Engender Health

Evaluation of Pregnancy Prevention Approaches - First Follow-up

0990-0382Attachment E_ENGENDER HEALTH

Engender Health

OMB: 0990-0382

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2015-04-15 - Extension without change of a currently approved collection

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ATTACHMENT E:
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
FOLLOW- UP INSTRUMENT: ENGENDERHEALTH

The survey instrument for EngenderHealth divided into three sections:
PART A – FOR ALL YOUTH (this section ends with a question on whether the adolescent has had sex, in
which case the adolescent chooses to continue to either PART B1 or B2)
PART B1 – FOR SEXUALLY-ACTIVE YOUTH
PART B2 – FOR NON-SEXUALLY-ACTIVE YOUTH

Form approved
OMB No. 0990-0382
Exp. Date: xx/xx/20xx

FOLLOW-UP QUESTIONNAIRE
PART A
Engender Health
CONFIDENTIALITY
Thank you for your help with this important study. It will help us understand what things are like
for people your age today. Your answers are confidential and everything you say will be kept
private. Your name will not be on the questionnaire. Please answer all questions as well as you
can.
We want you to know that:
1.

We hope that you will answer all the questions, but you may skip any questions you do not
wish to answer.

The answers you give will never be identified as yours. Your responses will be combined
with those of other people your age.
Mathematica Policy Research

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0382. The time
required to complete this information collection is estimated to average 36 minutes per response, including the time to review
instructions and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA,
200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

GENERAL INSTRUCTIONS
1.

PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED! USE A PEN OR PENCIL.
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.
EXAMPLE 1: MARK (X) ONE ANSWER
What is the color of your eyes?
MARK (X) ONE
X

Brown
Blue
Green

If the color of your eyes is brown, you would mark (X)
the first box as shown.

Another color
2.

EXAMPLE 2: MARK (X) ONE ANSWER and FILL IN THE BLANK
What is the color of your hair?
MARK (X) ONE

Brown
Black

If the color of your hair is purple, you would mark (X)
the last box and write the word “purple” in the blank as
shown. BE SURE TO WRITE CLEARLY.

Blond
Red
X

Some other color PRINT OTHER COLOR

purple

EXAMPLE 3: YOU MAY MARK (X) MORE THAN ONE ANSWER
Do you plan to do any of the following next week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X

Rent a movie

Go to a baseball game

If you plan to rent a movie and go to a baseball game
next week, you would mark (X) both boxes.

Study at a friend’s house

PPA Study – Part A –Follow-Up Engender Health – 2/3/12

EXAMPLE 4: QUESTION WITH A SKIP
1. Do you ever eat chocolate?
Because you answered “Yes” to question 1, you would
continue to question 2 and then question 3.

MARK (X) ONE
X

Yes
GO TO QUESTION 3

If you answered “No” to question 1, you would skip
question 2 and go right to question 3.

2. Do you always brush your teeth after eating chocolate?
MARK (X) ONE

Yes
X

3. Did you do any of the following last week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X

Went to a play

Went to a movie
Attended a sporting event

EXAMPLE 5: FILL IN THE NUMBER
In the last seven (7) days, how many chocolate bars have you eaten?
0

NUMBER OF CHOCOLATE BARS – Your best guess is fine.
Fill in the boxes with the correct number. For any number less than 10, put a
zero (0) in the first box. For example, if you had eaten 2 chocolate bars in the
last 7 days, you would write “0” in the first box and “2” in the second box. If
you had eaten 15 chocolate bars, you would write “1” in the first box and “5”
in the second box.

EXAMPLE 6: MARK (X) ONE ANSWER FOR EACH QUESTION
In the last 12 months, have you done any of the following?
MARK (X) ONE FOR EACH QUESTION

a.
b.
c.
d.
e.
f.

YES
NO
Walked a dog on a leash ............................................................................................................................ X
Played Frisbee ............................................................................................................................................ X
X
Weeded a garden .......................................................................................................................................
Eaten a piece of fresh fruit.......................................................................................................................... X
X
Played a piano ............................................................................................................................................
X
Watched a movie ........................................................................................................................................
Mark (x) either “yes” or “no” for each of the six (6) questions
(a–f) by marking (x) one of the of two boxes in each row.

PPA Study – Part A –Follow-Up Engender Health 2/3/12

EXAMPLE 7: MARK (X) ONE MONTH AND ONE YEAR
In what month and year did you finish elementary school?
MARK (X) ONE MONTH AND ONE YEAR

Month finished

Year finished

January

2010
X

February

2009

March

2008

April

2007

May

2006

June

2005

July

2004

August

2003

September

2002

October

2001

November

2000

December

1999

If you finished elementary school in
June of 2009, you would mark (X) the
box next to June and mark (X) the box
next to 2009.

EXAMPLE 8: FOR GIRLS or FOR BOYS
1a. FOR GIRLS Do you want to be a mother someday?
MARK (X) ONE

Yes
No

GO TO 2

1b. FOR BOYS Do you want to be a father someday?
MARK (X) ONE

Yes
No
2.

Do you have any brothers or sisters?
MARK (X) ONE

Yes

Some questions are just for girls and some
questions are just for boys. These
questions are marked with FOR GIRLS or
FOR BOYS. If a question is not marked
specifically FOR GIRLS or FOR BOYS, then
it is a question for everyone to answer.
In the example, if you are a girl, you would
answer 1a (FOR GIRLS), skip 1b (FOR
BOYS), and then answer question 2, for
everyone. If you are a boy, you would skip
1a (FOR GIRLS), answer 1b (FOR BOYS),
and answer question 2, for everyone.

PPA Study – Part A –Follow-Up Engender Health 2/3/12

SECTION 1: YOU AND YOUR BACKGROUND
1.1. In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

Month born

Year born

January

2002

February

2001

March

2000

April

1999

May

1998

June

1997

July

1996

August

1995

September

1994

October

1993

November

1992

December

1991

PPA Study – Part A –Follow-Up Engender Health 2/3/12

1.2. What grade are you in? (If you are currently on vacation between grades, please indicate the grade
you will be in when you go back to school).
MARK (X) ONE

6th
7th
8th
9th
10th
11th
12th
Ungraded
College/technical school
Not currently in school

GO TO 1.4

1.3. What high school do you attend?
MARK (X) ONE

(NOTE: LIST OF HIGH SCHOOLS WILL APPEAR HERE)
Other (PRINT NAME OF SCHOOL):

1.4. Are you male or female?
MARK (X) ONE

Male
Female

1.5. Are you Hispanic/Latino?
MARK (X) ONE

Yes
No

PPA Study – Part A –Follow-Up Engender Health 2/3/12

1.6. What is your race?
YOU MAY MARK (X) MORE THAN ONE ANSWER

American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Some other race PRINT OTHER RACE

1.7. In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION

YES

a. Relationships, dating, marriage, or family life ................................................................................................
b. Abstinence from sex ......................................................................................................................................
c. Methods of birth control .................................................................................................................................
d. Where to get birth control ..............................................................................................................................
e. Sexually transmitted diseases, also known as STDs ....................................................................................
f.

How to talk to your partner about whether to have sex or whether to use birth control ................................

g. How to say no to sex......................................................................................................................................
h. How babies are made ....................................................................................................................................

PPA Study – Part A –Follow-Up Engender Health 2/3/12

1.8. Thinking about the past 12 months, how many times did you get information on relationships,
abstinence, birth control, or sexually transmitted diseases at each of the following places?
MARK (X) ONE FOR EACH

NEVER

1-3 TIMES

4-9 TIMES

10 OR MORE
TIMES

a. School class ....................................................................................................................................................
b. Church, synagogue, mosque, or religious
classes outside of school ................................................................................................................................
c. Community center, youth organization, or
after-school activity .........................................................................................................................................
d. Doctor, nurse, or clinic ....................................................................................................................................
e. Friends ............................................................................................................................................................
f.

Parents and other relatives or family members ..............................................................................................

g. Internet and media ..........................................................................................................................................
h. Summer youth program ..................................................................................................................................
i.

Other

LIST OTHER SOURCE

...........................................................................................................

1.9. Was ANY of the information you received helpful to you?
MARK (X) ONE

Yes
No

GO TO 1.11

1.10. Thinking about the past 12 months, where did you get information on relationships, abstinence,
birth control, or sexually transmitted diseases that was helpful to you?
SELECT ONE OR MORE

School class
Church, synagogue, mosque or religious classes outside of school
Community center, youth organization, or after-school activity
Doctor, nurse, or clinic
Friends
Parents and other relatives or family members
Internet and media
Summer youth program
Other (Please specify)

PPA Study – Part A –Follow-Up Engender Health 2/3/12

1.11. How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. You can do things now that will help you to be
healthy when you are an adult .......................................................................................................................
b. Nothing you do as a teen will affect how healthy
you are as an adult ........................................................................................................................................
c.

Taking risks as a teen, like drinking and drugs, does
not really matter for your health in the long run .............................................................................................

d. The good and bad decisions you make as a teen will
affect your health as an adult .........................................................................................................................

1.12. How likely is it that you will do each of the following things?
MARK (X) ONE FOR EACH QUESTION

NOT AT ALL
LIKELY

A LITTLE BIT
LIKELY

SOMEWHAT
LIKELY

VERY
LIKELY

a. Graduate from high school ............................................................................................................................
b. Go to a technical or vocational school after high school ...............................................................................
c. Go to college ..................................................................................................................................................
d. Graduate from a 2-year or community college program ................................................................................
e. Graduate from a 4-year college program.......................................................................................................

1.13. In the past 30 days, how often have you felt that you were unable to control the important things
in your life?
MARK (X) ONE

Never
Almost never
Sometimes
Fairly often
Very often

1.14. In the past 30 days, how often have you felt difficulties were piling up so high that you could not
overcome them?
MARK (X) ONE

Never
Almost never
Sometimes
Fairly often
Very often

PPA Study – Part A –Follow-Up Engender Health 2/3/12

SECTION 2: FAMILY
The next questions are about where you live and who lives with you.
2.1. Which of the following best describes where you live?
MARK (X) ONE

You live in one home

GO TO 2.2

You live in two or more homes and go back and forth

GO TO 2.3

You are homeless (living on the street, in a car or shelter, or staying with friends/relatives)

GO TO 2.4

2.2. Who lives with you in your home?
MARK (X) ALL THAT APPLY

Your biological mother
Your biological father
A stepmother or adoptive mother
A foster mother
A stepfather or adoptive father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandfathers
Any older brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

AFTER ANSWERING

PPA Study – Part A –Follow-Up Engender Health 2/3/12

GO TO 2.4

2.3. Who lives with you in each of your homes?
MARK (X) ALL THAT APPLY

MAIN HOME

OTHER HOME(S)

Mark (X) all the people who live with you in your
MAIN home

Mark (X) all the people who live with you in your
OTHER home(s)

Your biological mother

Your biological father

A stepmother or adoptive mother

A foster mother

A stepfather or adoptive father

A foster father

Your parent’s partner, boyfriend, or girlfriend

Any grandmothers

Any grandfathers

Any older brothers or sisters

Any younger brothers or sisters

Any aunts, uncles, or other relatives

Any other people you are not related to

You live by yourself

MOTHER
2.4. Now we have some questions about your mother, or the person you think of as your mother.
Is this person…?
MARK (X) ONE

Your biological mother, that is, the woman who gave birth to you
Your stepmother or adoptive mother
Your foster mother
Your grandmother
Your aunt or your older sister
Some other adult
Don’t have a mother or person I think of as my mother

PPA Study – Part A –Follow-Up Engender Health 2/3/12

GO TO 2.9

2.5. Please answer the following questions about the person you just marked in question 2.4 – that is,
your mother or the person you think of as your mother.
Is she working now?
MARK (X) ONE

She is not working at a paid job
Yes, she is working part-time or less than 30 hours a week
Yes, she is working full-time or at more than one job for 30 hours a week or more
Yes, she works, but I don’t know how many hours
Don’t know if she is working

2.6. How comfortable are you sharing ideas or talking with her about things that are important to
you?
MARK (X) ONE

Not at all comfortable
Somewhat comfortable
Comfortable
Very comfortable

2.7. Now thinking about your biological mother, that is, the woman who gave birth to you, how old is
she (or would she be if she were alive)?
NUMBER OF YEARS OLD – Your best guess is fine.
I do not know about my biological mother

GO TO 2.9

2.8. Again thinking about your biological mother and all the children she has ever had—how old is the
oldest one? If the oldest one is not alive, how old would that child be if still living?
NUMBER OF YEARS OLD – Your best guess is fine.
I do not know about my biological mother

PPA Study – Part A –Follow-Up Engender Health 2/3/12

FATHER
2.9. Next we have some questions about your father, or the person you think of as your father. Is this
person…?
MARK (X) ONE

Your biological father, that is, the man who is genetically related to you
Your stepfather or adoptive father
Your foster father
Your grandfather
Your uncle or your older brother
Some other adult
You don’t have a father or person you think of as your father

GO TO 2.12a

2.10. Please answer the following questions about the person you marked in 2.9 – that is, your father
or the person you think of as your father.
Is he working now?
MARK (X) ONE

He is not working at a paid job
Yes, he is working part-time or less than 30 hours a week
Yes, he is working full-time or at more than one job for 30 hours a week or more
Yes, he works, but I don’t know how many hours
Don’t know if he is working

2.11. How comfortable are you and sharing ideas or talking with him about things that are important to
you?
MARK (X) ONE

Not at all comfortable
Somewhat comfortable
Comfortable
Very comfortable

PPA Study – Part A –Follow-Up Engender Health 2/3/12

2.12a. Which of the following best describes the relationship between your biological mother and
biological father? If one or both of your biological parents have died, please answer about their
relationship when both were alive.
MARK (X) ONE

Married to each other
They were married to each other, but then separated
They were married to each other, but then divorced
They were never married to each other
I don’t know

2.12b. Do your biological mother and biological father live together now?
MARK (X) ONE

Yes
No
One or both of my biological parents have died
I don’t know

PPA Study – Part A –Follow-Up Engender Health 2/3/12

PARENTS
2.13.

The next questions ask what your parents know about your activities. By parents, we mean the
parents or guardians you live with most of the time.
Thinking about the past month, how often did your parents know where you were after school?
MARK (X) ONE

Always
Usually
Sometimes
Rarely
Never

2.14.

Thinking about the past month, how often did your parents know who you were going to be with
before you went out?
MARK (X) ONE

Always
Usually
Sometimes
Rarely
Never
I did not go out

2.15.

Thinking about the past month, how often did your parents know where you were when you
went out at night?
MARK (X) ONE

Always
Usually
Sometimes
Rarely
Never
I did not go out at night

2.16.

If you were going to be home late, would your parents expect you to call?
MARK (X) ONE

Yes
No

PPA Study – Part A –Follow-Up Engender Health 2/3/12

SECTION 3: VIEWS AND PERCEPTIONS
3.1. The next series of questions is about your views on sexual intercourse. In this survey, when we
ask about sexual intercourse, we mean a male putting his penis into a female’s vagina. How
strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. Having sexual intercourse is a good thing for you to
do at your age .................................................................................................................................................
b. At your age right now, having sexual intercourse
would create problems....................................................................................................................................
c. At your age right now, not having sexual intercourse
is important for you to be safe and healthy.....................................................................................................
d. At your age right now, it is okay for you to have sexual
intercourse if you use birth control, like a condom .........................................................................................
e. It is against your values to have sexual intercourse
before marriage ..............................................................................................................................................

3.2. These questions are about what sex means to boys and girls your age. How strongly do you
agree or disagree that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. It is embarrassing for a 16-year old boy if he has never
had sexual intercourse...................................................................................................................................
b. It is alright for a boy to pressure a girl to have sex if she
has had sex with him in the past ...................................................................................................................
c. When a girl says no to sex, she expects the boy to
keep trying .....................................................................................................................................................
d. One way for a guy to prove he is a real man is to have
sex with a lot of girls ......................................................................................................................................
e. A guy should have sexual intercourse as early as he
can in his life
f.

It is alright for a boy to pressure a girl to start having
sex if they have been dating for nine months ................................................................................................

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.3. Imagine you are alone with someone you like very much. How likely is it that you could…?
MARK (X) ONE FOR EACH QUESTION

NOT AT ALL
LIKELY

A LITTLE
BIT LIKELY

SOMEWHAT
LIKELY

VERY
LIKELY

a. Stop them if they wanted to touch your chest and
you did not want them to do that (FOR GIRLS)...............................................................................................
b. Stop them if they wanted to touch your private parts
below the waist, meaning the parts of the body covered
by underwear, and you did not want them to do that ......................................................................................
c. Avoid having sexual intercourse if you didn’t want to ......................................................................................

3.4. These questions are about what happens if a girl gets pregnant around your age, or a boy gets a
girl pregnant. How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. Getting pregnant/getting a girl pregnant in the
next year or two would hurt my chances of
being successful in life ...................................................................................................................................
b. If a girl and boy have sex, the girl is more
responsible for preventing pregnancy than the boy ......................................................................................
c. If I got pregnant/got a girl pregnant in the next year
or two I would have to become a responsible adult
before I wanted to ..........................................................................................................................................
d. If I got pregnant/got a girl pregnant in the next year
or two my life would become a lot better .......................................................................................................

3.5. These questions are about boys and girls. How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. The best way for a boy to show he is strong is to act
tough ..............................................................................................................................................................
b. Boys should let it show when their feelings are hurt .....................................................................................
c. In a good dating relationship the boy gets his way
most of the time .............................................................................................................................................
d. A girl who really likes a guy needs to have sex with him
to prevent him from finding someone else.....................................................................................................
e. It’s embarrassing for a boy when he needs to ask for help ...........................................................................

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.6. FOR GIRLS ONLY
These questions are about how girls feel. How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. Teenage girls who have a boyfriend feel better about
themselves than girls who don’t have a boyfriend .........................................................................................
b. When a teenage girl has a boyfriend, other girls look
up to her .........................................................................................................................................................
c. A girl is likely to feel bad about herself if she has never
had a boyfriend ..............................................................................................................................................

3.7. FOR GIRLS ONLY
If you got pregnant now, how would you feel?
MARK (X) ONE

Very happy
A little happy
Neither happy nor upset
A little upset
Very upset

3.8. FOR BOYS ONLY
If you got someone pregnant now, how would you feel?
MARK (X) ONE

Very happy
A little happy
Neither happy nor upset
A little upset
Very upset

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.9.

The next series of questions is about condom use. How strongly do you agree or disagree
that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Condoms should always be used if a
person your age has sexual intercourse ......................................................................................................
b. Using condoms means you don’t trust
your partner ..................................................................................................................................................
c. Condoms are important to make sex safer ..................................................................................................
d. Condoms are a hassle to use ......................................................................................................................
e. Using a condom is one way for a boy to
show he cares about his partner ..................................................................................................................
f. Using condoms is morally wrong .................................................................................................................
g. If two people love each other they don’t
have to use condoms ...................................................................................................................................
h. Girls who carry condoms get bad
reputations ....................................................................................................................................................
i. Condoms are pretty easy to get ...................................................................................................................
j. If a girl asks a boy to use a condom it
means she doesn’t trust him ........................................................................................................................
k. Condoms decrease sexual pleasure ............................................................................................................

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.10.

The next series of questions is about condoms, birth control pills, pregnancy and sexually
transmitted diseases, also known as STDs.
If condoms are used correctly and consistently, how much can they reduce the risk of
pregnancy?
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

GO TO 3.11

3.10a. How confident are you that your answer to 3.10 is correct?
MARK (X) ONE

Not at all confident
A little confident
Somewhat confident
Very confident

3.11.

If condoms are used correctly and consistently, how much can they reduce the risk of getting
HIV, the virus that causes AIDS?
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.12.

If birth control pills are used correctly and consistently, how much can they reduce the risk of
pregnancy?
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

GO TO 3.13

3.12a. How confident are you that your answer to 3.12 is correct?
MARK (X) ONE

Not at all confident
A little confident
Somewhat confident
Very confident

3.13.

If birth control pills are used correctly and consistently, how much can they reduce the risk of
getting HIV, the virus that causes AIDS?
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

3.14. The next series of questions is about other methods of birth control, NOT including condoms.
How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Birth control should always be used
if a person your age has sexual intercourse ..................................................................................................
b. Birth control is a hassle to use .......................................................................................................................
c. Birth control is pretty easy to get ...................................................................................................................
d. Birth control is important to make sex safer ..................................................................................................
e. Birth control has too many negative side effects ...........................................................................................
f.

Using birth control is morally wrong ...............................................................................................................

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.15. The following questions are about how you can get birth control where you live. How true do you
think it is that…?
MARK (X) ONE FOR EACH

DEFINITELY
TRUE

PROBABLY
TRUE

PROBABLY
FALSE

DEFINITELY
FALSE

DON’T
KNOW

a. In Texas, teenage girls can get a birth
control method like the pill or the shot at
a family planning or health clinic without
their parent’s permission ................................................................................................................................
b. I would know where to go for birth control
methods like the pill or the shot for me or
my partner ......................................................................................................................................................
c. I would know where to go if I wanted to
get tested for a sexually transmitted
disease (STD) ................................................................................................................................................
d. I would have enough money to pay for
birth control pills for me or my partner ...........................................................................................................

3.16. In the past 3 months, how many TIMES have you gone out on a date?
Zero or None

GO TO 3.18

NUMBER OF TIMES – Your best guess is fine.

3.17. Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you go out
on a date with?
NUMBER OF PEOPLE – Your best guess is fine.

3.18. In the past 6 months, have you had a boyfriend or girlfriend?
MARK (X) ONE

Yes
No

GO TO 3.20

3.19. In the past 6 months, how many different boyfriends or girlfriends have you had?
NUMBER OF PEOPLE – Your best guess is fine.

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.20. Do you intend to have sexual intercourse in the next year, if you have the chance?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.21. If you were to have sexual intercourse in the next year, do you intend to use (or have your partner
use) a condom?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.22. The next question is about your intention to use other methods of birth control, NOT including
condoms:
•
•
•
•
•
•

Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)

If you were to have sexual intercourse in the next year, do you intend to use (or have your partner
use) any of these other methods of birth control?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.23. Do you intend to have sexual intercourse without being married?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

PPA Study – Part A –Follow-Up Engender Health 2/3/12

3.24. Have you ever had sexual intercourse?
Yes

GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE ENVELOPE

GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE ENVELOPE

Complete the correct Part B (B1 or B2),
but not both.
(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents will be modified to
serve as instructions to telephone interviewers.)

PPA Study – Part A –Follow-Up Engender Health 2/3/12

Put this booklet back in
the envelope and

Go to Part B1 or Part B2.
(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents will be modified to
serve as instructions to telephone interviewers.)

PPA Study – Part A –Follow-Up Engender Health 2/3/12

Form approved
OMB No. 0990-0382
Exp. Date: xx/xx/20xx

FOLLOW-UP QUESTIONNAIRE
PART B1
Engender Health
Please be sure that you have the correct Part B.
If you answered “Yes” to the last question of Part A, you have the correct version of
Part B. If you answered “No,” please put this version back in your envelope and fill out
Part B2 instead.
Thank you.
Mathematica Policy Research
(NOTE:

This follow-up questionnaire will be administered by telephone, so instructions to
respondents will be modified to serve as instructions to telephone interviewers.)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0382. The time
required to complete this information collection is estimated to average 36 minutes per response, including the time to review
instructions and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance
Officer

PART B
4.1. The next questions are about your sexual behaviors and experiences. Please be as honest as
possible. Your answers are confidential and everything you say will be kept private.
The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Just to confirm, have you ever had sexual intercourse?
MARK (X) ONE

STOP AND GO TO PART B2

Yes

CONTINUE WITH THIS BOOKLET

(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents will be modified to
serve as instructions to telephone interviewers.)

4.2. The very first time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

Month of First Sexual
Intercourse

Year of First Sexual
Intercourse

January

2011

February

2010

March

2009

April

2008

May

2007

June

2006

July

2005

August

2004

September

2003

October

2002

November

2001

December

2000 or earlier

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

4.3. The very first time you had sexual intercourse, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.

4.4. The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE

Three or more years younger than you
A year or two younger than you
The same age as you
A year or two older than you
Three or more years older than you

4.5. The very first time you had sexual intercourse, would you say that it was voluntary or not
voluntary?
MARK (X) ONE

Voluntary
Not voluntary

4.6. Birth control methods are something used to reduce the risk of pregnancy, and some can reduce
the risk of sexually transmitted diseases, also known as STDs.
The first time you had sexual intercourse, did you or your partner use any type of birth control—
including condoms or any other method?
MARK (X) ONE

Yes
No

GO TO 4.8

4.7. The first time you had sexual intercourse, did you or your partner use…?
MARK (X) ONE FOR EACH QUESTION

YES
NO
a. Condoms........................................................................................................................................................
b. Birth control pills or the patch ........................................................................................................................
c. Depo-Provera or other injectable birth control ...............................................................................................
d. NuvaRing or the ring ......................................................................................................................................
e. Withdrawal or pulling out ...............................................................................................................................
f.

Another method? PRINT OTHER METHOD USED

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

..............................................................................

4.8. Have you had sexual intercourse more than one time?
MARK (X) ONE

Yes
GO TO 4.14

4.9. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
NUMBER OF PEOPLE – Your best guess is fine.

4.10. Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
sexual intercourse?
None

GO TO 4.14

NUMBER OF TIMES – Your best guess is fine.

4.11. In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?
None
NUMBER OF TIMES – Your best guess is fine.

4.12. The next question is about your use of the following methods of birth control:
•
•
•
•
•
•
•

Condoms
Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)

In the past 3 months, how many TIMES have you had sexual intercourse without using any of
these methods of birth control?
None
NUMBER OF TIMES – Your best guess is fine.

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

4.13. Now think about when you had sexual intercourse in the past 3 months and WERE using birth
control. In the past 3 months, how many TIMES did you have intercourse when you used a
condom AND were using another method of birth control in the list above?
None
NUMBER OF TIMES – Your best guess is fine.

4.14. FOR BOYS AND GIRLS
a.

To the best of your knowledge, have you ever been pregnant or gotten someone pregnant,
even if no child was born?
MARK (X) ONE

Yes
GO TO 4.15

To the best of your knowledge, how many TIMES have you been pregnant or gotten someone
pregnant?
None
NUMBER OF TIMES – Your best guess is fine.

Have you ever had a baby or has anyone you got pregnant actually had the baby?
MARK (X) ONE

Yes
No
Don’t know

4.15. In the past 12 months, have you spoken with a doctor or nurse about having sex, birth control or
sexually transmitted diseases, also known as STDs?
MARK (X) ONE

Yes
No

4.16. In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
disease (STD), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE

Yes
No

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

4.17. In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted disease (STD)?
MARK (X) ONE

Yes
No

4.18. Have you ever been in a situation where someone touched you in a sexual way that you did not
want, or someone forced you to touch him or her in a sexual way that you did not want to?
MARK (X) ONE

Yes
No

4.19. Have you ever been fearful that someone you were dating or having sex with might physically
hurt you?
MARK (X) ONE

Yes
No
I have never dated anyone

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

SECTION 5: ALCOHOL AND DRUG USE
5.1. The next questions are about alcohol and drugs. Please be as honest as possible, and remember
that everything you tell us will be kept private.
Have you ever had an alcoholic drink, such as beer, wine or other liquor, NOT counting any times
you just had a sip?
MARK (X) ONE

Yes
No

GO TO 5.5

5.2. The very first time you had an alcoholic drink, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.

5.3. During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

5.4. During the past 30 days, on how many days did you have 5 or more drinks in a row?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

5.5. Have you ever used marijuana, also called weed or pot?
MARK (X) ONE

Yes
No

5.6. Have you ever used any other type of illegal drug, prescription drugs, or an inhalant that were not
prescribed for you?
MARK (X) ONE

Yes
No

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

SECTION 6: FRIENDS AND RELATIONSHIPS
6.1. How many of your friends who are your age think the following things? Your best guess is fine.
MARK (X) ONE FOR EACH

NONE

SOME

HALF

MOST

ALL

DON’T
KNOW

a. Having sexual intercourse is a
good thing for them to do at their age ..............................................................................................................
b. It would be okay for them to have
sexual intercourse as long as they
used birth control, like a condom .....................................................................................................................
c. It would be okay for them to have
sexual intercourse if they were
dating the same person for a long time ...........................................................................................................
d. They should wait until they are older
to have sexual intercourse ...............................................................................................................................
e. They should wait until marriage to
have sexual intercourse ...................................................................................................................................

6.2. How many of your friends who are your age have had sexual intercourse?
MARK (X) ONE

None
Some
Half
Most
All
Don’t know

6.3. In general, how much pressure, if any, do you feel from your friends to have sexual intercourse?
MARK (X) ONE

A lot of pressure
Some pressure
A little pressure
No pressure

6.4. How much do you feel that your friends care about you?
MARK (X) ONE

Do not care at all
Care a little bit
Care somewhat
Care very much

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

FOR TREATMENT GROUP ONLY
(NOTE: This section, or a corresponding blank section, will be opened by telephone interviewers only after they complete
the preceding questions, to avoid disclosing to the interviewers the assignment status of the respondent.)

How many other people do you know of at your high school who participated in Gen.M this past
summer?
GO TO QUESTION 3

None

NUMBER OF PEOPLE – Your best guess is fine.

How often do you hang out with any of those kids?
MARK (X) ONE

A lot
Sometimes
Rarely
Never

Did you attend an event sponsored by Gen.M after you completed your summer Gen.M group?
MARK (X) ONE

Yes
No

If a friend asked, how likely would you be to recommend Gen.M to them?
MARK (X) ONE

Not at all likely
A little likely
Somewhat likely
Very likely

How many times have you done the following things in the past six months?
MARK (X) ONE FOR EACH

1-2

3-5

6-10

MORE
THAN 10

a. Gotten together with members of your
Gen.M group ...................................................................................................................................................
b. Texted members of your Gen.M group ...........................................................................................................
c. Spoken to a member of your group on
the phone ........................................................................................................................................................
d. Friended somebody from your group
on Facebook ...................................................................................................................................................
e. Been in touch with members of your
group in any other way ...................................................................................................................................

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

Please put all three parts of the survey back
into the envelope and give the envelope back
to the moderator.
Thank you!
(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents will be modified to
serve as instructions to telephone interviewers.)

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

We thank you for
completing this survey!

PPA Study – Follow-Up Part B1 – Engender Health – 2/3/12

Form approved
OMB No. 0990-0382
Exp. Date: xx/xx/20xx

FOLLOW-UP QUESTIONNAIRE
PART B2
Engender Health
Please be sure that you have the correct Part B.
If you answered “No” to the last question of Part A, you have the correct version of
Part B. If you answered “Yes,” please put this version back in your envelope and fill
out Part B1 instead.
Thank you.
Mathematica Policy Research

(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents
will be modified to serve as instructions to telephone interviewers.)

PART B
4.1. This booklet is for youth who have not had sex. We want to be sure you are in the correct
booklet. We know we asked this before but…
Just to confirm, have you ever had sexual intercourse?
MARK (X) ONE

Yes

STOP AND GO TO PART B1

CONTINUE WITH THIS BOOKLET

(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents will be modified to
serve as instructions to telephone interviewers.)

4.2. The first two questions in this booklet are about your schooling.
Do you expect that you will graduate from high school?
MARK (X) ONE

Yes
I already graduated from high school
No

GO TO 4.4

PPA Study – FU Part B2 – Engender Health 2/3/12

4.3. In what month and year do you expect to graduate from high school? (If you already graduated,
in what month and year did you graduate from high school?)
MARK (X) ONE MONTH AND ONE YEAR

Month of Graduation

Year of Graduation

January

2018 or later

February

2017

March

2016

April

2015

May

2014

June

2013

July

2012

August

2011

September

2010

October

2009

November

2008

December

2007 or earlier

PPA Study –FU Part B2 – Engender Health 2/3/12

4.4. The next questions are about where you live.
In the past 7 days, did you spend any nights somewhere like a shelter, someone else’s home, in a
car, on the street or in any other temporary housing because you did not have a regular place to
stay?
MARK (X) ONE

GO TO 4.11

Yes
No

4.5. In how many homes, places, or households do you live: one, two, or three or more?
MARK (X) ONE

1 home

GO TO 4.9

2 homes
3 or more homes

4.6. Do you consider one of these homes to be your main home?
MARK (X) ONE

Yes
No

4.7. Thinking about the past 30 days, how many nights did you spend in each home?
FILL IN TWO OR THREE NUMBERS

Number of nights at home #1 – Your best guess is fine.
Number of nights at home #2 – Your best guess is fine.
Number of nights at another home or other homes – Your best guess is fine.

4.8. Is there anyone who moves with you from home to home?
MARK (X) ONE

Yes
No

4.9. Is your home or any of your homes a group home or halfway house?
MARK (X) ONE

Yes
No

PPA Study – FU Part B2 – Engender Health 2/3/12

4.10. This question is about who lives with you in your home. If you have more than one home, please
think about your main home.
How many people usually live in your home, including all children and anyone who normally lives
there even if they are not there now, like someone who is away traveling or in a hospital?
NUMBER OF PEOPLE

4.11. These next few questions are about you and your friends.
How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. You have friends who will give you good advice ...........................................................................................
b. You have a friend who cares about you ........................................................................................................
c. You have a friend you can talk to when you need to .....................................................................................
d. You have someone who you can call your best friend ..................................................................................

4.12. How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. When you start a project, you finish it ............................................................................................................
b. You only work as hard as you have to ...........................................................................................................
c. You are someone people can count on .........................................................................................................
d. When you do work, you do a good job ..........................................................................................................

PPA Study –FU Part B2 – Engender Health 2/3/12

4.13. Here are some reasons people your age might choose NOT to have sexual intercourse. How
important is each of these reasons to you?
MARK (X) ONE FOR EACH QUESTION

VERY
IMPORTANT

SOMEWHAT
IMPORTANT

NOT TOO
IMPORTANT

NOT AT ALL
IMPORTANT

a. I don’t want to get a sexually transmitted
disease, also known as an STD ..................................................................................................................
b. I don’t want to disappoint my parents ..........................................................................................................
c. I am too young to have sex..........................................................................................................................
d. My boyfriend or girlfriend doesn’t want
to have sex...................................................................................................................................................
e. I want to wait until I’m married .....................................................................................................................
f.

It is against my personal values ..................................................................................................................

g. I haven’t met the right person yet ................................................................................................................
h. I haven’t had the chance..............................................................................................................................
i.

I don’t want to ..............................................................................................................................................

FOR GIRLS I do not want to get pregnant ..................................................................................................

k. FOR BOYS I do not want to get a girl pregnant ..........................................................................................

4.14. Have you ever done any of the following?
MARK (X) ONE FOR EACH QUESTION

YES

a. Kissed someone on the lips .........................................................................................................................
b. French kissed, that is put your tongue in someone’s mouth while kissing ..................................................
c. Touched another person’s private parts ......................................................................................................
d. Let someone touch your private parts .........................................................................................................

4.15. Have you ever been in a situation where someone touched you in a sexual way that you did not
want, or someone forced you to touch him or her in a sexual way that you did not want to?
MARK (X) ONE

Yes
No

PPA Study –FU Part B2 – Engender Health 2/3/12

4.16. Have you ever been fearful that someone you were dating might physically hurt you?
MARK (X) ONE

Yes
No
I have never dated anyone

4.17. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted diseases, also known as STDs?
MARK (X) ONE

Yes
No

4.18. If you decided to have sexual intercourse outside of marriage, how likely is it that you would use
a condom or other contraceptive method?
MARK (X) ONE

Not at all likely
A little bit likely
Somewhat likely
Very likely
Don’t plan to have sexual intercourse outside of marriage

PPA Study –FU Part B2 – Engender Health 2/3/12

THIS PAGE IS INTENTIONALLY BLANK
Please continue on the next page with Section 5: Alcohol and
Drug Use.
(NOTE: This follow-up questionnaire will be administered by telephone, so instructions to respondents will be
modified to serve as instructions to telephone interviewers.)

PPA Study –FU Part B2 – Engender Health 2/3/12

Yes
No

GO TO 5.5

5.2. The very first time you had an alcoholic drink, how old were you?
NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

5.3. During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

5.4. During the past 30 days, on how many days did you have 5 or more drinks in a row?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

5.5. Have you ever used marijuana, also called weed or pot?
MARK (X) ONE

Yes
No

PPA Study –FU Part B2 – Engender Health 2/3/12

5.6. Have you ever used any other type of illegal drug, prescription drugs or an inhalant that were not
prescribed for you?
MARK (X) ONE

Yes
No

PPA Study –FU Part B2 – Engender Health 2/3/12

SECTION 6: FRIENDS AND RELATIONSHIPS
6.1. How many of your friends who are your age think the following things? Your best guess is fine.
MARK (X) ONE FOR EACH

NONE

SOME

HALF

MOST

ALL

DON’T
KNOW

a. Having sexual intercourse is a good
thing for them to do at their age ......................................................................................................................
b. It would be okay for them to have
sexual intercourse as long as they
used birth control, like a condom ....................................................................................................................
c. It would be okay for them to have
sexual intercourse if they were
dating the same person for a long
time .................................................................................................................................................................
d. They should wait until they are
older to have sexual intercourse .....................................................................................................................
e. They should wait until marriage
to have sexual intercourse ..............................................................................................................................

6.2. How many of your friends who are your age have had sexual intercourse?
MARK (X) ONE

None
Some
Half
Most
All
Don’t know

6.3. In general, how much pressure, if any, do you feel from your friends to have sexual intercourse?
MARK (X) ONE

A lot of pressure
Some pressure
A little pressure
No pressure

6.4. How much do you feel that your friends care about you?
MARK (X) ONE

Do not care at all
Care a little bit
Care somewhat

PPA Study –FU Part B2 – Engender Health 2/3/12

Care very much

PPA Study –FU Part B2 – Engender Health 2/3/12

How many other people do you know of at your high school who participated in Gen.M this past
summer?
GO TO QUESTION 3

None

NUMBER OF PEOPLE – Your best guess is fine.

How often do you hang out with any of those kids?
MARK (X) ONE

A lot
Sometimes
Rarely
Never

Did you attend an event sponsored by Gen.M after you completed your summer Gen.M group?
MARK (X) ONE

Yes
No

If a friend asked, how likely would you be to recommend Gen.M to them?
MARK (X) ONE

Not at all likely
A little likely
Somewhat likely
Very likely

PPA Study –FU Part B2 – Engender Health 2/3/12

How many times have you done the following things in the past six months?
MARK (X) ONE FOR EACH

1-2

3-5

6-10

MORE
THAN 10

PPA Study –FU Part B2 – Engender Health 2/3/12

We thank you for
completing this survey!

PPA Study –FU Part B2 – Engender Health 2/3/12

File Type	application/pdf
Author	MThomas
File Modified	2012-03-27
File Created	2012-03-27