24 month Followup survey California and Texas

INSERT LOGO HERE

Form Approved

OMB No: 0990-0424
Exp Date:

Positive Adolescent Futures
(PAF)

DRAFT 24 MONTH FOLLOW-UP SURVEY California

Web Version

April 1, 2016

50023.01.061.170.G00

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Section 1: Background

This section focuses on you and your background.

1.1. Are you currently enrolled in any type of school or education program?

If you are currently on summer vacation, a semester break or taking a short break to have a baby but plan to return to school, please select “yes.”

 Yes

 No

1.2. In what type of school or education program are you currently enrolled?

 Middle school

 High school

 A GED education program

 A vocational training program that is post high school

 Two-year or community college

 four-year college

1.3. Are you enrolled in a GED program or a post high school vocational training program?

 Yes, a GED education program

 Yes, a vocational training program (post high school)

 No

1.4 Of the grades listed below, what is the highest grade you have finished?

For example, if you are in 11th grade now, but have not finished the school year, select 10th grade.

 Less than 7th grade

 7th grade

 8th grade

 9th grade

 10th grade

 11th grade

 12th grade

1.5. Do you have any of these degrees or certificates? Check all that apply.

 A high school diploma

 A GED

 A certificate or license, for example, from a vocational training program

 An associate degree from a two-year college or community college

 A bachelor’s degree from a four-year college

 None of these

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.]

 Mostly As

 About half As and half Bs

 Mostly Bs

 About half Bs and half Cs

 Mostly Cs

 About half Cs and half Ds

 Mostly Ds

 Mostly below Ds

 Your courses were not graded

1.7. What is the highest level of education that you think you will complete?

 Less than high school, that is, you don’t think you will graduate or get a GED

 A high school diploma or GED

 A technical or trade school certificate or industry certification

 An associate’s degree from a two-year college or community college

 A bachelor’s degree from a four-year college

 A master’s degree, doctorate or other advanced degree

1.8. Are you currently working at a full or part-time job or jobs?

 Yes

 No

1.9. Have you been employed in the past 12 months?

 Yes

 No

1.10. Next, please answer some questions about how you feel about yourself and your future. How much do you agree or disagree with the following statement?
	Strongly Disagree	Disagree	Agree	Strongly Agree
a. You have a positive attitude about yourself.				
b. You are aware of your personal strengths.				
c. You use your strengths to solve your problems.				
d. You often feel that there is little you can do to change what happens to you.				
e. You usually make quick decisions based on what feels right in the moment.				
f. When you have a serious disagreement with someone you can talk calmly about it without losing control.				
g. You can resist doing something when you know that you shouldn’t do it.				
h. Your life has meaning.				

1.11. The next questions focus on how you feel about your goals. How much do you agree or disagree with the following statement?
	Strongly Disagree	Disagree	Agree	Strongly Agree
a. You are focused on preventing negative things from happening in your life.				
b. You set goals and think about what you need to do to reach those goals.				
c. When faced with a problem, you can usually find a solution.				
d. You think going to college is important for getting a good job.				
e. You are focused on achieving good and positive things in your life.				
f. You have a plan for achieving your future education or career goals.				
g. You don’t like to plan too far ahead because things don’t usually go the way you planned.				
h. You have opportunities that are challenging and interesting.				

1.12. The next questions focus on how others may help you. How much do you agree or disagree with the following statement?
	Strongly Disagree	Disagree	Agree	Strongly Agree
a. There is an adult who you can count on when things go wrong.				
b. There is an adult who helps you make good decisions.				
c. There is an adult who encourages you to do your best.				
d. There is an adult in your life who supports you with the plans and goals you have for your future.				
e. You know where to go to get support for the things you need.				
f. You express your ideas, concerns, and opinions with important people in your life (such as family, partner, or friends).				

Section 2: services received

The next section focuses on services you may have received.

2.1 INTRO:

The following questions ask about services you may have received from your [PROGRAM NAME] [case manager/home visitor], from a place recommended by your [case manager/home visitor], or from another place.

2.1. In the past 12 months, did you attend any classes or sessions (individual or group) about:
	Yes	No
a. relationships, dating, or marriage		
b. parenting or how to care for your baby		
c. how to get health insurance or apply for Medicaid/MediCal for your baby		
d. where to get healthcare for your baby		
e. how to get childcare for your baby		
f. how to get health insurance or apply for Medicaid/MediCal/STAR for yourself		
g. where to get healthcare for yourself		
h. where to get food assistance and support for yourself and your baby		
i. where to find affordable housing		
j. where to get counseling or treatment for depression or anxiety		

2.2. Where did the classes or sessions about [insert 2.2 item name] take place? Check all that apply.
	With your [PROGRAM NAME] [case manager/home visitor]	At a place recommended by your [case manager/home visitor]	At another place
a. relationships, dating, or marriage			
b. parenting or how to care for your baby			
c. how to get health insurance or apply for Medicaid/MediCal for your baby			
d. where to get healthcare for your baby			
e. how to get childcare for your baby			
f. how to get health insurance or apply for Medicaid/MediCal for yourself			
g. where to get healthcare for yourself			
h. where to get food assistance and support for yourself and your baby			
i. where to find affordable housing			
j. where to get counseling or treatment for depression or anxiety			

2.3. In the past 12 months, have you participated in this education related service:
	Yes	No
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. help finding financial aid		

2.3g In the past 12 months, have you participated in any other education related services?

 Yes

 No

2.3g_spec. What is the other education related service you received in the past 12 months?

2.4. Where did you receive [insert 2.4 item name] from? Check all that apply.
	Your [PROGRAM NAME] [case manager/home visitor]	A place recommended by your [case manager/home visitor]	Another place
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			
f. help finding financial aid			
g. “[2.3G SPECIFY RESPONSE]”			

2.5e In the past 12 months, have you received any other training or job related services?

 Yes

 No

2.5e_spec. What is the other training or job related service you received in the past 12 months?

2.6. Where did you receive [insert 2.6 item name] from? Check all that apply.
	Your [PROGRAM NAME] [case manager/home visitor]	A place recommended by your [case manager/home visitor]	Another place
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. “[2.5E SPECIFY RESPONSE]”			

Section 3: LIFE EXPERIENCES

The next section focuses on your life experiences.

3.1. We will now list several things that might happen to people. Has this happened to you in the last 12 months?
	Yes	No
a. Someone in your family or you went hungry because you could not afford enough food.		
b. Someone in your family or you didn’t have enough money for housing.		
c. You got in trouble with the law, or went to jail.		
d. The person you are currently in a relationship with got in trouble with the law or went to jail.		
e. A parent, guardian, or other adult you lived with (not including the person you are currently in a relationship with), got in trouble with the law or went to jail.		
f. You were placed in foster care (removed from your home by the court or child welfare agency).		
g. You saw or heard your parents, guardians, or other adults in your home slap, hit, kick, punch, or beat each other up.		
h. A parent, guardian, or other adult you lived with had a serious drinking or drug problem.		
i. A parent, guardian, or other adult you lived with was mentally ill or suicidal, or severely depressed for more than a couple of weeks.		
j. A child of yours was placed in foster care (removed from your home by the court or child welfare agency).		

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 outside the study team.

During the past 30 days, on how many days did you smoke one or more cigarettes?

Your best estimate is fine.

 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

3.3. The next question asks about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. 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?

Your best estimate is fine.

 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

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?

Your best estimate is fine.

 0 days

 1 day

 2 days

 3 to 5 days

 6 to 9 days

 10-19 days

 20 or more days

3.5. During the past 30 days, on how many days did you use marijuana, also called weed or pot?

Your best estimate is fine.

 0 days

 1 or 2 days

 3 to 5 days

 6 to 9 days

 10 to 19 days

• 20-29 days

• All 30 days

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?

Your best estimate is fine.

 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

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?

 Yes

 No

Section 4: contraceptive knowledge and information

Great effort, you are halfway to the end-stick with it!

4.1. The next statements are about condoms. Please select whether you think the statement is true, false, or you don’t know.
	True	False	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.			

4.2. The next statements are about birth control pills. Please select whether you think the statement is true, false, or you don’t know.
	True	False	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 risk of getting a sexually transmitted disease or STD.			

4.3. Next are several statements about IUDs (such as Mirena, ParaGard, or Skyla). Please select whether you think the statement is true, false, or you don’t know.
	True	False	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.			

4.4. The last set of statements are about other forms of birth control. Please select whether you think the statement is true, false, or you don’t know.
	True	False	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 (such as Implanon or Nexplanon) or an IUD (such as 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 or an IUD can make it more difficult to become pregnant in the future when a woman is no longer using them.			

4.5 In the past 12 months, did you receive information from a doctor, nurse, case manager, home visitor, or clinic about…
	Yes	No
a. Methods of birth control, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant?		
b. Where to get birth control?		
c. Sexually transmitted diseases, also known as STDs or STIs?		

4.6. In the past 12 months, did you get any type of birth control from a doctor, nurse, case manager, home visitor, or clinic, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant?

 Yes

 No

Section 5: family and relationships

The next section focuses on family and relationships.

5.1. How much do you agree or disagree with the following statement about romantic/sexual relationships?
	Strongly Disagree	Disagree	Agree	Strongly Agree
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 problem.				

ASK 5.2 – 5.8 ONLY IF FIRST FOLLOW UP INTERVIEW WAS NOT COMPLETED. ALL OTHER GO TO 5.9

5.2. Our records show that you [had/were expecting to have] a baby [on/around/before] [BABYDATEFUP]. [Is that the date when the baby was born?/Is that correct?]

 Yes

 No, baby was born on a different date

 I lost the baby/baby died

5.2a We are sorry to hear about your loss. There are a few more questions we would like to ask you about the father of the child you lost.

5.3. On what date was the baby born?

5.4. What is the baby’s first name?

If you had multiple babies during that pregnancy, such as twins or triplets, please enter the name of the first baby born.

5.5. Is [CHILD] male or female?

 Male

 Female

5.6. Did you ever breastfeed or pump breast milk to feed [CHILD] after delivery, even for a short period of time?

 Yes

 No

5.7. Are you currently breastfeeding or feeding pumped breast milk to [CHILD]?

 Yes

 No

5.8. How old was [CHILD] when you stopped breastfeeding or giving (him/her) pumped breast milk?

You can tell us in weeks, or months. Enter the number in the box and then select whether that is weeks or months. If less than a week, enter 0 and select weeks.

 Weeks

 Months

ASK ALL:

[The next questions are about [INSESRT CHILD NAME FROM 12 MONTH FU SURVEY OR 5.4. ]

5.9. 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?

 Yes

 No

5.10. 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.

5.11. Has [CHILD] been seen by a doctor or nurse as many times as you wanted when [he/she] was sick?

 Yes

 No

5.12. In the 3 months after you had [CHILD], did you have a checkup with a doctor, nurse, or other health care worker for yourself?

 Yes

 No

5.13. Since [CHILD] was born, have you asked for help for depression from a doctor, nurse, or other health care worker?

 Yes

 No

5.14. The next questions are about health insurance. This can include private insurance, Medicaid/MediCal, or any other government program that pays for medical care.

Do you have health insurance for [CHILD]?

 Yes

 No

5.15. Do you have health insurance for yourself?

 Yes

 No

5.16. Next, please think about where you and [CHILD] currently live.

How much of the time do you live with [CHILD] in the same household?

 All of the time

 Most of the time

 Some of the time

 None of the time

5.17. Have you seen [CHILD] in the past month?

 Yes

 No

5.18. [When [CHILD] is not living with you, who]/[Who] does [CHILD] live with? Check all that apply.

 Father

 Grandparent(s)

 Other relative(s)

 Adoptive parent(s)

 Foster parent(s)

 Someone else

5.18a. You selected “someone else” in the last question. Who else does [CHILD] live with?

5.19. Since [CHILD] was born, how much of the time have you lived with [CHILD] in the same household?

 All of the time

 Some of the time

 None of the time

5.19a. Since [CHILD] was born, how many months have you lived with [CHILD] in the same household?

If your child has lived with you on and off since [his/her] birth, please count the total number of months.

5.20. The next questions are about things you may have done with [CHILD] in the past month. In the past month, how often have you…
	Every day or almost every day	A few times a week	A few times in the past month	Never in the past month
a. Played games like “peek-a-boo” or “gotcha” with [CHILD]?				
b. Sung songs with [CHILD]?				
c. Read or looked at books with [CHILD]?				
d. Played outside or at the playground with [CHILD]?				
e. Played with games or toys with [CHILD] ?				

5.21. The next questions are about your relationship with [[CHILD]’s father/him].

How much of the time do you live with him?

 None of the time

 Some of the time

 All of the time

 [CHILD]’s father died

5.21a We are sorry to hear about your loss. There are a few more questions we would like to ask you.

5.22. How would you define your current relationship status with [[CHILD]’s father/him]?

 Married to each other

 In a serious romantic relationship

 In a casual romantic relationship

 Not currently in a romantic relationship, but in regular contact

 No longer in regular contact

5.23. Taking all things together, on a scale from 1 to 5, how happy would you say your relationship [with [CHILD]’s father is/is with him]?

 1 Not at all Happy

 2

 3

 4

 5 Completely Happy

5.24. How often do you and [[CHILD]’s father/he] see or talk to each other?

 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

 Hardly ever or never

5.25. You mentioned that since [CHILD] was born, you have [always lived in same household with [CHILD]/ lived in the same household with [CHILD] for [NUMBER OF MONTHS] months/lived in the same household].

Since [CHILD] was born, how much of the time have you lived with [CHILD] and [CHILD]’s father in the same household? Was it…

 All the time

 Some of the time

 None of the time

5.25a. Since [CHILD] was born, how many months have you lived in the same household with both [CHILD] and [CHILD]’s father?

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]?

 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

 Never

5.27. MISSING - THIS QUESTION IS TX ONLY

5.28. MISSING - THIS QUESTION IS TX ONLY

5.29. MISSING - THIS QUESTION IS TX ONLY

5.30. MISSING - THIS QUESTION IS TX ONLY

Section 6: health and sexual behavior

You’re almost done, this is the last section!

6.1. Now please think of the past 3 months. In the past 3 months, have you had sexual intercourse? By sexual intercourse we mean a male putting his penis into a female’s vagina.

 Yes

 No

6.2. In the past 3 months, how many different people have you ever had sexual intercourse with, even if only one time?

6.3. In the past 3 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?

 Yes

 No

6.4. The next question is about your use of the following methods of birth control:

• Condoms

• Birth control pills

• The patch (Ortho Evra)

• The shot (Depo-Provera)

• The ring (NuvaRing)

• IUD (Mirena, ParaGard, or Skyla)

• Implant (Implanon or Nexplanon)

In the past 3 months, how many times did you have sexual intercourse without using any of these methods of birth control?

Your best estimate is fine.

6.5. Now please think about the past 12 months. In the past 12 months, did you use any of the following methods of birth control?

Check all that apply.

 Condoms

 Birth control pills

 The patch, such as Ortho Evra

 The shot, such as Depo-Provera or other injectable birth control

 The ring, such as NuvaRing

 An IUD, such as Mirena, ParaGard, or Skyla

 An implant, such as Implanon or Nexplanon

 Another method of birth control (SPECIFY)

 None of these methods

6.5a. What was the other method of birth control you used in the past 12 months?

6.6. Which birth control methods are you currently using? Check all that apply.

 Condoms

 Birth control pills

 The patch, such as Ortho Evra

 The shot, such as Depo-Provera or other injectable birth control

 The ring, such as Nuvaring

 An IUD, such as Mirena, ParaGard, or Skyla

 An implant, such as Implanon or Nexplanon

 [FILL SPECIFY RESPONSE FROM 6.5A]

 Not currently using any method

6.7. The next few questions are about pregnancy. [Since [CHILD] was born / Since you lost your child], have you been pregnant?

 Yes

 No

6.8. [Since [CHILD] was born / Since you lost your child], how many times have you been pregnant, even if no baby has been born?

If you are currently pregnant, please include your current pregnancy.

6.9. Are you currently pregnant?

 Yes

 No

6.10. When is your baby’s due date?

6.11. Since [[CHILD] was born / you lost your child], have you had another baby?

 Yes

 No

6.12. When was your most recent baby born?

6.13. [After your current pregnancy, do] [Do] you ever want to have any more children?

 Yes

 No

6.14. How soon would you like to have your next child?

 Within the next year

 One year from now

 Two years from now

 Three years from now

 Four or more years from now

7.1. Thank you for your participation in the PAF follow up survey. We would like to request your permission to access information about your participation in the program offered by [PROGRAM NAME]. This would include the number of visits you had with your case manager and referrals they made for you. This would also include information your case manager used to assess your progress. This information will be combined with information from all other study participants. Your name will not be attached to the program data. No one outside the study team will see your records.

This data is important to better understand how the programs operate and help parenting youth, like yourself.

Do we have your permission to access this program data?

 Yes

 No

7.2. We will be sending you a $25 gift card in the next few weeks to thank you for completing the survey. What is the best address where we can mail your gift card to you?

Street Address 1/PO BOX:

Address 2 or Apt:

City:

State/Territory Abbreviation:

Zipcode:

SUBMIT.

You have reached the end of the survey. You will receive a gift card within the next few weeks to thank you for completing the survey!

Please select the Submit button below and then click Next to submit your survey.

PAF 24 Month Follow Up – 4/1/16 1

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Pregnancy Assistance Fund Baseline Survey
Subject	SAQ
Author	MATHEMATICA STAFF
File Modified	0000-00-00
File Created	2021-01-23