Download:
pdf |
pdf+Change Sailors Post-Interview/Focus
Group Survey
Start of Block: Privacy Act Statement
OMB CONTROL NUMBER: 0703-0080
OMB EXPIRATION DATE: 08/31/2022
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0703-0080, is estimated to
average 105 minutes per response (5, 90, and 10 minutes for pre-survey, interview/focus
group, and post-survey, respectively), including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or
burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at [email protected]. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to
any penalty for failing to comply with a collection of information if it does not display a currently
valid OMB control number.
Privacy Act Statement This statement serves to inform you of the purpose for collecting
personal information required by this system and how it will be used.
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR 199.17, TRICARE
program; and E.O. 9397 (SSN), as amended.
PURPOSE: To collect information from Navy service members in order to create a sexual
assault prevention and alcohol reduction intervention specific to Sailors ages 18-24
ROUTINE USES: Use and disclosure of your records outside of DoD may also occur in
accordance with the DoD Blanket Route Uses published at
http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html and as permitted by the
Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Any protected health information (PHI) in
your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45
CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI
include, but are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary; however, failure to provide information may result in the denial of
enrollment.
OMB Control Number 0703-0080
Page 1 of 13
End of Block: Privacy Act Statement
Start of Block: demographics
What is your age in years?
Age (1)
▼ 18 (1) ... Prefer not to answer (9)
What is your rank?
(1)
▼ E1 (1) ... O10 (25)
Please describe your current marital status:
o Not dating or in a relationship (1)
o Dating but not exclusively (2)
o Dating exclusively for less than 6 months (3)
o Dating exclusively for more than 6 months (4)
o Engaged (5)
o Separated/Divorced (6)
o Married (7)
o Other (8) ________________________________________________
o Prefer not to answer (999)
Page 2 of 13
What sex were you assigned at birth, on your original birth certificate?
o Male (0)
o Female (1)
o Prefer not to answer (999)
How would you describe your current gender?
o Male (0)
o Female (1)
________________________________________________
o Prefer not to answer (999)
Do you consider yourself to be Hispanic or Latino (Please check only one)
o Yes (1)
o No (2)
Page 3 of 13
What is your race? (Please check one or more)
▢
▢
▢
▢
▢
American Indian or Alaska Native (1)
Asian (2)
Black or African American (3)
Native Hawaiian or Other Pacific Islander (4)
White (5)
Do you consider yourself to be:
o Heterosexual or straight (1)
o Gay or Lesbian (2)
o Bisexual (3)
o
Something else, please specify (4)
________________________________________________
o Prefer not to answer (999)
Thinking about your entire life, how many sex partners have you had? (Please do not include any PII in
your response. Thank you!)
________________________________________________________________
Page 4 of 13
Who have you EVER had sex with?
o Men only (1)
o Women only (2)
o Both men and women (3)
o I have not had sex (4)
o Prefer not to answer (999)
Are you currently involved in any programs to address concerns relating to alcohol use? (i.e.,
AA, treatment, other support groups)?
o Yes (1)
o No (0)
o Prefer not to answer (999)
Are you currently involved in any efforts to support sexual harassment and assault awareness
and prevention above and beyond required trainings (i.e., Command resiliency teams,
community groups)?
o Yes (1)
o No (0)
o Prefer not to answer (999)
OMB Control Number 0703-0080
End of Block: demographics
Start of Block: audit-c
Page 5 of 13
How often did you have a drink containing alcohol in the past year?
o Never (0)
o Monthly or less (1)
o 2 to 4 times a month (2)
o 2 to 3 times a week (3)
o 4 or more times a week (4)
How many drinks containing alcohol did you have on a typical day when you were drinking in
the past year?
o None, I do not drink (0)
o 1 or 2 drinks (0)
o 3 or 4 drinks (1)
o 5 or 6 drinks (2)
o 7 or 9 drinks (3)
o 10 or more drinks (4)
Page 6 of 13
How often did you have six or more drinks on one occasion in the past year?
o Never (0)
o Less than monthly (1)
o Monthly (2)
o Weekly (3)
o Daily or almost daily (4)
OMB Control Number 0703-0080
End of Block: audit-c
Start of Block: demographics continued
How much do you identify with:
0 (Not at
all) (0)
1 (1)
2 (2)
3 (3)
4 (4)
5 (5)
6
(Completely)
(6)
The
typical
female
Sailor (1)
o
o
o
o
o
o
o
The
typical
male
Sailor (2)
o
o
o
o
o
o
o
Page 7 of 13
Is there another sub-population or group of Sailors that you identify with more?
o Yes (1)
o No (0)
o Prefer not to answer (999)
Display This Question:
If Is there another sub-population or group of Sailors that you identify with more? = Yes
Which sub-population or group do you identify with more? (Please do not include any PII in your response.
Thank you!)
________________________________________________________________
What feedback do you have for making the intervention more helpful or applicable for Sailors
like you? (Please do not include any PII in your response. Thank you!)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Generally speaking, what other feedback do you have that might be important for us to know? (Please do
not include any PII in your response. Thank you!)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 8 of 13
How comfortable were you viewing this intervention?
o Very uncomfortable (1)
o Moderately uncomfortable (2)
o Slightly uncomfortable (3)
o Neither comfortable nor uncomfortable (4)
o Slightly comfortable (5)
o Moderately comfortable (6)
o Very comfortable (7)
How distressing did you find the intervention content?
o Extremely distressing (1)
o Quite a bit distressing (2)
o Moderately distressing (3)
o A little bit distressing (4)
o Not at all distressing (5)
Page 9 of 13
How helpful did you find the intervention content?
o Very unhelpful (1)
o Moderately unhelpful (2)
o Slightly unhelpful (3)
o Neutral (4)
o Slightly helpful (5)
o Moderately helpful (6)
o Very helpful (7)
How comfortable do you think other Sailors would be viewing this intervention?
o Very uncomfortable (1)
o Moderately uncomfortable (2)
o Slightly uncomfortable (3)
o Neither comfortable nor uncomfortable (4)
o Slightly comfortable (5)
o Moderately comfortable (6)
o Very comfortable (7)
Page 10 of 13
How distressing do you think the intervention content would be for Sailors?
o Extremely distressing (1)
o Quite a bit distressing (2)
o Moderately distressing (3)
o A little bit distressing (4)
o Not at all distressing (5)
How helpful do you think the intervention content would be for Sailors?
o Very unhelpful (1)
o Moderately unhelpful (2)
o Slightly unhelpful (3)
o Neutral (4)
o Slightly helpful (5)
o Moderately helpful (6)
o Very helpful (7)
What do you think was missing from the intervention content that Sailors in the military should
know about? (Please do not include any PII in your response. Thank you!)
OMB Control Number 0703-0080
End of Block: demographics continued
Start of Block: IMI value/usefulness subscale & questions about interest and importance
Page 11 of 13
For each of the following statements, please indicate how true it is for you, using the following
scale:
1 (Not
true at
all) (1)
I believe
this
activity
could be
of some
value to
me. (1)
I think
that
doing this
activity is
useful.
(2)
I think
this is
important
to do. (3)
I would
be willing
to do this
again
because
it has
some
value to
me. (4)
I think
this
activity
could
help me.
(5)
I believe
doing this
activity
could be
beneficial
to me. (6)
I think
this is an
2 (2)
3 (3)
4
(Somewhat
true) (4)
5 (5)
7 (Very
true) (7)
6 (6)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 12 of 13
important
activity.
(7)
For each of the following statements, please indicate how true it is for you, using the following
scale:
1 (Not
true at
all) (1)
I am
interested in
doing this
intervention.
(1)
I think other
Sailors
would be
interested in
doing this
intervention.
(2)
I think this
intervention
is important.
(3)
I think other
Sailors
would think
this
intervention
is important.
(4)
2 (2)
3 (3)
4
(Somewhat
true) (4)
5 (5)
7 (Very
true) (7)
6 (6)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OMB Control Number 0703-0080
End of Block: IMI value/usefulness subscale & questions about interest and importance
Page 13 of 13
| File Type | application/pdf |
| File Title | Microsoft Word - Change_Sailors_Post-InterviewFocus_Group_Survey.docx |
| File Modified | 2022-08-03 |
| File Created | 2022-04-12 |