Self-Regulation Training Approaches and Resources to Improve Staff Capacity for Implementing Healthy Marriage Services for Youth (SARHM)

INSTRUMENT 5: youth questionnaire MATHEMATICA POLICY RESEARCH

O MB No.: 0970-0355

Expiration Date: 05/31/2021

Youth Questionnaire

Self-Regulation Approaches and Resources in Healthy Marriage programs (SARHM)

Youth Questionnaire

The purpose of this survey is to better understand the ways in which [HMRE program name] has helped you manage your thoughts, feelings, and behaviors to achieve your goals. We are also interested in learning what you thought of the program. Before you start the survey, we want you to know that:

1. Participation in this information collection is voluntary.

2. Your responses will remain private. Please do not include any personal information, such as your name or contact information, on this form.

3. The survey will take about 15 minutes to complete.

4. We hope you will answer all of the questions, but you may skip any questions you do not wish to answer.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is 0970-0355, expiring 51/31/2021. We estimate that it will take about 15 minutes to read the instructions and answer the questions.

A. What I learned

The following items ask about what you learned from participating in [HMRE program name].

A1. Please select one answer for each item:

	SELECT ONE RESPONSE PER ROW
In this program…	I didn’t learn anything about this	I learned a little about this	I learned some things about this	I learned a great deal about this
a. I learned ways to control my feelings.	1 □	2 □	3 □	4 □
b. I learned ways to control my behaviors.	1 □	2 □	3 □	4 □
c. I learned how to focus on other things, even when I’m upset.	1 □	2 □	3 □	4 □
d. I learned how to get things done, even when I’m upset.	1 □	2 □	3 □	4 □
e. I learned ways to make myself feel better when I’m upset.	1 □	2 □	3 □	4 □
f. I learned ways to make myself feel better when I’m feeling overwhelmed and out of control.	1 □	2 □	3 □	4 □
g. I learned how to label and describe my feelings.	1 □	2 □	3 □	4 □
h. I learned how to pay attention to my feelings.	1 □	2 □	3 □	4 □
i. I learned how to accept how I am feeling.	1 □	2 □	3 □	4 □
j. I learned how to see things from someone else’s point of view.	1 □	2 □	3 □	4 □
k. I learned how to look at everybody’s side of a disagreement before making a decision.	1 □	2 □	3 □	4 □
l. I learned ways to calm down when I’m upset with someone.	1 □	2 □	3 □	4 □
m. I learned how to take a time out before I get angry with someone.	1 □	2 □	3 □	4 □
n. I learned ways to prevent arguments from getting worse.	1 □	2 □	3 □	4 □
o. I learned how to set goals.	1 □	2 □	3 □	4 □
p. I learned how to be a better listener.	1 □	2 □	3 □	4 □
q. I learned how to use words to let others know how I am feeling.	1 □	2 □	3 □	4 □
r. I learned how to develop step-by-step plans to reach my goals.	1 □	2 □	3 □	4 □
s. I learned that what I do now may impact my relationships in the future.	1 □	2 □	3 □	4 □
t. I learned that what I do now may impact my education and career in the future.	1 □	2 □	3 □	4 □

Adapted from Difficulties in Emotion Regulation Scale, Gratz and Roemer 2004; Interpersonal Reactivity Index, Davis 1980; Conflict Tactics Scale; Feldman and Gowen 1998, Goal Orientation Scale, Lippman et al. 2014.

B. Program Impressions

The following items ask what you thought about the [HMRE program name]. Please be honest. Remember, your names will not be shared with anyone from [HMRE program name].

B1. As you read the items below, please think about the [staff title] you’ve worked with the most during the program. Please select one answer for each item:

	SELECT ONE RESPONSE PER ROW
In this program…	Strongly Disagree	Disagree	Agree	Strongly Agree
a. My [staff title] can tell when I’m upset about something.	1 □	2 □	3 □	4 □
b. My [staff title] helps me to understand myself better.	1 □	2 □	3 □	4 □
c. I can tell my [staff title] about my problems and troubles.	1 □	2 □	3 □	4 □
d. If my [staff title] knows something is bothering me, he or she asks me about it.	1 □	2 □	3 □	4 □
e. My [staff title] knows me well.	1 □	2 □	3 □	4 □
f. My [staff title] cares about what I think.	1 □	2 □	3 □	4 □
g. My [staff title] understands my problems.	1 □	2 □	3 □	4 □
h. My [staff title] is available if I need to talk with him or her.	1 □	2 □	3 □	4 □
i. My [staff title] cares about me.	1 □	2 □	3 □	4 □
j. My [staff title] makes me feel good about myself.	1 □	2 □	3 □	4 □
k. My [staff title] wants me to be successful.	1 □	2 □	3 □	4 □

Adapted from Inventory of Parent and Peer Attachment, Armsden and Greenberg 1987; Youth-Mentor Relationship Questionnaire, Rhodes et al. 2005; ED School Climate Survey; U.S. Department of Education 2018

B2. The following items ask about [HMRE program name]. Please select one answer for each item:

	SELECT ONE RESPONSE PER ROW
In this program…	Strongly Disagree	Disagree	Agree	Strongly Agree
a. People in this program respect one another.	1 □	2 □	3 □	4 □
b. If I a miss a workshop, someone will notice.	1 □	2 □	3 □	4 □
c. In this program, I can sometimes decide activities and rules.	1 □	2 □	3 □	4 □
d. In this program, I can be a part of discussions or activities.	1 □	2 □	3 □	4 □
e. People in this program get along well with each other.	1 □	2 □	3 □	4 □
f. In this program, we talk about understanding how we feel and how other people feel.	1 □	2 □	3 □	4 □
g. In this program, we work on listening to others to understand what they are trying to say.	1 □	2 □	3 □	4 □
h. I am happy to be in this program.	1 □	2 □	3 □	4 □
i. I feel like an important part of this program.	1 □	2 □	3 □	4 □
j. In this program, I feel like I can be myself.	1 □	2 □	3 □	4 □

Adapted from ED School Climate Survey; U.S. Department of Education 2018

Thank you for taking the time to complete this survey.