Children Hopital of Los Angeles/Project AIM

ATTACHMENT C
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
FOLLOW- UP INSTRUMENT: CHILDREN’S HOSPITAL LOS ANGELES (CHLA)

The CHLA survey instrument is for adolescent mothers and therefore 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
CHLA
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

GENERAL INSTRUCTIONS
1.

PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED! USE A PEN OR PENCIL.
PLEASE READ EACH QUESTION CAREFULLY. There are different ways to answer the questions in this
survey. It is important that you follow the instructions when answering each kind of question. Here are some
examples.
EXAMPLE 1: MARK (X) ONE ANSWER
What is the color of your eyes?
MARK (X) ONE
X

Brown
Blue
Green

If the color of your eyes is brown, you would mark (X)
the first box as shown.

Another color
2.

EXAMPLE 2: MARK (X) ONE ANSWER and FILL IN THE BLANK
What is the color of your hair?
MARK (X) ONE

Brown
Black

If the color of your hair is purple, you would mark (X)
the last box and write the word “purple” in the blank as
shown. BE SURE TO WRITE CLEARLY.

Blond
Red
X

3.

Some other color PRINT OTHER COLOR

purple

EXAMPLE 3: YOU MAY MARK (X) MORE THAN ONE ANSWER
Do you plan to do any of the following next week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X

Rent a movie

X

Go to a baseball game

If you plan to rent a movie and go to a baseball game
next week, you would mark (X) both boxes.

Study at a friend’s house

PPA Study –Follow-Up – CHLA – 2/9/12

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4.

EXAMPLE 5: FILL IN THE NUMBER
In the last seven (7) days, how many chocolate bars have you eaten?
0

2

NUMBER OF CHOCOLATE BARS – Your best guess is fine.
Fill in the boxes with the correct number. For any number less than 10, put a
zero (0) in the first box. For example, if you had eaten 2 chocolate bars in the
last 7 days, you would write “0” in the first box and “2” in the second box. If
you had eaten 15 chocolate bars, you would write “1” in the first box and “5”
in the second box.

5.

EXAMPLE 6: MARK (X) ONE ANSWER FOR EACH QUESTION
In the last 12 months, have you done any of the following?
MARK (X) ONE FOR EACH QUESTION

a.
b.
c.
d.
e.
f.

YES
NO
Walked a dog on a leash ............................................................................................................................ X
Played Frisbee ............................................................................................................................................ X
X
Weeded a garden .......................................................................................................................................
Eaten a piece of fresh fruit.......................................................................................................................... X
X
Played a piano ............................................................................................................................................
X
Watched a movie ........................................................................................................................................
Mark (x) either “yes” or “no” for each of the six (6) questions
(a–f) by marking (x) one of the of two boxes in each row.

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6.

EXAMPLE 7: MARK (X) ONE MONTH AND ONE YEAR
In what month and year did you finish elementary school?
MARK (X) ONE MONTH AND ONE YEAR

Month finished

Year finished

January
February

X

2010
X

2009

March

2008

April

2007

May

2006

June

2005

July

2004

August

2003

September

2002

October

2001

November

2000

December

1999

PPA Study –Follow-Up – CHLA – 2/9/12

If you finished elementary school in
June of 2009, you would mark (X) the
box next to June and mark (X) the box
next to 2009.

3

SECTION 1: YOU AND YOUR BACKGROUND
1.1. In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

Month born

Year born

January

2002

February

2001

March

2000

April

1999

May

1998

June

1997

July

1996

August

1995

September

1994

October

1993

November

1992

December

1991

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1.2. What is the last grade you completed?
MARK (X) ONE

Less than 6th grade
6th
7th
8th

GO TO 1.4

9th
10th
11th
th

GO TO 1.6

12

Completed GED pretest
Completed GED

GO TO 1.4

GO TO 1.6

Some school after high school

1.3. What type of schooling did you complete after high school?
MARK (X) ONE

Some adult education classes
Some technical or vocation school
Some classes at a 2-year college
Some classes at a 4-year college or university

1.4. Did you go back to school or a GED program after having your first baby?
MARK (X) ONE

Yes – I went back to my old high school
Yes – I went back to a different school
Yes – I went back to a GED program
I never stopped school
No, I did not go back

GO TO 1.6

1.5. How old was your baby when you returned to school or your GED program?
NUMBER OF MONTHS OLD

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1.6. What is your current school status?
MARK (X) ONE

Enrolled in public or private middle or high school
Enrolled in a continuation/alternative school or court/community school
Enrolled in adult education classes
Enrolled in technical or vocation school
Enrolled in 2-year college
Enrolled in 4-year college or university
Not currently enrolled in any school or classes

1.7. What is the highest level of education you expect to complete?
MARK (X) ONE

Graduate from high school or obtain a GED
Attend technical or vocational school
Graduate from a 2-year community college (Associate’s degree)
Graduate from a 4-year college (Bachelor’s degree)
Obtain a graduate degree (Masters, PhD, MD, etc.)

1.8. Are you currently working?
MARK (X) ONE

Yes – full-time
Yes – part-time
No – but currently looking for a job
No – and not currently looking for a job

GO TO 1.11

1.9. Do you make enough money in this job to support yourself?
MARK (X) ONE

Yes
No

1.10. Do you plan on staying in this job for the next two years?
MARK (X) ONE

Yes
No

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1.11. Are you…?
MARK (X) ONE

Not currently seeing anyone

GO TO 2.1

Casually dating
Seriously dating
Engaged
Married

1.12. Is this person the father of your first child?
MARK (X) ONE

Yes
No

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SECTION 2: FAMILY
2.1. Now we have some questions about your mother, or the person you think of as your mother.
Is this person…?
MARK (X) ONE

Your biological mother, that is, the woman who gave birth to you
Your stepmother or adoptive mother
Your foster mother
Your grandmother
Your aunt or your older sister
Some other adult (Please specify)
Don’t have a mother or person I think of as my mother

GO TO 2.3

Please answer the questions below about your mother or the person you think of as your mother that
you identified in the previous question.
2.2. How much do you agree with the following statements about your mother or the person you think
of as your mother?
MARK (X) ONE FOR EACH

STRONGLY
DISAGREE

DISAGREE

NEITHER
DISAGREE
NOR
AGREE

AGREE

STRONGLY
AGREE

a. My mother supports me to be a good parent ..................................................................................................
b. My mother’s help with the baby is just
about right .......................................................................................................................................................
c. My mother criticizes the way I take care
of my baby ......................................................................................................................................................
d. My mother gives me too much help
with my baby ...................................................................................................................................................

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The next questions are about where you live and who lives with you.
2.3. Which of the following best describes where you live?
MARK (X) ONE

You live in one home
You live in two or more homes, and go back and forth

GO TO 2.5

GO TO 2.6

You live in a residential program

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

GO TO 2.6

2.4. Who lives with you in your home?
MARK (X) ALL THE PEOPLE WHO LIVE WITH YOU

Your mother, or the person you think of as your mother
Your father, or the person you think of as your father
Any grandmothers
Any grandfathers
Any brothers or sisters
Any aunts, uncles, or other relatives
Your baby
The father of your baby
The parent(s) of the father of your baby
Your current boyfriend/partner who is not the father of your baby
Friends or roommates
You live by yourself

AFTER ANSWERING

PPA Study –Follow-Up – CHLA – 2/9/12

GO TO 2.6

9

2.5

Who lives with you in each of your homes?
MARK (X) ALL THAT APPLY

MAIN HOME

OTHER HOME(S)

Mark (X) all the people who live with you in your MAIN
home

Mark (X) all the people who live with you in your OTHER
home(s)

Your mother, or the person you think of as your mother

Your mother, or the person you think of as your mother

Your father, or the person you think of as your father

Your father, or the person you think of as your father

Any grandmothers

Any grandmothers

Any grandfathers

Any grandfathers

Any brothers or sisters

Any brothers or sisters

Any aunts, uncles, or other relatives

Any aunts, uncles, or other relatives

Your baby

Your baby

The father of your baby

The father of your baby

The parent(s) of the father of your baby

The parent(s) of the father of your baby

Your current boyfriend/partner who is not the father of
your baby

Your current boyfriend/partner who is not the father of
your baby

Friends or roommates

Friends or roommates

You live by yourself

You live by yourself

2.6. How many times have you moved in the past 6 months?
None
NUMBER OF TIMES – Your best guess is fine.

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SECTION 3: SERVICES
3.1. In the past 12 months, have you received any information about the following:
MARK (X) ONE FOR EACH

YES

NO

a. Methods of birth control? .....................................................................................................
b. Where to get birth control? ..................................................................................................

FOR THOSE WHO RECEIVED ANY INFORMATION ABOUT METHODS OF BIRTH CONTROL AND/OR
WHERE TO GET BIRTH CONTROL
3.2. In the past 12 months, did you receive information about…?
MARK (X) ONE FOR EACH

YES

NO

a. Condoms..............................................................................................................................
b. Birth control pills ..................................................................................................................
c. The shot (Depo-Provera) .....................................................................................................
d. The patch .............................................................................................................................
e. The ring (NuvaRing) ............................................................................................................
f.

IUD (Mirena or Paragard) ....................................................................................................

g. Implant (Implanon) ...............................................................................................................

FOR THOSE WHO RECEIVED ANY INFORMATION ABOUT METHODS OF BIRTH CONTROL AND/OR
WHERE TO GET BIRTH CONTROL
3.3. Where did you receive information about birth control?
MARK (X) ALL THAT APPLY

At a hospital
At a clinic from a doctor, nurse or other health professional
At home from a nurse, social worker, or other health care professional
At school in a class
In an after-school program/activity
From a friend
Other (Please specify)

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3.4. What services have you received or what programs have you been involved in over the past
12 months?
MARK (X) ALL THAT APPLY

School or community-based program for pregnant or parenting teens
Parenting education
Case Management
WIC
CalLearn
AFLP
Other (Please specify)

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SECTION 4: BEHAVIORS
4.1. The next questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Now please think about the past 3 months. Have you had sexual intercourse in the past 3 months?
MARK (X) ONE

Yes
GO TO 4.6

No

4.2. In the past 3 months, how many TIMES have you had sexual intercourse?
None

GO TO 4.6

NUMBER OF TIMES – Your best guess is fine.

4.3. In the past 3 months, how many TIMES have you had sexual intercourse without you or your
partner using a condom?
NUMBER OF TIMES – Your best guess is fine.

4.4. 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 you or your
partner using any of these methods of birth control?
None

GO TO 4.6

NUMBER OF TIMES – Your best guess is fine.

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4.5. There are different reasons people give for not using contraception. Please mark ALL of the
reasons that are true for you.
MARK (X) ALL THAT APPLY

I just haven’t gotten around to getting anything yet
I don’t think I can get pregnant right now
My partner doesn’t want me to use contraception
I don’t use it because of the side effects for me or my baby
Other (Please specify)

4.6. Now please think about the past 12 months. Have you had sexual intercourse in the past
12 months?
MARK (X) ONE

Yes
GO TO 4.9

No

4.7. How many DIFFERENT PEOPLE have you had sexual intercourse with, even if only one time, in
the past 12 months?
None

GO TO 4.9

NUMBER OF PEOPLE – Your best guess is fine.

4.8. Thinking about the past 12 months, in which months were you sexually active (had sexual
intercourse)?
MARK (X) ONE FOR EACH

YES

NO

January ................................................................................................................................................
February...............................................................................................................................................
March ...................................................................................................................................................
April ......................................................................................................................................................
May ......................................................................................................................................................
June .....................................................................................................................................................
July.......................................................................................................................................................
August ..................................................................................................................................................
September ...........................................................................................................................................
October ................................................................................................................................................
November ............................................................................................................................................
December ............................................................................................................................................
(NOTE: Relevant months will appear based on baseline date.)

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4.9. Have you used any of the following birth control methods in the past 12 months?
MARK (X) ONE FOR EACH

YES

NO

a. Condom ..................................................................................................................................................
b. Emergency contraception, also known as “Plan B” or “Preven”,
or “morning after pills” .............................................................................................................................
c. Birth control pills ......................................................................................................................................
d. The shot (Depo-Provera) ........................................................................................................................
e. The patch ................................................................................................................................................
f.

The ring (NuvaRing)................................................................................................................................

g. IUD (Mirena or Paragard) .......................................................................................................................
h. Implant (Implanon) ..................................................................................................................................
i.

Foam .......................................................................................................................................................

j.

Sponge ....................................................................................................................................................

k. Female condom ......................................................................................................................................
l.

Withdrawal ..............................................................................................................................................

m. Other (Please specify)

.........................................................................................................................

(NOTE: Specific questions on each method of contraception will only be asked of those who indicate using that method of
contraception in 4.9.)

FOR CONDOM USE
4.10. In which months did you use condoms?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

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4.11. In the months you used a condom, would you say you used a condom with your partner for sexual
intercourse…?
MARK (X) ONE

Every time
Most of the time
About half of the time
Some of the time
None of the time

FOR EMERGENCY CONTRACEPTION USE
4.12. How many different times have you used emergency contraception (Plan B) in the past
12 months?
NUMBER OF TIMES– Your best guess is fine.

FOR BIRTH CONTROL PILLS USE:
4.13. In which months did you use birth control pills?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

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4.14. In general over this time, would you say you took your birth control pills consistently…?
Taking your birth control pills consistently means taking your pills every day. Some types of pills
have a set of 7 different colored pills that do not contain any hormones. Women may opt not to
take these 7 pills only.
MARK (X) ONE

All of the time
Most of the time
Some of the time
None of the time

4.15. During the last month you used birth control pills, how many pills that you were supposed to take
did you miss…?
MARK (X) ONE

None
One

GO TO 4.17

Two or more

4.16. Did you miss two or more pills in a row?
MARK (X) ONE

Yes
No

4.17. Some people try a method and then don’t use it again, or stop using it. What was the reason or
reasons why you stopped using birth control pills?
MARK (X) ALL THAT APPLY

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

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FOR THE SHOT (DEPO-PROVERA) USE
4.18. In which months did you receive the shot (Depo-Provera)?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

4.19. Some people try a method and then don’t use it again, or stop using it. What was the reason or
reasons why you stopped using the shot (Depo-Provera)?
MARK (X) ALL THAT APPLY

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

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FOR THE PATCH (ORTHO-EVRA) USE
4.20. In which months did you use the patch (Ortho-Evra)?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

4.21. In general over this time, would you say you used the patch consistently…?
Using the patch consistently means applying a new patch the same day each week for 3 weeks.
You would not use a patch in week 4 then would resume using the patch on the same day in
week 5.
MARK (X) ONE

All of the time
Most of the time
Some of the time
None of the time

4.22. During the last month you used the patch, were you one or more days late in changing the patch?
MARK (X) ONE

Yes
No

GO TO 4.24

4.23. Please indicate all the weeks that you were late in changing the patch.
MARK (X) ONE

First week
Second week
Third week

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4.24. Some people try a method and then don’t use it again, or stop using it. What was the reason or
reasons why you stopped using the patch (Ortho-Evra)?
MARK (X) ALL THAT APPLY

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

FOR IUD (MIRENA OR PARAGARD) USE
4.25. In which months did you have the IUD (Mirena or Paragard) inserted?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

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4.26. Have you had the IUD removed since then?
MARK (X) ONE

Yes
No

GO TO 4.29

4.27. In which months did you have the IUD (Mirena or Paragard) removed?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

4.28. Did you have the IUD inserted a second time?
MARK (X) ONE

Yes
No

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4.29. Some people try a method and then don’t use it again, or stop using it. What was the reason or
reasons why you stopped using the IUD (Mirena or Paragard)?
MARK (X) ALL THAT APPLY

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

FOR THE RING (NUVARING) USE
4.30. In which months did you use the ring (NuvaRing)?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

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4.31. In general over this time, would you say you used the ring consistently…?
Using the ring consistently means removing the ring on the same day 3 weeks after it was
inserted and inserting a new one on the same day one week after it was removed (even if your
period has not stopped).
MARK (X) ONE

All of the time
Most of the time
Some of the time
None of the time

4.32. Some people try a method and then don’t use it again, or stop using it. What was the reason or
reasons why you stopped using the ring (NuvaRing)?
MARK (X) ALL THAT APPLY

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

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FOR IMPLANT (IMPLANON) USE
4.33. In which months did you have the implant (Implanon) inserted?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

4.34. Have you had it removed since then?
MARK (X) ONE

Yes
No

GO TO 4.36

4.35. In which month did you have the implant removed?
MARK (X) ALL THAT APPLY

January
February
March
April
May
June
July
August
September
October
November
December

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4.36. Some people try a method and then don’t use it again, or stop using it. What was the reason or
reasons why you stopped using the implant (Implanon)?
MARK (X) ALL THAT APPLY

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

4.37. Do you intend to have sexual intercourse in the next year, if you have the chance?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

4.38. If you were to have sexual intercourse in the next year, do you intend to use a condom?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

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4.39. The next question is about your intention to use other methods of birth control, NOT including
condoms:
•
•
•
•
•
•

Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)

If you were to have sexual intercourse in the next year, do you intend to use any of these other
methods of birth control?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

4.40. Which of the following do you plan on using?
MARK (X) ALL THAT APPLY

Oral Contraceptives/birth control pill
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
Other (Please specify)

4.41. The next question is about methods of birth control, NOT including condoms. How strongly do
you agree or disagree that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

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 ..................................................................................................................

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4.42. 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
GO TO 4.45

No

4.43. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.

4.44. Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
oral sex?
GO TO 4.46

None

NUMBER OF TIMES – Your best guess is fine.

4.45. In the past 3 months, how many TIMES did you have oral sex without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

4.46. The next questions are about anal sex. Anal sex is when a male puts his penis in someone else’s
anus, or their butt, or someone lets a male put his penis in their anus or butt.
Have you ever had anal sex?
MARK (X) ONE

Yes
GO TO 4.50

No

4.47. How many DIFFERENT PEOPLE have you ever had anal sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.

4.48. Now please think about the past 3 months. In the past 3 months, how many TIMES did you have
anal sex?
None

GO TO 4.50

NUMBER OF TIMES – Your best guess is fine.

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4.49. In the past 3 months, how many TIMES did you have anal sex without using a condom?
None
NUMBER OF TIMES – Your best guess is fine.

4.50. These next questions ask about sexually transmitted diseases, or STDs. In the past 12 months,
have you been told by a doctor or nurse that you had a sexually transmitted disease (STD)?
MARK (X) ONE

Yes
No

4.51. In the past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION

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 disease (STD) PRINT OTHER STD

PPA Study –Follow-Up – CHLA – 2/9/12

.........................................................

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SECTION 5: PREGNANCY AND RELATIONSHIP WITH BABY’S FATHER
The next questions ask about your pregnancy and your relationship with your baby’s father.
5.1. Are you currently pregnant?
MARK (X) ONE

Yes
GO TO 4.6

No

5.2. When is your baby due?
Month

Year

5.3. When you got pregnant this time, were you trying to get pregnant?
MARK (X) ONE

Yes
No

5.4. What is your relationship with the father of your current pregnancy?
MARK (X) ONE

No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

5.5. To the best of your knowledge, were you pregnant any other time since the birth of your first
child?
MARK (X) ONE

Yes

GO TO 4.7

No

GO TO 4.13

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5.6. To the best of your knowledge, have you been pregnant since the birth of your first child?
MARK (X) ONE

Yes
GO TO 4.13

No

5.7. How many times have you been pregnant since the birth of your first child?
NUMBER OF TIMES – Your best guess is fine.

5.8. Have you given birth since your first child was born?
MARK (X) ONE

Yes
GO TO 4.13

No

5.9. Please list the birth date for each child you have given birth to since your first child.
Month

Day

Year

5.10. When you got pregnant with your youngest child, were you trying to get pregnant?
MARK (X) ONE

Yes
No

5.11. What is your relationship with the father of your youngest child?
MARK (X) ONE

No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

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5.12. Do all of your children have the same biological father?
MARK (X) ONE

Yes
No

5.13. How much is your first child’s father involved in raising that child?
MARK (X) ONE

A lot
A little
Not very much
Not at all

5.14. How likely do you think it is that you will be pregnant again before your child turns two?
MARK (X) ONE

I am sure I will
I probably will
There is a 50/50 chance I will
I probably will not
I am sure I will not

5.15. Ideally, when would you want to get pregnant again?
MARK (X) ONE

Before my baby is 1 year old
When my baby is between 1 and 2 years old
When my baby is between 2 and 3 years old
When my baby is over three years old
I don’t know if I want to get pregnant again
Unsure

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SECTION 6: ATTITUDES
6.1. Please indicate how true each of the following statements are for you, using the numbers 1
through 9, with 1 being NOT AT ALL TRUE and 9 being VERY TRUE.
MARK (X) ONE FOR EACH

NOT AT
ALL
TRUE

1

2

3

4

5

6

7

8

VERY
TRUE

9

a. In general, I am focused on preventing
negative events in my life ..........................................................................................................................................................................
b. I am anxious that I will fall short of my
responsibilities and obligations ..................................................................................................................................................................
c. I frequently imagine how I will
achieve my hopes and aspirations ............................................................................................................................................................
d. I often think about the person I am
afraid I might become in the future ............................................................................................................................................................
e. I often think about the person I
would ideally like to be in the future ...........................................................................................................................................................
f. I typically focus on the success I
hope to achieve in the future .....................................................................................................................................................................
g. I often imagine myself experiencing bad
things that I fear might happen to me ........................................................................................................................................................
h. I frequently think about how I can
prevent failures in my life ...........................................................................................................................................................................
i. I see myself as someone who is
primarily striving to reach my “ideal
self”—to fulfill my hopes, wishes,
and aspirations ..........................................................................................................................................................................................
j. I see myself as someone who is
primarily striving to become the self
I “ought” to be – to fulfill my duties,
responsibilities, and obligations .................................................................................................................................................................
k. In general, I am focused on achieving
positive outcomes in my life .......................................................................................................................................................................
l. I often imagine myself experiencing good
things that I hope will happen to me ..........................................................................................................................................................
m. Getting pregnant before my baby is 2
will lower my chances of getting the
future I want for myself and my family .......................................................................................................................................................
n. Contraception is an important way
that I can be a responsible parent .............................................................................................................................................................
o. Focusing on my education and work
experience now will help me achieve
a successful future .....................................................................................................................................................................................
p. Having another baby too soon may make
it much harder on myself and my family ....................................................................................................................................................
q. I plan to put extra effort into my education
or experience to get a (better) job.........................................................................................................................................................
r. I plan to stop doing things that
interfere with my job preparation ...............................................................................................................................................................

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6.2. For the following statements, indicate to what degree the statement reflects your own thoughts
and feelings using the numbers 1 through 6, with 1 being STRONGLY AGREE and 6 being
STRONGLY DISAGREE. If a statement has more than one part, please indicate your reaction to
the whole statement.
MARK (X) ONE FOR EACH
STRONGLY
AGREE
1

2

3

4

5

STRONGLY
DISAGREE
6

a. I just can’t decide what to do as a parent, there are so
many possibilities ....................................................................................................................................................................................
b. I’ve thought a lot about the kind of mother I want to be,
but there’s no question that I will follow what my “mother”
says to do ...............................................................................................................................................................................................
c. My “mom” tells me how to be a parent to my child, and
that’s what I do ........................................................................................................................................................................................
d. I haven’t really decided what kind of mother I want to be.
I’m just taking it day by day .....................................................................................................................................................................
e. I’m sure it will be pretty easy to change the kind of mother
I am when I’m ready ...............................................................................................................................................................................
f. It took me awhile to figure it out, but now I know for sure
what direction to move in as a parent .....................................................................................................................................................
g. It took me a while to figure it out, but now I know what
kind of mother I want to be .....................................................................................................................................................................
h. I’m still trying to decide how capable I am as a person
and what kind of parenting is right for me ...............................................................................................................................................
i. I just can’t decide what to do for a career. There are so
many possibilities ....................................................................................................................................................................................
j. I might have thought about a lot of different jobs, but
there’s really never been any question since my
parents said what they wanted ...............................................................................................................................................................
k. My parents decided a long time ago what I should go
into for employment and I am following through with
their plans ...............................................................................................................................................................................................
l. It took me a while to figure it out, but now I know for
sure what direction to move in for a career.............................................................................................................................................
m. I’m still trying to decide how capable I am as a person
and what jobs will be right for me ...........................................................................................................................................................
n. It took me a while to figure it out, but now I really know
what I want for a career ..........................................................................................................................................................................
o. When I’m ready, I’m sure it’ll be pretty easy to change
or get the kind of job that’s right for me ..................................................................................................................................................
p. I haven’t chosen the occupation I really want to get
into, and I’m just working at what is available until
something better comes along ................................................................................................................................................................

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6.3. Who will you be in fifteen years? Each of us has some image or picture of what we will be like and
what we want to avoid being like in the future. Think about 15 years from now—imagine what
you’ll be like, and what you’ll be doing.
In the lines below, write what you expect you will be like and what you expect to be doing.
•

In the space next to each expected goal, mark “No” (X) if you are not currently working on that goal or
expectation and mark “Yes” (X) if you are currently doing something to get to that expectation or goal.

•

For each expected goal that you marked “Yes”, use the space to the right to write what you are doing
this year to attain that goal.

EXAMPLE:
In 15 years, I expect to be…

Am I am doing
something now
about this?
No

What I am doing now is…

Yes

(P1)

a cosmetologist

X

(s1) practice hair braiding on my friends and little sister

(P2)

a home owner

X

(s2) getting my GED

1.

In 15 years, I expect to be…

Am I doing
something
to be that
way?
Yes
No

(IF YES) What I am doing now to be that
way in 15 years?

(P1)

(s1)

(P2)

(s2)

(P3)

(s3)

(P4)

(s4)

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6.3a. Was your first or second goal about a job or an occupation?
MARK (X) ONE

Yes
No

GO TO 6.4

6.3b. Thinking of your first occupational goal listed, how much do you hope for the kind of work that
occurs with this occupational goal?
MARK (X) ONE

Barely
Not much
Somewhat
Very much

6.3c. Thinking of your first occupational goal, please indicate how likely it will be that you obtain this
possible self, using the numbers 1 through 7, with 1 being very unlikely and 7 being very likely.
Very unlikely
1

Very likely
2

PPA Study –Follow-Up – CHLA – 2/9/12

3

4

5

6

7

35

6.4. In addition to expectations and expected goals, we all have images or pictures of what we DON’T
want to be like; what we don’t want to do or want to avoid being. First, think a minute about ways
you would not like to be in 15 years—things you are concerned about or want to avoid being like.
•
•

•

Write those concerns or selves to-be-avoided in the lines below.
Next to each concern or to-be-avoided self, mark “No” (X) if you are not currently working on avoiding
that concern or to-be-avoided self and mark “Yes” (X) if you are currently doing something so this will
not happen in 15 years.
For each concern or to-be-avoided self that you marked “Yes”, use the space at the end of each line
to write what you are doing this year to reduce the chances that this will describe you in 15 years.

EXAMPLE:
Next year, I want to avoid…

Am I doing
something to
avoid this?
No

(P5)

Unemployed

(P6)

In debt_____

1.

In 15 years, I want to avoid…

(IF YES) What I am doing now to avoid
being that way next year?

Yes
X

X

Am I doing
something to
avoid this?
Yes
No

(s5) finding out how to get some part time
job experience
(s6) _____________________________
(IF YES) What I am doing now to avoid
being that way in 15 years?

(P5)

(s5)

(P6)

(s6)

(P7)

(s7)

(P8)

(s8)

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6.5. For each sentence, please think about how you are in most situations. Rate each statement in a
way that describes YOU the best using the numbers 0 through 5, with 0 being NONE OF THE
TIME and 5 being ALL OF THE TIME.
MARK (X) ONE FOR EACH

NONE
OF THE
TIME
0

1

2

3

4

ALL OF
THE
TIME
5

a. I can do what it takes to get the specific
work I choose ....................................................................................................................................................
b. I know how to prepare for the kind of work
I want to do .......................................................................................................................................................
c. When I look into the future, I have a clear
picture if what my work life will be like ..............................................................................................................
d. I have a difficult time identifying my own
goals for the next five years ..............................................................................................................................

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