Form 3 Baseline Evaluation Survey

Baseline Survey

Form Approved

OMB No. __0920-xxxx_

Exp. Date:

Public Reporting burden of this collection of information is estimated at 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-xxxx).

Instructions

We would like to ask you a few questions about your relationships. This is not a test, so there are no right or wrong answers.

Please read the directions and questions carefully and answer the questions as honestly as you can. The Expect Respect Facilitator will assist you if you need help.

Your answers are completely private. School personnel will not see your questionnaire. Your name will not appear on the survey.

By answering the questions you help us to understand what is important to teens like you and how we can improve programs for teens.

To be completed by SafePlace staff (Baseline Survey)

1. SafePlace ID
2. School Code 3. Facilitator Code
4. Date 5. Age _________________

Part 1: About You

6. What grade are you in?
	1 6th	2 7th		3 8th		4 9th	5 10th	6 11th		7 12th
7. Are you?
	1 Female		2 Male		3 Transgender
8. What were your grades for the last semester or grading period you completed? (Mark one.) 1 mostly A’s 2 mostly B’s 3 mostly C’s 4 mostly D’s 5 some A’s, some B’s and some C’s
9. Which of the following best describes you? (Mark one.)
	1 American Indian or Alaska Native					5 Native Hawaiian or Other Pacific Islander
	2 Asian					6 White
	3 Black or African American					7 Other
	4 Hispanic or Latino					8 Multiracial
10. Have you participated in any of the following activities in the past 12 months? (Mark all that apply.) 1 I have participated in Expect Respect Support Groups. 2 I have participated in a leadership group to prevent bullying, sexual harassment and dating violence. 3 I have participated in a poster, poetry or other contest about dating violence and healthy relationships. 4 We have talked about dating violence and healthy relationships in class. 5 We have talked about dating violence and healthy relationships in my after-school program. 6 I have seen a theater performance about bullying, sexual harassment and dating violence. 7 I have participated in an assembly about bullying, sexual harassment and dating violence. 8 I have seen posters and handouts in my school about dating violence. 9 I talk to my parents about how to have good relationships. 10 I have talked to my friends about healthy relationships. 11 I have gotten information about healthy relationships in other ways (please list): __________________________________________________

April 2010 Compiled and adapted by SafePlace.

Please, contact SafePlace before using this survey and for information about sources. (512) 356 1623 or (512) 356 1628.

Are the following statements true for you?

11. I always speak out when someone is being harassed.

• ₁ False

• ₂True

12. I sometimes feel upset when I don’t get my way.

• ₁ False

• ₂True

13. I like to gossip sometimes.

• ₁ False

• ₂True

14. I’m always a good listener.

• ₁ False

• ₂True

15. I’m always willing to admit it when I make a mistake.

• ₁ False

• ₂True

16. I am always nice with people.

• ₁ False

• ₂True

17. I have never hurt someone’s feelings on purpose.

• ₁ False

• ₂True

Part 2: Relationships

By dating we’re talking about having a boyfriend or a girlfriend, going out or hanging out in a romantic way, or hooking up with one person. This can be a relationship of any length.

18. Have you ever dated someone? If NO, skip to question 99 (page 10). If YES, continue with the next questions.	1 Yes	2 No
19. How many dating partners have you had in your life?	1 1	2 2 - 3	3 4 - 7	4 More than 7 people
20. How long was your longest dating relationship?	1 less than a month	2 1 – 3 months	3 3 - 6 months	4 More than 6 months
21. Have you dated in the past 3 months? If NO, skip to question 99 (page 10). If YES, continue with the next questions.	1 Yes	2 No
22. How many people have you dated in the past 3 months?	1 1	2 2 - 3	3 4 - 7	4 More than 7 people
Think about your longest dating relationship in the past 3 months. This can be a past or current relationship.
23. How often did you and this dating partner spend time together in the past 3 months?	1 About once a month	2 About once a week	3 Several times a week	4 Daily
24. How much time did you and this partner spend together all alone in the past 3 months?	1 Never, we were usually with other friends	2 Some- times all alone	3 Mostly all alone	4 Always all alone
25. Who do you feel had more power in this dating relationship in the past 3 months?	1 I had more power	2 My dating partner had more power	3 We had equal power
26. How physically affectionate were you and your partner in the past 3 months?	1 Not much, we mostly held hands	2 A little, we hugged or kissed sometimes	3 A lot, but there were things we didn’t do physically	4 There was not much my partner and I didn’t do to show each other physical affection

When you answer the following questions, please think about all the dating relationship(s) you’ve had in the past 3 months.

By dating partner we’re talking about a boyfriend or girlfriend, someone you go out with or hang out with in a romantic way, or someone you hook up with.

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I let my partner know what was important to me.	0	1	2	3
I said “no” when I was uncomfortable with what was going on.	0	1	2	3
I calmed myself down before talking when I was mad.	0	1	2	3
I talked to my partner about how I really felt.	0	1	2	3
I let my partner know what I wanted.	0	1	2	3
I told my partner when I was angry and why.	0	1	2	3
I asked my partner what he/she was feeling.	0	1	2	3
I offered a solution that would make us both happy.	0	1	2	3
I listened to my partner’s side of the story.	0	1	2	3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I tried to keep my partner from spending time with other people.	0	1	2	3
My partner tried to keep me from spending time with other people.	0	1	2	3
I checked where my partner was and who he/she was hanging out with.	0	1	2	3
My partner checked where I was and who I was hanging out with.	0	1	2	3
I did not let my partner do things with other people.	0	1	2	3
My partner did not let me do things with other people.	0	1	2	3
I threatened to end the relationship if my partner didn’t do what I wanted.	0	1	2	3
My partner threatened to end the relationship if I didn’t do what he/she wanted.	0	1	2	3
I put my partner down.	0	1	2	3
My partner put me down.	0	1	2	3
I yelled and screamed at my partner.	0	1	2	3
My partner yelled and screamed at me.	0	1	2	3
I made nasty comments about my partner to others.	0	1	2	3
My partner made nasty comments about me to others.	0	1	2	3
I made fun of my partner in front of others.	0	1	2	3
My partner made fun of me in front of others.	0	1	2	3
I threatened to hurt or hit my partner.	0	1	2	3
My partner threatened to hurt or hit me.	0	1	2	3
I showed up at my partner’s home, school or work or waited for him/her even when my partner didn’t want me to.	0	1	2	3
My partner showed up at my home, school or work or waited for me even when I didn’t want him/her to.	0	1	2	3
I repeatedly used cell phone, text messaging, or e-mail to check up on my partner and to see where he/she was.	0	1	2	3
My partner repeatedly used cell phone, text messaging, or e-mail to check up on me and to see where I was.	0	1	2	3
I used e-mails, text messaging, web chat, blog Facebook, MySpace or Twitter to spread rumors about my partner.	0	1	2	3
My partner used e-mails, text messaging, web chat, blog Facebook, MySpace or Twitter to spread rumors about me.	0	1	2	3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I hit my partner with a fist or a hard object.	0	1	2	3
My partner hit me with a fist or a hard object.	0	1	2	3
I scratched or slapped my partner.	0	1	2	3
My partner scratched or slapped me.	0	1	2	3
I beat my partner up.	0	1	2	3
My partner beat me up.	0	1	2	3
I twisted my partner’s arm or bent his/her fingers.	0	1	2	3
My partner twisted my arm or bent my fingers.	0	1	2	3
I pushed, shoved, or kicked my partner.	0	1	2	3
My partner pushed, shoved or kicked me.	0	1	2	3
I used physical force to protect or defend myself.	0	1	2	3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I was afraid of my partner.	0	1	2	3
My partner was afraid of me.	0	1	2	3
I had a bruise or small cut.	0	1	2	3
My partner had a bruise or small cut.	0	1	2	3
I felt physical pain that still hurt the next day.	0	1	2	3
My partner felt physical pain that still hurt the next day.	0	1	2	3
I went to a doctor or nurse because of an injury.	0	1	2	3
My partner went to a doctor or nurse because of an injury.	0	1	2	3
I felt unsafe.	0	1	2	3
My partner felt unsafe.	0	1	2	3
I worried that I could get hurt physically.	0	1	2	3
I worried that I could hurt my partner physically.	0	1	2	3

In the past 3 months, how often did the following things happen in your dating relationship(s)?	Never	Rarely	Some- times	Often
I spread sexual rumors about my partner.	0	1	2	3
My partner spread sexual rumors about me.	0	1	2	3
I showed nude or almost nude pictures/ video of my partner to others.	0	1	2	3
My partner showed nude or almost nude pictures/ video of me to others.	0	1	2	3
I called my partner bitch, slut, ho, player or gay.	0	1	2	3
My partner called me bitch, slut, ho, player or gay.	0	1	2	3
I grabbed or touched my partner’s private parts without his/her consent.	0	1	2	3
My partner grabbed or touched my private parts without my consent.	0	1	2	3
I forced my partner to kiss me.	0	1	2	3
My partner forced me to kiss him/her.	0	1	2	3
I told my partner that he/she should touch me in a sexual way to prove their love.	0	1	2	3
My partner told me that I should touch him/her in a sexual way to prove my love.	0	1	2	3
I got my partner drunk or high to get him/her to do something sexual.	0	1	2	3
My partner got me drunk or high to get me to do something sexual.	0	1	2	3
I pressured my partner to engage in a sexual act.	0	1	2	3
My partner pressured me to engage in a sexual act.	0	1	2	3

Part 3: Dealing with Anger

Most of us feel angry sometimes. Do not spend a lot of time thinking about the questions – just give your first response.

In the past 3 months, how often have you …	Never	Rarely	Sometimes	Often
Yelled at others when they annoyed you	0	1	2	3
Had fights with others to show who was on top	0	1	2	3
Reacted angrily when provoked by others	0	1	2	3
Taken things from other students	0	1	2	3
Gotten angry when frustrated	0	1	2	3
Damaged something for fun	0	1	2	3
Had temper tantrums	0	1	2	3
Damaged things because you felt mad	0	1	2	3
Had a gang fight to be cool	0	1	2	3
Hurt others to win a game	0	1	2	3
Become angry or mad when you don’t get your way	0	1	2	3
Used physical force to get others to do what you want	0	1	2	3
Gotten angry or mad when you lost a game	0	1	2	3
Gotten angry when others threatened you	0	1	2	3
Used force to obtain money or things from others	0	1	2	3
Felt better after hitting or yelling at someone	0	1	2	3
Threatened or bullied someone	0	1	2	3
Made obscene phone calls for fun	0	1	2	3
Hit others to defend yourself	0	1	2	3
Gotten others to gang up on someone else	0	1	2	3
Carried a weapon to use in a fight	0	1	2	3
Gotten angry or mad or hit others when teased	0	1	2	3
Yelled at others so they would do things for you	0	1	2	3

Part 4: Your Opinion

Is it OKAY if you do these things in a dating relationship?	Definitely not okay			Probably not okay		Probably okay		Definitely okay
Take charge of everything that goes on.	0			1		2		3
Tell your dating partner to spend all their time with you and drop other friends.	0			1		2		3
Check up or spy on your dating partner.	0			1		2		3
Put your partner down and call him/her mean names.	0			1		2		3
Make your partner dress a certain way.	0			1		2		3
Constantly send text messages.	0			1		2		3
Ignore your partner when you are unhappy with him/her.	0			1		2		3
Try to find out where your partner is every minute.	0			1		2		3
Slap, push, or shove your partner.	0			1		2		3
Forward private emails or photos to other people.	0			1		2		3
Act jealous if your partner talks to other people.	0			1		2		3
Kiss your partner when they say “No.”	0			1		2		3
Tell your partner that to show their love they should have sex with you.	0			1		2		3
How strongly do you agree or disagree with each statement?		Strongly agree	Agree somewhat		Disagree somewhat		Strongly disagree
It is OK for a boy to hit his girlfriend if she does something to make him mad.		0	1		2		3
It is OK for a boy to hit his girlfriend if she insults him in front of friends.		0	1		2		3
Girls sometimes deserve to be hit by the boys they date.		0	1		2		3
A girl who makes her boyfriend jealous on purpose deserves to be hit.		0	1		2		3
Boys sometimes deserve to be hit by the girls they date.		0	1		2		3
Sometimes boys have to hit their girlfriends to get them to do what they want them to do.		0	1		2		3
It is OK for a boy to hit a girl if she hits him first.		0	1		2		3
It is OK for a girl to hit a boy if he hits her first.		0	1		2		3

Look back at ALL of the dating relationships you have EVER had to answer these last questions.

Have you ever felt scared, put down or controlled by a dating partner?	1 Yes	2 No
Have you ever been hit, slapped, kicked or otherwise physically hurt by a dating partner?	1 Yes	2 No
Have you ever been pressured to do something sexual when you didn’t want to?	1 Yes	2 No
Have you ever threatened, put down or controlled a dating partner?	1 Yes	2 No
Have you ever hit, slapped, kicked or otherwise physically hurt a dating partner?	1 Yes	2 No
Have you ever pressured a dating partner to do something sexual when he/she didn’t want to?	1 Yes	2 No

Thank you for your hard work in answering these questions.

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