	Your parent tells you that you are doing a good job.					
4.	You fail to leave a note or to let your parent know where you are going.					
7.	You stay out in the evening past the time you are supposed to be home.					
8.	You have a boy/girlfriend and your parent doesn’t know it.					
10.	Your parent compliments you when you have done something well.					
11.	Your parent asks you what your plans are for the coming day.					
13.	Your parent praises you for behaving well.					
14.	Your parent does not know the friends you are with.					
15.	Your parent does not know the people you date.					
18.	Your parent talks to you about your friends.					
19.	Your parent talks to you about your boyfriends/girlfriends.					
	Your parent asks you about your day in school.					

28. In a typical week, how many days from 0 - 7 do you eat a meal with your family?

 0

 1-2

 3-4

 5-7

Delinquency Scale (Adapted from Add Health and NLSY97)

The next few questions are about vandalism, violence, and weapons.

In the past 12 months, how often did you:		Never	1 or 2 times	3 or 4 times	5 or more times	Don’t know
1.	deliberately damage property that didn’t belong to you (including painting graffiti or signs)?					
2.	get into a serious physical fight?
3.	run away from home?					
4.	drive a car without its owner’s permission?					
5.	steal something worth more than $50?					
6.	sell marijuana or other drugs?					
7.	steal something worth less than $50?					
8.	get attacked by someone who seemed to want to seriously hurt you?					
9.	attack someone with the idea of seriously hurting them?					

10. Have you ever been initiated into a named gang?

 No

 Yes

 Don’t know

JVQ-R2, Reduced Item Version, Youth Lifetime Form

Now we are going to ask you about some things that might have happened in your life.

1. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?

 0 days

 1 day

 2 or 3 days

 4 or 5 days

 6 or more days

10. At any time in your life, did you SEE a parent get pushed, slapped, hit, punched, or beat up by another parent, or their boyfriend or girlfriend?

 Yes

 No

11. At any time in your life, did you HEAR a parent get pushed, slapped, hit, punched, or beat up by another parent, or their boyfriend or girlfriend?

 Yes

 No

12. At any time in your life, in real life, did you SEE anyone get attacked on purpose with a stick, rock, gun, knife, or other thing that would hurt? Somewhere like: at home, at school, at a store, in a car, on the street, or anywhere else?

 Yes

 No

13. At any time in your life, were you in any place in real life where you could see or hear people being shot, bombs going off, or street riots?

 Yes

 No

{SOURCE: http://www.cdc.gov/healthyyouth/yrbs/pdf/questionnaire/2011_ms_questionnaire.pdf}

The next 4 questions ask about sexual intercourse.

1. Have you ever had sexual intercourse?

 Yes

 No

2. How old were you when you had sexual intercourse for the first time?

 I have never had sexual intercourse

 8 years old or younger

 9 years old

 10 years old

 11 years old

 12 years old

 13 years old or older 8 2011 middle school YRBS

3. With how many people have you ever had sexual intercourse?

 I have never had sexual intercourse

 1 person

 2 people

 3 people

 4 people

 5 people

 6 or more people

4. The last time you had sexual intercourse, did you or your partner use a condom?

 I have never had sexual intercourse

 Yes

 No

{SOURCE: following is question 8 from the ASES }

5. If you did NOT WANT TO have sex, how sure are you that you could keep from having sex?

 Very sure I could keep from having sex

 Sort of sure I could keep from having sex

 Not too sure I could keep from having sex

 I probably couldn’t keep from having sex

School Climate (YRBSS)

1. Is there at least one teacher or other adult in this/her school that you can talk to if you have a problem?

 Yes

 No

 Not sure

	Strongly Agree	Agree	Not Sure	Disagree	Strongly Disagree
2. Do you agree or disagree that your school has clear rules and consequences for behavior?					
3. Do you agree or disagree that harassment and bullying by other students is a problem at your school?					
4. Do you agree or disagree that illegal drugs are a problem at your school?					
5. Do you agree or disagree that violence is a problem at your school?					
6. Do you agree or disagree that students help decide what goes on in your school?					

AAVW Sexual Harassment Survey (new version)

1. In your lifetime, has anyone you know done the following to you IN PERSON?		Never	1-3	4-9	10 or more
a.	Made unwelcome sexual comments, jokes or gestures				
b.	Called you gay or lesbian in a negative way				
c.	Touched you in an unwelcome sexual way				
d.	Showed you sexy or sexual pictures that you didn’t want to see				
e.	Physically intimidated you in a sexual way				
f.	Forced you to do something sexual				

2. In your lifetime, have you done the following to someone else IN PERSON?		Never	1-3	4-9	10 or more
a.	Made unwelcome sexual comments, jokes or gestures				
b.	Called you gay or lesbian in a negative way				
c.	Touched you in an unwelcome sexual way				
d.	Showed you sexy or sexual pictures that you didn’t want to see				
e.	Physically intimidated you in a sexual way				
f.	Forced you to do something sexual				

Technology-Based Bullying and Sexual Harassment Perpetration and Victimization

1. In the past 4 months, how often, if at all, did someone do the following things to you?		Never	1-3 times	4-9 times	10 or more times
a.	Someone made a rude or mean comment to me online.				
b.	Someone spread rumors about me online, whether they were true or not.				
c.	Someone made a threatening or aggressive comment to me online.				
d.	Someone tried to get me to talk about sex online when I did not want to.				
e.	Someone online asked me for sexual information about myself when I did not want to tell the person, e.g., really personal questions, like what my body looks like or sexual things I have done.				
f.	Someone asked me to do something sexual when I was online that I did not want to do.				

2. In your lifetime, how often, if at all, did you do the following to others?		Never	1-3 times	4-9 times	10 or more times
a.	Made rude or mean comments to anyone online.				
b.	Spread rumors about someone online, whether they were true or not.				
c.	Made aggressive or threatening comments to anyone online.				
d.	Tried to get someone else to talk about sex online when they did not want to.				
e.
f.	Asked someone to do something sexual online when the other person did not want to do it.				
g.	Sent a text message that said rude or mean things.				
i.	Sent a picture text message that was sexual in any way when that person did not want to receive it.				

Adolescent Substance Involvement (Modified from LONGSCAN)

In the past 4 months, how many times have you...	1 or 2 times	3 to 5 times	6 to 9 times	10 or more times	Never times
Drank beer (more than a sip or taste)?					
Drank wine or wine coolers (more than a sip or taste)?					
Smoked cigarettes?					
Been drunk?					
Drank liquor (like whiskey or gin)?					
Used marijuana or weed (pot, hash, reefer)?					
Used inhalants?					
Used other drugs (nonprescription)?					
Used a prescription drug when it was not prescribed for you or that you took only for the experience or feeling it caused?					

Prescribed Dating Abuse Norms

1. These statements are about hitting in situations in which boys and girls are dating. How strongly do you agree or disagree with each statement?

   MARK ONE ANSWER FOR EACH	Strongly agree	Agree somewhat	Disagree somewhat	Strongly disagree
   a.   It is OK for a girl to hit her boyfriend if he did something to make her mad.	3	2	1	0
   b.   It is OK for a girl to hit her boyfriend if he insulted her in front of friends.	3	2	1	0
   c.   Boys sometimes deserve to be hit by the girls they date.	3	2	1	0
   d.   A boy who makes his girlfriend jealous on purpose deserves to be hit.	3	2	1	0
   e.   It is OK for a girl to hit a boy if he hit her first.	3	2	1	0

2. These statements are about hitting in situations in which boys and girls are dating. How strongly do you agree or disagree with each statement?

MARK ONE ANSWER FOR EACH	Strongly agree	Agree somewhat	Disagree somewhat	Strongly disagree
a.   It is OK for a boy to hit his girlfriend if she did something to make him mad.	3	2	1	0
b.   It is OK for a boy to hit his girlfriend if she insulted him in front of friends.	3	2	1	0
c.   Girls sometimes deserve to be hit by the boys they date.	3	2	1	0
d.   A girl who makes her boyfriend jealous on purpose deserves to be hit.	3	2	1	0
e.   It is OK for a boy to hit a girl if she hit him first.	3	2	1	0

 

Awareness of Community Services; Knowledge regarding available resources

1. Are there any services in [INSERT COMMUNITY NAME] for helping teenagers who are victims in abusive and violent dating relationships?

 Yes

 No

 I don’t know

2. Are there any websites or telephone hotlines for helping teenagers who are victims in abusive and violent dating relationships?

 Yes

 No

 I don’t know

Knowledge about TDV

Please indicate whether you think the following statements are true or false.		TRUE	FALSE
1.	Boys are the victims of dating abuse about as often as girls.		
2.	I can name at least two S.A.F.E. skills that help me communicate in a healthy way in my relationships.		
3.	The majority of teens in abusive dating relationships have witnessed abuse between their parents.		
4.	Dating violence only affects students in high school and college.		
5.	Most teen rapes are by someone the teen does not know.		
6.	Dating violence refers to only those behaviors that cause physical injury (e.g., bruises, cuts).		
7.	I can name at least three local or national organizations/resources that can help teens who are in unhealthy or unsafe relationships.		

Gender Roles/Stereotypes

1. How strongly do you agree or disagree with the following statements? Please choose one answer for each line.
	strongly agree	agree somewhat	disagree somewhat	strongly disagree
a. Most girls/women can’t be trusted.				
b. In a dating relationship the boy should be smarter than the girl.				
c. Girls are always trying to manipulate boys.				
d. In a dating relationship, the boy and girl should have about equal power.				
e. Swearing is worse for a girl than for a boy.				
On a date, the boy should be expected to pay all expenses.				
g. In general, the father should have greater authority than the mother in making family decisions.				
h. It is all right for a girl to ask a boy out on a date.				
It is more important for boys than girls to do well in school.				
j. If both husband and wife have jobs, the husband should do a share of the housework, such as washing dishes and doing the laundry.				
k. Girls should have the same freedom as boys.				

Illinois Bully Scale (Modified)

For each of the following questions, choose how many times you did this activity or how many times these things happened to you in the LAST 30 DAYS.

In the past 12 months, how often did you:		Never	1 or 2 times	3 or 4 times	5 or more times
1.	I upset other students for the fun of it.				
2.	In a group I teased other students.				
4.	Other students made fun of me.				
5.	Other students called me names.				
7.	I helped harass other students.				
10.	I spread rumors about other students.				
11.	I started (instigated) arguments or conflicts.				
13.	I excluded other students from my clique of friends.				

Stalking (Modified from NSVISS)

Has someone you were dating, or used to date, ever…..		No	Yes
1.	Repeatedly followed, harassed, and contacted you when you didn’t want to be (and in a way that felt uncomfortable, scary or threatening to you)?		
2.	Made unwanted phone calls or left you voice messages (hang-ups, text, voicemails) AND/OR Sent you unwanted emails, instant messages, or messages through websites like Facebook & MySpace?		

Have you ever done the following to someone you were dating or used to date…		No	Yes
1.	Repeatedly followed, harassed, and contacted them when they didn’t want to be (and in a way that felt uncomfortable, scary or threatening to them)?		
2.	Made unwanted phone calls or left them voice messages (hang-ups, text, voicemails) AND/OR Sent them unwanted emails, instant messages, or messages through websites like Facebook & MySpace?		

Communications Campaign Awareness

1. Have you seen, read, or heard about any campaigns (on Facebook, in your school, advertisements, [insert other descriptive vehicles to help students understand the term campaign]) that talk about or focus on young people and healthy dating relationships?

 Yes

 No

 Not sure

2. Have you heard of [CAMPAIGN NAME]?

 Yes

 No

 Not sure

3. Which of the following is the [CAMPAIGN NAME] slogan?

 Being bullied? Use your voice. Be heard.

 XX.

 Think it’s important? Say so.

 I don’t know

4. Which of the following have you seen or heard about?

 [CAMPAIGN NAME] Brand Ambassadors

 [CAMPAIGN NAME] Facebook Page

 [CAMPAIGN NAME] Healthy Relationships Texts

 [CAMPAIGN NAME] posters, flyers, or postcards

 I haven’t seen or heard about any of these.

5. Have you participated in any [CAMPAIGN NAME] activities?

 Yes

 No

5a. If yes, which ones? (Select all that apply.)

 [CAMPAIGN NAME] event

 Read or posted on the [CAMPAIGN NAME] facebook page

 Received an [CAMPAIGN NAME] relationship text

 Received an [CAMPAIGN NAME] poster, flyer or post card

 Talked with an [CAMPAIGN NAME] brand ambassador

 Other activity ( )

 Other activity ( )