Instrument 1 - Participant Entry Survey

INSTRUMENT 1

SRAE PARTICIPANT ENTRY SURVEY QUESTIONS

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PARTICIPANT ENTRY SURVEY QUESTIONS

Thank you for your help with this important study. This survey includes questions about your family, friends, school, and also your attitudes and behaviors. Your name will not be on the survey and your responses will remain private to the extent permitted by law. We want you to know that:

1. Your participation in this survey is voluntary.

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

3. The answers you give will be kept private to the extent permitted by law.

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 8 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. The information collected will help policy makers, program providers and other stakeholders understand the experiences of youth today and identify ways to reduce risky behaviors. This information will also inform programs on how best to serve their participants. The collection of this information is voluntary and responses will be kept private to the extent allowed by law. The OMB number for this information collection is XXXX-XXXX and the expiration date is XX/XX/XXXX.

General Instructions

PLEASE READ EACH QUESTION CAREFULLY: There are different ways to answer the questions in this survey. It is important that you follow the instructions when answering each kind of question. Here are some examples.

• PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED.

• USE A PEN OR PENCIL.

1. EXAMPLE 1: MARK ONLY ONE ANSWER

What is the color of your eyes?

MARK ONLY ONE ANSWER

Brown

Blue

Green

Another color

2. EXAMPLE 2: MARK ALL THAT APPLY

Do you plan to do any of the following next week?

If you plan to rent a movie and go to a baseball game next week, you would mark (X) both boxes.

MARK ALL THAT APPLY

Watch a movie

Go to a baseball game

Study at a friend’s house

Please answer the following questions as best you can. This first set of questions are about you.

1. How old are you?

MARK ONLY ONE ANSWER

□ 10

□ 11

□ 12

□ 13

□ 14

□ 15

□ 16

□ 17

□ 18

□ 19

□ 20

2. What grade are you in? (If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)

MARK ONLY ONE ANSWER

□ 4th

□ 5th

□ 6th

□ 7th

□ 8th

□ 9th

□ 10th

□ 11th

□ 12th

□ My school does not assign grade levels

□ I dropped out of school, and I am not working on getting a high school diploma or GED

□ I am working towards a GED

□ I have a high school diploma/GED but I am not currently enrolled in college/technical school

□ I have a high school diploma/GED and I am currently enrolled in college/technical school

3. When you are at home or with your family, what language or languages do you usually speak?

mark all that apply

□ English

□ Spanish

□ Other (please specify)

4. What is your race?

MARK ONE OR MORE

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White or Caucasian

5. Are you Hispanic or Latino?

MARK ONLY ONE ANSWER

□ Yes

□ No

6. Which of the following best represents how you think of yourself?

MARK ONLY ONE ANSWER

□ Straight, that is not gay or lesbian

□ Gay or lesbian

□ Bisexual

□ Something else (specify): _________________________

□ Not sure

□ I choose not to answer this question.

7. What is your sex?

MARK ONLY ONE ANSWER

□ Male

□ Female

8. Are you currently …?

MARK ALL THAT APPLY

□ In foster care, living with a family

□ In foster care, living in a group home, independent living

□ Couch surfing or moving from house to house

□ Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle or in an abandoned building

□ Staying in an emergency shelter or transitional living program

□ Staying in a hotel or motel

□ In juvenile detention, jail, prison, or other correctional facility, or under the supervision of a probation officer

□ None of the above

The next questions ask about alcohol, tobacco, and other substance use. Remember, all of your responses will be kept private.

9. In the past three months, have you ...

MARK ONLY ONE ANSWER PER ROW
	Yes	No
drank alcohol (more than a few sips, including beer, wine, and liquor)? ………………………………………
smoked cigarettes? …………………………………..
smoked cigars, cigarillos, or little cigars? …............
used other tobacco products (such as chewing tobacco, snuff, dip, or snus)? ………………………
e. used electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? (electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, hookahs, hookah pens, and mods) ..………..
f. used marijuana (also called pot, weed, or cannabis)?
g. taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it? ………………………………………………...

10. In the past three months, how often would you say you…

MARK ONLY ONE ANSWER PER ROW
	All of the Time	Most of the Time	Some of the Time	None of the Time
resisted or said no to peer pressure?
b. managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)?
c. worked together to find a solution when you disagreed with a friend?
d. chose to spend time with friends that keep you out of trouble?
e. were respectful to others?
f. thought about the consequences before making a decision?

11. For each of the items below, please mark how true each statement is of you.

MARK ONLY ONE ANSWER PER ROW
	Not true at all	Somewhat true of me	Very true of me
a. I make plans to reach my goals ……………………………
b. I care about doing well in school …………………………
c. I save money to get something I want …………
d. I plan to graduate high school or get my GED
e. I plan to get more education and/or training after high school or completing my GED …………………………
f. I plan to get a steady job after school …………………
g. I feel comfortable talking to my parent, guardian, or caregiver about sex. ……………………………………
h. I would speak up or ask for help if I was being bullied in person. …………………………………………………...
i. I would speak up or ask for help if I was being bullied online, via text, while gaming, or through other social media.

12. For each of the items below, please mark how true each statement is of you.

MARK ONLY ONE ANSWER PER ROW
	Not true at all	Somewhat true of me	Very true of me
I understand what makes a relationship healthy …
I look for information and resources about dating violence (for example, websites, social media, hotlines, organizations, etc.) ………………………
I would be able to resist or say no to someone I am dating or going out with if they pressured me to participate in sexual acts, such as kissing, touching private parts, or sex ………………………………
I would talk to a friend if someone I am dating or going out with makes me uncomfortable, hurts me, or pressures me to do things I don’t want to do ……
I would talk to a trusted adult (for example, a family member, teacher, counselor, coach, etc.) if someone I am dating or going out with makes me uncomfortable, hurts me, or pressures me to do things I don’t want to do ……………………………
I would talk to a trusted adult if someone other than the person I am dating or going out with makes me uncomfortable, hurts me, or pressures me to do things I don’t want to do............................

13. For each of the items below, please mark how true each statement is of you.

MARK ONLY ONE ANSWER PER ROW
	Not true at all	Somewhat true of me	Very true of me
a. I plan to delay having sex until I graduate high school or receive my GED …………………………………………
b. I plan to delay having sex until I graduate college or complete another education or training program. ………
c. I plan to delay having sex until I am married. ……………
d. I plan to be married before I have a child. ………………
I plan to have a steady full time job before I get married.
I plan to have a steady full time job before I have a child.

The next questions ask about some personal behaviors, including sex and pregnancy. Remember, all of your responses will be kept private.

14. Have you ever kissed someone on the mouth who is not a member of your family?

MARK ONLY ONE ANSWER

□ Yes

□ No

15. Have you ever touched another person’s private parts or let someone touch your private parts? By private parts, we mean parts covered by underwear or a bra.

MARK ONLY ONE ANSWER

□ Yes

□ No

16. Have you ever had sexual intercourse?

MARK ONLY ONE ANSWER

□ Yes

□ No

17. To the best of your knowledge, have you ever been pregnant or gotten someone else pregnant?

MARK ONLY ONE ANSWER

□ Yes

□ No

□ Not Sure

18. Have you ever been told by a doctor or other medical provider that you had a sexually transmitted infection (STI)?

MARK ONLY ONE ANSWER

□ Yes

□ No

Thank you for participating in this survey!

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