Grantee program staff

Instrument 1

Perceived impact questions

New data collection for Tier 1 A/B grantees. Demographic questions have previously been approved by OMB #0970-0360, perceived impact questions are new.

Date ______/_______/______

Demographic Questions

1. In what month and year were you born?

MARK (X) ONE Month and One Year

• January  2002

• February  2001

• March  2000

• April  1999

• May  1998

• June  1997

• July  1996

• August  1995

• September  1994

• October  1993

• November  1992

• December  1991

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-XXXX . The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, 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.

2. What grade are you in? (If you are currently on vacation between grades, please indicate the grade you will be in when you go back to school).   

MARK (X) ONE ANSWER

• 6^th

• 7^th

• 8^th

• 9^th

• 10^th

• 11^th

• 12^th

• Ungraded

• College/Technical school

• Not currently in school

2. Are you male or female?

MARK (X) ONE ANSWER

• Male

• Female

2. Are you Hispanic or Latino?

MARK (X) ONE ANSWER

• Yes

• No

2. 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 (please specify):___________________________

2. When you are at home or with your family, what language or languages do you usually speak?

YOU MAY MARK (X) MORE THAN ONE ANSWER

• English

• Spanish

• Chinese language such as Mandarin or Cantonese

• Some other language: _________________________

Perceived Impact of Program

For the next few questions, please think about [NAME OF PROGRAM] and how it may have influenced you. You may not have thought about these situations before, but please still answer the questions. Think about what you would do and answer as best you can.

1. Would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to have sexual intercourse in the next year?

• Much more likely

• More likely

• About the same

• Less likely

• Much less likely

2. Would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to abstain (abstain means choose not to have sex) from sexual intercourse in the next year?

• Much more likely

• More likely

• About the same

• Less likely

• Much less likely

3. If you were to have sexual intercourse in the next year, would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to use any of these methods of birth control?

• Condoms

• Birth control pills

• The shot (Depo Provera)

• The patch

• The ring (NuvaRing)

• IUD (Mirena or Paragard)

• Implant (Implanon)

• Much more likely

• More likely

• About the same

• Less likely

• Much less likely

4. If you were to have sexual intercourse in the next year, would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to use a condom?

• Much more likely

• More likely

• About the same

• Less likely

• Much less likely