ATTACHMENT B
QUESTION BY QUESTION SOURCE TABLE FOR THE Follow up survey
QUESTION BY QUESTION SOURCE LIST FOR the PAF follow up SURVEY
This document lists each question on the PAF follow up survey, along with its source(s). Most questions are taken from the PAF baseline survey (OMB control number 0990-0424) and have come from the ongoing Evaluation of Adolescent Pregnancy Prevention Approaches (PPA) study (OMB Control Number: 0990-0382); the Personal Responsibility Education Program (PREP) Multi-Component Evaluation (OMB Control Number: 0970-0398); or the Concordance Survey (OMB Control Number: 0990-0382).
PAF Follow-Up Question # |
Question Text |
Question from Baseline PAF survey |
Question from PPA, PREP, or Concordance Survey |
Additional Information |
1.1 |
Are you currently enrolled in any type of school or education program? If you are currently on summer vacation or taking a short break to have your baby but plan to return to school, please answer “yes” |
X |
X |
Adapted from the National Longitudinal Survey of Youth
|
1.2 |
In what type of school or education program are you currently enrolled? |
X |
X |
Adapted from the National Longitudinal Survey of Youth
|
1.3 |
Are you enrolled in a GED program or a post high school vocational training program? |
X |
X |
Adapted from the National Longitudinal Survey of Youth
|
1.4 |
What is the highest grade you have finished? For example, if you are in 9th grade now, but have not finished the school year, select 8th grade
|
X |
X |
Adapted from the Evaluation of the School Dropout Demonstration Assistance Program (SDDAP) |
1.5 |
Do you have any of these degrees or certificates? a. A high school diploma b. A GED c. A certificate or license (for example, from a vocational training program) d. An associate’s degree from a two year college or community college e. A bachelor’s degree from a four year college |
X |
X |
Adapted from the Evaluation of the School Dropout Demonstration Assistance Program (SDDAP) |
1.6 |
On your last report card, what kind of grades did you get? If you are not currently attending school,answer based on the last school you attended |
X |
X |
Adapted from National Longitudinal Survey of Youth |
1.7 |
What is the highest level of education you think you will complete?
|
X |
X |
Adapted from All About Youth Study
|
1.8 |
Are you currently working at a full or part-time job or jobs? |
|
|
Chafee Independent Living Evaluation |
1.9 |
Have you been employed in the past 12 months? |
|
|
Chafee Independent Living Evaluation |
1.10 (CA only) |
How much do you agree or disagree with the following statements?
|
|
|
Adapted from the following:
|
1.11 (item h CA only) |
How much do you agree or disagree with the following statements?
a. I am focused on preventing negative things from happening in my life.
b. I set goals and think about what I need to do to reach those goals.
c. When faced with a problem, I can usually find a solution.
d. I think going to college is important for getting a good job.
e. I am focused on achieving good and positive things in my life.
f. I have a plan for achieving my future education or career goals.
g. I don’t like to plan too far ahead because things don’t usually go the way I planned.
h. I have opportunities that are challenging and interesting |
X |
|
Adapted from the following:
|
1.12 (items d, e, and f are CA only) |
How much do you agree or disagree with the following statements?
a. There is an adult who I can count on when things go wrong.
b. There is an adult who I can count on to help me make good decisions.
c. There is an adult who encourages me to do my best
d. There is an adult in my life who supports me with the plans and goals I have for my future
e. I know where to go to get support for the things I need
f. I express my ideas, concerns, and opinions with important people in my life (such as family, partner, or friend). |
X |
|
Adapted from the following:
|
2.1 |
In the past 12 months, did you attend any classes or sessions (individual or group) about the following?
|
X |
X |
|
2.2 |
And did these classes or sessions take place with your [IF SITE=CA-{case manager from [PROGRAM SITE]} IF SITE = TX {home visitor}], at somewhere recommended by your [case manager/home visitor], or somewhere else? |
|
|
Developed by the PAF team |
2.3 |
In the past 12 months, have you participated in any of the following education related services? a. GED preparation b. Tutoring or outside help with school work c. Programs to prepare for a high school diploma d. Standardized achievement test preparation for state or local tests e. College preparation activities such as college awareness or college guidance activities, college preparation or transition programs, or preparing for college entrance examinations or college applications f. Getting help finding financial aid g. Another education related service |
X |
|
Adapted from the Evaluation of the Impact of the Youth Build Program Follow-Up Survey |
2.4 |
And did you receive these education related services from your [IF SITE=CA-{case manager from [PROGRAM SITE]} IF SITE = TX {home visitor}], at somewhere recommended by your [case manager/home visitor], or somewhere else? |
|
|
Developed by the PAF team |
2.5 |
In the past 12 months, have you participated in any of the following training or job related services?
a. Career counseling b. Help finding or applying for a job training program c. Job training d. Help looking for or applying for a job e.Another training or job related service
|
X |
|
Adapted from the Evaluation of the Impact of the Youth Build Program Follow-up Survey |
2.6 |
And did you receive these training or job related services from your [IF SITE=CA-{case manager from [PROGRAM SITE]}, IF SITE = TX {home visitor}], at somewhere recommended by your [case manager/home visitor], or somewhere else? |
|
|
Developed by the PAF team |
3.1 |
Some of the things listed below might happen to people. Please tell us if any of these things ever happened to you in the past 12 months? a. Someone in my family or I went hungry because we could not afford enough food. b. Someone in my family or I didn’t have enough money for housing c. I got in trouble with the law, or went to jail. d. The person I am currently in a relationship with got in trouble with the law or went to jail e. A parent or guardian, or other adult that I lived with (not including the person I am currently in a relationship with), got in trouble with the law or went to jail. f. I was placed in foster care (removed from my home by the court or child welfare agency). g. I saw or heard my parents, guardians, or other adults in my home slap, hit, kick, punch, or beat each other up. h. A parent or guardian or other adult I lived with had a serious drinking or drug problem. i. A parent or guardian or other adult I lived with was mentally ill or suicidal, or severly depressed for more than a couple of weeks. j. A child of mine was placed in foster care (removed from my home by the court or child welfare agency).
|
X |
|
Sources: |
3.2 |
The next questions are about alcohol, drugs and general health. Please be as honest as possible, and remember that your answers will be kept private and will not be shared with anyone.
During the past 30 days, on how many days did you smoke one or more cigarettes? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days
|
X |
X |
Adapted from National Longitudinal Survey of Youth, 1997
|
3.3 |
The next 2 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiske. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes
During the past 30 days, on how many days did you have at least one drink of alcohol? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days
|
X |
X |
Adapted from National Longitudinal Survey of Youth, 1997 and National Survey on Drug Use and Health
|
3.4 |
During the past 30 days, on how many days did you have 5 or more drinks in a row, that is, within a couple hours? 0 days 1 day 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days
|
X |
X |
Adapted from National Longitudinal Survey of Youth, 1997 and National Survey on Drug Use and Health
|
3.5 |
During the past 30 days, on how many days did you use marijuana, also called weed or pot? 0 days 1 or 2 days 3 to 9 days 10 to 19 days 20 or more days
|
X |
X |
Adapted from National Longitudinal Survey of Youth, 1997 and National Survey on Drug Use and Health
|
3.6 |
During the past 30 days, on how many days did you use any other type of illegal drug, inhalant, or a prescription drug in a way that was not prescribed? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days
|
X |
X |
National Longitudinal Survey of Youth, 1997 and National Longitudinal Study of Adolescent Health
|
3.7 |
During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? |
X |
|
2013 National Youth Risk Behavior Survey |
4.1 |
Below are several statements about condoms. Please mark whether you think each statement is true, false or you don’t know.
a. It is okay to use the same condom more than once. b. Condoms have an expiration date. c. When putting on a condom, it is important to leave a space at the tip. d. It is okay to use petroleum jelly or Vaseline as a lubricant when using latex condoms. e. When using a condom, it is important for the man to pull out right after ejaculation. f. Wearing two latex condoms will provide extra protection.
|
X |
|
Adapted from The Fog Zone (2009) The National Campaign to Prevent Teen and Unplanned Pregnancy |
4.2 |
Below are several statements about birth control pills. Please mark whether you think each statement is true, false or you don’t know.
a. Birth control pills are effective, even if a woman misses taking them for two or three days in a row. b. Women should “take a break” from the pills every couple of years. c. After a woman stops taking birth control pills, she is unable to get pregnant for at least two months. d. In order to get the birth control pill, a woman must have a pelvic exam. e. Birth control pills can reduce the risk of getting a sexually transmitted disease or (STD
|
X |
|
Adapted from The Fog Zone (2009) The National Campaign to Prevent Teen and Unplanned Pregnancy |
4.3 |
Below are several statements about IUDs (such as Mirena, ParaGard, or Skyla). Please mark whether you think each statement is true, false or you don’t know
a. Women who use IUDs cannot use tampons b. A woman can get an IUD without going to a doctor’s office, clinic, or medical professional c. An IUD cannot be felt by a woman’s partner during sex d. IUDs can move around in a woman’s body e. An IUD is effective (prevents pregnancy) for at least 3 years f. Using an IUD will cause weight gain |
X |
|
Adapted from The Fog Zone (2009) The National Campaign to Prevent Teen and Unplanned Pregnancy |
4.4 |
Below are some statements about other forms of birth control. Please mark whether you think each statement is true, false or you don’t know.. a. Women using the birth control shot, Depo-Provera, must get an injection about every 3 months b. Even if a woman is late getting her birth control shot, she is still protected from pregnancy for at least 3 months. c. Women using the vaginal ring, or NuvaRing, must have it inserted by a doctor or health care provider every month d. Long-acting methods like the implant (Implanon or Nexplanon) or an IUD (Mirena, ParaGard, or Skyla) cannot be removed early, even if a woman changes her mind about wanting to get pregnant e. Long-acting methods like the implant (Implanon or Nexplanon) or an IUD (Mirena, ParaGard, or Skyla) can make it more difficult to become pregnant in the future when a woman is no longer using them. |
X |
|
Adapted from The Fog Zone (2009) from The National Campaign to Prevent Teen and Unplanned Pregnancy |
4.5 |
In the past 12 months, did you receive information from a doctor, nurse, case manager, or clinic about any of the following? a. Methods of birth control, such as condoms, birth control pills, the patch, IUD, or an implant b. Where to get birth control c. Sexually transmitted diseases, also known as STDs or STIs |
X |
X |
Adapted from the National Survey of Family Growth
|
4.6 |
In the past 12 months, did you get any type of birth control from a doctor, nurse, case manager, or clinic, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant? |
X |
X |
Adapted from the National Survey of Family Growth |
5.1 |
Now I would like to ask you some questions about children. Our records show that you [had/were expecting to have] a baby on [DATE]. Is that the date the baby was born? |
|
X |
Adapted from the Building Storng Families Evaluation |
5.2 |
On what date was the baby born? |
|
X |
Building Strong Families Evaluation |
5.3 |
So that I can refer to the baby,what is the baby’s first name? |
|
X |
Adapted from Building Strong Families Evaluation |
5.4 |
Is [CHILD] male or female? |
|
X |
Building Strong Families Evaluations |
5.5 |
Did you ever breastfeed or pump breast milk to feed [CHILD] after delivery, even for a short period of time? |
|
|
Adapted from PRAMS (Pregnancy Risk Assessment Monitoring System) |
5.6 |
Are you currently breastfeeding or feeding pumped breast milk to [CHILD]? |
|
|
Adapted from PRAMS (Pregnancy Risk Assessment Monitoring System) |
5.7 |
How old was [CHILD] when you stopped breastfeeding or giving (him/her) pumped breast milk? |
|
|
Developed by the PAF team |
5.8 |
During the past 12 months, did [CHILD] see a doctor, nurse, or other health care professional for any kind of medical care, including sick child care, well child checkups, physical exams, and hospitalizations? |
|
|
National Survey of Children’s Health 2011 |
5.9 |
During the past 12 months, how many times did [CHILD] see a doctor, nurse, or other health care provider for a regular checkup, not a sick child care visit or hospitalization? Your best estimate is fine. |
|
|
Adapted from National Survey of Children’s Health 2011
|
5.10 |
Has [CHILD] been seen by a doctor or nurse as many times as you wanted when (he/she) was sick? |
|
|
Adapted from PRAMS (Pregnancy Risk Assessment Monitoring System) |
5.11 |
In the 3 months after you had [CHILD] , did you have a checkup with a doctor, nurse, or other health care worker for yourself? |
|
|
Developed by the PAF team |
5.12 |
Since [CHILD] was born, have you asked for help for depression from a doctor, nurse, or other health care worker? |
|
|
Adapted from PRAMS (Pregnancy Risk Assessment Monitoring System) |
5.13 |
The next questions are about health insurance. This can include private insurance, Medicaid, [IF Site=CA {MediCal}], or any other government program that pays for medical care. Do you have health insurance for [CHILD]? |
|
|
Developed by the PAF team |
5.14 |
Do you have health insurance for yourself? |
|
|
Developed by PAF team |
5.15 |
Do you currently live with [CHILD] in the same household… All of the time Most of the time Some of the time, or None of the time?
|
|
X |
Building Strong Families Evaluation
|
5.16 |
Have you seen [CHILD] in the past month? |
|
X |
Building Strong Families Evaluation
|
5.17 |
When [CHILD] is not living with you, (W/w)ho does [CHILD] live with? Father Grandparent/s Other relative/s Adoptive parent/s Foster parent/s Someone else |
|
X |
Building Strong Families Evaluation
|
5.18 |
Since [CHILD] was born, have you lived with [CHILD] in the same household All of the time Some of the time None of the time
|
|
|
Developed by PAF team
|
5.18a |
Since [CHILD] was born, how many months have you lived with [CHILD] in the same household? |
|
X |
Adapted from Building Strong Families Evaluation
|
5.19 |
The next questions are about things YOU may have done with [CHILD] in the past month. In the past month, how often have you done each of the following? Was it everyday or almost every day, a few times a week, a few times in the past month, or never in the past month?
|
|
X |
Adapted from Building Strong Families Evaluation
|
5.20 |
How much do you agree or disagree with the following statements about romantic/sexual relationships?
a. In a good relationship, you don’t always get your own way.
b. There are times when hitting or pushing is okay in a relationship.
c. A good relationship is based on mutual respect, not just sex.
d. People who make their partner jealous deserve to be hit or pushed.
e. It would be easy to trust your partner, even when you’re apart.
f. Avoiding a disagreement with your partner is always better than talking about your problems. |
X |
X |
Adapted from the Acceptance of Couple Violence Questionnaire (Foshee et al. 1992) |
5.21 |
The next questions are about your relationship with [CHILD’S] father. Do you live with him? None of the time, Some of the time, or All of the time? |
X |
X |
|
5.22 |
How would you define your current relationship status with [CHILD’S] father? |
X |
X |
|
5.23 |
Taking all things together, on a scale from 0 to 10, where 0 is not at all happy and 10 is completely happy, how happy would you say your relationship with [CHILD’S] father is? You can choose any number from 0 to 10. |
|
X |
Adapted from Building Strong Families Evaluation
|
5.24 |
How often do you and [CHILD’S] father see or talk to each other? Is it…
Every day or almost every day, A few times a week, A few times a month, About once a month, A few times in the past year, or Hardly ever or never? |
|
X |
Building Strong Families Evaluation
|
5.25 |
You mentioned that since [CHILD] was born, you have [if 5.18=1, always] lived in the same household with [CHILD] [if 5.18=2, fill months from 5.18a,for [NUMBER OF MONTHS] months]. Since [CHILD] was born, have you lived with [CHILD] and [CHILD]’s father in the same household… All of the time Some of the time None of the time |
|
|
Developed by PAF team |
5.25a |
Since [CHILD] was born, how many months have you lived in the same household with both [CHILD] and [CHILD]’s father? |
|
X |
Building Strong Families Evaluation |
5.26 |
The next question is about time [CHILD’s] father spends with [CHILD]. In the past month, how often has [CHILD’s] father spent one or more hours a day with [CHILD]? Was it …
Every day or almost every day, A few times a week, A few times in the past month, Once or twice in the past month, or Never? |
|
X |
Adapted from Building Strong Families Evaluation
|
5.27 (TX only) |
Has [CHILD’S] father seen [CHILD] in the past month? |
|
X |
Building Strong Families Evaluation
|
5.28(TX only) |
Parents deal with meeting the expenses of raising a child in different ways. When answering the next question, I’d like you to think about all the expenses associated with raising [CHILD] such as [CHILD]’s food, clothing, medical expenses, diapers, and any other costs of raising [CHILD]. How much of the cost of raising [CHILD] does [CHILD’s] father cover? Would you say it’s … All or almost all, More than half, About half, Less than half, or Little or none?
|
|
X |
Building Strong Families Evaluation
|
5.29 (TX only) |
The next questions are about things [CHILD’s] father may have done with [CHILD] in the past month. In the past month, how often has [CHILD’S] father [STATEMENT a to h]? Was it everyday or almost every day, a few times a week, a few times in the past month, or never in the past month?
|
|
X |
Adapted from Building Strong Families Evaluation
|
5.30 (TX only) |
Now, I would like to talk about you and [CHILD’S] father as parents. For each statement, please answer if you strongly agree, agree, are not sure, disagree, or strongly disagree. [STATEMENT a to e] Do you strongly agree, agree, are not sure, disagree, or strongly disagree with this statement?
|
|
X |
PACT Healthy Marriage Baseline Survey and Building Strong Families Evaluation
|
6.1 |
In the past 12 months, have you been sexually active? |
X |
|
Developed by the PAF team |
6.2 |
In the past 12 months, how many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one time?
|
|
X |
National Longitudinal Study of Youth, 1997
|
6.3 |
In the past 12 months, did you ever have sexual intercourse without using birth control, such as condoms, birth control pills, the patch, the shot, the ring, an IUD, or an implant? |
X |
|
Developed by the PAF team |
6.4 |
The next question is about your use of the following methods of birth control:
In the past 12 months, how many TIMES did you have sexual intercourse without using any of these methods of birth control? Your best estimate is fine
|
X |
X |
Adapted from National Longitudinal Survey of Youth, 1997
|
6.5 |
In the past 12 months, did you use any of the following types of birth control…
a. Condoms? b. Birth control pills? c. The patch, such as Ortho Evra? d. The shot, such as Depo-Provera or other injectable birth control? e. The ring, such as NuvaRing? f. An IUD, such as Mirena, Paragard, or Skyla? g. An implant, such as Implanon, or Nexplanon? h. Another type of birth control? |
|
X |
|
6.6 |
Are you currently using …
MARK ONE FOR EACH a. Condoms? b. Birth control pills? c. The patch, such as Ortho Evra? d. The shot, such as Depo-Provera or other injectable birth control? e. The ring, such as NuvaRing? f. An IUD, such as Mirena, Paragard, or Skyla? g. An implant, such as Implanon, or Nexplanon? h. [THE TYPE OF BIRTH CONTROL IN 6.5h]? |
|
X |
|
6.7 |
These next few questions are about pregnancy. Since [CHILD] was born, have you been pregnant? |
|
X |
|
6.8 |
Since [CHILD] was born, how many times have you been pregnant, even if no baby has been born? If you are currently pregnant, please include your current pregnancy. |
|
X |
|
6.9 |
Are you currently pregnant? |
|
X |
|
6.10 |
What is the baby’s due date? |
|
X |
Adapted from Building Strong Families Evaluation |
6.11 |
Since [CHILD] was born, have you had another baby? |
|
X |
Adapted from Building Strong Families Evaluation |
6.12 |
When was your most recent baby born? |
|
X |
Adapted from Building Strong Families Evaluation |
6.13 |
[IF 6.9=1 FILL “After your current pregnancy”] Do you ever want to have any more children? |
|
X |
|
6.14 |
How soon would you like to have your next child? Would you like to have it… Within the next year, One year from now, Two years from now, Three years from now, or Four or more years from now? |
|
X |
Building Strong Families Evaluation |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | BCollette |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |