Ohio Health/T.O.P.P.

Form Approved
OMB No. 0990-0382
Exp. Date:

FOLLOW-UP SURVEY

PRIVACY
Thank you for your help with this important study. It will help us understand what things are like
for people your age today. All of the information collected in this survey will be kept private.
Your name will not be on the questionnaire and no unauthorized person will see your answers.
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 42 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

INTRODUCTION
INTERVIEWERS: INSTRUCTIONS TO YOU ARE IN BLUE BOLD CAPS. DO NOT READ TEXT IN
BLUE BOLD CAPS ALOUD.
GET RESPONDENT ON PHONE
Hello. My name is ____________________, and I’m calling from Mathematica Policy Research. Could I
speak with [RESPONDENT’S NAME] please?
RESOLVE ANY QUESTIONS AND ATTEMPT TO GET RESPONDENT ON PHONE OR MAKE
APPOINTMENT TO CALL BACK.
INTRODUCTION WITH RESPONDENT
[Hello. My name is ____________________, and I’m calling from Mathematica Policy Research.]
I’m calling as part of a research study about birth spacing called TOPP that you agreed to participate in at
[RECRUITMENT SITE]. You might remember filling out a survey about 12 months ago. I’m calling to do
the current survey with you, which is very similar. It will ask about you, your perspectives and your
behaviors.
START
Before we begin the survey, I need to tell you that your participation in this study is voluntary, and we want
you to know that:


The answers you give to this survey will never be identified as yours. All of your responses will
be kept private and will not be shared with anyone.



We hope that you will answer all the questions honestly, but you may skip any questions you
do not want to answer.



And, we will send you a $25 gift card after we complete the survey.

Some of the questions we ask could be considered sensitive. Are you somewhere you can freely answer
questions?
Do you have any questions before we begin?
**YOUR RESPONSE TO ANY QUESTIONS ABOUT SURVEY CONTENT SHOULD BE
Just answer the question the best you can.

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SECTION 1: YOU AND YOUR BACKGROUND
1.1. The first questions are about you and your background.
Are you currently enrolled in school or studying school subjects through a program at home,
online or somewhere else?
MARK (X) ONE

Yes
No

1.2. What is the highest grade in school you completed?
MARK (X) ONE

6th grade or lower
7th
8th
9th
10th
11th
12th
GED
A year or more of community college or vocational school
A year or more in a four-year college
Your schooling does not have grade levels
Other

1.3. Now I am going to ask you how likely it is you will do a series of things. Your answer choices are
[READ CHOICES].
How likely is it that you will…
MARK (X) ONE FOR EACH
NOT AT
ALL
LIKELY

A LITTLE
BIT
LIKELY

SOMEWHAT
LIKELY

VERY
LIKELY

YOU
ALREADY
DID

a. Graduate from high school [READ CHOICES] ................................................................................................
b. [REPEAT STEM] Go to a technical or vocational
school after high school [READ CHOICES] .....................................................................................................
c. Go to college .....................................................................................................................................................
d. Graduate from a 2-year or community college program ...................................................................................
e. Graduate from a 4-year college program ..........................................................................................................

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1.4. What is your current marital status – are you currently [READ CHOICES]
MARK (X) ONE

Never married
Married
Divorced
Separated or
Widowed?

1.5. In the past 12 months, how often did you attend religious services or activities? [READ CHOICES]
MARK (X) ONE

Never
Less than once a month
1-3 times per month
Once a week
More than once a week

1.6. How important is religion in your life? [READ CHOICES]
MARK (X) ONE

Not at all important
Somewhat important
Very important

1.7. What is your religion or faith? [READ CHOICES]
MARK (X) ONE

Atheist or Agnostic
Buddhist
Catholic
Christian – Other than Catholic or Orthodox
Orthodox Christian, for example Greek or Russian Orthodox
Hindu
Jewish
Mormon
Muslim
Nothing in particular or
Something else PRINT OTHER RELIGION OR FAITH

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1.8. Now I’m going to ask you questions about the past 12 months. In the past 12 months, have you
received any information or learned about any of the following?
MARK (X) ONE FOR EACH

YES

NO

a. Relationships, dating, marriage, or family life ................................................................................................
b. Abstinence from sex ......................................................................................................................................
c. Methods of birth control .................................................................................................................................
d. Where to get birth control ..............................................................................................................................
e. Sexually transmitted diseases, also known as STDs ....................................................................................
f. How to talk to a partner about whether to have sex or whether to use birth control .....................................
g. How to say no to sex......................................................................................................................................

1.9. INTERVIEWER: DID THE RESPONDENT SAY “YES” TO ANY ITEM IN 1.8 ABOVE?
MARK (X) ONE

Yes
No

GO TO 1.11

1.10. Now I am going to ask you about the number of times you got information on relationships,
abstinence, birth control, or sexually transmitted diseases from a series of places in the past
12 months. Your answer choices are [READ ANSWER CHOICES].
In the past 12 months, how many times did you get information on relationships, abstinence,
birth control, or sexually transmitted diseases from…
MARK (X) ONE FOR EACH

NEVER

1-3 TIMES

4-9 TIMES

10 OR MORE
TIMES

a. A school class [READ CHOICES] ..................................................................................................................
b. [REPEAT STEM] A church, synagogue, mosque, or
religious classes outside of school [READ CHOICES] ..................................................................................
c. A community center, youth organization, or
after-school activity .........................................................................................................................................
d. [REPEAT STEM] A doctor or nurse you saw at a
hospital, clinic, or trailer ..................................................................................................................................
e. A nurse, social worker, or other health care
professional who came to your home .............................................................................................................
f.

A nurse or other provider from the Nurse Family
Partnership or Help Me Grow program who
came to your home .........................................................................................................................................

g. Your friends .....................................................................................................................................................
h. Your parents or other relatives or family members .........................................................................................
i.

Another person or place LIST OTHER SOURCE

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1.11. In the past 12 months, how many different times, if any, did you receive birth control from a
doctor or a nurse at a place such as a hospital, clinic, or trailer, or during a visit to your home?
None
NUMBER OF TIMES – Your best guess is fine.

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SECTION 2: FAMILY
2.1. The next questions are about where you live and those you live with.
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
You are homeless, for example, living on the street, in a car or shelter,
or temporarily staying with friends or relatives

2.2. I’m going to ask about some different types of financial assistance.
In the past 30 days, did you or someone who lives with you receive…
MARK (X) ONE FOR EACH

a.
b.
c.
d.
e.

[DON’T
YES
NO
KNOW]
Social Security Disability .....................................................................................................................................
[REPEAT STEM] Food stamps, now called SNAP or
Supplemental Nutrition Assistance Program ......................................................................................................
WIC or The Women, Infants and Children Supplemental Nutrition Program .....................................................
Welfare, also called TANF or Temporary Assistance for Needy Families ..........................................................
Unemployment ....................................................................................................................................................

2.3. Now I’m going to ask how many times you or someone who lives with you did certain things in
the past 30 days. Your answer choices are [READ CHOICES].
In the past 30 days, how many times did you or someone who lives with you…
MARK (X) ONE FOR EACH

NO
TIMES

LESS THAN
ONCE A
WEEK

ABOUT
ONCE A
WEEK

MORE THAN
ONCE A
WEEK

a. Feel sick, in pain or injured but did NOT go for
medical help because they did not have
insurance or the money [READ CHOICES] .............................................................................................
b. [REPEAT STEM] Skip a meal because there
was no food in the house or money to get food
[READ CHOICES] ....................................................................................................................................
c. Visit a food pantry .....................................................................................................................................
d. Miss school, going to a job, or something else
important because there was no money for gas, a
bus, a train, or some other type of transportation .....................................................................................

2.4. At any time in the past 12 months, has there been a period of time when you have not had any
health insurance at all?
MARK (X) ONE

Yes
No

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SECTION 3: VIEWS AND PERCEPTIONS
3.1. The next series of questions is about how strongly you agree or disagree with a series of
statements about condom use. Your answer choices are [READ CHOICES].
How strongly do you agree or disagree that…
MARK (X) ONE FOR EACH
STRONGLY
AGREE

AGREE

NEITHER
AGREE NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Condoms should always be used if a person
your age has sexual intercourse [READ CHOICES] ..........................................................................................
b. [REPEAT STEM] Condoms are a hassle to
use [READ CHOICES] .......................................................................................................................................
c. Condoms are pretty easy to get..........................................................................................................................
d. Condoms are important to make sex safer.........................................................................................................
e. Using condoms means you don’t trust
your partner.........................................................................................................................................................
f.

Using condoms is morally wrong ........................................................................................................................

g. Condoms decrease sexual pleasure ..................................................................................................................

3.2. If condoms are used correctly and consistently, how much can they decrease the risk of
pregnancy? [READ CHOICES]
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

3.3. If condoms are used correctly and consistently, how much can they decrease the risk of getting
HIV, the virus that causes AIDS? [READ CHOICES]
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

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3.4. If condoms are used correctly and consistently, how much can they decrease the risk of getting
gonorrhea? [READ CHOICES]
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

3.5. The next series of questions is about how strongly you agree or disagree with a series of
statements about other methods of birth control NOT including condoms. Your answer choices
are [READ CHOICES].
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
[READ CHOICES] ..............................................................................................................................................
b. [REPEAT STEM] Birth control is a
hassle to use [READ CHOICES] ........................................................................................................................
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 ....................................................................................................................
g. My friends have good things to say about
birth control .........................................................................................................................................................
h. My family members have good things to
say about birth control.........................................................................................................................................

3.6. The next series of questions is about birth control pills.
If birth control pills are used correctly and consistently, how much can they decrease the risk of
pregnancy? [READ CHOICES]
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

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3.7. If birth control pills are used correctly and consistently, how much can they decrease the risk of
getting HIV, the virus that causes AIDS? [READ CHOICES]
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

3.8. If birth control pills are used correctly and consistently, how much can they decrease the risk of
getting gonorrhea? [READ CHOICES]
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

3.9. The next series of questions is about how strongly you agree or disagree with a series of
statements about ALL methods of birth control, including condoms and birth control pills.
Your answer choices are [READ CHOICES].
How strongly do you agree or disagree that…
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Women can trust what doctors and nurses say
about birth control [READ CHOICES] ...........................................................................................................
b. [REPEAT STEM] The use of birth control improves
a relationship [READ CHOICES] ...................................................................................................................
c. If a woman uses birth control, her partner will know
she really cares about herself ........................................................................................................................
d. If a man uses birth control, his partner will know
he really cares about her ...............................................................................................................................
e. If a woman uses birth control, her partner will
think she’s pretty smart ..................................................................................................................................
f.

If a man makes sure that one of them is using
birth control, his partner will know he really
cares about her ..............................................................................................................................................

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3.10. Now please think about your friends who have sexual intercourse. How often do you think they
use ANY method of birth control, such as condoms or birth control pills? [READ CHOICES]
MARK (X) ONE

Never
Sometimes
Half the time
Most of the time
Always

3.11. How many of your friends had a baby before they were 20 years old? [READ CHOICES]
MARK (X) ONE

None
One or two
Three or more

3.12. How many of your friends had more than one baby before they were 20 years old? [READ
CHOICES]
MARK (X) ONE

None
One or two
Three or more

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SECTION 4: BEHAVIORS AND EXPERIENCES
SEXUAL INTERCOURSE AND BIRTH CONTROL
4.1. Excuse me one moment as I look up a date.
INTERVIEWER: CALCULATE THE DATE IT WAS 3 MONTHS AGO TODAY AND PUT THE DATE IN
THE BLANK BELOW. THEN CONTINUE WITH THIS QUESTION.
Sorry for the delay. The next questions are about your sexual behaviors and experiences. Please
be as honest as possible. Your answers and everything you say will be kept private.
The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Please think about the past 3 months, that is, from __________________ until today. In the past
3 months, have you had sexual intercourse, even once?
MARK (X) ONE

Yes
No

GO TO 4.9

4.2. In the past 3 months, how many DIFFERENT PEOPLE have you had sexual intercourse with, even
once?
None

GO TO 4.1

INTERVIEWER: THIS SKIP IS CORRECT

NUMBER OF PEOPLE – Your best guess is fine.

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

GO TO 4.1

NUMBER OF TIMES – Your best guess is fine.

4.4. In the past 3 months, have you had sexual intercourse without you or your partner using a
condom?
MARK (X) ONE

Yes
No

GO TO 4.8

4.5. In the past 3 months, how many TIMES have you had sexual intercourse without you or your
partner using a condom?
None

GO TO 4.4

NUMBER OF TIMES – Your best guess is fine.

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4.6. In the past 3 months, have you had sexual intercourse without you or your partner using any of
these methods of birth control:








Condoms
Birth control pills
The shot or Depo-Provera
The patch
The ring or NuvaRing
An IUD such as Mirena or Paragard or
Implants such as IMPLANON?

MARK (X) ONE

Yes
No

GO TO 4.8

4.7. 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:








Condoms
Birth control pills
The shot or Depo-Provera
The patch
The ring or NuvaRing
An IUD such as Mirena or Paragard or
Implants such as IMPLANON?
None

GO TO 4.6

NUMBER OF TIMES – Your best guess is fine.

4.8. I’m going to read you some methods of birth control and ask how often you used each method in
the past 3 months. Your answer choices are [READ CHOICES].
In the past 3 months, when you had sexual intercourse, how much of the time did you use…
MARK (X) ONE FOR EACH

NONE OF
SOME OF
HALF THE
MOST OF
ALL OF
THE TIME
THE TIME
TIME
THE TIME
THE TIME
a. Condoms [READ CHOICES] ............................................................................................................................
b. [REPEAT STEM] A diaphragm
[READ CHOICES] ............................................................................................................................................
c. Female condoms ...............................................................................................................................................
d. Fertility awareness ............................................................................................................................................
e. Withdrawal .........................................................................................................................................................
f. A spermicide ......................................................................................................................................................
g. Another method PRINT OTHER METHOD

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4.9. In the past 3 months, how much of the time did you use…
MARK (X) ONE FOR EACH

NONE OF
THE TIME

SOME OF
THE TIME

HALF THE
TIME

MOST OF
THE TIME

ALL OF
THE
TIME

a. Birth control pills [READ CHOICES] ...................................................................................................................
b. [REPEAT STEM] the shot or
Depo-Provera [READ CHOICES] .......................................................................................................................
c. The patch.............................................................................................................................................................
d. The ring or NuvaRing ..........................................................................................................................................
e. An IUD such as Mirena or Paragard ...................................................................................................................
f. An Implant such as IMPLANON ..........................................................................................................................
g. Male vasectomy...................................................................................................................................................
h. Breastfeeding ......................................................................................................................................................
i.

Another method of birth control
.............................................................................................................................
PRINT OTHER METHOD

4.10. INTERVIEWER:

IF THE ANSWER TO 4.8a. IS NONE OF THE TIME, GO TO 4.12.
IF THE ANSWERS TO 4.8 ARE BLANK, GO TO 4.13.
OTHERWISE, GO TO 4.11.

4.11. The most recent time you had sexual intercourse, did you use a condom?
MARK (X) ONE

Yes
No

4.12. The most recent time you had sexual intercourse, did you use any method of birth control other
than a condom, such as birth control pills, the shot, the patch, the ring, an IUD, an Implant, a
diaphragm, spermicide, or any other method?
MARK (X) ONE

Yes
No

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ORAL AND ANAL SEX
4.13. The next question is 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.
In the past 3 months, how many TIMES have you had oral sex?
None

GO TO 4.15

NUMBER OF TIMES – Your best guess is fine.

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

4.15. The next question is about anal sex. Anal sex is when a male puts his penis in someone else’s
anus, or their butt. In the past 3 months, how many TIMES have you had anal sex?
None

GO TO 4.18

NUMBER OF TIMES – Your best guess is fine.

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

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SEXUALLY TRANSMITTED DISEASES
4.17. Now please think about the past 12 months. In the past 12 months, have you been told by a
doctor or nurse that you had a sexually transmitted disease, also known as an STD?
MARK (X) ONE

Yes
No

4.18. The next series of questions is about the types of sexually transmitted diseases, or STDs, you
have had.
In the past 12 months, did you have…
MARK (X) ONE FOR EACH

YES

NO

DON’T
KNOW

a. Chlamydia ......................................................................................................................................................
b. [REPEAT STEM] Gonorrhea.........................................................................................................................
c. Genital herpes ...............................................................................................................................................
d. Syphilis...........................................................................................................................................................
e. HIV infection or AIDS .....................................................................................................................................
f.

Human Papillomavirus, also known as HPV or genital warts ........................................................................

g. Another sexually transmitted disease or STD PRINT OTHER STD

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PREGNANCY HISTORY
4.19. You were pregnant about 18 months ago, right before or when you filled out a paper survey
similar to this one for this same study.
Please think back to that pregnancy you experienced about 18 months ago. Have you been
pregnant again since that pregnancy ended?
MARK (X) ONE

Yes
No

GO TO 4.36

4.20. At the time you became pregnant the most recent time, did you want to become pregnant then,
did you want to become pregnant later, or did you not want to become pregnant at all?
MARK (X) ONE

Wanted to become pregnant then
Wanted to become pregnant later
Did not want to become pregnant at all

4.21. How did your most recent pregnancy end – a live birth or births, a miscarriage, a stillbirth, an
abortion or are you still pregnant?
MARK (X) ONE

Live birth or births

GO TO 4.26

Miscarriage
Stillbirth

GO TO 4.24

Abortion
Still pregnant

4.22. How many weeks along in your current pregnancy are you?
NUMBER OF WEEKS
Don’t know

4.23. GO TO 4.36

4.24. How many weeks along in your most recent pregnancy were you when that pregnancy ended?
NUMBER OF WEEKS
Don’t know

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4.25. GO TO 4.36

4.26. How many weeks along in your most recent pregnancy were you when your baby was born?
NUMBER OF WEEKS
Don’t know

4.27. Did you have a c-section delivery, also known as a Caesarean section delivery, OR did you have a
vaginal birth, also known as pushing the baby out?
MARK (X) ONE

C-section
Vaginal birth

4.28. Was your baby born full-term, that is after you were 37 weeks pregnant, or premature, that is
before you were 37 weeks pregnant?
MARK (X) ONE

Full-term

GO TO 4.31

Premature

4.29. Was the delivery of your baby spontaneous, that is – no medicine was used to cause your baby
to be born, or induced, that is – medicine was used to start labor to cause your baby to be born?
MARK (X) ONE

Spontaneous birth – no medicine was used to start labor

GO TO 4.31

Induced

4.30. Was the delivery of your baby induced, that is – medicine was used to start labor to cause your
baby to be born, because of your own health complications or because of complications
involving the baby?
MARK (X) ONE

Induced because of your own health complications
Induced because of complications involving the baby

4.31. How much did your baby weigh at birth?
POUNDS

OUNCES

Don’t know

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4.32. How many days was your baby in the hospital after he or she was born?
Her baby is still in the hospital
NUMBER OF DAYS

4.33. How many days was your baby in the intensive care unit at the hospital after he or she was born?
None
Her baby is still in the intensive care unit at the hospital
NUMBER OF DAYS

4.34. Did you breastfeed your baby at all?
MARK (X) ONE

Yes
No

GO TO 4.36

4.35. How many months did you breastfeed your baby or are you still breastfeeding him or her?
Still breastfeeding
NUMBER OF MONTHS

4.36. Including all the times you have been pregnant, how many times have you EVER been pregnant,
even if no child was born?
NUMBER OF TIMES

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SECTION 5: PLANNING FOR THE FUTURE
5.1. The next questions are about your plans for the future.
Again, in this survey, by sexual intercourse, we mean a male putting his penis into a female’s
vagina.
Do you intend to have sexual intercourse in the next year, if you have the chance?
[READ CHOICES]
MARK (X) ONE

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

5.2. If you were to have sexual intercourse in the next year, do you intend to have your partner use a
condom? [READ CHOICES]
MARK (X) ONE

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

5.3. If you were to have sexual intercourse in the next year, do you intend to use or have your partner
use any of these methods of birth control:
 Birth control pills
 The shot or Depo-Provera
 The patch
 The ring or NuvaRing
 An IUD such as Mirena or Paragard or
 Implants such as IMPLANON? [READ CHOICES]
MARK (X) ONE

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

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5.4. Do you want to have any more children?
MARK (X) ONE

Yes
No

GO TO 5.6

Don’t know

5.5. How many more children do you want to have?
NUMBER OF CHILDREN

5.6. INTERVIEWER: IF RESPONDENT IS CURRENTLY PREGNANT [SEE QUESTION 4.21], GO TO 5.8.
Please think about the next year. Over the next year, will you be [READ CHOICES]
MARK (X) ONE

Trying to get pregnant again
Neither trying to get pregnant nor trying avoid getting pregnant
Trying to avoid getting pregnant or
You don’t know?

5.7. Over the next year, from your partner’s point of view, will he be…
MARK (X) ONE

Trying to get you pregnant
Neither trying to get you pregnant nor trying to avoid getting you pregnant
Trying to avoid getting you pregnant
You don’t know or
You don’t have a partner right now?

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5.8. Okay, that was the end of our survey. Thank you so much for your help with this study.
I’d like to confirm your address, so that we are sure you will receive your $25 gift card.
CONFIRM ADDRESS AND UPDATE IF NECESSARY.
I would also like to confirm your other contact information, so that we will be able to reach you
for the last of our four surveys, 12 months from now.
CONFIRM PHONE NUMBER/S AND ADDRESS, AND UPDATE IF NECESSARY.
Finally, we will contact you about every 3 months to be sure your contact information hasn’t
changed. Would you prefer we contact you by postcard or text message?
NOTE WHETHER POST CARD OR TEXT.
That’s it. Thank you so much again!
Good-bye.

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