Grantee program staff-PREIS grantees

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

Appendix E: Perceived Impact Questions (PREIS Grantees Only)

PREIS Grantees
Only

Construct

Perceived impact
of program on
sex**

% of youth who report that they
are either less likely or much
less likely to have sex in the
next year

Perceived impact
of program on
condom use**

% of youth who report that they
are either more likely or much
more likely to use a condom

Perceived impact
of program on
contraceptive

% of youth who report that they
are either more likely or much
more likely to use a

Question
For the next few questions, please think about [NAME OF
PROGRAM] and how it may have influenced you. You
may not have thought about these situations before, but
please still answer the questions. Thank about what you
would do and answer as best you can.
Would you say that being in [NAME OF PROGRAM] has
made you more likely or less likely to have sexual
intercourse in the next year?
Much more likely
More likely
About the same
Less likely
Much less likely
If you were to have sexual intercourse in the next year,
would you say that being in [NAME OF PROGRAM] has
made you more likely or less likely to use (or ask your
partner to use) a condom?
Much more likely
More likely
About the same
Less likely
Much less likely
If you were to have sexual intercourse in the next year,
would you say that being in [NAME OF PROGRAM] has
made you more likely or less likely to use (or ask your

Surveyed
Population

All youth

All youth

All youth

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 3 hours and 5minutes 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
use**

contraceptive method

Perceived impact
of program on
abstinence†

% of youth who report that they
are either more likely or much
more likely to abstain from sex

partner to use) any of these methods of birth control?
 Condoms
 Birth control pills
 The shot (Depo Provera)
 The patch
 The ring (NuvaRing)
 IUD (Mirena or Paragard)
 Implant (Implanon)
Much more likely
More likely
About the same
Less likely
Much less likely
Would you say that being in [NAME OF PROGRAM] has
made you more likely or less likely to abstain from sexual
intercourse in the next year (abstaining means choosing not
to have sex)?
Much more likely
More likely
About the same
Less likely
Much less likely

All youth

** The first year of data collection will supply these baseline figures and remaining years will be reported as % of grantees that meet
or exceed or that baseline level.
†
The measure of perceived impact on abstinence is included as a check. Responses to this question will be compared the responses to
the perceived impact on sex measure to assess the extent to which youth are reporting consistently.