Form 1 Follow-up

OMB Control No: 0970-0272

Expiration date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

F ollow-up Questions for Inclusion in the Division of Abstinence Education’s Core Measure:

The first four questions are important in meeting the requirement placed on the Division of Abstinence Education by the Office of Management and Budget to evaluate the results of our program’s goal of affecting the rates of sexual intercourse among students in the U.S.

The [fill in name of program] abstinence education program is [provide unique description of program – unique details are important to help youth recall the program at follow-up].  Since you participated in the [fill in name of program] abstinence education program you are being asked to complete the survey below.

1. Have you ever had sexual intercourse?

__No ***If you marked NO, go to question 5

__Yes ***If you marked YES, go to question 2

2. When was the last time that you had sexual intercourse?

__I have never had sexual intercourse __2–3 months ago

__within the last week __4–6 months ago

__2–3 weeks ago __7-12 months ago

__1 month ago __More than 12 months ago

3. Have you had sexual intercourse since completing the abstinence education program?

__No

__Yes

4. How many different people have you had sexual intercourse with?

__I have never had sexual intercourse

__One

__Two

__Three

__Four

__Five Or More

The additional seven questions were developed with input of experienced abstinence education evaluators and are designed to measure factors associated with rates of sexual intercourse among adolescents.

4. It is important to me to wait until marriage before having sexual intercourse.

__Strongly agree

__Agree

__Neutral

__Disagree

_ _Strongly disagree

4. Having sexual intercourse before marriage is against my own personal standards of what is right and wrong.

__Strongly agree

__Agree

__Neutral

__Disagree

__Strongly disagree

4. I have a strong commitment to wait until marriage before having sexual intercourse.

__Strongly agree

__Agree

__Neutral

__Disagree

__Strongly disagree

4. I have decided to wait to have sexual intercourse until… (Please select one answer)

__I’m married

__I’m engaged

__I’m an adult in a long-term committed relationship

__I’m in love

__I finish high school

__It is not important for me to delay having sex

__Not sure

4. During the next year, how likely do you think it is that someone might try to get you to have sexual intercourse with them?

__I'm sure this won't happen.

__This probably won't happen.

_ _I don’t know whether this will happen or not.

__This probably will happen.

__I'm sure this will happen.

4. If someone did want you to have sexual intercourse with them during the next year, what would you do?

__I definitely would not do it.

__I probably would not do it.

__I'm not sure whether I would do it or not.

__I probably would do it.

__I definitely would do it.

4. How likely do you think it is that you will have sexual intercourse at any time before you get married?

__I'm certain I won't.

__I probably won't.

__I'm not sure whether I will or not.

__I probably will.

__I'm certain I will.