Program Participants (girl and female adolescents)

Prevention Education Pre-test Survey for Girls (12-17)– Part 1

We are asking you to complete this survey because you are a participant in a program for girls. This survey asks your thoughts, your behaviors and knowledge about health. Your responses will be combined with the responses of other girls to help us learn whether programs like the one that you are in help girls.

Please answer these questions based on what you think and feel, as honestly as possible. Your information will help us learn what parts of the program work best for girls and what can be done better.

Your answers will be kept private. Do not write your name anywhere on the survey. You will be asked to create a special code that you will use on all surveys. GEARS, Inc is the company that will handle all of the surveys. Your answers are private to the extent permitted by law. Also, completing this survey is completely voluntary which means that you can choose whether or not you want to fill out the survey. You can also choose not to answer any question on the survey. Choosing not to fill out the survey or answer a question will not affect your participation in the program. Thank you again.

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 0990-0360. The time required to complete this information collection is estimated to average 2 hours per respondent, 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/OIRM/PRA

200 Independence Ave., S.W. Suite 531-H

Washington, D.C. 20201

Attention: PRA Reports Clearance Officer

ID#: ­---- ---- ---- ---- ---- ---- ----
DATE: ­­____________________
Section I – About You!
INSTRUCTIONS: Check the box  next to your answer.
1.	How old are you now? I am _______ years old. What year were you born? _______________
2.	Is at least one of your parents Hispanic or Latino?  Yes  No
3.	Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
4.	Race: (You can choose more than one category.)  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White
5.	What language do your parents or other people who are raising you speak?  Only or mostly English  Only or mostly a language other than English  English and another language the same amount
6.	What languages do you speak where you live now?  Only or mostly English  Only or mostly a language other than English  English and another language about the same amount
7.	Where do you live now?  Home with parents  Foster home  Boarding school  With family members who are not my parents (aunt, uncle, grandparents, cousins)  A shelter with my family  Other (Specify) __________________
8.	Have you moved in the past 6 months?  Yes, I have moved but I’m in the same neighborhood  Yes, I have moved to a new neighborhood  No, I have not moved
9.	In general, is there an adult that you can talk to?  Yes  No
10.	How often do you talk to an adult about what you are doing or thinking?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
11.	How often do you do chores (cleaning, laundry, baby sitting, cooking)?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
12.	How often do you watch TV on school days?  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day  I do not watch TV
13.	How often do you spend time on the internet for non educational activities on school days?  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day  I do not spend time on the internet
14.	How often do you spend time texting or talking on the phone for non educational activities on school days?  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day  I do not spend time on the phone
15.	How often do you participate in activities involving members of your own racial or cultural group?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
16.	How often do you take lessons or classes out of school, including this after school program?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
17.	Last summer how often did you go to a summer program for learning or fun?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
18.	How often do you do volunteer work?  Almost every day  Once or twice a week  A few times a month  A few times a year  Never
19.	Do you consider yourself a religious or spiritual person?  Yes  No
20.	How often are you supervised or monitored by an adult?  Almost always  Often  Sometimes  Seldom (almost never)  Never
21.	When was the last time you were enrolled in school?  Still in school now  Within the last six months  Within the last year  Within the last two years  More than two years ago
22.	What is the highest grade you have completed?  3rd  10th  4th  11th  5th  12th  6th  GED  7th  Vocational or trade school  8th  Not in school  9th
23.	How interesting are most of your school subjects to you?  Very interesting  Quite interesting  Fairly interesting  Slightly boring  Very boring
24.	How important do you think things you are learning in school are going to be for you later in life?  Very important  Quite important  Fairly important  Slightly important  Not at all important
25.	Now thinking back over the past year in school, how often did you enjoy being in school?  Almost always  Often  Sometimes  Seldom (almost never)  Never
26.	Now thinking back over the past year in school, how often did you try to do your best in school?  Almost always  Often  Sometimes  Seldom (almost never)  Never
27.	During the last month, how many whole days of school have you missed because of illness?  None  1 day  2 days  3 days  4 to 5 days  6 to 10 days  11 or more days  Not in school last month
28.	During the last month, how many whole days of school have you missed because you skipped or cut? (To miss school means you did not attend all your classes and you have unexcused absences.)  None  1 day  2 days  3 days  4 to 5 days  6 to 10 days  11 or more days  Not in school last month
29.	During the last month, how many whole days of school have you missed for other reasons?  None  1 day  2 days  3 days  4 to 5 days  6 to 10 days  11 or more days  Not in school last month
30.	Putting all your grades together, what were your grades like last year?  Mostly As  Mostly Bs  Mostly Cs  Mostly Ds  Mostly Fs
31.	Do you have a full-time or a part-time job for pay?  No, I don’t have a job  Yes, full-time job (30 hours or more)  Yes, part-time job
32.	For how many months have you had this job?  I don’t have a job  1 month or less  2 to 6 months  7 to 12 months  More than 12 months

About Your Neighborhood.

For each statement, please circle “True” (T) or “False” (F).

1.	Within walking distance of my house, there is a park or playground where I like to walk and enjoy myself, playing sports or games.	T	F
2.	There are plenty of safe places to walk or play outdoors in my neighborhood.	T	F
3.	Every few weeks, some kid in my neighborhood gets beat-up, jumped or robbed.	T	F
4.	Every few weeks, some adult gets beat-up, jumped or robbed in my neighborhood.	T	F
5.	In my neighborhood, I see signs of racism and prejudice at least once a week.	T	F
6.	I have seen people using or selling drugs in my neighborhood.	T	F
7.	In the morning, or later in the day, I often see drunk people on the street in my neighborhood.	T	F
8.	Most adults in my neighborhood respect the law.	T	F
9.	There are abandoned or boarded up buildings in my neighborhood.	T	F
10.	I feel safe when I walk around my neighborhood by myself.	T	F
11.	The people who live in my neighborhood often damage or steal each other’s property.	T	F
12.	The people who live in my neighborhood always take care of each other and protect each other from crime.	T	F
13.	Almost every day I see homeless people walking or sitting around in my neighborhood.	T	F
14.	In my neighborhood, the people with the most money are the drug dealers.	T	F
15.	In my neighborhood, there are a lot of poor people who don’t have enough money for food and basic needs.	T	F
16.	For many people in my neighborhood, going to church on Sunday or religious days is an important activity.	T	F
17.	The people in my neighborhood are the best people in the world.	T	F
18.	There are gangs in my neighborhood.	T	F
19.	Gang members are troublemakers.	T	F
20.	I have friends that are gang members.	T	F
21.	There are gang members in my school.	T	F
22.	I would like to be a gang member.	T	F
23.	I am a gang member.	T	F
24.	If you are a gang member, when did you join the gang? I joined the gang in ____________________(Month/Year)

How You Solve Problems

The following questions ask about how often you respond when you have a problem. For each statement check the response that best describes how often you solve problems in this way.

When I have a problem:

		All the time	Most of the time	Some of the time	Almost never	Never
1.	I think about the different things I could do before I do anything.	.	.	.	.	.
2.	I think about the different ways of solving the problem and what good or bad things could happen.	.	.	.	.	.
	When I have a problem:	All the time	Most of the time	Some of the time	Almost never	Never
3.	I get information I need to deal with the problem.	.	.	.	.	.
4.	I compromise (meet halfway or work it out) to get something positive from the situation.	.	.	.	.	.
5.	I think about which of the different ways that I could solve the problem is really the best way.	.	.	.	.	.
6.	I try to listen to the other person, even if I do not agree with him or her.	.	.	.	.	.
7.	I take steps to solve the problem instead of complaining about it to everyone else.	.	.	.	.	.
8.	I give into the other person without giving an opinion.	.	.	.	.	.
9.	I tell the other person what I think no matter how they feel.	.	.	.	.	.
10.	I usually wait until the problem goes away by itself, instead of trying to solve it.	.	.	.	.	.
11.	I like to get everything out in the open so that the problem can be solved as quickly as possible.	.	.	.	.	.

More About You!

For each statement, please circle “Strongly agree” (SA), “Agree” (A), “Neither agree nor disagree” (ND), “Disagree” (DA), or “Strongly disagree” (SDA).

1.	I would tell a friend I think she looks nice, even if I think she shouldn’t go out of the house dressed like that.	SA	A	ND	DA	SDA
2.	I worry that I make others feel bad if I am successful.	SA	A	ND	DA	SDA
3.	I would not change the way I do things in order to please someone else.	SA	A	ND	DA	SDA
4.	I tell my friends what I honestly think even when it is an unpopular idea.	SA	A	ND	DA	SDA
5.	Often I look happy on the outside in order to please others, even if I don’t feel happy on the inside.	SA	A	ND	DA	SDA
6.	I wish I could say what I feel more often than I do.	SA	A	ND	DA	SDA
7.	I feel like it’s my fault when I have disagreements with my friends.	SA	A	ND	DA	SDA
8.	When my friends ignore my feelings, I think that my feelings weren’t very important anyway.	SA	A	ND	DA	SDA
9.	I usually tell my friends when they hurt my feelings.	SA	A	ND	DA	SDA
10.	The way that I can tell that I am a good weight is when I fit into a small size.	SA	A	ND	DA	SDA
11.	I often wish my body were different.	SA	A	ND	DA	SDA
12.	I think that a girl has to be thin to be beautiful.	SA	A	ND	DA	SDA
13.	I think that a girl has to have a light complexion and long hair to be thought of as beautiful.	SA	A	ND	DA	SDA
14.	I am more concerned about how my body looks than how my body feels.	SA	A	ND	DA	SDA
15.	I often feel uncomfortable in my body.	SA	A	ND	DA	SDA
16.	There are times when I have really good feelings in my body.	SA	A	ND	DA	SDA
17.	The way I decide I am at a good weight is when I feel healthy.	SA	A	ND	DA	SDA
18.	On the Whole, I am satisfied with myself.	SA	A	ND	DA	SDA
19.	At times, I think I am no good at all.	SA	A	ND	DA	SDA
20.	I feel that I have a number of good qualities.	SA	A	ND	DA	SDA
21.	I am able to do things as well as most other people.	SA	A	ND	DA	SDA
22.	I feel I do not have much to be proud of.	SA	A	ND	DA	SDA
23.	I certainly feel useless at times.	SA	A	ND	DA	SDA
24.	I feel that I’m a person of worth, at least on an equal plane with others.	SA	A	ND	DA	SDA
25.	I wish I could have more respect for myself.	SA	A	ND	DA	SDA
26.	All in all, I am inclined to feel that I am a failure.	SA	A	ND	DA	SDA
27.	I take a positive attitude toward myself.	SA	A	ND	DA	SDA

Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week.

	During the past week…
		Not At All	A Little	Some	A Lot
1.	I was bothered by things that usually don’t bother me.	.	.	.	.
2.	I did not feel like eating; my appetite was poor.	.	.	.	.
3.	I felt that I could not shake off the blues even with help from my family or friends.	.	.	.	.
4.	I felt I was just as good as other people.	.	.	.	.
5.	I had trouble keeping my mind on what I was doing.	.	.	.	.
6.	I felt depressed.	.	.	.	.
7.	I felt that everything I did was an effort.	.	.	.	.
8.	I felt hopeful about the future.	.	.	.	.
9.	I thought my life had been a failure.	.	.	.	.
10.	I felt fearful.	.	.	.	.
11.	My sleep was restless.	.	.	.	.
12.	I was happy.	.	.	.	.
13.	I talked less than usual.	.	.	.	.
14.	I felt lonely.	.	.	.	.
15.	People were unfriendly.	.	.	.	.
16.	I enjoyed life.	.	.	.	.
17.	I had crying spells.	.	.	.	.
18.	I felt sad.	.	.	.	.
19.	I felt that people disliked me.	.	.	.	.
20.	I could not get “going”.	.	.	.	.

For each statement, please circle “Strongly agree” (SA), “Agree” (A), “Neither agree nor disagree” (ND), “Disagree” (DA), or “Strongly disagree” (SDA).

1.	I will make sure a condom is used when I have sex.	SA	A	ND	DA	SDA
2.	I will only have one sexual relationship at a time.	SA	A	ND	DA	SDA
3.	I do not plan on having sex until I am married.	SA	A	ND	DA	SDA
4.	I would only have sex with a person who I have a long term relationship with.	SA	A	ND	DA	SDA
5.	I will not have sex with someone who refuses to use a condom.	SA	A	ND	DA	SDA
6.	I do not plan on having sex until I am at least eighteen years old.	SA	A	ND	DA	SDA

ID#: ­---- ---- ---- ---- ---- ---- ----

DATE: ­­____________________

Prevention Education Pre-test Survey for Girls (12-17)– Part 2

Section II – Health Knowledge/What You Know.

For each question or statement, please circle “Yes” (Y) or “No” (N).

1.	Can a person get HIV by sharing a glass of water with someone who has HIV?	Y	N
2.	Does pulling out the penis before a man climaxes (cums) keep a woman from getting HIV during sex?	Y	N
3.	Can a woman get HIV if she has anal sex (penis inside the buttocks) with a man?	Y	N
4.	Will all pregnant women infected with HIV have babies born with HIV?	Y	N
5.	Do all people who have been infected with HIV quickly show serious signs of being infected?	Y	N
6.	Is there a vaccine (shot) that can stop people from getting HIV?	Y	N
7.	Are people likely to get HIV by deep kissing (putting their tongue in their partner’s mouth) if their partner has HIV?	Y	N
8.	Can a woman get HIV if she has sex during her period?	Y	N
9.	Is there a female condom that can help decrease a woman’s chance of getting HIV?	Y	N
10.	Does a natural skin condom work better against HIV than a latex condom?	Y	N
11.	Can a person get HIV if she is taking antibiotics?	Y	N
12.	Will taking a test for HIV one week after having sex tell a person if she or he has HIV?	Y	N
13.	Can a person get HIV by sitting in a hot tub or swimming pool with a person who has HIV?	Y	N
14.	Can a person get HIV by having oral sex (mouth on penis) with a man?	Y	N
15.	Does using Vaseline or baby oil with condoms increase the chance of getting HIV?	Y	N
16.	Are women always tested for HIV during their Pap smears?	Y	N
17.	Does douching after sex keep a woman from getting HIV?	Y	N
18.	Is it possible to get HIV when a person gets a tattoo?	Y	N
19.	Does it take three to six months for the body to make enough antibodies to be found by the HIV antibody test?	Y	N
20.	Is viral load used to measure the amount of HIV in the body?	Y	N
21.	Can the currently available HIV drugs cure people of HIV infection or AIDS?	Y	N
22.	Can drugs and alcohol reduce your ability to practice safe sex?	Y	N
23.	Can sunlight, heat, and friction damage a latex condom?	Y	N
24.	If you are at risk for HIV from sex, are you then also at risk for other sexually transmitted infections?	Y	N
25.	Can HIV infected people who are taking antiretroviral therapy infect others through unprotected sex and needle-sharing?	Y	N
26.	Do sexually transmitted infections (STIs) such as genital herpes, affect a woman’s risk of being infected with HIV?	Y	N
27.	Do girls have double the chance of getting infected with HIV through unprotected heterosexual sex than men?	Y	N
28.	Can people who are already infected with one type of HIV contract another type of HIV?	Y	N
29.	Can a person be infected with HIV for years without having AIDS?	Y	N
30.	Does HIV die outside of the body?	Y	N
31.	Are HIV transmissions in women likely to occur through the vagina and cervix?	Y	N
32.	Is the risk of transmitting HIV from men to women higher because the vagina and the cervix have a much larger surface than the penis?	Y	N
33.	Are Cancroids, Chlamydia, Gonorrhea, and Syphilis caused by bacteria?	Y	N
34.	Can a person, who has engaged in oral sex, be infected with a sexually transmitted infection?	Y	N
35.	Do all sexually transmitted infections have symptoms, especially in females, and can only be detected by a medical test?	Y	N
36.	Once a person has been cured of Gonorrhea, can she/he contract it again?	Y	N
37.	Can Human Papilloma Virus (HPV) be spread by skin-on-skin contact?	Y	N
38.	Are all sexually transmitted infections curable?	Y	N
39.	Should girls always worry about itching around the vagina, sores or smelly discharge from the vagina?	Y	N
40.	Can Pubic lice (“crabs”) and Scabies (two skin diseases) be transmitted by intimate bodily contact of sex?	Y	N
41.	Can cervical cancer, pelvic inflammatory disease, and infertility/pregnancy problems be caused by sexually transmitted infection?	Y	N
42.	Are women at a higher risk than men of getting infected with Gonorrhea?	Y	N

Section III– What do you think?

For each statement, please circle “Strongly disagree” (SDA), “Disagree” (D), “Neither agree nor disagree” (ND), “Agree” (A), or “Strongly agree” (SA).

		Strongly Disagree	Disagree	Neither agree or disagree	Agree	Strongly Agree
1.	I think you are safer, and have protection, if you join a gang.	SDA	D	ND	A	SA
2.	I will probably join a gang.	SDA	D	ND	A	SA
3.	Some of my friends at school belong to gangs.	SDA	D	ND	A	SA
4.	I think it’s cool to be in a gang.	SDA	D	ND	A	SA
5.	My friends would think less of me if I join a gang.	SDA	D	ND	A	SA
6.	I believe it is dangerous to join a gang; you will probably end up getting hurt or killed if you belong to a gang.	SDA	D	ND	A	SA
7.	I think being in a gang makes it more likely that you will get into trouble.	SDA	D	ND	A	SA
8.	Some people in my family belong to a gang, or used to belong to a gang.	SDA	D	ND	A	SA
9.	I belong to a gang.	SDA	D	ND	A	SA
10.	A person angry enough to hit his or her girlfriend must love her very much.	SDA	D	ND	A	SA
11.	Violence between dating partners can improve the relationship.	SDA	D	ND	A	SA
12.	Girls sometimes deserve to be hit by the boys they date.	SDA	D	ND	A	SA
13.	A girl who makes her boyfriend jealous on purpose deserves to be hit.	SDA	D	ND	A	SA
14.	Boys sometimes deserve to be hit by the girls they date.	SDA	D	ND	A	SA
15.	A girl angry enough to hit her boyfriend must love him very much.	SDA	D	ND	A	SA
16.	There are times when violence between dating partners is okay.	SDA	D	ND	A	SA
17.	A boy who makes his girlfriend jealous on purpose deserves to be hit.	SDA	D	ND	A	SA
18.	Sometimes violence is the only way to express your feelings.	SDA	D	ND	A	SA
19.	Some couples must use violence to solve their problems.	SDA	D	ND	A	SA
20.	Violence between dating partners is a personal matter and people should not interfere.	SDA	D	ND	A	SA

Section IV – Your Experiences.

For each statement, please circle how often in the past 3 months you did the following things to solve a problem or conflict with a parent, brother, sister, or friend.

		All the time	Most of the time	Some of the time	Almost never	Never
1.	Discussed an issue calmly.	.	.	.	.	.
2.	Got information to back up your side of things.	.	.	.	.	.
3.	Brought in, or tried to bring in, someone to settle things.	.	.	.	.	.
4.	Insulted or swore at him/her.	.	.	.	.	.
5.	Sulked or refused to talk about an issue.	.	.	.	.	.
6.	Stomped out of the room or house or yard.	.	.	.	.	.
7.	Cried.	.	.	.	.	.
8.	Did or said something to spite him/her.	.	.	.	.	.
9.	Threatened to hit or throw something at him/her.	.	.	.	.	.
10.	Threw or smashed or hit or kicked something.	.	.	.	.	.
11.	Pushed, grabbed or shoved him/her.	.	.	.	.	.
12.	Slapped him/her.	.	.	.	.	.
13.	Kicked, bit, or hit him/her with a fist.	.	.	.	.	.
14.	Hit or tried to hit him/her with something.	.	.	.	.	.
15.	Beat him/her up.	.	.	.	.	.
16.	Choked him/her.	.	.	.	.	.
17.	Threatened him/her with a knife or gun.	.	.	.	.	.
18.	Used a knife or fired a gun.	.	.	.	.	.

Your Behavior.

1.	During the last 30 days, how many times were you in a physical fight?  0 times  1 time  2 or 3 times  4 or 5 times  6 or 7 times  8 or 9 times  10 or 11 times  12 or more times
2.	The last time you were in a physical fight, with whom did you fight?  I have never been in a physical fight  A total stranger  A friend or someone I know  A boyfriend, girlfriend, or date  A parent or another adult family member  Brother(s), sister(s), and/or cousin(s)  Someone not listed above  More than one of the persons listed above
3.	During the last 30 days, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?  0 times  1 time  2 or 3 times  4 or 5 times  6 or more times
4.	During the last 30 days, how many times were you in a physical fight on school property?  0 times  1 time  2 or 3 times  4 of 5 times  6 or 7 times  8 or 9 times  10 or 11 times  12 or more times

In the last 30 days, have you…

1.	Been bullied?	Yes	No
2.	Run away from home?	Yes	No
3.	Skipped classes without an excuse?	Yes	No
4.	Lied about your age to get into someplace or to buy something (for example, lying about your age to get into a movie or to buy alcohol)?	Yes	No
5.	Hitchhiked a ride with a stranger?	Yes	No
6.	Carried a hidden weapon?	Yes	No
7.	Been loud or rowdy in a public place where somebody complained and you got in trouble?	Yes	No
8.	Begged for money or things from strangers?	Yes	No
9.	Made obscene telephone calls, such as calling someone and saying dirty things?	Yes	No
10.	Been drunk in a public place?	Yes	No
11.	Damaged, destroyed or marked up somebody else’s property on purpose?	Yes	No
12.	Set fire on purpose or tried to set fire to a house, building, or car?	Yes	No
13.	Avoided paying for things, like a movie, taking bus rides, using a computer, or anything else (including video games)?	Yes	No
14.	Gone into or tried to go into a building to steal or damage something?	Yes	No
15.	Tried to steal or actually stolen money or things worth $5 or less?	Yes	No
16.	How about between $5 and $50?	Yes	No
17.	How about between $50 and $100?	Yes	No
18.	How about over $100?	Yes	No
19.	Shoplifted or taken something from a store on purpose (including anything you already told me about)?	Yes	No
20.	Stolen someone’s purse or wallet or picked someone’s pocket?	Yes	No
21.	Stolen something from a car that did not belong to you?	Yes	No
22.	Tried to buy or sell things that were stolen?	Yes	No
23.	Taken a car or motorcycle for a ride without the owner’s permission?	Yes	No
24.	Stolen or tried to steal a car or other motor vehicle?	Yes	No
25.	Forged a check or used fake money to pay for something?	Yes	No
26.	Used or tried to use a credit card, bank card, or automatic teller card without permission?	Yes	No
27.	Tried to cheat someone by selling them something that was not what you said it was or that was worthless?	Yes	No
28.	Attacked someone with a weapon with the idea of seriously hurting or killing them?	Yes	No
29.	Hit someone with the idea of hurting them.	Yes	No
30.	Been involved in gang or posse (group) fights?	Yes	No
31.	Thrown objects such as rocks or bottles at people (other than what you have already mentioned)?	Yes	No
32.	Used a weapon of force to make someone give you money or things?	Yes	No
33.	Been paid for having sexual relations with someone?	Yes	No
34.	Physically hurt or threatened to hurt someone to get them to have sex with you?	Yes	No
35.	Had or tried to have sexual relations with someone against their will (other than what you have already mentioned)?	Yes	No
36.	Sold marijuana, reefer or pot?	Yes	No
37.	Sold hard drugs such as crack, heroin, cocaine, LSD or acid?	Yes	No

In the last 30 days…

Have you been on a date (that is, hung out, chilled or kicked it) with someone you like more than as a friend? (If NO, please skip questions #1-20)  Yes  No
How many times has someone you liked more than as a friend done the following to you while you were hanging out, chillin’, or kicking it together alone? Only include it when the other person did it to you first. In other words, don’t count it if they did it to you in self-defense. Please circle one number on each line.
		Never	1 to 3 times	4 to 9 times	10 or more times
1.	Scratched me.	0	1	2	3
2.	Slapped me.	0	1	2	3
3.	Physically twisted my arm.	0	1	2	3
4.	Slammed me or held me against a wall.	0	1	2	3
5.	Kicked me.	0	1	2	3
6.	Bent my fingers.	0	1	2	3
7.	Bit me.	0	1	2	3
8.	Tried to choke me.	0	1	2	3
9.	Pushed, grabbed, or shoved me.	0	1	2	3
10.	Dumped me out of a car.	0	1	2	3
11.	Threw something at me that hit me.	0	1	2	3
12.	Forced me to have sex.	0	1	2	3
		Never	1 to 3 times	4 to 9 times	10 or more times
13.	Forced me to do other sexual things that I did not want to do.	0	1	2	3
14.	Burned me.	0	1	2	3
15.	Hit me with a fist.	0	1	2	3
16.	Hit me with something hard besides a fist.	0	1	2	3
17.	Beat me up.	0	1	2	3
18.	Assaulted me with a knife or gun.	0	1	2	3
19.	Said mean or hurtful things that made me feel bad about myself.	0	1	2	3
20.	Yelled or screamed at me.	0	1	2	3

Check the box  that best describes how often you do this.

		All of the time	Most of the time	Some of the time	Almost Never	Never
1.	Some kids tell lies about a classmate so that the other kids won’t like the classmate anymore. How often do you do this?	.	.	.	.	.
2.	Some kids try to keep certain people from being in their group when it is time to play or do an activity. How often do you do this?	.	.	.	.	.
3.	When they are mad at someone, some kids get back at the person by not letting the person be in their group anymore. How often do you do this?	.	.	.	.	.
4.	Some kids tell their friends that they will stop liking them unless the friends do what they say. How often do you tell friends this?	.	.	.	.	.
5.	Some kids try to keep others from liking a classmate by saying mean things about the classmate. How often do you do this?	.	.	.	.	.

More About Your Behavior.

The next few questions will ask about your sexual experiences. Sex is oral sex (mouth on penis or vagina), vaginal sex (penis in vagina), and anal sex (penis in butt).

1.	Have you ever had sex?  Yes  No
2	The first time sex happened (Check the best one)  You wanted to have sex  You did it to belong to a gang  You did it to please someone you liked  You were pressured, forced or/and frightened by someone into having sex
3.	If you were pressured, forced, or/and frightened into doing something sexual you did not want, what relation to you was the person responsible for this? Check all that apply.  I was never forced to have sex or do something sexual  A friend , boyfriend, or girlfriend  Friend of the family  Relative (uncle, aunt, brother, cousin, grandfather, grandmother)  Biological or Adoptive father  Biological or Adoptive mother  Step or Foster father  Step or Foster mother  Mom’s boyfriend  Mom’s girlfriend  Stranger  Other(specify)_____________  Prefer not to answer
4.	How old were you when you first had sex or the first time sex happened? I was ______ years old when I first had sex?  I have never had oral, vaginal or anal sex
5.	Have you ever had: (Check all that apply)  Oral Sex (mouth on penis or vagina)  Vaginal Sex (penis in vagina)  Anal Sex (penis in butt)  I have never had oral, vaginal or anal sex
6.	How old were you when you first: Gave Oral Sex? I was _____ years old Received Oral Sex? I was _____ years old Had Vaginal Sex? I was _____ years old Had Anal Sex? I was _____ years old  I have never had oral, vaginal, or anal sex
7.	About how old was your sexual partner when you first: Gave Oral Sex? My partner was _____ years old Received Oral Sex? My partner was _____ years old Vaginal Sex? My partner was _____ years old Anal Sex? My partner was _____ years old  I have never had oral, vaginal, or anal sex
8.	How many sexual partners have you had? I have had _______ sexual partners.
9.	When you have sex, you have sex with: (Check One)  Boys  Girls  Both  Neither – I have never had oral, vaginal, or anal sex.
10.	Have you had sex in the last 30 days?  Yes  No
11.	In the last 30 days, how often did you use condoms when you had sex?  All the time  Almost all the time  Sometimes  Almost never  I did not have oral, vaginal, or anal sex in the last 30 days
12.	How would you describe yourself? (Select all that apply)  Straight/Heterosexual  Gay/Lesbian/Homosexual  Bisexual (I have sex with both boys and girls)  Transgendered  Unsure/Bi-curious  Other (Specify) _____________
13.	For you, how long is a long-term relationship? A long-term relationship is _________ months.

Your Experience: Alcohol, Tobacco, and Other Drugs

Mark the box that applies to you and/or fill out the blank.

1.	How old were you the first time you smoked a cigarette, even one or two puffs?  The first time I smoked a cigarette, I was _______ years old.  I have never smoked a cigarette in my life.
2.	How old were you the first time you had a drink of any alcoholic beverage? (Do not include sips from another person’s drink.)  The first time I drank an alcoholic beverage, I was _______ years old.  I have never drunk an alcoholic beverage in my life.
3.	How old were you the first time you used marijuana or hashish, even if it was one or two puffs?  The first time I used marijuana or hashish, I was _______ years old.  I have never used marijuana or hashish in my life.
4.	How old were you the first time you used cocaine or crack, in any form?  The first time I used “cocaine” or “crack,” I was _______ years old.  I have never used “cocaine” or “crack” in my life.
5.	How old were you the first time you used heroin?  The first time I used heroin, I was _______ years old.  I have never used heroin in my life.
6.	How old were you the first time you used LSD, PCP, or any other hallucinogen?  The first time I used a hallucinogen, I was _______ years old.  I have never used a hallucinogen in my life.
7.	How old were you the first time you used any inhalant for kicks or to get high?  The first time I used an inhalant for kicks or to get high, I was _______ years old.  I have never used any inhalant for kicks or to get high in my life.
8.	How old were you the first time you used needles to inject drugs?  The first time I used needles to inject drugs, I was _______ years old.  I have never used needles to inject drugs.

Your Behavior: Alcohol, Tobacco, and Other Drugs

1.	How many cigarettes have you smoked during the last 30 days?  Not at all  Less than one cigarette per day  One to five cigarettes per day  About one-half pack per day  About one pack per days  About one and one-half packs per day  Two packs or more per day
2.	How often have you taken smokeless tobacco during the last 30 days?  Not at all  Once or twice  Once to twice per week  Three to five times per week  About once a day  More than once a day
3.	To be more precise, during the last 30 days about how many cigarettes have you smoked per day?  None  Less than 1 per day  1 to 2  3 to 7  8 to 12  13 to 17  18 to 22  23 to 27  28 to 32  33 to 37  38 or more
4.	How many times during the last 30 days have you had alcoholic beverages to drink (more than just a few sips)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
5.	How many times during the last 30 days (if any) have you been drunk or very high from drinking alcoholic beverages? (if you choose “0 times” go to Question #7)  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
6.	How many drinks do you drink at one time?  0 drinks  1 drinks  2 drinks  3 drinks  4 or more
7.	How many times during the last 30 days (if any) have you used marijuana (grass, pot, blunt) or hashish (hash, hash oil)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
8.	During the last 30 days, about how many marijuana cigarettes (joints, reefers), or the equivalent, did you smoke a day, on the average? (If you shared them with other people, count only the amount YOU smoked.)  None  Less than 1 a day  1 a day  2-3 a day  4-6 a day  7-10 a day  11 or more a day
9.	How many times during the last 30 days (if any) have you sniffed glue, or breathed the contents of aerosol spray cans, or inhaled any other gases or sprays in order to get high?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
10.	How many times (if any) during the last 30 days have you taken LSD (“acid”)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
	Amphetamines are sometimes called: uppers, ups, speed, bennies, dexies, pep pills, diet pills, meth or crystal meth. They include the following drugs: Benzedrine, Dexedrine, Methedrine, Ritalin, Preludin, Dexamyl, and Methamphetamine.
11.	How many times (if any) during the last 30 days have you taken amphetamines on your own – that is, without a doctor telling you to take them?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
12.	How many times (if any) during the last 30 days have you taken “crack” (cocaine in chunk or rock form)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
13.	How many times (if any) during the last 30 days have you taken cocaine in any other form (like cocaine powder)?  0 times  1-2 times  3-5 times  6-9 times  10-19 times  20-39 times  40 or more times
14.	During the last 30 days have you used needles to inject drugs?  Yes  No
	What are you most looking forward to in the program? CHECK YOUR TOP 3 CHOICES  Field trips  Building friendships with other girls.  Learning about my body  Learning how to make good choices for myself  For a new beginning in life  One-on-one time with a caring adult  Feeling better about myself  Having a safe place to go to  Being able to express my feelings  Other (Specify)­­­­­­­­­­­­­­­_________________________

Thank you for your participation!

Developed by GEARS, Inc. Page 30 of 30