Grantee program staff-Tier 1 C/D, Tier 2, and PREIS grantees

OMB Approval # 0990-0392
Expiration Date: 05/31/2015

TPP Performance Measures for Tier 1 C/D and Tier 2 Grantees
September 2014
ONLY GRANTEES WITH RIGOROUS EVALUATIONS (Tier 1C/D and Tier 2)
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Ever had sex
Ever been pregnant/gotten someone pregnant
# of times been pregnant/gotten someone pregnant
Any sex in past 3 months
# of times had sex in past 3 months
Had sex without a condom in past 3 months
# of times had sex without a condom in past 3 months
Had sex without birth control in past 3 months
# of times had sex without birth control in past 3 months
Intent to have sex in next year
Intent to use a condom in next year
Intent to use birth control in next year

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 0990-0392 . The time required to complete this information collection is estimated to
average 1 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
Actual Participant-Level Performance Measure Questions
Date ______/_______/______
Demographic Questions (Inform Reach)
1. In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

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

 2002
 2001
 2000
 1999
 1998
 1997
 1996
 1995
 1994
 1993
 1992
 1991

Alternative question:
How old are you? __________
2. What grade are you in? (If you are currently on vacation between grades, please indicate the
grade you will be in when you go back to school).
MARK (X) ONE ANSWER

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6th
7th
8th
9th
10th
11th
12th
Ungraded
College/Technical school
Not currently in school

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
3. Are you male or female?
MARK (X) ONE ANSWER

 Male
 Female

4. Are you Hispanic or Latino?
MARK (X) ONE ANSWER

 Yes
 No
5. What is your race?
MARK (X) ONE OR MORE THAN ONE ANSWER

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American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White

6. When you are at home or with your family, what language or languages do you usually
speak?
MARK (X) ONE OR MORE THAN ONE ANSWER

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English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language: _________________________

Indicate Special Populations (as applicable)
 Pregnant or parenting teens
 Youth in foster care
 Homeless youth
 Youth in the juvenile justice system
 Other

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
Participant-Level Questions (Rigorous evaluations only)
The (next/first) questions are about sexual intercourse. By sexual intercourse, we mean a male
putting his penis into a female’s vagina.
1. Have you ever had sexual intercourse?
 Yes
 No  Skip to Question 6

2. To the best of your knowledge, have you ever been pregnant or gotten someone pregnant,
even if no child was born?
 Yes
 No –> Skip to Question 3
2a. To the best of your knowledge, how many times have you been pregnant or gotten
someone pregnant?
_____

3.

Now please think about the past 3 months. In the past 3 months, have you had sexual
intercourse, even once?
 Yes
 No  Skip to Question 6

3a. In the past 3 months, how many times have you had sexual intercourse?
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4.

In the past 3 months, have you had sexual intercourse without you or your partner using a
condom?
 Yes
 No  Skip to Question 5
4a.

In the past 3 months, how many times have you had sexual intercourse without
using a condom?
_____

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
5.

In the past 3 months, have you had sexual intercourse without you or your partner using
any of these methods of birth control?
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Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
 Yes
 No  Skip to Question 6

5a.

6.

In the past 3 months, how many times have you had sexual intercourse without
using any of these methods of birth control?
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Do you intend to have sexual intercourse in the next year, if you have the chance?
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7.

If you were to have sexual intercourse in the next year, do you intend to use (or have your
partner use) a condom?
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8.

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

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

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?
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Condoms
Birth control pills
The shot (Depo Provera)
The patch

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
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The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
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Yes, definitely
Yes, probably
No, probably not
No, definitely not