Form Approved
OMB No: 0920-XXXX
Exp. Date: XX/XX/XXXX
“Promoting Adolescent Health through School-Based HIV Prevention”
Attachment 4
Priority School Questionnaire Items
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Enter the total student enrollment for [Priority School] according to the district’s latest official Fall Enrollment/Membership Report (excluding grades K-5):________________
Currently, does [Priority School] use the district-approved scope and sequence to guide health education that includes specific sexual health education learning outcomes and content for grades 6, 7, or 8? (Choose one)
Yes
No
There is no district-approved scope and sequence.
Unsure
[If yes to Q2, skip to Q3]
2A. If B, C, or D are selected, does [Priority School] use any of the following materials to guide sexual health education? (Check YES or NO for each)
A school-specific scope and sequence that includes sexual health education content and knowledge/skills expectations
A scope and sequence which was provided with a commercial sexual health education instructional program
Teacher pacing guides for sexual health education instruction
Other (specify):
Currently, does [Priority School] use the district-approved scope and sequence to guide health education that include specific sexual health education learning outcomes content for grades 9, 10, 11, or 12? (Choose one)
Yes
No
There is no district-approved scope and sequence
Unsure
[If yes to Q3, skip to Q4]
3A. If B, C, or D are selected, does [Priority School] use any of the following materials to guide sexual health education? (Check YES or NO for each)
A school-specific scope and sequence that includes sexual health education content and knowledge/skills expectations
A scope and sequence which was provided with a commercial sexual health education instructional program
Teacher pacing guides for sexual health education instruction
Other (specify):
During the past 6 months, in what setting does [Priority School] deliver sexual health education instruction to students in grades 6, 7, or 8? (Check YES or NO for each)
As part of a required health or physical education course
As part of an elective health education course
During out-of-school time (e.g., after school programming)
Other (specify):
During the past 6 months, in what setting does [Priority School] deliver sexual health education instruction to students in grades 9, 10, 11, or 12? (Check YES or NO for each)
As part of a required health or physical education course
As part of an elective health education course
During out-of-school time (e.g., after school programming)
Other (specify):
During the past 6 months, did teachers in [Priority School] teach the following sexual health education topics in a required or recommended course for students in grades 6, 7, or 8? (Check YES or NO for each)
How HIV and other STDs are transmitted
Health consequences of HIV, other STDs, and pregnancy
The benefits of being sexually abstinent
How to access valid and reliable health information, products, and services related to HIV, other STDs, and pregnancy
The influences of family, peers, media, technology and other factors on sexual risk behaviors
Communication and negotiation skills related to eliminating or reducing risk for HIV, other STDs, and pregnancy
Goal-setting and decision-making skills related to eliminating or reducing risk for HIV, other STDs, and pregnancy
Influencing and supporting others to avoid or reduce sexual risk behaviors
Efficacy of condoms, that is, how well condoms work and do not work
The importance of using condoms consistently and correctly
How to obtain condoms
How to correctly use a condom
Methods of contraception other than condoms
The importance of using a condom at the same time as another form of contraception to prevent both STDs and pregnancy
How to communicate sexual consent between partners
How to create and sustain healthy and respectful relationships
Recognizing and responding to sexual victimization and violence
The importance of limiting the number of sexual partners
Preventive care (such as screenings and immunizations) that is necessary to maintain reproductive and sexual health
Diversity of sexual orientations and gender identities
How gender roles and stereotypes affect goals, decision making, and relationships
The relationship between alcohol and other drug use and sexual risk behaviors
During the past 6 months, did teachers in [Priority School] teach the following sexual health education topics in a required or recommended course for students in grades 9, 10, 11, or 12? (Check YES or NO for each)
How HIV and other STDs are transmitted
Health consequences of HIV, other STDs, and pregnancy
The benefits of being sexually abstinent
How to access valid and reliable health information, products, and services related to HIV, other STDs, and pregnancy
The influences of family, peers, media, technology and other factors on sexual risk behaviors
Communication and negotiation skills related to eliminating or reducing risk for HIV, other STDs, and pregnancy
Goal-setting and decision-making skills related to eliminating or reducing risk for HIV, other STDs, and pregnancy
Influencing and supporting others to avoid or reduce sexual risk behaviors
Efficacy of condoms, that is, how well condoms work and do not work
The importance of using condoms consistently and correctly
How to obtain condoms
How to correctly use a condom
Methods of contraception other than condoms
The importance of using a condom at the same time as another form of contraception to prevent both STDs and pregnancy
How to communicate sexual consent between partners
How to create and sustain healthy and respectful relationships
Recognizing and responding to sexual victimization and violence
The importance of limiting the number of sexual partners
Preventive care (such as screenings and immunizations) that is necessary to maintain reproductive and sexual health
Diversity of sexual orientations and gender identities
How gender roles and stereotypes affect goals, decision making, and relationships
The relationship between alcohol and other drug use and sexual risk behaviors
During the past 6 months, did teachers in [Priority School] assess the ability of students to do the following in a required or recommended course in grades 6, 7, or 8? (Check YES or NO for each)
Comprehend concepts important to prevent HIV, other STDs, and pregnancy
Analyze the influence of family, peers, culture, media, technology, and other factors on sexual risk behaviors
Access valid information, products, and services to prevent HIV, other STDs, and pregnancy
Use interpersonal communication skills to avoid or reduce sexual risk behaviors
Use decision-making skills to prevent HIV, other STDs, and pregnancy
Set personal goals that enhance health, take steps to achieve these goals, and monitor progress in achieving them
Practice health-enhancing behaviors to avoid or reduce HIV, other STD, and unintended pregnancy
Advocate for self and others to avoid or reduce sexual risk behaviors
During the past 6 months, did teachers in [Priority School] assess the ability of students to do the following in a required or recommended course in grades 9, 10, 11, or 12? (Check YES or NO for each)
Comprehend concepts important to prevent HIV, other STDs, and pregnancy
Analyze the influence of family, peers, culture, media, technology, and other factors on sexual risk behaviors
Access valid information, products, and services to prevent HIV, other STDs, and pregnancy
Use interpersonal communication skills to avoid or reduce sexual risk behaviors
Use decision-making skills to prevent HIV, other STDs, and pregnancy
Set personal goals that enhance health, take steps to achieve these goals, and monitor progress in achieving them
Practice health-enhancing behaviors to avoid or reduce HIV, other STD, and unintended pregnancy
Advocate for self and others to avoid or reduce sexual risk behaviors
During the past 6 months, did [Priority School] deliver a sexual health education instructional program in grades 6, 7, or 8? (Check YES or NO)
[If no to Q10, skip to Q11]
10A. If yes, which of the following components did the sexual health education instructional program(s) include? (Check YES or NO for each)
Learning objectives and outcomes
Planned progression of learning experiences
Continuity between lessons or learning experiences focused on maintaining health-enhancing skills
Relevant and appropriate content and materials
Assessment strategies
[If no to Q10A, skip to Q10C]
10B.
If yes to Question 10,
did [Priority School] deliver a sexual health education instructional
program that was locally
developed?
(Check YES or NO)
10B.1) If yes to Question 10B, specify the name(s) of the curriculum/instructional program and enter the number students reached by each program
Name of locally developed program #1:
Number of students reached by locally developed program #1:
Name of locally developed program #2
Number of students reached by locally developed program #2
Name of locally developed program #3
Number of students reached by locally developed program #3
Name of locally developed program #4
Number of students reached by locally developed program #4
Name of locally developed program #5
Number of students reached by locally developed program #5
10C. What sexual health instructional program(s) was delivered in [Priority School] for grades 6, 7, or 8? (Check all that apply and enter the number of students reached by each instructional program delivered.)
Be Proud! Be Responsible!
Family Life and Sexual Health (FLASH) 4/5/6
Family Life and Sexual Health (FLASH) 7/8
Health Smart Middle/High School: Abstinence, Puberty & Personal Health
Making Proud Choices! A Safer-sex Approach to HIV/STDs and Teen Pregnancy Prevention
Michigan Model for Health: Healthy and Responsible Relationships: HIV, Other STI, and Pregnancy Prevention
Pearson Sexual Health Curriculum
Project AIM (Adult Identity Mentoring)
Reducing the Risk: Building Skills to Prevent Pregnancy, STD & HIV
Rights, Respect, Responsibility (3R’s)
Teen Outreach Program (TOP)
10D. Did [Priority School] deliver any other sexual health education instructional programs for grades 6, 7, or 8? (Check YES or NO)
[If no to Q10D, skip to Q11]
10D.1. If yes to Question 10D, provide the name(s) of the other program and number of students reached:
Name of program #1:
Number of students reached by program #1:
Name of program #2
Number of students reached by program #2
Name of program #3
Number of students reached by program #3
Name of program #4
Number of students reached by program #4
Name of program #5
Number of students reached by program #5
During the past 6 months, did [Priority School] deliver a sexual health education instructional program in grades 9, 10, 11, or 12? (Check YES or NO)
[If no to Q11, skip to Q12]
11A. If yes, which of the following components does the sexual health education instructional program include for grades 9, 10, 11, or 12? (Check YES or NO for each)
Learning objectives and outcomes
Planned progression of learning experiences
Continuity between lessons or learning experiences focused on maintaining health-enhancing skills
Relevant and appropriate content and materials
Assessment strategies
11B.
If yes to Question 11, did
[Priority School] deliver a sexual health education instructional
program that was locally
developed for grades 9, 10, 11, or 12?
(Check YES or NO).
[If no to Q11B, skip to Q11C]
11B.1. If yes to Question 11B, specify the name(s) of the curriculum/instructional program and enter the number students reached by each program:
Name of locally developed program #1:
Number of students reached by locally developed program #1:
Name of locally developed program #2
Number of students reached by locally developed program #2
Name of locally developed program #3
Number of students reached by locally developed program #3
Name of locally developed program #4
Number of students reached by locally developed program #4
Name of locally developed program #5
Number of students reached by locally developed program #5
11C. What sexual health instructional programs were delivered by [Priority School] for grades 9, 10, 11, or 12? (Check all that apply and enter the number of students reached by each instructional program delivered.)
Aban Aya Youth Project
Adult Identity Mentoring (Project AIM)
All4You!
Be Proud! Be Responsible!
Be Proud! Be Responsible! Be Protective!
Becoming a Responsible Teen (BART)
Big Decisions
Comprehensive Health Textbook and Curriculum Guidance
¡Cuídate!
Family Life and Sexual Health (FLASH) 9-12
FOCUS
Focus on Youth + IMPACT
Game Plan
Get Real about AIDS: An Adolescent STD/HIV/AIDS Prevention Program
Heritage Keepers Abstinence Education
Love Notes
Making a Difference!
Making Proud Choices! A Safer-sex Approach to HIV/STDs and Teen Pregnancy Prevention
Michigan Model for Health: Healthy and Responsible Relationships: HIV, Other STI, and Pregnancy Prevention
Peer Health Exchange
Positive Prevention – HIV/STD Prevention Education for California Youth
Positive Prevention – PLUS – HIV/STD Prevention Education for California Youth
Promoting Health among Teens! Abstinence-Only Intervention (formally 'Promoting Health among Teens!')
Promoting Health among Teens! Comprehensive Abstinence and Safer Sex Intervention (formally ‘Comprehensive Abstinence and Safer Sex Intervention!')
Reducing the Risk: Building Skills to Prevent Pregnancy, STD & HIV
RESPECT
Rights, Respect, Responsibility (3R’s)
Safer Choices: Preventing HIV, Other STD, and Pregnancy – Level 2
Safer Sex
Teen Health Project
Teen Outreach Program (TOP)
11D. Did [Priority School] deliver other sexual health education instructional program(s) for grades 9, 10, 11, or 12? (Check YES or NO)
[If no to Q11D, skip to Q12]
11D.1. If yes to Question 11D, provide the name(s) of the other program(s) and enter the number of students reached:
Name of program #1:
Number of students reached by program #1:
Name of program #2
Number of students reached by program #2
Name of curriculum #3
Number of students reached by program #3
Name of program #4
Number of students reached by program #4
Name of program #5
Number of students reached by program #5
Currently, does the [Priority School] have a School Health Advisory Council (SHAC) or similar advisory committee/council/team in place? (Check YES or NO)
[If no to Q12, skip to Q13]
12A. If yes, during the past 6 months, which of the following activities has the SHAC or similar committee/council/team completed? (Check YES or NO for each)
Identified student sexual health needs based on relevant data
Communicated the importance of sexual health education instructional programs, policies, and activities to district administrators, school administrators, teachers and curriculum staff, parents, and community partners
Assessed the availability of sexual health education instructional programs and opportunities for students
Recommended new or revised sexual health education instructional programs, policies, and activities to school administrators or the school improvement plan teams
Developed a written plan for delivering a sexual health education instructional program for students in the district
Leveraged resources to support sexual health education priorities for students and staff
During the past 6 months, did [Priority School] implement a condom availability program that allowed students to obtain condoms? (Check YES or NO)
During the past 6 months, did [Priority School] implement any school-wide, student-planned marketing campaigns that promote recommended sexual health services for teens? (Check YES or NO)
During the past 6 months, how many referrals did [Priority School] designated school staff provide to students for sexual health services? (Enter the number of referrals)
During the past 6 months, did [Priority School] provide students with referrals to any organizations or health care professionals not on school property for the following services? (Check YES or NO for each)
HIV testing
STD testing
Pregnancy testing
Provision of condoms
Provision of condom-compatible lubricants (i.e., water- or silicone-based);
Provision of contraceptives other than condoms (e.g., birth control pill, birth control shot, intrauterine device [IUD])
Human papillomavirus (HPV) vaccine administration
During the past 6 months, did any staff at [Priority School] receive professional development on any of the following: (Check YES or NO for each)
Classroom management best practices (e.g., social skills training, environmental modification, conflict resolution and mediation, and behavior management)
How to support lesbian, gay, bisexual, and transgender (LGBT) students (e.g., bystander intervention skills, implementing safe spaces, use of inclusive language)
Additional professional development designed to strengthen safe and supportive environments
During the past 6 months, did [Priority School] do any of the following related to disseminating resources to parents? (Check YES or NO for each)
Provide parents with information to support parent- adolescent communication about sex
Provide parents with information to support parent- adolescent communication about topics other than sex
Provide parents with information about how to monitor their teen (e.g., setting parental expectations, keeping track of their child, responding when their child breaks the rules)
Provide parents with information to support 1-on-1 time between adolescents and their health care providers
During the past 6 months, did [Priority School] implement any of the following school-based positive youth development programs? (Check YES or NO for each)
A program in which students receive service-learning opportunities, that is community service designed to meet specific learning objectives
A program in which family or community members serve as role models to students or mentor students
Some other type of school-based positive youth development program
During the past 6 months, did [Priority School] connect students to any of the following community-based positive youth development programs? (Check YES or NO for each)
A program in which students receive service-learning opportunities, that is community service designed to meet specific learning objectives
A program in which family or community members serve as role models to students or mentor students
Some other type of community-based positive youth development program
Currently, does [Priority School] have a student-led club that supports LGBT youth (often known as Gay-Straight Alliances or Genders and Sexualities Alliances)? (Check YES or NO)
End
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Orenstein, Diane (CDC/OID/NCHHSTP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |