Administration for Children and Families Youth Programs –Youth Participant Entry and Exit Survey Pretest

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Form approved
OMB Control No: 0970-0536
Expiration Date: XX/XX/XXXX
   
SEXUAL RISK AVOIDANCE EDUCATION PROGRAM (SRAE)

  PARTICIPANT EXIT SURVEY
MIDDLE SCHOOL 


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


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 SELECT ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED.
    • USE A PEN OR PENCIL.


1.		EXAMPLE 1: SELECT ONLY ONE ANSWER
	What is the color of your eyes?
SELECT ONLY ONE ANSWER
	Brown
	Blue
	Green
	Another color

2.	EXAMPLE 2: SELECT ALL THAT APPLY
	Do you plan to do any of the following next week?
SELECT 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.	What age are you today?
	SELECT ONLY ONE ANSWER
□	10 years
□	11 years
□	12 years
□	13 years
□	14 years
□	15 years
□	16 years

2.	When you are at home or with your family, what language or languages do you usually speak?
SELECT ALL THAT APPLY
□	English
□	Spanish
□	Other (specify): ____________________________________ 	

3.	What is your race?
SELECT ALL THAT APPLY
□	American Indian or Alaska Native 
□	Asian
□	Black or African American
□  Hispanic or Latino
□  Middle Eastern or North African
□	Native Hawaiian or Other Pacific Islander
□	White 

4. 	What is your sex? 
SELECT ONLY ONE ANSWER
□   Male 
□   Female 




5.	Are you currently …? 
	SELECT ALL THAT APPLY
□	In foster care
□	Unstably housed (moving from place to place), living outside (in a tent or in a car), in a hotel, or in an emergency shelter
□	In juvenile detention center, juvenile group home, and/or under the supervision of a probation officer
□	None of the above 
For questions 6 – 8, please think about how the program you just completed has affected you, even if your program did not cover the topic.  (Note: If the program has not affected your likelihood to do any of the following, choose “About the same.”)
6.	Has being in the program made you more likely, about the same, or less likely to… 
SELECT ONLY ONE ANSWER PER ROW




More likely
About the same
Less likely
a.	avoid drinking alcohol (more than a few sips) including beer, wine, and liquor)? …………………….……………...



b.	avoid smoking cigarettes or using other tobacco products? …………………………………………………….



c.	avoid using electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? ………....................................



d.	avoid using marijuana (also called pot or weed)?............



e.	avoid using any other drugs that you didn’t get from a doctor?..............................................................................



7.	Has being in the program made you more likely, about the same, or less likely to… 
SELECT ONLY ONE ANSWER PER ROW






More likely
About the same
Less likely

a.	do harmful things because your friends want you to? ….




b.	handle your feelings in ways that are not hurtful to yourself or others)? ........................................................




c.	think about what might happen before making a decision? ............................. ……………………………..




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




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





8.	Has being in the program made you more likely, about the same, or less likely to… 
SELECT ONLY ONE ANSWER PER ROW





More likely
About the same
Less likely
a.	plan to delay having sexual intercourse until you are married?………………………………



b.	plan to be married before you have a child? 




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.
9.	How often in this program… 
SELECT ONLY ONE ANSWER PER ROW
Most of the time
Some of the time
None of the time
a.	did you feel the information for the program was clear?.………..



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



c.	did you feel respected by the facilitator?	…………………





10.  Did you get enough information about abstaining from sex (choosing not to have sex)?
SELECT ONLY ONE ANSWER
□	  Yes 
□	  No

Thank you for participating in this survey!