Youth Baseline

DRAFT – Youth Survey

Youth Baseline
Survey
Spring 2007

1

DRAFT – Youth Survey

Instructions (to be read by survey administrator)
I will read each question, and then tell you the answer choices. Each answer choice has a
number that goes with it. For example, if the question was “What is your favorite color,”
then the answer choices might be: 1) Red, 2) Blue, 3) Green, 4) Yellow, or 5) Other. You
should circle the number on your paper that goes with your answer. You don’t need to
say your answers out loud.
If you want to hear a question or the answer choices again, please ask and I will read
them again. If you don’t understand a question or the answer choices, please tell me and
I will try to explain them. Do you have any questions before we start?

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number. The valid
OMB control number for this information collection is XXXX-XXXX.
The time required to complete this information collection is estimated to average XX minutes per
response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: XXXX.
If you have comments or concerns regarding the status of your individual submission of this form,
write directly to: XXXXX.

2

DRAFT – Youth Survey

1.

When is your birthday?
________ / ________ / _____________
Month
Day
Year

2.

Are you a…
1 Boy
2. Girl

3.

Are you Hispanic or Latino?
1. Yes
2. No

4.

What race do you consider yourself to be? (Please check only one)
1.
2.
3.
4.
5.
6.

5.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Mixed-race or bi-racial

Have you ever lived apart from your birth mother for more than 12 months?
1. Yes
2. No

6.

Have you ever lived apart from your birth father for more than 12 months?
1. Yes
2. No

In the next few questions, we’d like to know about the kinds of things that have been going
on in your life during the LAST SIX MONTHS. For each of these questions, place a check
next to NO if the activity or event has not happened in the last six months, OR check YES
if it has happened.
7.

In the last six months…
YES

NO

a. Have you moved or changed where you live?

1

2

b. Has a parent or guardian started working?

1

2

c.

1

2

d. Have you broken up with a boy/girlfriend?

1

2

e. Has a close friend moved away?

1

2

f.

1

2

g. Have you changed schools?

1

2

h. Did someone you know well die?

1

2

Has a parent or guardian stopped working or lost his/her job?

Have you been picked on or bullied at school or in your neighborhood?

3

DRAFT – Youth Survey

8.

YES

NO

i.

Have your parents separated (that is, have they started living in different
places)?

1

2

j.

Has anyone moved into or out of your house?

1

2

k.

Was someone you know well hurt badly or very ill?

1

2

l.

Has anyone you live with (like your mom or sister) had a baby?

1

2

These questions ask about how things are going with your parent or guardian. If
you live with two parents, please think about the parent or guardian you feel
closest to when you answer these questions. How often do you feel that…

Hardly
ever

Not very
often

Someti
mes

Pretty
often

a. My parent respects my feelings

1

2

3

4

b. I tell my parent about my problems and
troubles.

1

2

3

4

c.

1

2

3

4

d. If my parent knows something is bothering me,
they ask me about it.

1

2

3

4

e. My parent accepts me as I am

1

2

3

4

f.

I like to get my parent’s point of view on things
I’m concerned about.

1

2

3

4

g. When we discuss things, my parent considers
my point of view.

1

2

3

4

h. I feel it’s no use letting my feelings show
around my parent.

1

2

3

4

i.

My parents trust my judgment.

1

2

3

4

j.

My parent can tell when I’m upset about
something.

1

2

3

4

k.

When I'm angry about something, my parent
tries to be understanding.

1

2

3

4

l.

My parent helps me to talk about my
difficulties.

1

2

3

4

m. I trust my parent.

1

2

3

4

n. My parent has their own problems, so I don’t
bother them with mine.

1

2

3

4

o. I can count on my parent when I need to get
something off my chest.

1

2

3

4

p. My parent helps me to understand myself
better.

1

2

3

4

I wish I had a different parent

4

DRAFT – Youth Survey
These questions ask how you feel about things like school, other kids your age, and
yourself. For each sentence, decide how true the sentence is for you. Then circle one
number that fits best. There are no "right" or "wrong" answers because kids feel
differently about these things. If you think the statement is NOT AT ALL TRUE, circle “1”;
if you think the statement is NOT VERY TRUE, circle “2”; if the statement is SORT OF
TRUE, circle “3”; or if you think the statement is VERY TRUE, circle “4.”
9.

How true are the following statements?
Not at
all true

Not very
true

Sort of
true

Very
true

a. I find it hard to make friends.

1

2

3

4

b. I have trouble figuring out the answers in
school.

1

2

3

4

c.

I am popular with others my age.

1

2

3

4

d. I would like to have a lot more friends.

1

2

3

4

e. In general, I like school a lot.

1

2

3

4

f.

1

2

3

4

g. I sometimes think I am a failure (a “loser”).

1

2

3

4

h. I am happy with myself as a person.

1

2

3

4

i.

I am the kind of person I want to be.

1

2

3

4

j.

I often feel ashamed of myself.

1

2

3

4

k.

I look forward to going to school every day.

1

2

3

4

l.

I like being just the way I am.

1

2

3

4

m. I am as good a person as I want to be.

1

2

3

4

n. I wish I had more to be proud of.

1

2

3

4

o. I’m pretty slow at finishing my schoolwork.

1

2

3

4

p. I have a lot of friends.

1

2

3

4

q. I am always doing things with a lot of kids.

1

2

3

4

r.

I often forget what I learn.

1

2

3

4

s.

I feel that I am just as smart as other kids my
age.

1

2

3

4

t.

I feel that I am very good at my schoolwork.

1

2

3

4

u. I wish more people my age liked me.

1

2

3

4

v.

1

2

3

4

1

2

3

4

I do very well at my class work

I often feel excited at school.

w. I am happy with the way I can do most things.
10.

Which of the following best describes the grades on your last report card? Mostly…
(Check only one box)
1

D’s, E’s and F’s

5

DRAFT – Youth Survey
2.
3.
4.
5.
6.
7.
8.
11.

D’s
C’s and D’s
C’s
B’s and C’s
B’s
A’s and B’s
A’s

How sure are you that you will…
Not at
all sure

Not
really
sure

Mostly
sure

Very
sure

x.

Finish high school

1

2

3

4

y.

Go to college

1

2

3

4

z.

Finish college

1

2

3

4

In the next set of questions, we’d like to know about different things you’ve done during
the LAST THREE MONTHS. For each of the following questions, circle “1” if you HAVE
NEVER DONE the activity; circle “2” if you HAVE DONE the activity BUT NOT IN THE LAST
3 MONTHS; circle “3” if you HAVE DONE IT 1-2 TIMES IN THE LAST 3 MONTHS; circle “4”
if you HAVE DONE IT 3-4 TIMES IN THE LAST 3 MONTHS; or circle “5” if you HAVE DONE
IT 5 OR MORE TIMES IN THE LAST 3 MONTHS. Remember, there are no right or wrong
answers and your answers will be kept completely private—your name will not be on your
survey.
12.

During the last three months, have you…
I have
NEVER
done
this

I have
done this,
but not in
the last 3
months

I did it 1–2
times in
the last 3
months

I did it 3–
4 times
in the
last 3
months

I did it 5
or more
times in
the last 3
months

a. Broken something on purpose?

1

2

3

4

5

b. Gotten into a fight at school?

1

2

3

4

5

1

2

3

4

5

d. Taken care of a sister or brother
after school without an adult there?

1

2

3

4

5

e. Had a fight or argument with your
parents/guardians?

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

c.

f.

Gotten into a fight in your
neighborhood?

Taken something on purpose that
didn’t belong to you?

g. Skipped school without permission?

6

DRAFT – Youth Survey

h. Been home alone after school
without an adult there?

13.

I have
NEVER
done
this

I have
done this,
but not in
the last 3
months

I did it 1–2
times in
the last 3
months

I did it 3–
4 times
in the
last 3
months

I did it 5
or more
times in
the last 3
months

1

2

3

4

5

i.

Hit someone because you didn’t like
something they said or did?

1

2

3

4

5

j.

Taken something from a store
without paying for it?

1

2

3

4

5

k.

Had to have your parents come to
school about a problem?

1

2

3

4

5

l.

Drank alcohol without your parents
knowing?

1

2

3

4

5

m. Used marijuana (pot)?

1

2

3

4

5

n. Used other drugs (inhalants,
cocaine, LSD, heroin, steroids,
etc.)?

1

2

3

4

5

o. Have you ever sold or helped sell
marijuana (pot, grass), hashish
(hash), or other hard drugs such as
heroin, cocaine or LSD?

1

2

3

4

5

p. Carried a handgun? When we say
handgun, we mean any firearm other
than a rifle or shotgun.

1

2

3

4

5

q. Been arrested by the police?

1

2

3

4

5

Are you a member of a gang? (A gang is a group that does some illegal things
together, and may have a special name or an area it calls its own.)
1. Yes
2. No
13b.

Do any of your friends belong to a gang?

1. Yes
2. No
14.

Right now in your life, is there a SPECIAL ADULT (not your parent or guardian)
who you often spend time with? A special adult is someone who does a lot of
good things for you. For example someone (a) who you look up to and
encourages you to do your best, (b) who really cares about what happens to you,
(c) who influences what you do and the choices you make, and (d) who you can
talk to about personal problems?
1. No, I don’t have a special adult in my life right now.
2. Yes, I do have a special adult in my life.

7

DRAFT – Youth Survey
15.

Right now in your life, is there a SPECIAL OLDER YOUTH (not your older brother
or sister) who you often spend time with? A special older youth is someone who
does a lot of good things for you. For example someone (a) who you look up to
and encourages you to do your best, (b) who really cares about what happens to
you, (c) who influences what you do and the choices you make, and (d) who you
can talk to about personal problems?
1. No, I don’t have a special older youth in my life right now.
2. Yes, I do have a special older youth in my life.

8

DRAFT – Youth Survey

Youth FollowUp Survey

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number. The valid
OMB control number for this information collection is XXXX-XXXX.
The time required to complete this information collection is estimated to average XX minutes per
response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: XXXX.
If you have comments or concerns regarding the status of your individual submission of this form,
write directly to: XXXXX.
1

DRAFT – Youth Survey

1

Have you ever lived apart from your birth mother for more than 12 months?
1
2

3

Yes
No

Have you ever lived apart from your birth father for more than 12 months?
1
2

Yes
No

In the next few questions, we’d like to know about the kinds of things that have been going
on in your life during the LAST SIX MONTHS. For each of these questions, place a check
next to NO if the activity or event has not happened in the last six months, OR check YES
if it has happened.
4

In the last six months…
YES

NO

a. Have you moved or changed where you live?

1

2

b. Has a parent or guardian started working?

1

2

c.

1

2

d. Have you broken up with a boy/girlfriend?

1

2

e. Has a close friend moved away?

1

2

f.

1

2

g. Have you changed schools?

1

2

h. Did someone you know well die?

1

2

i.

Have your parents separated (that is, have they started living in different
places)?

1

2

j.

Has anyone moved into or out of your house?

1

2

k.

Was someone you know well hurt badly or very ill?

1

2

l.

Has anyone you live with (like your mom or sister) had a baby?

1

2

1

2

Has a parent or guardian stopped working or lost his/her job?

Have you been picked on or bullied at school or in your neighborhood?

m. Have either of your parents been in prison?
5

These questions ask about how things are going with your parent or guardian. If you
live with two parents, please think about the parent or guardian you feel closest to
when you answer these questions. How often do you feel that…

Hardly
ever

Not very
often

Someti
mes

Pretty
often

a. My parent respects my feelings

1

2

3

4

b. I tell my parent about my problems and
troubles.

1

2

3

4

c.

1

2

3

4

I wish I had a different parent

2

DRAFT – Youth Survey

Hardly
ever

Not very
often

Someti
mes

Pretty
often

d. If my parent knows something is bothering me,
they ask me about it.

1

2

3

4

e. My parent accepts me as I am

1

2

3

4

f.

I like to get my parent’s point of view on things
I’m concerned about.

1

2

3

4

g. When we discuss things, my parent considers
my point of view.

1

2

3

4

h. I feel it’s no use letting my feelings show
around my parent.

1

2

3

4

i.

My parents trust my judgment.

1

2

3

4

j.

My parent can tell when I’m upset about
something.

1

2

3

4

k.

When I'm angry about something, my parent
tries to be understanding.

1

2

3

4

l.

My parent helps me to talk about my
difficulties.

1

2

3

4

m. I trust my parent.

1

2

3

4

n. My parent has their own problems, so I don’t
bother them with mine.

1

2

3

4

o. I can count on my parent when I need to get
something off my chest.

1

2

3

4

p. My parent helps me to understand myself
better.

1

2

3

4

These questions ask how you feel about things like school, other kids your age, and
yourself. For each sentence, decide how true the sentence is for you. Then circle one
number that fits best. There are no "right" or "wrong" answers because kids feel
differently about these things. If you think the statement is NOT AT ALL TRUE, circle “1”;
if you think the statement is NOT VERY TRUE, circle “2”; if the statement is SORT OF
TRUE, circle “3”; or if you think the statement is VERY TRUE, circle “4.”
6

How true are the following statements?
Not at
all true

Not very
true

Sort of
true

Very
true

a. I find it hard to make friends.

1

2

3

4

b. I have trouble figuring out the answers in
school.

1

2

3

4

c.

I am popular with others my age.

1

2

3

4

d. I would like to have a lot more friends.

1

2

3

4

e. In general, I like school a lot.

1

2

3

4

3

DRAFT – Youth Survey

Not at
all true

Not very
true

Sort of
true

Very
true

1

2

3

4

g. I sometimes think I am a failure (a “loser”).

1

2

3

4

h. I am happy with myself as a person.

1

2

3

4

i.

I am the kind of person I want to be.

1

2

3

4

j.

I often feel ashamed of myself.

1

2

3

4

k.

I look forward to going to school every day.

1

2

3

4

l.

I like being just the way I am.

1

2

3

4

m. I am as good a person as I want to be.

1

2

3

4

n. I wish I had more to be proud of.

1

2

3

4

o. I’m pretty slow at finishing my schoolwork.

1

2

3

4

p. I have a lot of friends.

1

2

3

4

q. I am always doing things with a lot of kids.

1

2

3

4

r.

I often forget what I learn.

1

2

3

4

s.

I feel that I am just as smart as other kids my
age.

1

2

3

4

t.

I feel that I am very good at my schoolwork.

1

2

3

4

u. I wish more people my age liked me.

1

2

3

4

v.

1

2

3

4

1

2

3

4

f.

I do very well at my class work

I often feel excited at school.

w. I am happy with the way I can do most things.
7

Which of the following best describes the grades on your last report card? Mostly…
(Check only one box)
1
2
3
4
5
6
7
8

8

D’s, E’s and F’s
D’s
C’s and D’s
C’s
B’s and C’s
B’s
A’s and B’s
A’s

How sure are you that you will…

Not at
all sure

Not
really
sure

Mostly
sure

Very
sure

a. Finish high school

1

2

3

4

b. Go to college

1

2

3

4

4

DRAFT – Youth Survey

c.

Finish college

Not at
all sure

Not
really
sure

Mostly
sure

Very
sure

1

2

3

4

In the next set of questions, we’d like to know about different things you’ve done during
the LAST THREE MONTHS. For each of the following questions, circle “1” if you HAVE
NEVER DONE the activity; circle “2” if you HAVE DONE the activity BUT NOT IN THE LAST
3 MONTHS; circle “3” if you HAVE DONE IT 1-2 TIMES IN THE LAST 3 MONTHS; circle “4”
if you HAVE DONE IT 3-4 TIMES IN THE LAST 3 MONTHS; or circle “5” if you HAVE DONE
IT 5 OR MORE TIMES IN THE LAST 3 MONTHS. Remember, there are no right or wrong
answers and your answers will be kept completely private—your name will not be on your
survey.
9

During the last three months, have you…
I have
NEVER
done
this

I have
done this,
but not in
the last 3
months

I did it 1–2
times in
the last 3
months

I did it 3–
4 times
in the
last 3
months

I did it 5
or more
times in
the last 3
months

a. Broken something on purpose?

1

2

3

4

5

b. Gotten into a fight at school?

1

2

3

4

5

1

2

3

4

5

d. Taken care of a sister or brother
after school without an adult there?

1

2

3

4

5

e. Had a fight or argument with your
parents?

1

2

3

4

5

1

2

3

4

5

g. Skipped school without permission?

1

2

3

4

5

h. Been home alone after school
without an adult there?

1

2

3

4

5

c.

f.

Gotten into a fight in your
neighborhood?

Taken something on purpose that
didn’t belong to you?

i.

Hit someone because you didn’t like
something they said or did?

1

2

3

4

5

j.

Taken something from a store
without paying for it?

1

2

3

4

5

k.

Had to have your parents come to
school about a problem?

1

2

3

4

5

l.

Drank alcohol without your parents
knowing?

1

2

3

4

5

m. Used marijuana (pot)?

1

2

3

4

5

n. Used other drugs (inhalants,
cocaine, LSD, heroin, steroids,
etc.)?

1

2

3

4

5

5

DRAFT – Youth Survey

I have
NEVER
done
this

I have
done this,
but not in
the last 3
months

I did it 1–2
times in
the last 3
months

I did it 3–
4 times
in the
last 3
months

I did it 5
or more
times in
the last 3
months

o. Have you ever sold or helped sell
marijuana (pot, grass), hashish
(hash), or other hard drugs such as
heroin, cocaine or LSD?

1

2

3

4

5

p. Carried a handgun? When we say
handgun, we mean any firearm other
than a rifle or shotgun.

1

2

3

4

5

q. Been arrested by the police or taken
into custody for an illegal or
delinquent offense (do not include
arrests for minor traffic violations)?

1

2

3

4

5

10 Are you a member of a gang? (A gang is a group that does some illegal things
together, and may have a special name or an area it calls its own.)
1
2

10b.

Yes
No

Do any of your friends belong to a gang?
1
2

Yes
No

11 Right now in your life, is there a SPECIAL ADULT (not your parent or guardian) who
you often spend time with? A special adult is someone who does a lot of good things
for you. For example someone (a) who you look up to and encourages you to do your
best, (b) who really cares about what happens to you, (c) who influences what you do
and the choices you make, and (d) who you can talk to about personal problems?
1
2

Yes, I do have a special adult in my life.
No, I don’t have a special adult in my life right now.

12 Right now in your life, is there a SPECIAL OLDER YOUTH (not your older brother or sister) who
you often spend time with? A special older youth is someone who does a lot of good things for
you. For example someone (a) who you look up to and encourages you to do your best, (b) who
really cares about what happens to you, (c) who influences what you do and the choices you
make, and (d) who you can talk to about personal problems?

1
2

Yes, I do have a special older youth in my life.
No, I don’t have a special older youth in my life right now.

13 Do you still meet with the mentor you were matched with when you enrolled in the
program?
1
2

Yes (Continue with question 12a)
No (Go to question 13)

6

DRAFT – Youth Survey

13a.

13b.

How often do you meet with your mentor?
1

Once a week or more

2

Once or twice a month

3

Less than once a month

How much time do you usually spend with your mentor when you meet?
1

Less than one hour

2

1–4 hours

3

5–10 hours

4

More than 10 hours

14 For about how many months did you meet with your mentor regularly after you
enrolled in the program?
1
2

Less than 6 months
6 months or more

7