Exit Survey (Instrument 2)

Collection of Performance Measures - Personal Responsibility Education Program (PREP)

Instrument 2_PREP Participant Exit Survey_AsstSecApproved_040519_CLEAN_053119

Exit Survey (Instrument 2)

OMB: 0970-0497

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INSTRUMENT 2

prep participant Exit Survey

May 31, 2019





Form approved

OMB Control No:

Expiration Date:



PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP)

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PARTICIPANT EXIT 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.

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 15 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 0970-0497and the expiration date is XX/XX/XXXX.

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.

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

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X

Brown

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If the color of your eyes is brown, you would mark (X) the first box as shown.

Blue

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Green

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Another color

2. EXAMPLE 2: MARK ALL THAT APPLY

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

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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

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X

Watch a movie

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X

Go to a baseball game

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Study at a friend’s house



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  • Because you answered “Yes” to question 1, you would continue to question 2 and then question 3.

  • If you answered “No” to question 1, you would skip question 2 and go right to question 3.

  • 1.

3. EXAMPLE 3: QUESTION WITH A SKIP

Do you ever eat chocolate?

MARK (X) ONE

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X

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No GO TO QUESTION 3

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2.

Do you always brush your teeth after eating chocolate?

MARK (X) ONE

Yes

No

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3.

Did you do any of the following last week?

MARK ALL THAT APPLY

Went to a play

Went to a movie

Attended a sporting event


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

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1.

How old are you?

MARK ONLY ONE ANSWER

10

11

12

13

14

15

16

17

18

19

20

21 or older

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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 toward a GED

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

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

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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)

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4.

What is your race?

MARK ALL THAT APPLY

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

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5.

Are you Hispanic or Latino?

MARK YES OR NO

Yes

No

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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

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7.

What is your sex?

Male

Female


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8.

Are you currently…?

MARK ALL THAT APPLY

In foster care, living with a family

In foster care, living in a group home

Couch surfing or moving from home to home

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 motel or hotel

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

None of the above

For questions 9 – 13, please think about how the program you just completed has affected you, even if your program did not cover the topic.

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9.

9. Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

MARK ONLY ONE ANSWER PER ROW







Much more likely

Somewhat more likely

About the same

Somewhat less Likely

Much less likely

a. resist or say no to peer pressure?

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b. manage your emotions in healthy ways (for example, ways that are not hurtful to you or others)?

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c. work together to find a solution when you disagree with a friend?

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d. choose to spend time with friends that keep you out of trouble?

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e. make decisions to not use drugs and alcohol?

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f. be respectful toward others?

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g. think about the consequences before making a decision?

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10.

Has being in the program made you more likely, about the same, or less likely to…(Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

MARK ONLY ONE ANSWER PER ROW







Much more likely

Somewhat more likely

About the same

Somewhat less Likely

Much less likely

a. make plans to reach your goals?

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b. care about doing well in school?

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c. graduate high school or get your GED?

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d. get more education or training after high school or completing your GED?

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e. get a steady full-time job after school? .....................

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11.

Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

MARK ONLY ONE ANSWER PER ROW







Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely

a. save money to get things you want

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b. feel confident about how to open a bank account

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c. feel confident about how to prepare a budget

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d. feel confident about how to track your expenses

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e. understand the costs associated with raising a child

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12.

12. Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

MARK ONLY ONE ANSWER PER ROW







Much more likely

Somewhat more likely

About the same

Somewhat less Likely

Much less likely

a. talk with your parent, guardian, or caregiver about things going on in your life?

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b. talk with your parent, guardian, or caregiver about sex?

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c. feel comfortable talking with your parent, guardian, or caregiver about sex?

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d. speak up or ask for help if you are being bullied in person or online, via text, while gaming, or through other social media?

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e. speak up or ask for help if others are being bullied in person or online, via text, while gaming, or through other social media?

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13.

Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

MARK ONLY ONE ANSWER PER ROW







Much more likely

Somewhat more likely

About the same

Somewhat less Likely

Much less likely

a. better understand what makes a relationship healthy?

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b. look for information and resources about dating violence (for example, websites, social media, hotlines, organizations, etc.)?

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c. resist or say no to someone you are dating or going out with if they pressure you to participate in sexual acts, such as kissing, touching private parts, or sex? ……………..

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d. talk to a friend if someone you are dating or going out with makes you uncomfortable, hurts you or pressures you to do things you don’t want to do?

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e. talk to a trusted adult (for example, a family member, teacher, counselor, coach, etc.) if someone you are dating or going out with makes you uncomfortable, hurts you, or pressures you to do things you don’t want to do?

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f. talk to a trusted adult if someone other than the person you are dating or going out with makes you uncomfortable, hurts you or pressures you to do things you don’t want to do?

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14.

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 sexual intercourse until I graduate high school or receive my GED

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b. I plan to delay having sexual intercourse until I graduate college or complete another education or training program

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c. I plan to delay having sexual intercourse until I am married

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d. I plan to be married before I have a child

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e. I plan to have a steady full-time job before I get married

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f. I plan to have a steady full-time job before I have a child

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The next questions ask about sexual intercourse.

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15.

As a result of being in the program, are you planning to abstain from sexual intercourse (choose to not have sexual intercourse) for at least the next 3 months?

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Yes GO TO QUESTION 16

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No GO TO QUESTION 17, NEXT PAGE

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Not sure GO TO QUESTION 17, NEXT PAGE

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16.

How important are each of these reasons in your decision to not have sexual intercourse for at least the next 3 months? (Note: Do not answer this question if you responded “No” or “Not sure” to question 15.)

MARK ONLY ONE ANSWER PER ROW



Not at all important

Not too important

Somewhat important

Very important

a. how it might affect your plans for the future

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b. the possible emotional consequences (for example, feeling sadness or regret)

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c. the possible social consequences (for example, get a bad reputation or have rumors spread about you, have to deal with drama, make your relationship with someone you are dating or going out with worse, or get in trouble with your parents)

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d. the risk of getting a sexually transmitted infection (STI)

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e. the risk of getting pregnant or getting someone pregnant

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I F YOU ANSWERED QUESTION 16, GO TO QUESTION 18

IF YOU ANSWERED “NO” OR “NOT SURE” TO QUESTION 15: SKIP QUESTION 16 AND GO TO QUESTION 17 ON THE NEXT PAGE


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17.



The next few questions refer to sexual intercourse and your risk of pregnancy and sexually transmitted infections (STIs). Remember, all of your responses will be kept private. (Note: Do not answer this question if you responded “Yes” to question 15.)

Has being in the program made you more likely, about the same, or less likely to…(Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

  1. have sexual intercourse in the next 3 months?

MARK ONLY ONE ANSWER

Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely

b. use (or ask your partner to use) a condom if you were to have sexual intercourse in the next 3 months?

MARK ONLY ONE ANSWER

This question does not apply to me because I choose to not have sexual intercourse
in the next 3 months

Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely

c. use (or ask your partner to use) birth control OTHER than condoms if you were to have sexual intercourse in the next 3 months? By birth control, we mean methods that can prevent pregnancy, like using birth control pills, the shot, the patch, the ring, IUD, or implant.

MARK ONLY ONE ANSWER

This question does not apply to me because I choose to not have sexual intercourse
in the next 3 months

Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely




The next questions ask you about your experiences in the program that you just completed. Think about all of the sessions or classes of the program that you attended.

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18.

Even if you didn’t attend all of the sessions or classes in this program, how often in this program

MARK ONLY ONE ANSWER PER ROW



All of the Time

Most of the Time

Some of the Time

None of the Time

a. did you feel interested in program sessions and classes?

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b. did you feel the material presented was clear?

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c. did discussions or activities help you to learn program lessons?

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d. did you have a chance to ask questions about topics or issues that came up in the program?

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e. did you feel respected as a person?

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f. were you picked on, teased, or bullied in this program?

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19.

Now thinking about all youth in this program, how often…

MARK ONLY ONE ANSWER PER ROW



All of the Time

Most of the Time

Some of the Time

None of the Time

a. were any youth in this program picked on, teased, or bullied because people thought they were lesbian, gay, bisexual, or transgender?

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b. were any youth in this program picked on, teased, or bullied because of their race or ethnic background?

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20.

Thinking about the program, how satisfied are you with…

MARK ONLY ONE ANSWER PER ROW



Very satisfied

Somewhat satisfied

A little satisfied

Not at all satisfied

a. the amount of information you received about abstaining from sex (choosing to not have sex)?

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b. the amount of information you received about condoms and birth control?

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Thank you for participating in this survey!

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePREP ENTRY-EXIT SURVEY
SubjectNON STANDARD SAQ
AuthorMATHEMATICA STAFF
File Modified0000-00-00
File Created2021-01-11

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