Attachment A Question by Question Source Table for the Followup Survey

ATTACHMENT A

QUESTION BY QUESTION SOURCE TABLE FOR THE follow-up survey

QUESTION BY QUESTION SOURCE LIST FOR the Federal Evaluation of Making Proud Choices! Follow-up Survey

This document lists each question on the follow-up survey for the Federal Evaluation of Making Proud Choices!, along with an indicator of whether the item was included on the OMB-approved baseline survey. If any revisions were made to the item from the baseline survey, those revisions are noted in the “Revisions” column. If no revision is listed, the item is the same as the baseline survey. The primary question source is noted in the last column. More details on each source is provided in Appendix B: Sources Referenced.

KEY:

AddHealth = National Longitudinal Study of Adolescent Health;

AP-MTV = Associated Press-MTV Digital Abuse Study;

Girls Inc. = Girls Shape the Future Study;

ETR Associates = Education, Training and Research Associates

PAF FADS = The Pregnancy Assistance Fund: Feasability and Design Study;

PPA = Evaluation of Adolescent Pregnancy Prevention Approaches;

PREP = The Personal Responsibility Education Program Evaluation;

SDDAP = Evaluation of the School Dropout Demonstration Assistance Program;

YRBSS = 2017 Youth Risk Behavior Surveillance System;

Jemmott Survey= Survey for the Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents: A Randomized Controlled Trial from their original evaluation of the Making Proud Choices! Program (Jemmott et al, 1998)

Follow up Question #	Question Text	On Baseline (Y/N)	Revisions	Primary Question Source
1.1	In what month and year were you born?	Y		PAF FADS
1.2	Are you Hispanic /Latino? (only if missing baseline)	Y		PAF FADS
1.3	What is your race? (only is missing baseline)	Y		PAF FADS
1.4	What grade are you currently in? (If during the summer break): If you are currently on summer break, please answer this question about the last school year.	Y	Added note for respondent on summer break	SDDAP
1.5	Do you have any of these degrees or certificates? A high school diploma A GED	N		PREP
1.6	How often would you say you skip school?	Y		Adapted from PREP
1.7	How many times have you been suspended or expelled from school?	Y		Adapted from PREP
1.8	How likely is it that you will graduate from high school?	Y		Adapted from PREP
1.9	In the past 12 months, how many times have you changed where you live?	Y		PPA
2.1	In the past 12 months, how often did you attend any classes or sessions where the following were discussed? Relationships, dating, or marriage Abstinence from sex Methods of birth control, such as condoms, pills, the patch, the shot, the ring, IUD, or an implant Where to get birth control Sexually transmitted disease, also known as STDs or STIs	Y	Modified from “yes/no” to “how often”	PREP
2.2	How strongly do you agree or disagree with each of the following statements? Having sex is a good thing for you to do at your age At your age right now, having sex would create problems At your age right now, not having sex is important for you to be safe and healthy At your age right now, it is okay for you to have sexif you use birth control, such as condoms, pills, the patch, the shot, the ring, IUD, or an implant Having sex at your age would make you less likely to graduate from high school Having sex at your age would make you less likely have the career that you are hoping for. It is against your beliefs to have sex before marriage It is against your beliefs to use any form of birth control, such as condoms, pills, the patch, the shot, the ring, IUD, or an implant	Y	Items e & f are new.	Jemmott Survey
2.3	In the past 12 months, about how many times have you asked one or both of your parents/guardians questions about sex?	Y	Recall period modified from 3 months to 12 month.	Adapted from Girls Inc.
2.4	How comfortable are you talking to your parents/guardians about sex? Please answer for the parent/guardian whom you feel most comfortable talking to.	Y		Adapted from Girls Inc.
2.5	Sometimes people don’t want to have sex but have difficulty saying “no.” If you were [fill a-e], how likely is it you would be able to say “no” to having sex? With someone you have known for a few days or less With someone you have dated for a long time With someone with whom you have already had sex With someone who is pushing you to have sex With someone who does not want to use a condom	Y		Adapted from PREP
2.6	The next series of statements is about condom use. How strongly do you agree or disagree with each of these statements? a. Condoms should always be used if a person your age has sexual intercourse b. Condoms decrease sexual pleasure c. Condoms are embarrassing to use. d. Condoms ruin the mood because you have to stop to put one on. e. Sex feels unnatural when a condom is used. f. Condoms are important to make sex safer. g. Using condoms means you don’t trust your partner h. You would be concerned your partner would break up with you if you suggested using a condom i. Using condoms is morally wrong j. It is too much trouble to carry around condoms. k. Condoms are a hassle to use l. Condoms are pretty easy to get	Y	Items c,d,e,h,j are new	PPA & Jemmott survey
2.7	The next series of statements is about how confident you feel doing different things. How strongly do you agree or disagree with each of these statements? I can say to my partner that we should use a condom. I feel confident talking about condom use If I had a condom with me, I would not take it out I feel confident I could put a condom on myself or my partner I could get my partner to agree to use a condom without turning them off I could not put a condom on my partner or myself without ruining the mood If I were sexually aroused I could stop before sex to use a condom I could get my partner to use a condom, even if they didn’t want to I am sure that I can use a condom if I have sex.	N	New item	Developed for MPC! based on Jemmott survey items
2.8	If condoms are used correctly and consistently, how much can they decrease the risk of pregnancy?	Y		PREP
2.9	If condoms are used correctly and consistently, how much can they decrease the risk of getting HIV, the virus that causes AIDS?	Y		PREP
2.10	If birth control pills are used correctly and consistently, how much can they decrease the risk of pregnancy?	Y		PREP
2.11	If birth control pills are used correctly and consistently, how much can they decrease the risk of getting HIV, the virus that causes AIDS?	Y		PREP
2.12	Can you get a sexually transmitted disease, also known as an STD or STI, from having oral sex?	Y		PREP
2.13	Can you get a sexually transmitted disease, also known as an STD or STI, from having anal sex?	Y		PREP
2.14	Below are several statements about condoms. Please mark whether you think each statement is true, false, or you 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.	Y		PAF FADS
2.15	Below are several statements about birth control pills. Please mark whether you think each statement is true, false, or you don’t know. a. Birth control pills are less effective if a woman misses taking them for two or three days in a row b. It is not necessary for women to “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 the risk of getting a sexually transmitted disease (STD).	Y		PAF FADS
2.16	The next statements are about about IUDs (such as Mirena, ParaGard, or Skyla). Please select whether you think each statement is true, false, or you don’t know. a. All IUDs are banned from use in the United States b. A woman can use an IUD, even if she has never had a child c. Women who use IUDs cannot use tampons d. A woman can get an IUD without going to a doctor’s office, clinic or medical professional e. An IUD cannot be felt by a woman’s partner during sex f. IUDs can move around in a woman’s body g. An IUD prevents pregnancy for at least 3 years	Y		Adapted from PAF FADS and the Fog Zone
2.17	The next statements are about other forms of birth control. Please select whether you think each statement is true, false, or you don’t know. a. Women using the birth control shot, Depo Provera, must get an injection 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 more months c. Women using the vaginal ring, NuvaRing, must have it inserted by a doctor or health care provider every month d. Long acting methods like the implant (Implanon or Nexplanon) or IUD(Mirena, ParaGard, or Skyla can be removed early 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. f. Long-acting methods like the implant, an IUD, the shot and the ring can reduce the risk of getting a sexually transmitted disease (STD).	Y		Adapted from PAF FADS and the Fog Zone
2.18	The next statements are about sexually transmitted diseases, also known as STDs or STIs, and AIDS. Please select whether you think each statement is true, false, or you don’t know. You can have an STD and feel healthy A woman who has a STD can get an infection in her uterus and tubes. A person with HIV/AIDS can give it to other people only if they look and feel sick The HIV virus is present in blood, semen, and vaginal fluid.	N	New item	Developed for MPC! based on items from the Jemmott survey
2.19	The next statements are about pregnancy. Please select whether you think each statement is true, false, or you don’t know. a. During a woman’s monthly cycle, there are certain days when she is more likely to become pregnant if she has sex b. The very first time a woman has sex, she cannot get pregnant c. Douching (washing the vagina) after sex can prevent pregnancy d. Pregnancy is much less likely to occur if a couple has sex standing up e. The only way to completely prevent pregnancy is by not having sex	Y		Adapted from the Fog Zone
3.1	How do you describe your gender? Male Female Transgender Unsure Other (specify)	Y		Adapted from OAH recommended measure
3.2	People are different in their sexual attraction to other people. Which best describes your feelings? Are you…? Only attracted to females Mostly attracted to females Equally attracted to females and males Mostly attracted to males Only attracted to males Questioning/not sure Other (specify)	Y		Adapted from OAH recommended measure
3.3	In the past 3 months, have you sent nude or nearly nude pictures or videos of yourself to others?	Y	Recall period modified from “ever” to 3 months1	Adapted from AP-MTV
3.4	In the past 3 months, have you received nude or nearly nude pictures or videos of someone else?	Y	Recall period modified from “ever” to 3 months	Adapted from AP-MTV
3.5	In the past 3 months, have you touched someone’s private parts? Private parts are the parts of the body covered by underwear or a bra.	Y	Recall period modified from “ever” to 3 months	ETR Associates
3.6	In the past 3 months, other than a doctor or a nurse, have you let someone touch your private parts?	Y	Recall period modified from “ever” to 3 months	Adapted from ETR Associates
3.7	The next questions are about vaginal sex. By vaginal sex we mean a male putting his penis into a female’s vagina. Have you ever had vaginal sex?	Y		Adapted from PREP
3.8	Now please think about the past 3 months. In the past 3 months, have you had vaginal sex, even once?	Y		Adapted from PREP
3.9	In the past 3 months, how many DIFFERENT PEOPLE have you had vaginal sex, even if only one time?	Y	Recall period modified from “ever” to 3 months	Adapted from PREP
3.10	In the past 3 months, how many TIMES have you had vaginal sex?	Y		Adapted from PREP
3.11	The next question is about your use of the following methods of birth control: Condoms Birth control pills The shot (Depo-Provera) The patch The ring (NuvaRing) IUD (Mirena, Paragard, or Skyla) Implant (Implanon or Nexplanon) In the past 3 months, how many TIMES did you have vaginal sex without using any of these methods of birth control?	Y		PAF FADS
3.12	In the past 3 months, how many TIMES have you had vaginal sex without using a condom?	Y		Adapted from PREP
3.13	Do you intend to have vaginal sex in the next 3 months, if you have the chance?	Y	Recall period modified from “next year” to 3 months	Adapted from PREP
3.14	If you were to have vaginal sex in the next 3 months, do you intend to use (or have your partner use) a condom?	N	New item	PPA
3.15	If you were to have vaginal sex in the next 3 months, do you intend to use (or have your partner use) any of these methods of birth control? Birth control pills The shot (for example, Depo Provera) The patch (for example, Ortho Evra) The ring (for example, NuvaRing) IUD (for example, Mirena or Paragard) Implants (for example, Implanon)	N	New item	PPA
3.16	Oral sex is when someone puts his or her mouth on another person's penis, anus or vagina, OR lets someone else put his or her mouth on their penis, anus or vagina. Have you ever had oral sex?	Y		PREP
3.17	Now please think about the past 3 months. In the past 3 months, have you had oral sex?	Y		PREP
3.18	In the past 3 months, how many TIMES have you had oral sex?	Y		PREP
3.19	In the past 3 months, how many TIMES have you had oral sex without using a condom or a dental dam?	Y		PREP
3.20	Do you intend to have oral sex in the next 3 months, if you have the chance?	N	New item	Developed for MPC!, based on PPA item on intention to have vaginal sex
3.21	If you were to have oral sex in the next 3 months, do you intend to use (or have your partner use) a condom or dental dam?	N	New item	Developed for MPC!, based on PPA item on intention to use condom
3.22	Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a male put his penis in their anus or butt. Have you ever had anal sex?	Y		Adapted from PREP
3.23	Now please think about the past 3 months. In the past 3 months, have you had anal sex?	Y		Adapted from PREP
3.24	In the past 3 months, how many TIMES have you had anal sex?	Y		Adapted from PREP
3.25	In the past 3 months, how many TIMES have you had anal sex without using a condom?	Y		Adapted from PREP
3.26	Do you intend to have anal sex in the next 3 months, if you have the chance?	N	New item	Developed for MPC!, based on PPA item on intention to have vaginal sex
3.27	If you were to have anal sex in the next 3 months, do you intend to use (or have your partner use) a condom?	N	New item	Developed for MPC!, based on PPA item on intention to use condom
3.28	In the past 3 months, have you hung out alone with someone you were attracted to?	Y	Recall period modified from “ever” to 3 months	Adapted from Girls Inc.
3.29	In the past 3 months, have you kissed someone you were attracted to on the mouth?	Y	Recall period modified from “ever” to 3 months	Adapted from Girls Inc.
3.30	In the past 3 months, have you tongue kissed or French kissed someone?	Y	Recall period modified from “ever” to 3 months	Adapted from Girls Inc.
3.31	In the past 3 months, have you laid down alone with someone you were attracted to?	Y	Recall period modified from “ever” to 3 months	Adapted from Student Health Questionnaire
3.32	In the past 3 months, have you had a boyfriend or girlfriend?	Y	Recall period modified from “ever” to 3 months	Adapted from Student Health Questionnaire
3.33	In the past 3 months, how many boyfriends or girlfriends have you had?	Y	Recall period modified from “ever” to 3 months	Adapted from Student Health Questionnaire
3.34	In general, how much pressure, if any, do you feel from your friends to have sexual intercourse?	Y		Adapted from PREP
3.35	How many of your friends who are your age think the following things? Having sex is a good thing for them to do at their age It would be okay for them to have sex as long as they used birth control, like a condom It would be okay for them to have sex if they were dating the same person for a long time They should wait until they are older to have sex They should wait until marriage to have sex	Y		Adapted from PREP
3.36	How many of your friends who are your age have had sex?	Y		Adapted from PREP
3.37	Here are some reasons people your age might choose NOT to have sex. How important is each of these reasons to YOU? I don’t want to get a sexually transmitted disease, also known as an STD or an STI I don’t want to disappoint my parents I am too young to have sex I want to wait until I’m in a serious relationship. I want to wait until I’m married It is against my personal beliefs I haven’t met the right person yet I haven’t had the chance I do not want to get pregnant or get someone pregnant	Y	Item “d” is new	Adapted from PREP , new item developed for MPC! based on Jemmott survey item
4.1	In the past 12 months, did you receive information from a doctor, nurse, or clinic about any of the following? Methods of birth control, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant Where to get birth control Sexually transmitted diseases, also known as STDs or STIs The HPV vaccine, also known as Gardasil or Cervarix	Y		Adapted from PREP
4.2	In the past 12 months, did you get any of the following types of birth control from a doctor, nurse, or clinic? a. Condoms b. Birth control pills c. The patch, such as Ortho-Evra d. The shot, such as Depo-Provera or other injectable birth control e. The ring, such as NuvaRing f. An IUD, such as Mirena, ParaGard, or Skyla g. An implant, such as Implanon or Nexplanon h. Emergency contraceptive pills, such as Plan B i. Another method PRINT OTHER METHOD USED	Y	The baseline survey asked whether any of the forms listed were aquired in one item. The follow up now asks about each item individually.	Adapted from PREP
4.3	In the past 3 months, have you been told by a doctor, nurse, or some other health professional that you had any of the following sexually transmitted diseases? a. Chlamydia b. Gonorrhea c. Genital herpes d. Syphilis e. HIV infection or AIDS f. Human papilloma virus, also known as HPV or genital warts g. Another sexually transmitted disease (STD) PRINT OTHER STD	Y	Recall period modified from “ever” to 3 months	PAF FADS
4.4	Now think about the past 3 months. In the past 3 months, have you talked about contraception or sexually transmitted diseases with someone you were attracted to?	Y	Recall period modified from “ever” to 3 months	Adapted from AddHealth
4.5	These next few questions are about pregnancy. To the best of your knowledge, are you currently or have you ever been pregnant or have you gotten someone pregnant?	Y		Adapted from PREP
5.1	The next questions are about tobacco, 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. During the past 30 days, on how many days did you use an electronic vapor product such as blu, NJOY, Vuse, MarkTen, Logic, Vapin Plus, eGo, and Halo? Electronic vapor products include e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens? □ 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	Y		Adapted from YRBSS
5.2	During the past 30 days, on how many days did you smoke one or more cigarettes? □ 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	Y		Adapted from YRBSS
5.3	The next 2 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. During the past 30 days, on how many days did you have at least one drink of alcohol? □ 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	Y		YRBSS
5.4	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? □ 0 days □ 1 day 2 days □ 3 to 5 days □ 6 to 9 days □ 10 to 19 days □ 20 or more days	Y		Adapted from YRBSS
5.5	During the past 30 days, on how many days did you use marijuana, also called weed or pot? □ 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	Y		Adapted from PAF FADS and YRBSS
5.6	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? □ 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	Y		PAF FADS
6.1	The next questions are about your experiences and attitudes toward relationships and dating. How would you define your current relationship status? Not currently in a relationship or dating Casually dating Seriously dating Engaged Married	Y		Adapted from PREP
6.2	In the past 3 months, have you been contacted online or through social media by a complete stranger who wanted to meet in-person?	Y	Recall period modified from “ever” to 3 months	Adapted from 2012 Teens and Privacy Management Survey
6.3	In the past 3 months, have you contacted a complete stranger online or through social media who you wanted to meet in-person?	Y	Recall period modified from “ever” to 3 months	Adapted from 2012 Teens and Privacy Management Survey
6.4	How much do you agree or disagree with the following statements? In a good relationship, you don’t always get your own way. There are times when hitting or pushing between people who are dating is okay. A good dating relationship is based on mutual respect, not just sex. People who make their partner jealous deserve to be hit or pushed. It would be easy to trust your partner, even when you’re apart. Avoiding a disagreement with your partner is always better than talking about your problems.	Y		PAF FADS

1 We updated several items on the follow up to a 3 month recall period. A 3 month recall period was used in original Jemmott evaluation of MPC!