0990-0382Attachment H_ Combined

ATTACHMENT H
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES:
CROSSWALKS OF FOLLOW-UP AND BASELINE ITEMS FOR EACH OF THE PPA
SITES
A separate crosswalk is presented for each site, in the following order: Chicago Public Schools,
OhioHealth, Children’s Hospital of Los Angeles (CHLA), Oklahoma Institute for Child Advocacy (OICA),
EngenderHealth, Live the Life (LtL), and Princeton Center for Leadership Training (PCLT).

SUMMARY OF DIFFERENCES BETWEEN THE CHICAGO BASELINE QUESTIONNAIRE AND THE CHICAGO FOLLOW-UP
QUESTIONNAIRE

Chicago Follow-up #

Chicago Baseline #

Items are listed in the order in which they appear on the follow-up instrument (OMB approval received on September 27, 2011; OMB Control No. 0970-0360).
The number for the corresponding item on the baseline instrument is listed in the “Chicago Baseline #” column. Items in Part A are listed first, followed by items
in Section 4, Part B1 (for sexually active respondents), items in Section 4, Part B2 (for non-sexually active respondents) and items in Sections 6 and 7, Parts B1
and B2 (these sections are the same for sexually active and non-sexually active respondents).
Modifications to an existing baseline item are listed in the “Modifications for Follow-up” column; otherwise, the question text on the follow-up
instrument is the same as that on the baseline instrument.
If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “Chicago Baseline #” column and the text is noted in the
“Modifications for Follow-up” column.

1.1

1.1

What is your date of birth?
MARK (X) ONE MONTH AND ONE YEAR

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1.2

1.2

Added 6th grade as an answer.

1.3

1.3

What grade are you in?
MARK (X) ONE
□
7th
□
8th
□
9th
□
10th
□
11th
□
12th
□
Not currently in school
Are you male or female?

Chicago Baseline Text

Modifications for Follow-up

MARK (X) ONE
□
Male
□
Female

1

Chicago Follow-up #

Chicago Baseline #

Chicago Baseline Text

1.4

1.4

Are you Hispanic or Latino?

Modifications for Follow-up
Are you Hispanic/Latino?

MARK (X) ONE
□
Yes
□
No
1.5

1.5

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

2

Chicago Follow-up #

Chicago Baseline #

1.6

1.9

1.6a

N/A

Chicago Baseline Text

Modifications for Follow-up

In the last 12 months, have had any classes, special programs, or
instruction at school, church, a health clinic, a community center,
or some other place about each of the following?

In the past 12 months, have you received information or learned about any
of the following?

MARK (X) ONE FOR EACH QUESTION

MARK (X) ONE FOR EACH QUESTION

Yes, No

Yes, No

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

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

About relationships, dating, marriage, or family life?
About abstinence from sex?
About methods of birth control?
About sexually transmitted diseases, also known as STDs?
About alcohol or drug use?
About physical development and reproduction?
About refusal skills, such as how to say no to sex, or how to
resist peer pressure?

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
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
Did you say “yes to any item a through h in question 1.6 above?
MARK (X) ONE
□
Yes
□
No - GO TO 1.9

3

Chicago Follow-up #

Chicago Baseline #

1.7

N/A

Chicago Baseline Text

Modifications for Follow-up
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 QUESTION
Never, 1-3 times, 4-9 times, 10 or more times
a.
b.
c.
d.
e.
f.
g.
h.

4

School class, workshop, or event
Church, synagogue, mosque or religious classes outside of
school
Community center, youth organization, or after-school activity
Doctor, nurse, or clinic
Friends or other students
Parents and other relatives or family members
Internet and media
Other (List other source)

Chicago Follow-up #

Chicago Baseline #

1.8

N/A

Chicago Baseline Text

Modifications for Follow-up
Thinking about the past 12 months, where did you get information on
relationships, abstinence, birth control, or sexually transmitted diseases that
was very helpful to you?
SELECT ONE OR MORE
□ School class, workshop, or event
□ Church, synagogue, mosque or religious classes outside of
school
□ Community center, youth organization, or after-school activity
□ Doctor, nurse, or clinic
□ Friends or other students
□ Parents and other relatives or family members
□ Internet and media
□ Other (Please specify)

1.9

N/A

How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH
Strongly agree, Agree, Disagree, Strongly disagree
a.
b.
c.
d.

5

You can do things now that will help you to be healthy when
you are an adult
Nothing you do as a teen will affect how healthy you are as an
adult
Taking risks as a teen, like drinking and drugs, does not really
matter for your health in the long run
The good and bad decisions you make as a teen will affect
your health as an adult

Chicago Baseline #

Chicago Follow-up #
2.1a,
2.2,
and
2.3

Chicago Baseline Text

Modifications for the Follow-up

2.1

The next question is about where you live and who lives with you.

Question is split into three separate questions on the concordance version:

Do you live in one home, place, or household all of the time or do you go
back and forth between two or more different places?

2.1a Which of the following best describes where you live?

MARK (X) ONE
1 □ Live in one home - FILL OUT ONLY THE FIRST COLUMN BELOW Mark
(X) all the people who live with you in your home
2 □ Live in two or more homes FILL OUT THESE TWO COLUMNS BELOW
Same Categories as above listed, two columns for two homes.
Mark all the people who live with you in your MAIN home and Mark all
the people who live with you in your other home
□
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

□ 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 ALL THAT APPLY
(List is the same as the one in the OMB-approved version)

2.3 Who lives with you in your homes?
MARK ALL THAT APPLY
Mark all the people who live with you in your MAIN home.
Mark all the people who live with you in your OTHER home(s).
(List for both the main home and other homes is the same as the one in the OMBapproved version)

6

2.4

2.5

Now we have some questions about your mother, or the person
you think of as a mother. Is this person…

Added to response:
Your aunt or older sister

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
□
Some other adult
□
Don’t have a mother or person I think of as a mother
GO
TO QUESTION 2.13
2.5

2.8

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
□
Don’t know

The following questions are about the person you marked as 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
□

2.6

N/A

Don’t know

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)?
|

|
□

7

| NUMBER OF YEARS OLD –Your best guess is fine
I do not know about my biological mother

2.7

N/A

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

□
2.8

2.13

Next we have some questions about your father, or the person you
think of as a father. Is this person…

I do not know about my biological mother

Added to response:
Your uncle or older brother

MARK (X) ONE

2.9

2.16

□
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
□
Some other adult
□
Don’t have a father or person I think of as a father GO TO
2.21
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
□
Don’t know

The following questions are about the person you marked as 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

8

2.10
a

2.10
b

2.2

2.2

Which of the following best describes your parents’ living
arrangement?
MARK (X) ONE
□
Both of my parents live together in one household and they
are married to each other
□
Both of my parents live together in one household and they
are not married to each other
□
My parents live in different households and are married to
each other
□
My parents live in different households and are not married
to each other
□
I have only one living parent
□
Don’t know

Question was modified and split into two separate questions for the
concordance:

Which of the following best describes your parents’ living
arrangement?
MARK (X) ONE
□
Both of my parents live together in one household and they
are married to each other
□
Both of my parents live together in one household and they
are not married to each other
□
My parents live in different households and are married to
each other
□
My parents live in different households and are not married
to each other
□
I have only one living parent
□
Don’t know

Question was modified and split into two separate questions for the
concordance:

2.10a Which of the following best describes the relationship between your
biological mother and biological father? If one or both of your biological
parents have passed away, please answer about their relationship when both
were alive.
MARK (X) ONE
 They are married to each other
 They used to be married to each other, but are now separated
 They used to be married to each other, but are now divorced
 They have never been married to each other
 I don’t know

2.10b Do your biological mother and
biological father live together now?
MARK (X) ONE
 Yes
 No
 One or both of my biological parents have passed away
 I don’t know

9

3.1

3.1

The next series of questions is about your views on sexual
intercourse. By sexual intercourse, we mean when a male inserts
his penis into a female’s vagina. How strongly do you agree or
disagree that . . .

Slight modification to the definition of sexual intercourse:
In this survey, when we ask about sexual intercourse we mean a male putting
his penis into a female’s vagina.

MARK (X) ONE FOR EACH QUESTION
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.
d.
e.
3.2

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

N/A

How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH
Strongly agree, Agree, Disagree, Strongly disagree
a. You have goals you want to accomplish before you have a child
b. It is important for you to finish school before you have a child
c. It is important for you to have a job and stable income before you
have a child
d. Having a good marriage seems possible for you

3.3

3.2

FOR GIRLS
If you got pregnant now, how would you feel?

Order of the response categories is reversed
(Very happy to Very upset).

MARK (X) ONE
□
□
□
□
□

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

10

3.4

3.2

FOR BOYS
If you got a female pregnant now, how would you feel?

Order of the response categories is reversed
(Very happy to Very upset).

MARK (X) ONE
□
□
□
□
□
3.5

3.3

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

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 likely, Somewhat Likely, Very Likely
a.
b.

c.
3.6

3.6a

N/A

N/A

Stop them if they wanted to touch your chest and you did not
want them to do that?
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?
Avoid having sexual intercourse if you didn’t want to?
How likely is it that you will get pregnant (or get someone pregnant) between
now and age 20?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely
How likely is it that you will get pregnant (or get someone pregnant) between
now and when you get married?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely

11

3.7

3.7a

3.8

3.9

3.5

3.5a

3.6

3.8

The next series of questions is about condoms, birth control pills,
pregnancy and sexually transmitted diseases, also called STDs.
If a condom is used correctly, how much can it decrease the risk of
pregnancy?

The next series of questions is about condoms, birth control pills, pregnancy
and sexually transmitted diseases, also called STDs.
If condoms are used correctly and consistently, how much can they decrease
the risk of pregnancy?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□ Completely
□
Don’t know

GO TO 3.6

GO TO 3.8

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If a condom is used correctly, how much can it decrease the risk of
getting HIV, the virus that causes AIDS?

If condoms are used correctly and consistently, how much can they decrease
the risk of getting HIV, the virus that causes AIDS?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□ Completely

If birth control pills are used correctly, how much can they
decrease the risk of pregnancy?

□
Don’t know
If birth control pills are used correctly and consistently, how much can they
decrease the risk of pregnancy?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□ Completely

GO TO 3.9

□

Don’t know

12

GO TO 3.10

3.9a

3.10

3.8a

3.9

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If birth control pills are used correctly, how much can they
decrease the risk of getting HIV, the virus that causes AIDS?

If birth control pills are used correctly and consistently, how much can they
decrease the risk of getting HIV, the virus that causes AIDS??

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□ Completely
□

3.11

3.10

Don’t know

If birth control pills are used correctly, how much can they
decrease the risk of getting Chlamydia and gonorrhea?

If birth control pills are used correctly and consistently, how much can they
decrease the risk of getting Chlamydia and gonorrhea?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□ Completely
□

3.12

3.11

Can you get a sexually transmitted disease, or STD, from having
oral sex?
MARK (X) ONE
□
Yes
□
No
□
Don’t know
GO TO 3.12

3.12
a

3.11a

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident

Don’t know

13

3.13

3.4

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

Added response options:




Condoms are pretty easy to get
Using condoms is morally wrong
Condoms decrease sexual pleasure

Removed “sexual” from item d (now reads: Using condoms means you
don’t trust your partner)

a. Condoms should always be used if a person your age has sexual
intercourse?
b. Condoms are a hassle to use?
c. Condoms are important to make sex safer?
d. Using condoms means you don’t trust your sexual partner?
3.14

N/A

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 QUESTION
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

14

3.15

N/A

Read each statement below and check the answer that fits best.
MARK (X) ONE FOR EACH
I am sure it’s true, I think it’s true, I don’t know, I think it’s false, I am sure it’s
false

3.16

N/A

a. You can’t get AIDS if you have sex only once or twice without a condom
b. If condoms are used correctly and consistently, they can reduce the risk of
STDs such as Chlamydia and gonorrhea
c. Once you are infected with HIV, you are infected for life
d. If a young couple has had unprotected sex a few times and a pregnancy did
not happen, they do not have to worry about her getting pregnant
e. There is a vaccine or shot available to prevent girls from becoming infected
with certain types of HPV (also known as Human Papilloma virus)
Thinking about the future, how likely do you think it is that you will get
HIV/AIDS?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely

3.17

N/A

How likely do you think it is that you will get an STD other than HIV/AIDS?

MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely

15

3.18

3.19

3.13

3.12

Thinking about the future, which statement is most true for you?

Do you intend to have oral sex in the next year?

MARK (X) ONE
□
You will not have oral sex in the next year
□
You probably will not have oral sex in the next year
□
You probably will have oral sex in the next year
□
You will have oral sex in the next year

MARK (X) ONE

Thinking about the future, which statement is most true for you?
MARK (X) ONE
□
You will not have sexual intercourse in the next year
□
You probably will not have sexual intercourse in the next year
□
You probably will have sexual intercourse in the next year
□
You will have sexual intercourse in the next year

3.20

N/A

□
Yes, definitely
□
Yes, probably
□
No, probably not
□
No, definitely not
Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
□
Yes, definitely
□
Yes, probably
□
No, probably not
□
No, definitely not
If you have sexual intercourse in the next year, do you intend to use a
condom?
MARK (X) ONE
□
□
□
□

3.21

N/A

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

The next question is about your intention to use following other methods of
birth control:
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?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not

16

3.22

3.23

3.24

3.25

3.26

3.14

Thinking about the future, which statement is most true for you?

Do you intend to have sexual intercourse without being married?

MARK (X) ONE
□
You will not have sexual intercourse between now and when
you get married
□
You probably will not have sexual intercourse between now
and when you get married
□
You probably will have sexual intercourse between now and
when you get married
□
You will have sexual intercourse between now and when you
get married

MARK (X) ONE

N/A

3.15

3.16

3.17

□
□
□
□

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

Right now, do you have a boyfriend or girlfriend – someone in particular you
are going out with?

In the last 3 months, how many times have you gone out on a
date?
□ Zero or None
GO TO 3.17
| | | NUMBER OF TIMES - Your best guess is fine
Thinking about these dates in the last 3 months, how many
different people did you go out on a date with?
□ Zero or None
| | | NUMBER OF PEOPLE - Your best guess is fine.
Have you ever had sexual intercourse, oral sex, or anal sex?

MARK (X) ONE
□
Yes
□
No
Changed “last” to “past”.

Changed “last” to “past”.
Deleted

□ YES: PLEASE PUT THIS BOOKLET BACK IN THE ENVELOPE AND GO
TO PART B1
□ NO: PLEASE PUT THIS BOOKLET BACK IN THE ENVELOPE AND GO
TO PART B2

17

□

Zero or None

4.1
Part
B1

4.2
Part
B1

4.3
Part
B1

4.1
Part
B1;
4.1
Part
B2

4.2
Part
B1

4.3
Part
B1

The next questions are about your sexual behaviors and
experiences. Please be as honest as possible. Everything you say
will be kept private.
Just to confirm, have you ever had sexual intercourse, oral sex, or
anal sex?
□ No: THIS IS THE WRONG PART B BOOKLET. PLEASE PUT THIS
BOOKLET BACK IN THE ENVELOPE AND FILL OUT PART B2
□ Yes : CONTINUE WITH THIS BOOKLET.
The first questions are about sexual intercourse. By sexual
intercourse, we mean when a male puts his penis into a female’s
vagina.

Slight modification to the definition of sexual intercourse:
By sexual intercourse, we mean a male putting his penis into a female’s
vagina.

Have you ever had sexual intercourse?
MARK (X) ONE
□
Yes
□
No
GO TO QUESTION 4.14
The very first time you had sexual intercourse, what month and
year was it?
MARK (X) ONE MONTH AND ONE YEAR

4.4
Part
B1

4.4
Part
B1

The very first time you had sexual intercourse, how old were you?

4.5
Part
B1

4.9
Part
B1

Have you had sexual intercourse more than one time?

4.6
Part
B1

4.10
Part
B1

| |
fine.

| NUMBER OF YEARS OLD YOU WERE - Your best guess is

MARK (X) ONE
□ Yes
□ No
GO TO QUESTION 4.14
How many DIFFERENT PEOPLE have you ever had sexual
intercourse with?
|

|

| NUMBER OF PEOPLE - Your best guess is fine.

18

4.7

N/A

The most recent time you had sexual intercourse, what month and year was
it?
MARK (X) ONE MONTH AND ONE YEAR

4.8
Part
B1

4.8
Part
B1

The first time you had sexual intercourse, did you or your partner
use …

Modified reference period from “ the first time” to “ the most recent” time

MARK (X) ONE FOR EACH ITEM
YES,NO
a.
b.
c.
d.
e.
f.

4.9
Part
B1

4.11
Part
B1

Condoms?
Birth control pills or the patch?
Depo-Provera, the shot, or other injectable birth control?
Nuva ring or the ring?
Withdrawal or pulling out?
Another method of birth control? PRINT OTHER METHOD
USED

Now please think about the last 3 months. In the last 3 months,
how many TIMES have you had sexual intercourse?

Changed “last” to “past”.

□
None
GO TO QUESTION 4.14
| | | NUMBER OF TIMES - Your best guess is fine.
4.10
Part
B1

4.11

4.13
Part
B1

N/A

In the last 3 months, how many TIMES did you or your partner use
a condom when you had sexual intercourse?

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.

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
In the past 3 months, of those times you used a condom during sexual
intercourse, how many times did the condom break or slip off during sex?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

19

4.12
Part
B1

4.12
Part
B1

In the last 3 months, how many TIMES did you or your partner use
any type of birth control, including condoms, when you had sexual
intercourse?

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 (Implanaon)

□
None
GO TO QUESTION 4.14
| | | NUMBER OF TIMES - Your best guess is fine.

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.
4.13

N/A

Now please think about the past 12 months.
In the past 12 months, how often have you had a relationship that was just
sexual?
MARK (X) ONE
□
□
□

4.14
Part
B1

4.14
Part
B1

Never
Once
More than once

Oral sex is when someone puts his or her mouth on another
person’s penis or vagina, or lets someone else put his or her mouth
on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE
□
□

4.15
Part
B1

4.15
Part
B1

Yes
No

GO TO QUESTION 4.19

The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

20

4.16
Part
B1

4.16
Part
B1

How many DIFFERENT PEOPLE have you ever had oral sex with,
even if only one time?
|

4.17
Part
B1

4.17
Part
B1

|

| NUMBER OF PEOPLE – Your best guess is fine.

Now please think about the last 3 months. In the last 3 months,
how many TIMES have you had oral sex?

Changed “last” to “past”.

□
None
| | | NUMBER OF TIMES – Your best guess is fine.
4.18
Part
B1

4.19
Part
B1

4.18
Part
B1

4.19
Part
B1

In the last 3 months, how many TIMES did you or your partner use
a condom when you had oral sex?

In the past 3 months, how many TIMES have you had oral sex without using a
condom?

□
None
| | | NUMBER OF TIMES – Your best guess is fine.

□
None
| | | NUMBER OF TIMES – Your best guess is fine.

Anal sex is when a male puts his penis in someone else’s anus, or
their butt, or someone lets a male put his penis in their anus or
butt. Have you ever had anal sex?
MARK (X) ONE
□
□

4.20
Part
B1

4.20
Part
B1

GO TO QUESTION 4.23

How many DIFFERENT PEOPLE have you ever had anal sex with,
even if only one time?
|

4.21

Yes
No

|

| NUMBER OF PEOPLE – Your best guess is fine.

N/A

The very first time you had anal sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

4.22
Part
B1

4.21
Part
B1

Now please think about the last 3 months. In the last 3 months,
how many TIMES have you had anal sex?

Changed “last” to “past”.

□
None
GO TO QUESTION 4.23
| | | NUMBER OF TIMES - Your best guess is fine.

21

4.23
Part
B1

5.1

4.22
Part
B1

In the last 3 months, how many TIMES did you or your partner use
a condom when you had anal sex?

In the past 3 months, how many TIMES have you had anal sex without using a
condom?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
Have you or your partner ever taken a pregnancy test?

N/A

MARK (X) ONE
□
□

5.2a

4.24c
Part
B1

FOR GIRLS ONLY-- To the best of your knowledge, have you ever
been pregnant, even if no child was born?

Yes
No

□ Don’t know
On the follow-up, this question is combined for boys and girls:
To the best of your knowledge, have you ever been pregnant or gotten
someone pregnant, even if no child was born?

MARK (X) ONE
And
4.25b
Part
B1

□
□

Yes
No

GO TO QUESTION 4.26
GO TO QUESTION 4.26

MARK (X) ONE
□
□

Yes
No – GO TO 5.3

FOR BOYS ONLY – To the best of your knowledge, have you ever
gotten someone pregnant, even if no child was born?
MARK (X) ONE
□
□
5.2b

N/A

Yes
No
To the bets of your knowledge, how many times have you been pregnant or
gotten someone pregnant?
MARK (X) ONE
|

5.2c

N/A

|

| NUMBER OF TIMES - Your best guess is fine

How old were you the first time you got pregnant or got someone pregnant?
MARK (X) ONE
|

|

22

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine

5.2d

N/A

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

5.3

4.26
Part
B1;
4.19
Part
B2

In the last 12 months, have you spoken with a doctor or nurse
about having sex, birth control or sexually transmitted diseases,
also called STDs?

Yes
No
Don’t know

Changed “last” to “past”.

MARK (X) ONE
□ Yes
□ No

5.4

4.27
Part
B1

In the last 12 months, have you been tested by a doctor or nurse
for a sexually transmitted disease, or STD, like gonorrhea,
Chlamydia, syphilis, or HIV?

Changed “last” to “past”.

MARK (X) ONE

5.5

4.28
Part
B1

□
Yes
□
No
In the last 12 months, have you been told by a doctor or other
health professional that you had a sexually transmitted disease, or
STD?

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

MARK (X) ONE
□
□
□

Yes
No
GO TO QUESTION 4.30
Don’t know
GO TO QUESTION 4.30

□
□

Yes
No

23

5.6

4.29
Part
B1

The next series of questions is about the types of sexually
transmitted diseases or STDs you had. In the last 12 months, did
you have…

Changed “last” to “past”.

Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.
4.1
Part
B2

4.2
Part
B2

4.1
Part
B1;
4.1
Part
B2

4.2
Part
B2

Chlamydia?
Gonorrhea?
Genital herpes?
Syphilis?
HIV infection or AIDS?
Human papilloma virus, also called HPV or genital warts?
Another sexually transmitted disease or STD? PRINT OTHER
STD
The next questions are about your sexual behaviors and
experiences. Please be as honest as possible. Everything you say
will be kept private.

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, oral sex, or anal sex?

Just to confirm, have you ever had sexual intercourse, oral sex, or
anal sex?

□ Yes: STOP! GO TO PART B1 INSTEAD.
□ No: CONTINUE WITH THIS BOOKLET

□ No: THIS IS THE WRONG PART B BOOKLET. PLEASE PUT THIS
BOOKLET BACK IN THE ENVELOPE AND FILL OUT PART B2
□ Yes : CONTINUE WITH THIS BOOKLET.
The first two questions in this booklet are about your schooling.
Do you expect that you will graduate from high school?
MARK (X) ONE
□
□
□

4.3
Part
B2

4.3
Part
B2

Yes
I already graduated from high school
No
GO TO QUESTION 4.4

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

24

4.4
Part
B2

4.13
Part
B2

The next set of questions is about decision-making, development
and behaviors.

Here are some reasons people your age might choose NOT to have sexual
intercourse. How important is each of these reasons to YOU?

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

MARK (X) ONE FOR EACH QUESTION
Very Important, Somewhat Important, Not Too Important, Not At
All Important
a.
a.
b.
STD
c.
d.
f.
g.
h.
i.
j.
k.
4.5
Part
B2

N/A

4.6
Part
B2

N/A

(GIRLS ONLY) I do not want to get pregnant
(BOYS ONLY) I do not want to get a girl pregnant
I don’t want to get a sexually transmitted disease, that is, an
I don’t want to disappoint my parents
Having sex would interfere with my progress in school
My boyfriend or girlfriend doesn’t want to have sex
I want to wait until I’m married
It is against my personal values
I haven’t met the right person yet
It would interfere with my future goals
I haven’t had the chance

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

I don’t want to get a sexually transmitted disease, also known as an STD
I don’t want to disappoint my parents
I am too young to have sex
My boyfriend or girlfriend doesn’t want to have sex
I want to wait until I’m married
It is against my personal values
I haven’t met the right person yet
I haven’t had the chance
I don’t want to
FOR GIRLS: I do not want to get pregnant
FOR BOYS: I do not want to get a girl pregnant

What do you think are the benefits of waiting to have sexual intercourse?
a. Respect for yourself
b. Respect from parents
c. Keeping true to religious values
d. Respect from friends
e. Not having to worry about pregnancy
f. Not having to worry about sexually transmitted diseases, also known as
STDs
g. Better chance for a good marriage in the future
h. Fewer distractions so you can focus on school work
Do people need religion to have good values?
MARK (X) ONE
□
□

Yes
No

25

4.7
Part
B2

4.8
Part
B2

4.9
Part
B2

4.10
Part
B2

4.11
Part
B2

N/A

Should religious teachings be obeyed in every situation?
MARK (X) ONE

N/A

□ Yes
□
No
Do you pray every day?
MARK (X) ONE

N/A

□ Yes
□
No
Do you think it’s embarrassing for people your age to admit they are virgins?
MARK (X) ONE

N/A

□ Yes
□
No
Do you think it’s embarrassing for girls your age to get pregnant?
MARK (X) ONE

N/A

□ Yes
□
No
In the group you hang out with, how important is it to have a girlfriend or
boyfriend or to be going out with someone?
MARK (X) ONE

4.12
Part
B2

N/A

□ Very important
□
Not too important
□
Not important at all
The next few questions are about your access to and use of TV, cell phones,
computers and other forms of technology.
Do you personally have a phone, computer, or other device that can connect
to the internet?
MARK (X) ONE
□ Yes
□
No

26

4.13
Part
B2

N/A

4.14
Part
B2

N/A

4.15
Part
B2

N/A

4.16
Part
B2

Do your parents have any rules about…?
MARK (X) ONE FOR EACH
a. The amount of time or when you can text, talk on the phone,
watch TV or be on the computer
b. Whether or not you can have a profile on a social networking
site like MySpace or Facebook

N/A

Do your parents have any rules about what you are allowed to watch on TV?
MARK (X) ONE
□ Yes
□
No
Do your parents have any rules about what sites you can access on the
internet?
MARK (X) ONE
□ Yes
□
No
Some people exchange sexy text messages, videos, or pictures of themselves
or their friends. How common would you say each of the following is among
people your age?
MARK (X) ONE FOR EACH
Not common at all, Not very common, Fairly common, Very common
a. Sending or posting sexy text messages
b. Sending or posting sexy pictures or video

4.17
Part
B2

N/A

Have you ever sent or posted a sexy message, picture, or video of yourself by
email, IM or text (or posted one to the internet)?
MARK (X) ONE
□ Yes
□
No Go To 4.19

27

4.18
Part
B2

4.19
Part
B2

4.20
Part
B2

5.1
Part
B2

N/A

N/A

N/A

N/A

Which of the following reasons did you have for sending or posting a sexy
message, picture or video of yourself?
MARK (X) ONE FOR EACH
Yes, No
a. To get or keep a guy’s or girl’s attention
b. Your boyfriend/girlfriend pressured you to do it
c. As a “sexy” present for a boyfriend or girlfriend
d. To get back at someone or cause trouble
e. Pressure from friends
f. To be fun or to flirt
g. Everybody does it
h. Another reason? (Print reason)
Have you ever received a sexy text message, or a picture or video of someone
you know?
MARK (X) ONE
□ Yes
□
No GO TO 5.1
Have you ever shared or forwarded a sexy text message, or picture or video of
someone you know?
MARK (X) ONE
□ Yes
□
No
The next few questions ask about your community.
How often do you feel that there are teachers or other adults in your school
who really know and care about you?
MARK (X) ONE
□
□
□
□

Never
Sometimes
Often
Very often

28

5.2
Part
B2

N/A

How often do you feel there are adults in your neighborhood, or in religious
or youth organizations, who really know you and care about you?
MARK (X) ONE
□
□
□
□

N/A
5.3
Part
B3

5.4
Part
B2

Never
Sometimes
Often
Very often

How often do you feel safe in your community or neighborhood?
MARK (X) ONE
□
□
□
□

N/A

Never
Sometimes
Often
Very often

How often do you feel safe at school?
MARK (X) ONE
□
□
□
□

5.5
Part
B2

N/A

Never
Sometimes
Often
Very often

How often do you feel safe at home?
MARK (X) ONE
□
□
□
□

Never
Sometimes
Often
Very often

29

5.6
Part
B2

N/A

During the past 12 months, were you on a sports team or did you take sports
lessons after school or on weekends?
MARK (X) ONE
□
□

5.7
Part
B2

N/A

Yes
No

During the past 12 months, did you participate in any clubs or organizations
after school or on weekends, such as Scouts, a religious group, or Boy’s/Girl’s
Club?
MARK (X) ONE
□
□

6.1

5.6

During the last 30 days, on how many days did you have one or
more alcoholic drinks, such as beer, wine or other liquor, NOT
counting any times you just had a sip?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days

6.2

5.7

During the last 30 days, on how many days did you have 5 or more
drinks in a row?

Yes
No

Added introduction: The next questions are about alcohol and drug use.
Please remember, everything you tell us will be kept private.
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 GO TO 6.4
Changed “last” to “past”.

MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days

30

6.3

6.4

6.5

N/A

5.9

5.10

During the past 30 days, on how many days did you get drunk or wasted?

During the last 30 days, on how many days did you use marijuana?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used any other type of illegal drug, for example
Methamphetamine, speed, PCP, ecstasy, or any form of cocaine,
such as crack?
MARK (X) ONE
□
Yes
□
No

5.11

MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Changed question to: During the past 30 days, on how many days did you use
marijuana, also called weed or pot?

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

Have you ever used any prescription pills or other prescription
drugs that were not prescribed for you?
MARK (X) ONE
□
Yes
□
No

5.12

Have you ever used an inhalant, such as sniffed glue, breathed the
contents of spray cans, or inhaled any paints or solvents to get
high?
MARK (X) ONE
□
□

Yes
No

31

7.1

6.4

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

7.2

N/A

A lot of pressure
Some pressure
A little pressure
No pressure at all
How often is each of the following statements true for you?
MARK (X) ONE FOR EACH
Never true, Sometimes true, Often true, Almost always true
□
□
□
□

I can trust my friends
My friends want the best for me in my life
My friends care about me
My friends are there for me if I need them

32

DROPPED: The questions listed below are part of the baseline instrument, but are not part of the follow-up instrument.
1.7

In the last 12 months, how often did you attend religious services or
activities?
MARK (X) ONE
□
□
□
□
□

1.8

How important is religion in your life?
MARK (X) ONE
□
□
□

1.10

More than once a week
Once a week
1-3 times per month
Less than once a month
Never

Not at all important
Somewhat important
Very important

In an average week last month, including weekends, about how many hours
did you spend participating in each of the following?
MARK (X) ONE FOR EACH QUESTION
Zero Hours Per Week, Less Than 2 Hours Per Week,
2-5 Hours Per Week, More Than 5 Hours Per Week
a. Sports-related clubs, teams, or organizations?
b. Lessons, clubs, or performances for art, music, or drama?
c. Other clubs, teams, and organizations, such as academic clubs, Scouts,
chess clubs, or debating teams?
d. Services or programs at a church, temple, synagogue, mosque, or
other place of worship?
e. Working at a paid job?
f.
Volunteering?

1.11

How likely is it that you will do each of the following things?

33

MARK (X) ONE
Not at all likely, A little likely, Somewhat likely, Very likely
a.
b.
c.
d.
e.
2.3

2.4

Graduate from high school?
Go to a technical or vocational school after high school?
Go to college?
Graduate from a 2-year or community college program?
Graduate from a 4-year college program?
On how many days last week did all the family members who live in your
household sit down together for a meal?

MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7
On how many days last week did you do something with at least one adult
in your family like play a game, watch a movie, go to a sporting event, or
work on something you enjoy doing together?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7

34

2.6

The following questions are about the person you marked above, that is,
your mother or the person you think of as a mother.
Did she graduate from high school?
MARK (X) ONE
□
□
□

2.7

Yes
No
Don’t know

Did she graduate from a 4-year college?
MARK (X) ONE
□
□
□

2.9

Yes
No
Don’t know

How close do you feel to your mother or the person you think of as a
mother?
MARK (X) ONE
□
□
□
□

2.10

Not at all close
A little close
Somewhat close
Very close

In general, how much do you think she cares about you?
MARK (X) ONE
□
□
□
□

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

35

2.11

Whether you have done this or not, how would she feel about you having
sex at this time in your life?
MARK (X) ONE
□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove

2.12

How would she feel about you having a baby at this time in your life?
MARK (X) ONE
□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove

2.14

The following questions are about the person you marked above, that is
the person you think of as a father.
Did he graduate from high school?
MARK (X) ONE
□
□
□

2.15

Yes
No
Don’t know

Did he graduate from a 4-year college?
MARK (X) ONE
□ Yes
□ No
□ Don’t know

36

2.17

How close do you feel to your father or the person you think of as your
father?
MARK (X) ONE
□ Not at all close
□ A little close
□ Somewhat close
□ Very close

2.18

In general, how much do you think he cares about you?

MARK (X) ONE
□
□
□
□
2.19

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would he feel about you having
sex at this time in your life?
MARK (X) ONE
□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove

2.20

How would he feel about you having a baby at this time in your life?
MARK (X) ONE
□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove

37

2.21

The next questions ask about what your parents know about your
activities.
Thinking about the last month, how often did your parents know where
you were after school?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never

2.22

Thinking about the last 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
□
You did not go out

2.23

2.24

Thinking about the last month, how often did your parents know where
you were when you went out at night?
MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
□
You did not go out at night
If you were going to be home late, would your parents expect you to call?
MARK (X) ONE
□
Yes
□
No

38

3.7

4.5
Part
B1

If a condom is used correctly, how much can it decrease the risk of getting
Chlamydia and gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE
□
□
□
□
□

4.6
Part
B1

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

4.7
Part
B1

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

Voluntary
Not voluntary

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

Yes
No

GO TO QUESTION 4.9

39

4.23
Part
B1

Have you ever had oral sex or anal sex with a person the same sex as you?

4.24a
Part
B1;
4.14a
Part
B2

FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual
period?

4.24b
Part
B1;
4.14b
Part
B2
4.25a
Part
B1;
4.15a
Part
B2

4.15b
Part
B2

MARK (X) ONE
□ Yes
□ No

MARK (X) ONE
□ Yes
□ No GO TO QUESTION 4.26
FOR GIRLS ONLY- How old were you when you had your first period, that
is, your first menstrual period?
|

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

FOR BOYS ONLY
People reach puberty at different ages. Signs of puberty for males include
physical changes such as developing pubic or facial hair, or the voice
cracking or lowering. Which of the following best describes these changes
for you?
MARK (X) ONE
□ These changes have not yet started
□ These changes have barely started
□ These changes are definitely underway
□ These changes seem complete
FOR BOYS: How old were you when these changes started?
|

|

| NUMBER OF YEARS OLD YOU WERE

40

4.30
Part
B1;
4.17
Part
B2

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
□
□

4.31
Part
B1;
4.18
Part
B2
4.4
Part
B2

Yes
No

Have you ever been fearful that someone you were dating or having sex
with might physically hurt you?
MARK (X) ONE
□ Yes
□ No
The next questions are about where you live.
In the last 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
□
□

4.5
Part
B2

Yes GO TO QUESTION 4.11
No

In how many homes, places, or households do you live: one, two, or three
or more?
MARK (X) ONE
□ 1 home
GO TO QUESTION 4.9
□ 2 homes
□ 3 or more homes

4.6
Part
B2

Do you consider one of these homes to be your main home or are they
pretty much equal?
MARK (X) ONE
□
□

One is main home
Pretty much equal

41

4.7
Part
B2

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

4.8
Part
B2

|

|

| Number of nights at home #1 – Your best guess is fine.

|

|

| Number of nights at home #2 – Your best guess is fine.

|

|

Is there anyone who moves from home to home with you, like a brother or
sister?
MARK (X) ONE
□
□

4.9
Part
B2

4.10
Part
B2

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

Yes
No

Is your home or any of your homes a group home or halfway house?
MARK (X) ONE
□ Yes
□ No
The next 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

42

4.11
Part
B2

The next series of questions is about friends. How strongly do you agree or
disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree

4.12
Part
B2

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?
The next series of questions is about effort. How strongly do you agree or
disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree

5.1

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 work, you do a good job?
The next questions are about tobacco, alcohol and drugs. Please be as
honest as possible, and remember that everything you tell us will be kept
private.
Have you ever smoked a cigarette?
MARK (X) ONE
□
□

5.2

Yes
No GO TO QUESTION 5.4

The very first time you smoked a cigarette, how old were you?
|

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

43

5.3

During the last 30 days, on how many days did you smoke one or more
cigarettes?
MARK (X) ONE
□
□
□
□

5.4

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

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
□
□

5.5

Yes
No GO TO QUESTION 5.8

The very first time you had an alcoholic drink, how old were you?
|

5.8

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

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

□
□

Yes
No

GO TO QUESTION 5.10

44

6.2

How many of your friends who are your age think the following things?
Your best guess is fine
MARK (X) ONE FOR EACH QUESTION
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.

6.3

How many of your friends who are your age have done the following
things?
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know

6.5

a. Have had sexual intercourse.
b. Have had oral sex.
People are different in their sexual attraction to other people. Which of
the following best describes your feelings?
MARK (X) ONE
□
□
□
□
□

I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure

45

6.1

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

1.6

When you are at home or with your family, what language or
languages do you usually speak?
YOU MAY MARK (X) MORE THAN ONE ANSWER
□ English
□ Spanish
□ Chinese language such as Mandarin or Cantonese
□ Other PRINT OTHER LANGUAGES
____________________________

2.25

In the last 12 months, how many times have you talked with at
least one of your parents about . . .
MARK (X) ONE FOR EACH QUESTION
Never, 1-2 Times, 3-9 Times, 10 or more times

4.24a
Part
B1;
4.14a
Part
B2

a. How things are going with school work or with your grades?
b. A personal problem you were having?
c. How to have good romantic relationships?
d. Strategies for safe dating?
e. How to resist pressures to have sex?
f.
Avoiding drugs and alcohol?
g. Pregnancy or birth?
h. Sexually transmitted diseases, also called STDs, HIV, or AIDS?
FOR GIRLS ONLY- Have you ever had your period, that is, your
menstrual period?
MARK (X) ONE
□
□

Yes
No GO TO QUESTION 4.26

46

4.24b
Part
B1;
4.14b
Part
B2

FOR GIRLS ONLY- How old were you when you had your first
period, that is, your first menstrual period?

4.25a
Part
B1;
4.15a
Part
B2

FOR BOYS ONLY

4.15b
Part
B2
4.16
Part
B2

4.17
Part
B2

| |
fine.

| NUMBER OF YEARS OLD YOU WERE - Your best guess is

People reach puberty at different ages. Signs of puberty for males
include physical changes such as developing pubic or facial hair, or
the voice cracking or lowering. Which of the following best
describes these changes for you?
MARK (X) ONE
□ These changes have not yet started
□ These changes have barely started
□ These changes are definitely underway
□ These changes seem complete
FOR BOYS: How old were you when these changes started?
|

|

| NUMBER OF YEARS OLD YOU WERE

Have you ever done any of the following with a boy or girl?
Yes, No
a. Kissed someone on the lips?
b. French kissed, that is put your tongue in someone’s mouth
while kissing?
c. Touched another boy’s or girl’s private parts?
d. Let a boy or girl touch your private parts?
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

47

4.31
Part
B1;
4.18
Part
B2
4.26
Part
B1;
4.19
Part
B2
4.20
Part
B2

Have you ever been fearful that someone you were dating or
having sex with might physically hurt you?
MARK (X) ONE
□ Yes
□ No
In the last 12 months, have you spoken with a doctor or nurse
about having sex, birth control or sexually transmitted diseases,
also called STDs?
MARK (X) ONE
□ Yes
□ No
If you decided to have sexual intercourse before marriage, how
likely is it that you would use a condom?
MARK (X) ONE
□ Not at all likely
□ A little bit likely
□ Somewhat likely
□ Very likely
□ Don’t plan to have sexual intercourse before marriage

48

SUMMARY OF DIFFERENCES BETWEEN THE OHIOHEALTH BASELINE AND FOLLOW-UP INSTRUMENTS

Folow-up #

Baseline #

Items are listed in the order in which they appear on the OhioHealth follow-up instrument. The number for the corresponding baseline item is
listed in the “Baseline #” column. Items found on the baseline instrument that are not on the follow-up instrument are listed at the bottom of the
table.
Modifications to an existing baseline item are listed in the “Modifications for follow-up” column; otherwise, the question text on the followup instrument is the same as that on the baseline instrument.
If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “Baseline #” column and the text is noted in the
“Modifications” column.

1.1

1.2

OhioHealth Baseline Question Text

Modifications for follow-up

Are you currently enrolled in school or studying school subjects through a
program at home, online or somewhere else?
MARK (X) ONE
□
Yes
□
No

1

Folow-up #

Baseline #

OhioHealth Baseline Question Text

1.2

1.3

What is the highest grade in school you completed?

Modifications for follow-up

MARK (X) ONE
□
□
□
□
□
□
□
□
□
□
□
□
1.3

1.4

6th grade or lower
7th
8th
9th
10th
11th
12th
GED
Community college or vocational school
Four-year college
Your schooling does not have grade levels
Other

How likely is it that you will do each of the following things?
MARK (X) ONE
Not at all likely, A little bit likely, Somewhat likely, Very likely, You already did
a.
b.
c.
d.
e.

Graduate from high school
Go to a technical or vocational school after high school
Go to college
Graduate from a 2-year or community college program
Graduate from a 4-year college program

2

Folow-up #

Baseline #

1.4

N/A

OhioHealth Baseline Question Text

Modifications for follow-up
What is your current marital status?
MARK ONE

1.5

1.10

In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
□
□
□
□
□

1.6

1.11

Never
Less than once a month
1-3 times per month
Once a week
More than once a week

How important is religion in your life?
MARK (X) ONE
□
□
□

Not at all important
Somewhat important
Very important

3

□ Never married
□ Married
□ Divorced
□ Separated
□ Widowed
Changed to “In the past 6 months”

Folow-up #

Baseline #

OhioHealth Baseline Question Text

1.7

1.12

What is your religion or faith?

Modifications for follow-up

MARK (X) ONE
□
□
□
□
□
□
□
□
□
□
□
1.8

1.13

Atheist or Agnostic
Buddhist
Hindu
Jewish
Mormon
Muslim
Orthodox (for example Greek or Russian Orthodox)
Protestant
Roman Catholic
Nothing in particular
Other

In the past 12 months, have you received any information or learned about any
of the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or whether to use
birth control
How to say no to sex

4

Changed to “In the past 6 months”.

Folow-up #

Baseline #

1.9

N/A

OhioHealth Baseline Question Text

Modifications for follow-up
This is an interviewer instruction to route respondent to relevant
questions. No actual response required from the respondent.
Did the respondent say “yes” to any item in 1.7 above?
Yes
No – GO TO 1.10

1.10

N/A

In the past 6 moths, how many times did you get information on
relationships, abstinence, birth control, or sexually transmitted
diseases from… (Never, 1-3 times, 4-9 times, 10 or more times)
a.
b.
c.
d.
e.
f.

g.
h.
i.

5

A school class
A church, synagogue, mosque, or religious classes
outside of school
A community cebter, youth organization, or after-school
activity
A doctor or nurse you saw at a hospital, clinic, or trailer
A nurse, social worker, or other health care professional
who came to your home
A nurse or other provider from the Nurse Family
Partnership or Help me grow program who came to your
home
Your friends
Your parents or other relatives or family members
Another person or place (Please specify)

Follow-up #

Baseline #

1.11

N/A

OhioHealth Baseline Question Text

Modifications for follow-up
In the past 6 months, how many different times, if any, did you receive birth
control from a doctor or burse at a place such as a hospital, clinic, or trailer, or
during a visit to your home?
□ None
______ Number of times

2.1

2.1

The next question is about where you live and who lives with you.

Removed skips because subsequent questions are no longer included

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,
staying with friends/relatives) – GO
TO 2.6

6

Follow-up #

Baseline #

2.2

2.4

OhioHealth Baseline Question Text

Modifications for follow-up

In the past 30 days, did you or someone who lives with you receive
any of the following types of financial assistance?
MARK (x) YES OR NO FOR EACH QUESTION
Yes, no
a.
b.
c.
d.
e.

Social Security Disability
Food stamps, now called SNAP or Supplemental Nutrition
Assistance Program
WIC or The Women, Infants and Children Supplemental
Nutrition Program
Welfare, also called TANF or Temporary Assistance for
Needy Families
Unemployment

7

Follow-up #

Baseline #

2.3

2.5

OhioHealth Baseline Question Text

Modifications for follow-up

In the past 30 days, how many times did you or someone who lives
with you…
MARK (X) ONE
Never, Less than once a week, About once a week, More than
once a week
a.
b.
c.
d.

2.4

2.6

Feel sick, in pain or injured but did NOT go for medical
help because of no insurance or no money
Skip a meal because there was no food in the house or
money to get food
Visit a food pantry
Miss school, going to a job, or something else important
because there was no money for gas, a bus, a train, or
some other type of transportation

At any time in the past 12 months, has there been a period of time
when you have not had any health insurance at all?

Changed to “In the past 6 months”

MARK (X) ONE
□
Yes
□
No

8

Follow-up #

Baseline #

3.1

3.1

OhioHealth Baseline Question Text

Modifications for follow-up

The next series of questions is about condom use. How strongly do
you agree or disagree that …
MARK (X) ONE FOR EACH
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. Condoms are a hassle to use
c. Condoms are pretty easy to get
d. Condoms are important to make sex safer
e. Using condoms means you don’t trust your sexual partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure

3.2

3.2

If a condom is used correctly, how much can it decrease the risk of
pregnancy

If condoms are used correctly and consistently, how much can they decrease
the risk of pregnancy?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

9

Follow-up #

Baseline #

3.3

3.3

3.4

3.4

OhioHealth Baseline Question Text

Modifications for follow-up

If a condom is used correctly, how much can it decrease the risk of
getting HIV, the virus that causes AIDS?

If condoms are used correctly and consistently, how much can they decrease
the risk of getting HIV, the virus that causes AIDS?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

If a condom is used correctly, how much can it decrease the risk of
getting Chlamydia and gonorrhea?

If condoms are used correctly and consistently, how much can they decrease
the risk of getting gonorrhea?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

10

Follow-up #

Baseline #

3.5

3.5

OhioHealth Baseline Question Text

Modifications for follow-up

The next series of questions is about methods of birth control,
NOT including condoms. How strongly do you agree or disagree
that…

Added:
g. My friends have good things to say about birth control
h. My family members have good things ot say about birth control

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
3.6

3.6

If birth control pills are used correctly, how much can they
decrease the risk of pregnancy?

If birth control pills are used correctly and consistently, how much can they
decrease the risk of pregnancy?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

11

Follow-up #

Baseline #

3.7

3.7

3.8

3.8

OhioHealth Baseline Question Text

Modifications for follow-up

If birth control pills are used correctly, how much can they
decrease the risk of getting HIV, the virus that causes AIDS?

If birth control pills are used correctly and consistently, how much can they
decrease the risk of getting HIV, the virus that causes AIDS?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know
If birth control pills are used correctly and consistently, how much can they
decrease the risk of getting gonorrhea?

If birth control pills are used correctly, how much can they
decrease the risk of getting Chlamydia and gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

12

Follow-up #

Baseline #

3.9

3.9

OhioHealth Baseline Question Text

Modifications for follow-up

The next series of questions is about ALL methods of birth control,
including condoms and birth control pills. How strongly do you
agree or disagree that…
MARK (X) ONE
a.
b.
c.
d.
e.
f.

3.10

N/A

Women can trust what doctors and nurses say about birth
control methods
The use of birth control improves a relationship
If a woman uses birth control, her partner will know she
really cares about herself
If a man uses birth control, his partner will know he really
cares about her
If a woman uses birth control, her partner will think she’s
pretty smart
If a man makes sure that one of them is using birth
control, his partner will know he really cares about her
Now please think about your friends and the people you hang out with with
have secual intercourse. How often do you think they use ANY method of birth
control, such as condoms or birth control pills?
MARK ONE
Never
Sometimes
Half of the time
Most of the time
Always

13

Follow-up #

Baseline #

3.11

N/A

OhioHealth Baseline Question Text

Modifications for follow-up
How many of your friends orpeople you hang out with had a baby before they
were 20 years old?
MARK ONE
None
One or two
Three or more

3.12

N/A

How many of your friends or people you hang out with had more than one
baby before they were 20 years old?
MARK ONE
None
One or two
Three or more

4.1

N/A

Please think about the past 3 months, that is, from ___________ until today.
In the past 3 motnhs, have you had sexual intercourse, even once?
Yes
No

4.2

N/A

In the past 3 months, how many DIFFERENT PEOPLE have you had sexual
intercourse with, even once?
None
______ NUMBER OF PEOPLE

14

Follow-up #

Baseline #

4.3

4.3

OhioHealth Baseline Question Text

Modifications for follow-up

Please think about the 3 months before you found out you were
pregnant with your most recent pregnancy. In those 3 months,
how many TIMES did you have sexual intercourse?

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.

□
None
GO TO 4.8
| | | NUMBER OF TIMES - Your best guess is fine.
4.4

4.5

4.6

4.6

In those 3 months, how many TIMES did you have sexual
intercourse without using a condom?

In the past 3 months, have you had sexual intercourse without you or your
partner using a condom?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

Yes
No

In those 3 months, how many TIMES did you have sexual
intercourse without using a condom?

In the past 3 months, how many TIMES have you had sexual intercourse
without you or your partner using a condom?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

□
None
| | | NUMBER OF TIMES - Your best guess is fine

15

Follow-up #

Baseline #

4.6

4.7

OhioHealth Baseline Question Text

Modifications for follow-up

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

In the past 3 months, have you had sexual intercourse without you or your
partner using any of these methods of birth control:

Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanaon)
In the 3 months before you found out you were pregnant with
your most recent pregnancy, how many TIMES have you had
sexual intercourse without using any of these methods of birth
control?

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

Yes
No

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

16

Follow-up #

Baseline #

4.7

4.7

OhioHealth Baseline Question Text

Modifications for follow-up

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

In the past 3 months, how many times have you had sexual intercourse
without you or your partner using any of these methods of birth control:

Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanaon)
In the 3 months before you found out you were pregnant with
your most recent pregnancy, how many TIMES have you had
sexual intercourse without using any of these methods of birth
control?

Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanaon)
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

17

Follow-up #

Baseline #

4.8

4.4

OhioHealth Baseline Question Text

Modifications for follow-up

In the 3 months before you found out you were pregnant, when
you had sexual intercourse how often did you use each of the
following types of birth control?

In the past 3 months, when you had sexual intercourse, how much of the time
did you use…
MARK (X) ONE FOR EACH QUESTION

MARK (X) ONE FOR EACH QUESTION
Never, Sometimes, Always
a.
b.
c.
d.
e.
f.

Condoms
Diaphragm
Female condoms
Fertility awareness
Withdrawal
Spermicide

None of the time, Some of the time, Half of the time, Most of the time, All of
the time
a. Condoms
b. Diaphragm
c. Female condoms
d. Fertility awareness
e. Withdrawal
f. Spermicide
g. Another method

18

Follow-up #

Baseline #

4.9

4.5

OhioHealth Baseline Question Text

Modifications for follow-up

In the 3 months before you found out you were pregnant, when
you had sexual intercourse how often did you use each of the
following types of birth control?

In the past 3 months, how much of the time did you use…

MARK (X) ONE FOR EACH QUESTION
MARK (X) ONE FOR EACH QUESTION
Not at all, Some of the time, All of the time
a.
b.
c.
d.
e.
f.
g.
h.

None of the time, Some of the time, Half of the time, Most of the time, All of
the time

Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
Male vasectomy
Lactational amenorrhea

a.
b.
c.
d.
e.
f.
g.
h.
i.

Other PRINT OTHER METHOD __________
4.10
4.11

N/A
N/A

Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
Male vasectomy
Breastfeeding
Another method of brith control PRINT OTHER METHOD
__________

INSTRUCTION FOR INTERVIEWER
The most recent time you had sexual intercourse did you use a condom?
□
□

Yes
No

19

Follow-up #

Baseline #

4.12

N/A

OhioHealth Baseline Question Text

Modifications for follow-up
The most recent time you had sexual intercourse, did you use any method of
brith control other than a condom, such as birth control pills, theshot, the
patchm the ring, an IUD, an Implant, a diaphragm, spermicide, or any other
method?
□
□

4.13

4.8

In the 3 months before you found out you were pregnant, how
many TIMES have you had oral sex?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

4.14

4.15

4.9

4.10

Yes
No

In the past 3 months, how many TIMES did you have oral sex?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

In the 3 months before you found out you were pregnant, how
many TIMES have you had oral sex without using a condom?

In the past 3 months, how many TIMES did you have oral sex without using a
condom?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

□
None
| | | NUMBER OF TIMES - Your best guess is fine.

Anal sex is when a male puts his penis in someone else’s anus, or
their butt, or someone lets a male put his penis in their anus or
butt. In the 3 months before you found out you were pregnant,
how many TIMES have you had anal sex?

In the past 3 months, how many TIMES did you have anal sex?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

□
None
GO TO 4.23
| | | NUMBER OF TIMES - Your best guess is fine.

20

Follow-up #

Baseline #

4.16

4.11

4.17

4.12

OhioHealth Baseline Question Text

Modifications for follow-up

In the 3 months before you found out you were pregnant, how
many TIMES have you had anal sex without using a condom?

In the past 3 months, how many TIMES did you have anal sex without using a
condom?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
In the past 12 months, have you been told by a doctor or nurse
that you had a sexually transmitted disease (STD)?

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
Changed to “in the past 6 months” and removed “don’t know”

MARK (X) ONE
□
□
□
4.18

4.13

Yes
No
Don’t know

The next series of questions is about the types of sexually
transmitted diseases or STDs you have had. In the past 12 months,
did you have…

Changed to “in the past 6 months”

Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.

Chlamydia
Gonorrhea
Genital herpes
Syphilis
HIV infection or AIDS
Human papilloma virus, also called HPV or genital warts
Another sexually transmitted disease (STD) PRINT OTHER
STD:

21

Follow-up #

Baseline #

4.19

4.17

OhioHealth Baseline Question Text

Modifications for follow-up

How many weeks along in your pregnancy are you now or were
you when your new baby was born or the pregnancy ended?

Please think back to that pregnancy you experienced about 6 months ago.
How many weeks along in that pregnancy were you when your baby was born
or when that pregnancy ended?

|

|

| WEEKS – Your best guess is fine.

_____ NUMBER OF WEEKS
4.20

4.21

4.18

4.19

How did your most recent pregnancy end?

How did that pregnancy end?

MARK (X) ONE

MARK (X) ONE

□
□
□
□
□

□
□
□

Live birth or births
Still pregnant GO TO 4.25
Miscarriage GO TO 4.25
Stillbirth GO TO 4.25
Abortion GO TO 4.25

A live birth or births
A miscarriage
A stillbirth

Did you have a c-section delivery, also known as a Caesarean
section delivery, or a vaginal birth, also known as pushing the baby
out?
MARK (X) ONE
□
□

C-section
Vaginal birth

22

Follow-up #

Baseline #

4.22

4.20

OhioHealth Baseline Question Text

Modifications for follow-up

Was your new baby born full-term, that is after you were 37 weeks
pregnant, or premature, that is before you were 37 weeks
pregnant?

Was your baby born full-term, that is after you were 37 weeks pregnant, or
premature, that is before you were 37 weeks pregnant?
MARK (X) ONE

MARK (X) ONE
□
□
4.23

4.24

4.21

4.21

Full-term GO TO 4.25
Premature

□
□

Full-term GO TO 4.25
Premature

Was the delivery of your baby spontaneous, that is – no medicine
was used to cause your baby to be born, or induced, that is –
medicine was used to start labor to cause your baby to be born?

Was the delivery of your baby spontaneous, that is – no medicine was used to
cause your baby to be born, or induced, that is – medicine was used to start
labor to cause your baby to be born?

MARK (X) ONE

MARK (X) ONE

□
□
□

□
□

Spontaneous birth – no medicine was used to start labor
Induced because of your own health complications
Induced because of complications involving the baby

Spontaneous birth – no medicine was used to start labor – GO TO 4.25
Induced

Was the delivery of your baby spontaneous, that is – no medicine
was used to cause your baby to be born, or induced, that is –
medicine was used to start labor to cause your baby to be born?

Was the delivery of your baby induced, that is – medicine was used to start
labor to cause your baby to be born, because of your own health
complications or because of complications involving the baby?

MARK (X) ONE

MARK (X) ONE

□
□
□

□
□

Spontaneous birth – no medicine was used to start labor
Induced because of your own health complications
Induced because of complications involving the baby

Induced because of your own health complications
Induced because of complications involving the baby

23

Follow-up #

Baseline #

OhioHealth Baseline Question Text

4.25

4.22

How much did your new baby weigh at birth?

Modifications for follow-up
Added “don’t know” as a response

|_|_| Pounds |_|_| Ounces
4.26

4.23

How many days was your new baby in the hospital after he or she
was born?

Removed “new” so it just reads “my baby”

□
My new baby is still in the hospital
|_|_| NUMBER OF DAYS
4.27

4.24

How many days was your new baby in the intensive care unit at
the hospital after he or she was born?

Removed “new” so it just reads “my baby”

□
None
□
My new baby is still in the intensive care unit at the hospital
|_|_| NUMBER OF DAYS
4.28

N/A

Did you breastfeed your baby at all?
□
□

4.29

N/A

Yes
No – GO TO 4.30

How many months did you breastfeed your baby or are you still breastfeeding
him or her?
□ Still breastfeeding
____ NUMBER OF MONTHS

24

Follow-up #

Baseline #

4.30

N/A

OhioHealth Baseline Question Text

Modifications for follow-up
Have you been pregnant again since that pregnancy ended?
□
□

4.31

4.15

Yes
No – GO TO 4.34

At the time that you became pregnant the most recent time, did
you want to become pregnant then, did you want to become
pregnant later, or did you not want to become pregnant at all?
MARK (X) ONE

4.32

4.18

□
Wanted to become pregnant then
□
Wanted to become pregnant later
□
Did not want to become pregnant at all
How did your most recent pregnancy end?

GO TO 4.34

MARK (X) ONE
□
□
□
□
□
4.33

N/A

Live birth or births
Still pregnant GO TO 4.25
Miscarriage GO TO 4.25
Stillbirth GO TO 4.25
Abortion GO TO 4.25
How many weeks along in your current pregnancy are you?
|

|

| NUMBER OF WEEKS

□ Don’t know

25

Follow-up #

Baseline #

4.34

4.14

5.1

5.1

OhioHealth Baseline Question Text

Modifications for follow-up

Including your current or recent pregnancy, how many times have
you been pregnant, even if no child was born?

Including all the times you have been pregnant, how many times have you
EVER been pregnant, even if no child was born?

|

|

|

Do you intend to have sexual intercourse in the next year?
o
o
o
o

5.2

5.2

| NUMBER OF TIMES

Yes, definitely
Yes, probably
No, probably not
No, definitely not GO TO 5.4

If you have sexual intercourse in the next year, do you intend to
use a condom?
o
o
o
o

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

|

| NUMBER OF TIMES

Do you intend to have sexual intercourse in the next year, if you have the
chance?
o
o
o
o

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

If you were to have sexual intercourse in the next year, do you intend to have
your partner use a condom?
o
o
o
o

26

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

Follow-up #

Baseline #

5.3

5.3

OhioHealth Baseline Question Text

Modifications for follow-up

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

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

Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanaon)
If you have sexual intercourse in the next year, do you intend to
use any of these other methods of birth control?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not
5.4

5.4

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

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

Do you want to have any more children?
MARK (X) ONE
□
□
□

5.5

5.5

Yes
No GO TO 5.7
Don’t know

How many more children do you want to have?

How many more children do you want to have?

|_|_| CHILDREN

|_|_| CHILDREN

27

Follow-up #

Baseline #

5.6

5.7

OhioHealth Baseline Question Text

Modifications for follow-up

Please think about the next year and a half. Over the next year and
a half, will you be …

Changed to “over the next year”

MARK (X) ONE
□
Trying to get pregnant again
□
Neither trying to get pregnant nor trying avoid getting
pregnant
□
Trying to avoid getting pregnant
□
Don’t know
5.7

5.8

Over the next year and a half, from your partner’s point of view,
will he be…

Changed to “over the next year”

MARK (X) ONE
□
Trying to get you pregnant
□
Neither trying to get you pregnant nor trying to avoid getting
you pregnant
□
Trying to avoid getting you pregnant
□
Don’t know
□
I don’t have a partner right now

DROPPED: The questions listed below are part of the baseline instrument, but are not part of follow-up instrument.
N/A

1.1a

In what month were you born?
MARK (X) ONE MONTH

DROP

N/A

1.1b

In what year were you born?
MARK (X) ONE YEAR

DROP

28

Follow-up #

Baseline #

OhioHealth Baseline Question Text

N/A

1.5

Are you Hispanic/Latino?

Modifications for follow-up
DROP

MARK (X) ONE
□
Yes
□
No
N/A

1.6

What is your race?

DROP

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

N/A

1.7

What is your country of birth?

DROP

MARK (X) ONE

□
□
N/A

1.8

United States GO TO 1.9
Some other country PRINT OTHER COUNTRY_____________

How long have you lived in the United States?

DROP

MARK (X) ONE

□
□
□
□

Less than one year
1 to 5 years
More than 5 years to 10 years
More than 10 years

29

Follow-up #

Baseline #

OhioHealth Baseline Question Text

N/A

1.9

What is the main language you speak at home?
□
□
□
□

N/A

2.2

Modifications for follow-up
DROP

English
Spanish
Somali
Some other language PRINT OTHER
LANGUAGE_______________________

Who lives with you in your home?

DROP

MARK 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
The father of your most recent pregnancy or baby
Your current boyfriend or partner who is not the father of
your most recent pregnancy or baby
One or more parents of the father of your most recent
pregnancy or baby
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

30

Follow-up #

Baseline #

OhioHealth Baseline Question Text

N/A

2.3

Who lives with you in each of your homes?

Modifications for follow-up
DROP

Mark all of the people who live with you in your MAIN home, and
then mark all of the people who live with you in your OTHER
homes.
MARK ALL THAT APPLY (List appears for both the MAIN home
and the 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
The father of your most recent pregnancy or baby
Your current boyfriend or partner who is not the father of
your most recent pregnancy or baby
One or more parents of the father of your most recent
pregnancy or baby
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

31

Follow-up #

Baseline #

OhioHealth Baseline Question Text

N/A

2.7

The next two questions are about your baby’s father.

Modifications for follow-up
DROP

When you got pregnant, what was your relationship with the
baby’s father?
MARK (X) ONE
□
□
□
□
□
□
N/A

2.8

Did not know him well or at all
Knew him, but not dating
Casually dating
Seriously dating
Engaged or married
Other

Currently, what is your relationship with the baby’s father?

DROP

MARK (X) ONE
□
□
□
□
□
□
□

No contact
Have contact, but don’t get along
Have contact, get along, not dating
Casual dating
Seriously dating
Engaged or married
Other

32

Follow-up #

Baseline #

N/A

2.9

OhioHealth Baseline Question Text

Modifications for follow-up

Now we have some questions about your mother, or the person
you think of as your mother. Is this person…

DROP

MARK (X) ONE
□
you
□
□
□
□
□
□
2.12
N/A

2.10

Your biological mother, that is, the woman who gave birth to
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 a mother GO TO

The following questions are about the person you marked as your
mother or the person you think of as your mother.

DROP

Did she graduate from high school?
MARK (X) ONE
□
□
□

Yes
No
Don’t know

33

Follow-up #

Baseline #

N/A

2.11

N.A

2.12

OhioHealth Baseline Question Text

Modifications for follow-up

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
Next we have some questions about your father, or the person
you think of as your father. Is this person…

DROP

DROP

MARK (X) ONE
□
□
□
□
□
□
□
2.15

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
Don’t have a father or person I think of as a father GO TO

34

Follow-up #

Baseline #

N/A

2.13

OhioHealth Baseline Question Text

Modifications for follow-up

The following questions are about the person you marked as your
father or the person you think of as your father.

DROP

Did he graduate from high school?
MARK (X) ONE
□
□
□
N/A

2.14

Yes
No
Don’t know

Is he working now?

DROP

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

35

Follow-up #

Baseline #

N/A

2.15

OhioHealth Baseline Question Text

Modifications for follow-up

Which of the following best describes the relationship between
your biological mother and biological father? If one or both of your
biological parents have passed away, please answer about their
relationship when both were alive.

DROP

MARK (X) ONE
o
o
o
o
o
N/A

2.16

They are married to each other
They used to be married to each other, but are now
separated
They used to be married to each other, but are now
divorced
They have never been married to each other
Don’t know

Do your biological mother and biological father live together now?

DROP

MARK (X) ONE
o
o
o
o

Yes
No
One or both of my biological parents have passed away
Don’t know

36

Follow-up #

Baseline #

N/A

3.10

OhioHealth Baseline Question Text

Modifications for follow-up

Before you were in this study, had you ever heard that getting
pregnant less than 18 months after the end of a previous
pregnancy increases your risk of having a preterm baby, that is – a
baby born before you reached 37 weeks of pregnancy?

DROP

MARK (X) ONE

N/A

4.1

□
Yes
□
No
How many DIFFERENT PEOPLE have you ever had sexual
intercourse with, even if only one time?
|

|

DROP

| NUMBER OF PEOPLE - Your best guess is fine.

37

Follow-up #

Baseline #

OhioHealth Baseline Question Text

N/A

4.2

This question is about types of birth control you have ever used.

Modifications for follow-up
DROP

For birth control, have you ever used …
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.

Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
Diaphragm
Male vasectomy
Lactational amenorrhea
Female condoms
Fertility awareness
Withdrawal
Spermicide
Other? PRINT OTHER METHOD
_________________________

38

Follow-up #

Baseline #

N/A

4.15

OhioHealth Baseline Question Text

Modifications for follow-up

The next series of questions is about your current or most recent
pregnancy.

DROP

At the time that you became pregnant the most recent time, did
you want to become pregnant then, did you want to become
pregnant later, or did you not want to become pregnant at all?
MARK (X) ONE
□
□
□
N/A

4.16

Wanted to become pregnant then
Wanted to become pregnant later
Did not want to become pregnant at all

How many weeks along in your pregnancy were you when you
went to your first prenatal visit?
|

|

DROP

| WEEKS – Your best guess is fine.

39

Follow-up #

Baseline #

N/A

4.25

OhioHealth Baseline Question Text

Modifications for follow-up

Now please think about the time you were pregnant right before
your most recent pregnancy.
At the time that you became pregnant that previous time, did you
want to become pregnant then, did you want to become pregnant
later, or did you not want to become pregnant at all?
MARK (X) ONE
□
I HAVE NEVER BEEN PREGNANT BEFORE THE MOST RECENT
TIME GO TO 5.1
□
Wanted to become pregnant then
□
Wanted to become pregnant later
□
Did not want to become pregnant at all

N/A

5.6
How long do you plan to wait until you become pregnant again?

DROP

MARK (X) ONE
□
Less than 6 months after the end of my most recent
pregnancy
□
6 to 18 months after the end of my most recent pregnancy
□
More than 18 months after the end of my most recent
pregnancy

40

SUMMARY OF DIFFERENCES BETWEEN THE CHILDREN’S HOSPITAL LOS ANGELES (CHLA) BASELINE INSTRUMENT AND CHLA FOLLOW-UP SURVEY

CHLA Follow-up #

CHLA Baseline #

Items are listed in the order in which they appear on the CHLA first follow-up instrument. The number for the corresponding baseline item is listed in the “CHLA Baseline #”
column. The CHLA instrument will be administered to adolescent mothers so, there are no separate sections for sexually active and non-sexually active respondents. Items found
on the concordance instrument that are not on the CHLA instrument are listed at the bottom of the table.
• Modifications to an existing baseline concordance item are listed in the “Modifications for CHLA Follow-up” column; otherwise, the question text on the CHLA follow-up
instrument is the same as that on the baseline instrument.
• If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “CHLA Baseline #” column and the question text is noted in the “Modifications for
CHLA Follow-up” column.

1.1

1.1

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1.2

1.2

What is the last grade you completed?

CHLA Baseline Question Text

Modifications for CHLA Follow-up

MARK (X) ONE
th

□ Less than 6 grade
th
□7
th
□8
th
□9
th
□ 10
th
□ 11
th
□ 12
□ Completed GED pretest
□ Completed GED
□ Some school after high school

1

CHLA Follow-up #

CHLA Baseline #

1.3

N/A

CHLA Baseline Question Text

Modifications for CHLA Follow-up
What type of schooling did you complete after high school?
MARK (X) ONE
□ Some adult education classes
□ Some technical or vocation school
□ Some classes at a 2-year college
□ Some classes at a 4-year college or university

1.4

Did you go back to school or a GED program after having your first
baby?
MARK (X) ONE
□ Yes – I went back to my old high school
□ Yes – I went back to a different school
□ Yes – I went back to a GED program
□ I never stopped school - GO TO 1.6
□ No – I did not go back - GO TO 1.6

2

CHLA Baseline #

CHLA Follow-up #

CHLA Baseline Question Text

Modifications for CHLA Follow-up

1.5

How old was your baby when you returned to school or your GED
program?
|

1.6

1.3

|

| NUMBER OF MONTHS OLD

What is your current school status?
MARK (X) ONE

1.7

1.4

□ Enrolled in public or private middle or high school
□ Enrolled in a continuation/alternative school or court/community school
□ Enrolled in adult education classes
□ Enrolled in technical or vocation school
□ Enrolled in 2-year college
□ Enrolled in 4-year college or university
□ Not currently enrolled in any school or classes
What is the highest level of education you would like to complete?

Question changed to: What is the highest level of education you
expect to complete?

MARK (X) ONE
□ Graduate from high school or obtain a GED
□ Attend technical or vocational school
□ Graduate from a 2-year community college (Associate’s degree)
□ Graduate from a 4-year college (Bachelor’s degree)
□ Obtain a graduate degree (Masters, PhD, MD, etc.)

3

CHLA Follow-up #

CHLA Baseline #

CHLA Baseline Question Text

1.8

1.5

Are you currently working?

Modifications for CHLA Follow-up

MARK (X) ONE
□ Yes – full-time
□ Yes – part-time
□ No – but currently looking for a job
□ No – and not currently looking for a job

1.9

Do you make enough money in this job to support yourself?
MARK (X) ONE
□
Yes
□
No

1.10

Do you plan on staying in this job for the next two years?
MARK (X) ONE
□
Yes
□
No

1.11

1.8

Are you…
MARK (X) ONE
□ Not currently seeing anyone
□ Casually dating
□ Seriously dating
□ Engaged
□ Married

4

CHLA Follow-up #

CHLA Baseline #

1.12

N/A

CHLA Baseline Question Text

Modifications for CHLA Follow-up
Is this person the father of your first child?
MARK (X) ONE
□
Yes
□
No

2.1

2.1

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 (Please specify)
Don’t have a mother or person I think of as a mother
GO TO 2.3

5

2.2

2.2

Please answer the questions below about your mother or the person you
think of as your mother that you identified in the previous question.
How much do you agree with the following statements about your mother or
the person you think of as your mother?
MARK (X) ONE FOR EACH
Strongly disagree, Disagree, Neither disagree or agree, Agree, Strongly agree
a.
b.
c.
d.

2.3

2.4

My mother supports me to be a good parent
My mother’s help with the baby is just about right
My mother criticizes the way I take care of my baby
My mother gives me too much help with my baby

The next questions are about where you live and who lives with you.
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 live in a residential program
GO TO 2.7
□ You are homeless (living on the street, in a car or shelter, staying with
friends/relatives) – GO
TO 2.4

6

2.4

2.5

Who lives with you in your home?
MARK (X) ALL THE PEOPLE WHO LIVE WITH YOU

2.5

2.6

□Your mother, or the person you think of asyour mother
□Your father, or the person you think of as your father
□Any grandmothers
□Any grandfathers
□Any brothers or sisters
□Any aunts, uncles, or other relatives
□Your baby
□The father of your baby
□The parent(s) of the father of your baby
□Your current boyfriend/partner who is not the father of your baby
□Friends or roommates
□You live by yourself
Who lives with you in each of your homes?
Mark (X) all of the people who live with you in your MAIN home, and then
mark (X) all of the people who live with you in your OTHER homes.
MARK ALL THAT APPLY (List appears for both the MAIN home and the
OTHER home(s))
□
□
□
□
□
□
□
□
□
□
□
□

2.6

2.7

Your mother, or the person you think of as your mother
Your father, or the person you think of as your father
Any grandmothers
Any grandfathers
Any brothers or sisters
Any aunts, uncles, or other relatives
Your baby
The father of your baby
The parent(s) of the father of your baby
Your current boyfriend/partner who is not the father of your baby
Friends or roommates
You live by yourself

How many times have you moved in the past 6 months?
□
|

|

None
| NUMBER OF TIMES - Your best guess is fine.

7

3.1

In the past 12 months, have you received any information about
the following:
MARK (X) ONE FOR EACH
Yes, No
a. Methods of birth control
b. Where to get birth control

3.2

FOR THOSE WHO RECEIVED ANY INFO ABOUT METHODS OF
BIRTH CONTROL AND/OR WHERE TO GET BIRTH CONTROL
In the past 12 months, did you receive information about…
MARK (X) ONE FOR EACH
Yes, No
a.
c.
d.
e.
f.
g.
h.

8

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

3.3

FOR THOSE WHO RECEIVED ANY INFO ABOUT METHODS OF
BIRTH CONTROL AND/OR WHERE TO GET BIRTH CONTROL
Where did you receive information about birth control?
MARK (X) ALL THAT APPLY
□ At a hospital
□ At a clinic from a doctor, nurse or other health
professional
□ At home from a nurse, social worker, or other health
care professional
□ At school in a class
□ In an after-school program/activity
□ From a friend
□ Other (please specify)

3.4

What services have you received or what programs have you
been involved in over the past 12 months?
MARK (X) ALL THAT APPLY
□ School or community-based program for pregnant
or parenting teens
□ Parenting education
□ Case Management
□ WIC
□ CalLearn
□ AFLP
□ Other (Please specify)

9

4.1

3.4

Now please think about the past 4 weeks. Have you had sexual intercourse in
the past 4 weeks?

Modified reference period to past 3 months.
Added introduction.

MARK (X) ONE

The next questions are about sexual intercourse. By sexual
intercourse, we mean a male putting his penis into a female’s
vagina.

□ Yes
□ No

GO TO 3.10
Now please think about the past 3 months. Have you had sexual
intercourse in the past 3 months?
MARK (X) ONE

4.2

3.5

Now please think about the past 4 weeks. In the past 4 weeks, how many
TIMES have you had sexual intercourse?
□
|

4.3

3.7

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.

□
|

|

|

None - GO TO 4.6
| NUMBER OF TIMES - Your best guess is fine.

Modified reference period to past 3 months.
Modified question text.

In the past 4 weeks, how many TIMES have you had sexual intercourse
without using a condom?
□
|

□ Yes
□ No - GO TO 4.6
Modified reference period to past 3 months.

In the past 3 months, how many TIMES have you had sexual
intercourse without you or your partner using a condom?

None
| NUMBER OF TIMES - Your best guess is fine.

□
|

10

|

None - GO TO 4.6
| NUMBER OF TIMES - Your best guess is fine.

4.4

3.8

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)
Implant (Implanon)

Modified reference period to past 3 months.
Modified question text.
The next question is about your use of the following methods of
birth control:
•
•
•
•
•
•
•

In the past 4 weeks, 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.

In the past 3 months, how many TIMES have you had sexual
intercourse without you or your partner using any of these
methods of birth control?
□
|

4.5

3.9

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

Only ask if said “Yes” to having sex in last 4 weeks AND “No” to using any
birth control during last 4 weeks.

|

None
| NUMBER OF TIMES - Your best guess is fine.

Modified reference period to past 3 months.

There are different reasons people give for not using contraception. Please
mark ALL of the reasons that are true for you.

Only ask if said “Yes” to having sex in past months AND “No” to
using any birth control during past 3 months.

MARK (X) ALL THAT APPLY
□ I just haven’t gotten around to getting anything yet
□ I don’t think I can get pregnant right now
□ My partner doesn’t want me to use contraception
□ I don’t use it because of the side effects for me or my baby
□ Other (please specify):
4.6

Now please think about the past 12 months. Have you had sexual
intercourse in the past 12 months?
MARK (X) ONE
□ Yes
□ No - GO TO 4.9

11

4.7

How many DIFFERENT PEOPLE have you had sexual intercourse
with, even if only one time, in the past 12 months?
□
None - GO TO 4.9
| | | NUMBER OF PEOPLE - Your best guess is fine.
Thinking about the past 12 months, in which months were you
sexually active (had sexual intercourse)?

4.8

MARK (X) ONE FOR EACH
Yes, No
January – December (Note: Relevant months will appear based
on baseline date.)

4.9

Have you used any of the following birth control methods in the
past 12 months?
MARK (X) ONE FOR EACH
Yes, No
a.
b.

Condom
Emergency contraception, also known as “Plan B” or
“Preven”, or “morning after pills”
c. Birth control pills
d. The shot (Depo-Provera)
e. The patch
f. The ring (Nuva Ring)
g. IUD (Mirena or Paragard)
h. Implant (Implanon)
i. Foam
j. Sponge
k. Female condom
l. Withdrawal
m. Other (Please specify)
(NOTE: Specific questions on each method of contraception
will only be asked of those who indicate using that method of
contraception in 4.9)

12

4.10

FOR CONDOM USE
In which months did you use condoms?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

4.11

In the months you used a condom, would you say you used a
condom with your partner for sexual intercourse…?
MARK (X) ONE
□
□
□
□
□

4.12

Every time
Most of the time
About half of the time
Some of the time
None of the time

FOR EMERGENCY CONTRACEPTION USE
How many different times have you used emergency
contraception (Plan B) in the past 12 months?
| | | NUMBER OF TIMES - Your best guess is fine.
FOR BIRTH CONTROL PILL USE

4.13

In which months did you use birth control pills?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

13

4.14

In general over this time, would you say you took your birth
control pills consistently…?
Taking your birth control pills consistently means taking your
pills every day. Some types of pills have a set of 7 different
colored pills that do not contain any hormones. Women may
opt not to take these 7 pills only.

MARK (X) ONE
□
□
□
□
4.15

All of the time
Most of the time
Some of the time
None of the time

During the last month you used birth control pills, how many pills
that you were supposed to take did you miss…?
MARK (X) ONE
□ One - GO TO 4.17
□ None - GO TO 4.17
□ Two or more

4.16

Did you miss two or more pills in a row?
MARK (X) ONE
□ Yes
□ No

14

4.17

Some people try a method and then don’t use it again, or stop
using it. What was the reason or reasons why you stopped using
birth control pills?
MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

4.18

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you
that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

FOR THE SHOT (DEPO-PROVERA) USE
In which months did you receive the shot (Depo Provera)?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

15

4.19

Some people try a method and then don’t use it again, or stop
using it. What was the reason or reasons why you stopped using
the shot (Depo-Provera)?
MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

4.20

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you
that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

FOR THE PATCH (ORTHO-EVRA) USE
In which months did you use birth the patch (Ortho-Evra)?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

16

4.21

In general over this time, would you say you used the patch
consistently…?
Using the patch consistently means applying a new patch the same
day each week for 3 weeks. You would not use a patch in week 4
then would resume using the patch on the same day in week 5.
MARK (X) ONE
□
□
□
□

4.22

All of the time
Most of the time
Some of the time
None of the time

During the last month you used the patch, were you one or more
days late in changing the patch?
MARK (X) ONE
□ Yes
□ No - GO TO 4.24

4.23

Please indicate all the weeks that you were late in changing the
patch.
MARK (X) ONE
□ First week
□ Second week
□ Third week

17

4.24

Some people try a method and then don’t use it again, or stop
using it. What was the reason or reasons why you stopped using
the patch (Ortho-Evra)?
MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

4.25

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you
that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

FOR IUD (MIRENA OR PARAGARD) USE
In which months did you have the IUD (Mirena or Paragard)
inserted?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

4.26

Have you had the IUD removed since then?
MARK (X) ONE
□
□

18

Yes
No - GO TO 4.29

4.27

In which months did you have the IUD removed?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

4.28

Did you have the IUD inserted a second time?
MARK (X) ONE
□
Yes

□

4.29

No

Some people try a method and then don’t use it again, or stop
using it. What was the reason or reasons why you stopped using
the IUD (Mirena or Paragard)?
MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

19

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you
that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

4.30

FOR THE RING (NUVARING) USE
In which months did you use the ring (NuvaRing)?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

4.31

In general over this time, would you say you used the ring
consistently…?
Using the ring consistently means removing the ring on the same
day 3 weeks after it was inserted and inserting a new one on the
same day one week after it was removed (even if your period has
not stopped).
MARK (X) ONE
□All of the time
□Most of the time
□Some of the time
□None of the time

20

4.32

Some people try a method and then don’t use it again, or stop
using it. What was the reason or reasons why you stopped using
the ring (NuvaRing)?
MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

4.33

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you
that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

FOR IMPLANT (IMPLANON USE)
In which months did you have the implant (Implanon) inserted?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

4.34

Have you had it removed since then?
MARK (X) ONE
□
Yes
□
No - GO TO 4.36

21

4.35

In which months did you have the implant removed?
MARK (X) ALL THAT APPLY
January – December (Note: Relevant months will appear based
on baseline date.)

4.36

Some people try a method and then don’t use it again, or stop
using it. What was the reason or reasons why you stopped using
the implant (Implanon)?
MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

4.37

3.11

Do you intend to have sexual intercourse in the next year?

Too expensive
Too difficult to use
Too messy
Your partner did not like it
You had side effects
You were worried you might have side effects
You worried the method would not work
The method failed, you became pregnant
The method did not protect against disease
Because of other health problem, a doctor told you
that you should not use the method again
The method decreased your sexual pleasure
Too difficult to obtain the method
Did not like the changes to your menstrual cycle
You got pregnant
You were trying to get pregnant

Do you intend to have sexual intercourse in the next year, if you
have the chance?

MARK (X) ONE
MARK (X) ONE
o
o
o
o

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

□
□
□
□

GO TO 3.19

22

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

4.38

3.12

If you have sexual intercourse in the next year, do you intend to use a
condom?

If you were to have sexual intercourse in the next year, do you
intend to use a condom?

MARK (X) ONE

MARK (X) ONE

o
o
o
o
4.39

3.13

□
□
□
□

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

If you were to have sexual intercourse in the next year, do you
intend to use any of these other methods of birth control?

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

MARK (X) ONE

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

□
□
□

□

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

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

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

23

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

4.40

3.14

Removed:
Which of the following do you plan on using? (Only ask if answered Yes to
previous question)

□ Condoms

MARK (X) ALL THAT APPLY
□ Condoms
□ Oral Contraceptives/birth control pill
□ The shot (Depo-Provera)
□ The patch
□ The ring (NuvaRing)
□ IUD (Mirena or Paragard)
□ Implants (Implanon)
□ Other (Please specify)
4.41

3.15

The next series of questions is about methods of birth control, NOT including
condoms. 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. 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

4.42

3.16

Oral sex is when someone puts his or her mouth on another person’s penis or
vagina, OR lets someone else put his or her mouth on their penis or vagina.

Added introduction:
The next questions are about oral sex.

Have you ever had oral sex?
MARK (X) ONE
□
□

Yes
No

GO TO 4.19

24

4.43

3.17

How many DIFFERENT PEOPLE have you ever had oral sex with, even if only
one time?
|

4.44

4.45

4.46

3.18

3.19

3.20

|

| NUMBER OF PEOPLE - Your best guess is fine.

Now please think about the past 4 weeks.

Modified reference period to 3 months:

In the past 4 weeks, how many TIMES have you had oral sex?

Now please think about the past 3 months.

□
|

In the past 3 months, how many TIMES have you had oral sex?

|

None
| NUMBER OF TIMES - Your best guess is fine.

□
|

In the past 3 months, how many TIMES did you have oral sex
without using a condom?

□
|

□
|

|

None
| NUMBER OF TIMES - Your best guess is fine.

Anal sex is when a male puts his penis in someone else’s anus, or their butt,
or someone lets a male put his penis in their anus or butt.

MARK (X) ONE
□
□
3.21

None - GO TO 4.46
| NUMBER OF TIMES - Your best guess is fine.

In the past 4 weeks, how many TIMES have you had oral sex without using a
condom?

Have you ever had anal sex?

4.47

|

Yes
No

GO TO 4.23

How many DIFFERENT PEOPLE have you ever had anal sex with, even if only
one time?
|

|

| NUMBER OF PEOPLE - Your best guess is fine.

25

|

None
| NUMBER OF TIMES - Your best guess is fine.

Added intro: The next questions are about anal sex.

4.48

No w please think about the past 3 months. In the past 3 months,
how many TIMES did you have anal sex?
□
|

4.49

3.22

In the past 4 weeks, how many TIMES have you had anal sex without using a
condom?
□
|

3.23

None - GO TO 4.50
| NUMBER OF TIMES - Your best guess is fine.

Modified reference period to 3 months.
In the past 3 months, how many TIMES did you had anal sex
without using a condom? Your best guess is fine. If you always
used a condom, please enter zero.

None
| | NUMBER OF TIMES - Your best guess is fine.

□
|

4.50

|

|

None
| NUMBER OF TIMES - Your best guess is fine.

These next questions ask about sexually transmitted diseases, or STDs. 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
□
□

4.51

3.24

Yes
No

The next series of questions is about the types of sexually transmitted
diseases or STDs you have had. In the past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION

Removed: The next series of questions is about the types of
sexually transmitted diseases or STDs you have had.

Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.

Chlamydia
Gonorrhea
Genital herpes
Syphilis
HIV infection or AIDS
Human Papilloma virus, also known as HPV or genital warts
Another sexually transmitted disease (STD) PRINT OTHER STD:

26

5.1

The next questions ask about your pregnancy and your
relationship with your baby’s father.
Are you currently pregnant?
MARK (X) ONE
□
Yes
□
No - GO TO 5.6
When is your baby due?

5.2

Month | | | Year | | || | |
When you got pregnant this time, were you trying to get
pregnant?

5.3

5.4

4.7

MARK (X) ONE
□
Yes
□
No
What is your relationship with the father of your current
pregnancy?

What is your relationship with your baby’s father now?
MARK (X) ONE
□
□
□
□
□
□
□
□

MARK (X) ONE
No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

□
□
□
□
□
□
□
□

5.5

No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

(Only asked if currently pregnant)
To the best of your knowledge, were you pregnant any other time
since the birth of your first child?
MARK (X) ONE
□
Yes - GO TO 5.7
□
No - GO TO 5.13

27

5.6

(Only asked if not currently pregnant)
To the best of your knowledge, have you been pregnant since the
birth of your first child?
MARK (X) ONE
□
Yes
□
No - GO TO 5.13
How many times have you been pregnant since the birth of your
first child?

5.7

|
5.8

|

| NUMBER OF TIMES – Your best guess is fine

Have you given birth since your first child was born?
MARK (X) ONE
□
Yes
□
No - GO TO 5.13

5.9

5.10

Please list the birth date for each child you have given birth to
since your first child.

4.2

When you got pregnant with your baby, were you trying to get pregnant?
MARK (X) ONE
□
Yes
□
No

Month | | | Day | | | Year | | || | |
When you got pregnant with your youngest child, were you trying
to get pregnant?
MARK (X) ONE
□
Yes
□
No

28

5.11

4.7

What is your relationship with your baby’s father now?

What is your relationship with the father of your youngest child?

MARK (X) ONE

MARK (X) ONE
□ No contact
□ Have contact but don’t get along
□ Just friends, not dating
□ Casually dating
□ Seriously dating
□ Engaged
□ Married
□ Other (Please specify)

□
□
□
□
□
□
□
□

No contact
Have contact but don’t get along
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

5.12

Do all of your children have the same biological father?
MARK (X) ONE
□
Yes
□
No

5.13

How much is your first child’s father involved in raising that child?
MARK (X) ONE
□
A lot
□
A little
□
Not very much
□
Not at all

5.14

4.3

How likely do you think it is that you will be pregnant again before your child
turns two?
MARK (X) ONE
□ I am sure I will
□ I probably will
□ There is a 50/50 chance I will
□ I probably will not
□ I am sure I will not

29

5.15

4.4

Ideally, when would you want to get pregnant again?
MARK (X) ONE

6.1

5.1

□ Before my baby is 1 year old
□ When my baby is between 1 and 2 years old
□ When my baby is between 2 and 3 years old
□ When my baby is over three years old
□ I don’t know if I want to get pregnant again
□ Unsure

Please rate yourself on this set of statements, using the 9 point scale
below: (Scale: 1 = Not at all true to 9 =Very true)
MARK (X) ONE FOR EACH
a.
In general, I am focused on preventing negative events in my life
b.
I am anxious that I will fall short of my responsibilities and obligations
c.
I frequently imagine how I will achieve my hopes and aspirations
d.
I often think about the person I am afraid I might become in the future
e.
I often think about the person I would ideally like to be in the future
f.
I typically focus on the success I hope to achieve in the future
g.
I often imagine myself experiencing bad things that I fear might happen to me
h.
I frequently think about how I can prevent failures in my life
i.
I see myself as someone who is primarily striving to reach my “ideal self” – to
fulfill my hopes, wishes, and aspirations
j.
I see myself as someone who is primarily striving to become the self I “ought” to
be – to fulfill my duties, responsibilities, and obligations
k.
In general, I am focused on achieving positive outcomes in my life
l.
I often imagine myself experiencing good things that I hope will happen to me
m. Getting pregnant before my baby is 2 will lower my chances of getting the future
I want for myself and my family
n.
Contraception is an important way that I can be a responsible parent
o.
Focusing on my education and work experience now will help me achieve a
successful future
p.
Having another baby too soon may make it much harder on myself and my
family
q.
I plan to put extra effort into my education or experience to get a (better) job
r.
I plan to stop doing things that interfere with my job preparation

30

6.2

5.2

For the following statements, indicate to what degree the statement
reflects your own thoughts and feelings using the numbers 1through 6,
with 1 being STRONGLY AGREE and 6 being STRONGLY DISAGREE.
If a statement has more than one part, please indicate your reaction to
the whole statement.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.

I just can’t decide what to do as a parent, there are so many possibilities.
I’ve thought a lot about the kind of mother I want to be, but there’s no question that I will
follow what my “mother” says to do.
My “mom” tells me how to be a parent to my child, and that’s what I do.
I haven’t really decided what kind of mother I want to be. I’m just taking it day by day.
I’m sure it will be pretty easy to change the kind of mother I am when I’m ready.
It took me a while to figure it out, but now I know for sure what direction to move in as a
parent.
It took me a while to figure it out, but now I know what kind of mother I want to be.
I’m still trying to decide how capable I am as a person and what kind of parenting is right
for me.
I just can’t decide what to do for a career. There are so many possibilities.
I might have thought about a lot of different jobs, but there’s really never been any
question since my parents said what they wanted.
My parents decided a long time ago what I should go into for employment and I am
following through with their plans.
It took me awhile to figure it out, but now I know for sure what direction to move in for a
career.
I’m still trying to decide how capable I am as a person and what jobs will be right for me.
It took me awhile to figure it out, but now I really know what I want for a career.
When I’m ready, I’m sure it’ll be pretty easy to change or get the kind of job that’s right for
me.
I haven’t chosen the occupation I really want to get into, and I’m just
working at what is available until something better comes along.

31

6.3

5.3a

Who will you be in fifteen years? Each of us has some image or
picture of what we will be like and what we want to avoid being
like in the future. Think about 15 years from now—imagine what
you’ll be like, and what you’ll be doing.
In the lines below, write what you expect you will be like and what you expect
to be doing.
•

•

In the space next to each expected goal, mark No (X) if you are not
currently working on that goal or expectation and mark Yes(X) if you are
currently doing something to get to that expectation or goal.
For each expected goal that you marked Yes, use the space to the right to
write what you are doing this year to attain that goal.
1a. In 15 years, I expect to be ____________________________
1b . Am I doing something to be that way?
□ Yes
□ No
1c. (IF YES) What I am doing now to be that way in 15
years? _______________________

6.3a

Was your first or second goal about a job or an occupation?
MARK (X) ONE
□
Yes
□
No - GO TO 6.4

6.3b

Thinking of your first occupational goal listed, how much do you
hope for the kind of work that occurs with this occupational goal?
MARK (X) ONE
□
Barely
□
Not much
□
Somewhat
□
Very much

32

6.3c

Thinking of your first occupational goal, please indicate how likely
it will be that you obtain this possible self, using the numbers 1
through 7, with 1 being very unlikely and 7 being very likely.
(Scale: 1 = Vey unlikely to 9 =Very likely)

6.4

5.3b

In addition to expectations and expected goals, we all have images
or pictures of what we don’t want to be like; what we don’t want
to do or want to avoid being. First, think a minute about ways you
would not like to be in 15 years—things you are concerned about
or want to avoid being like.
Write those concerns or selves to-be-avoided in the lines below. Next to each
concern or to-be-avoided self, mark No (X) if you are not currently working on
avoiding that concern or to-be-avoided self and mark Yes (X) if you are
currently doing something so this will not happen in 15 years.
For each concern or to-be-avoided self that you marked Yes, use the space at
the end of each line to write what you are doing this year to reduce the
chances that this will describe you in 15 years.
1a. In 15 years, I want to avoid ____________________________
1b. Am I doing something to avoid this?
□ Yes
□ No
1c. (IF YES) What I am doing now to avoid being that way in 15 years?
________________

6.5

5.4

For each sentence, please think about how you are in most
situations. Rate each statement in a way that describes YOU the
best.
Scale: 0-5 (None of the time – All of the time)
a. I can do what it takes to get the specific work I choose
b. I know how to prepare for the kind of work I want to do
c. When I look into the future, I have a clear picture if what my work life
will be like
d. I have a difficult time identifying my own goals for the next five years.

33

DROPPED: The questions listed below are part of the baseline concordance instrument, but are not part of this site-specific baseline
instrument.
1.6

Are you Hispanic/Latino?
MARK (X) ONE
□
Yes
□
No

1.7

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

1.9

How many of your friends who are your age have done the
following things?
MARK (X) ONE FOR EACH
None, Some, Half, Most, All, Don’t Know
a. Had sexual intercourse
b. Been pregnant
Been a teen parent

1.10

Below is a list of some of the ways you may have felt or behaved.
Please indicate how often you have felt this way during the past
week by checking the appropriate response.
MARK (X) ONE FOR EACH
Rarely or none of the time (Less than 1 day)
Some of or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
a. I felt depressed

34

b. I felt lonely
c. I had crying spells
d. I felt sad

2.3

Were any of the following members of your family teen mothers?
MARK (X) ONE FOR EACH
Yes, No
a.
b.
c.

3.1

Mother
Grandmother
Sister

The next questions are about sexual intercourse. By sexual intercourse, we
mean a male putting his penis into a female’s vagina.
The very first time you had sexual intercourse, what month and year was it?

3.2

MARK (X) ONE MONTH AND ONE YEAR
The very first time you had sexual intercourse, how old were you?
|

3.3

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even
if only one time?
|

|

| NUMBER OF PEOPLE - Your best guess is fine.

35

3.6

In the past 4 weeks, have you used any of the following methods of birth
control?
MARK (X) ONE FOR EACH
Yes, No
a. Condoms
b. Birth control pills
c. The shot (Depo-Provera)
d. The patch
e. The ring (NuvaRing)
f. IUD (Mirena or Paragard)
g. Implants (Implanon)
h. Emergency contraception (Plan B)
i. Other (Please specify)

3.10

In general, how much pressure, if any, do you feel from your boyfriend/partner
to have sex without birth control?
MARK (X) ONE

4.1

□ A lot of pressure
□ Some pressure
□ A little pressure
□ No pressure
□ I do not have a boyfriend/partner
To the best of your knowledge, how many times have you been pregnant, even
if no child was born?
|

4.5

| NUMBER OF TIMES – Your best guess is fine

How old is your baby’s father?
|

4.8

|

|

| YEARS OLD

Has your baby’s father had any contact with your child since birth?
MARK (X) ONE
□Yes
□No – GO TO 4.10

36

4.9

In the past month, how often has your baby’s father spent one or
more hours with your child?
MARK (X) ONE

4.10

□ Every day
□ Almost every day
□ A few times a week
□ About once a week
□ Once or twice
□ Never
Do you currently use child care services other than your family or
friends?
MARK (X) ONE

4.11

□ Yes – Full-time
□ Yes – Part-time
□ No
In a typical week, how often do each of the following people
provide you with physical support (e.g., childcare, feeding,
changing diapers, bathing) to care for your baby?
MARK (X) ONE FOR EACH
6-7 times a week, 4-5 times a week, 2-3 times a week, 1 day a
week, Rarely or never, Not applicable
a. Baby’s father
b. Your boyfriend or partner who is not the baby’s father
c. Your parent(s)
d. Your baby’s father’s parent(s)
e. Another relative from your family
f. Another relative from your baby’s father’s family
g. A friend
h. Other (Please specify)

37

4.6

What was your relationship with your baby’s father when you got pregnant?
MARK (X) ONE
□
□
□
□
□
□
□

Did not know him well or at all
Just friends, not dating
Casually dating
Seriously dating
Engaged
Married
Other (Please specify)

38

SUMMARY OF DIFFERENCES BETWEEN THE OICA FOLLOW-UP AND BASELINE INSTRUMENTS

Follow-up #

OICA Baseline #

Items are listed in the order in which they appear on the OICA follow-up instrument (approval for the follow-up instrument was received on September 27,
2011; OMB Control No 0970-0360). The number for the corresponding site-specific baseline item is listed in the “OICA Baseline #” column. The OICA instrument
will be read aloud to youth in foster care homes, with make-ups conducted over the phone and online. There are no separate sections for sexually active and
non-sexually active respondents. Items found on the baseline instrument that are not on the follow-up instrument are listed at the bottom of the table (no items
were dropped from the baseline).
Modifications to an existing baseline item are listed in the “Modifications” column; otherwise, the question text on the follow-up instrument is the same
as that on the baseline instrument.
If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “OICA Baseline #” column and the question text is noted in the
“Modifications” column.

OICA Baseline Question Text

1.1

1.1

Are you male or female?

1.2

1.2

Modifications for follow-up

MARK (X) ONE
□
Male
□
Female
What is the last grade you completed?
MARK (X) ONE
□
□
□
□
□
□
□

6th
7th
8th
9th
10th
11th
12th

1

Follow-up #

OICA Baseline #

1.3

1.3

OICA Baseline Question Text
How old were you when you entered the foster care system?
MARK (X) ONE
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

1.4

Modifications for follow-up

<1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old

N/A

Do you currently live in a group home?
MARK (X) ONE
□
Yes
□
No

1.5

1.4

In what month and year did you start living in this group home?
MARK (X) ONE MONTH AND ONE YEAR

2

Follow-up #

OICA Baseline #

OICA Baseline Question Text

1.6

1.5

Are you Hispanic/Latino?

Modifications for follow-up

MARK (X) ONE
□
Yes
□
No
1.7

1.6

What is your race?

Dropped “some other race”; modified “White” to “White or Caucasian”

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: ___________________

1.8

1.7

What is the second letter of your first name?
MARK (X) ONE

1.9

1.8

What is the last letter of your first name?
MARK (X) ONE

1.10

1.9

In which month were you born?
MARK (X) ONE

3

Follow-up #

OICA Baseline #

1.11

1.10

On which day were you born?
MARK (X) ONE

1.12

1.11

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1.13

1.12

How likely is it that you will do each of the following things?
MARK (X) ONE

OICA Baseline Question Text

Modifications for follow-up

Not at all likely, A little bit likely, Somewhat likely, Very likely
a.
b.
c.
d.
e.

Graduate from high school
Go to a technical or vocational school after high school
Go to college
Graduate from a 2-year or community college program
Graduate from a 4-year college program

4

Follow-up #

OICA Baseline #

1.14

1.13

OICA Baseline Question Text

Modifications for follow-up

In the past 12 months, have you received any information or learned
about any of the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted infections, also known as STIs
How to talk to your partner about whether to have sex or whether to
use birth control
How to say no to sex
How babies are made

5

OICA Baseline #

Follow-up #

OICA Baseline Question Text

Modifications for follow-up

1.15

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 QUESTION
Never, 1-3 times, 4-9 times, 10 or more times
a.
b.
c.
d.
e.
f.
g.
h.

6

School class, workshop, or event
Church, synagogue, mosque or religious classes outside of
school
Community center, youth organization, or after-school
activity
Doctor, nurse, or clinic
Friends or other students
Parents and other relatives or family members
Internet and media
Other (List other source)

OICA Baseline #

Follow-up #

OICA Baseline Question Text

Modifications for follow-up

1.16

2.1

Thinking about the past 12 months, where did you get information on
relationships, abstinence, birth control, or sexually transmitted
diseases that was very helpful to you?

2.1

SELECT ONE OR MORE
□ School class, workshop, or event
□ Church, synagogue, mosque or religious classes outside of
school
□ Community center, youth organization, or after-school
activity
□ Doctor, nurse, or clinic
□ Friends or other students
□ Parents and other relatives or family members
□ Internet and media
□ Other (Please specify
Added “don’t know” as a response option

The next questions ask about the body, sexually transmitted infections
(STIs), and methods of protection.
The body part of the female body where a baby grows during pregnancy is
the:
□
□
□
□

Cervix
Uterus
Vagina
Ovary

7

Follow-up #

OICA Baseline #

OICA Baseline Question Text

2.2

2.2

The part of the male’s body that produces sperm is the:

Modifications for follow-up
Added “don’t know” as a response option

MARK (X) ONE

2.3

2.4

2.3

2.4

□ Testicles
□ Urethra
□ Penis
□ Prostate
When is it possible for a female to become pregnant?
MARK (X) ONE

Added “don’t know” as a response option

□ The first time she has sex
□ When she is ovulating
□ When her partner withdraws (pulls out) before ejaculating
□ All of the above
Of the following statements about methods of protection, which one is
false?
MARK (X) ONE

Added “don’t know” as a response option

□ You can get them with a prescription from a doctor
□ You can buy them at a local store in the drug or pharmacy section
□ Some require a prescription and others do not, depending on the type
of method
□ You must have your parent’s/guardian’s permission to get them if you
are under age 18

8

Follow-up #

OICA Baseline #

OICA Baseline Question Text

2.5

2.5

Please mark whether each statement is true, false, or you don’t know.
MARK (X) ONE FOR EACH QUESTION
True, False, Don’t Know
a.

A sexually active girl can become pregnant if she forgets to take
her birth control pills for several days in a row
b. Using a condom can help prevent HIV
c. A condom can be used more than once
d. If a condom is used, a young man should be careful how he
pulls out
e. If a young couple has had unprotected sex a few times and a
pregnancy did not occur, then they do not have to worry about
her getting pregnant
f. HIV destroys the immune system’s ability to fight off infections
and diseases
g. You cannot tell if a person has HIV by looking at them
h. HIV is the only sexually transmitted infection that is incurable
i.
All sexually active individuals are at risk for getting HIV
j.
Latex condoms are 100% effective in preventing pregnancy
and STIs (including HIV)
k. All sexually transmitted infections (STIs) can be cured
l. You can get the same sexually transmitted infection (STI) twice
m. You can get a sexually transmitted infection (STI) from having
oral sex

9

Modifications for follow-up
Added “don’t know” as a response option

Follow-up #

OICA Baseline #

2.6

2.6

OICA Baseline Question Text

Modifications for follow-up

Which of the following methods of protection offers the most protection
against HIV and other STIs?

Added “don’t know” as a response option

MARK (X) ONE

2.7

2.7

□ Depo-Provera (the shot)
□ Vaginal film
□ Condom (rubber)
□ Birth control pill
What is the safest and most effective method for avoiding pregnancy and
sexually transmitted infections (STIs)?

Added “don’t know” as a response option

MARK (X) ONE

2.8

2.8

□ Birth control pill
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Abstinence (not having sex)
Which one of the following methods listed below do you think is most
effective for preventing pregnancy?

Added “don’t know” as a response option

MARK (X) ONE
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Rhythm (safe period by calendar)
□ Patch (Ortho evra)
□ Birth control pill
□ Withdrawal method

10

Follow-up #

OICA Baseline #

2.9

2.9

3.1

3.1

OICA Baseline Question Text

Modifications for follow-up

Which one of the following methods listed below do you think is
least effective for preventing pregnancy?

Added “don’t know” as a response option

MARK (X) ONE
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Rhythm (safe period by calendar)
□ Patch (Ortho evra)
□ Birth control pill
□ Withdrawal method
The following questions are about your views on sex and protection.
Two people having vaginal intercourse should use some method of
protection if they are not ready for a child.
MARK (X) ONE

3.2

3.2

□ Strongly agree
□ Agree
□ Disagree
□ Strongly disagree
Using a method of protection is very important.
MARK (X) ONE
□ Strongly agree
□ Agree
□ Disagree
□ Strongly disagree

11

Follow-up #

OICA Baseline #

3.3

3.3

OICA Baseline Question Text

Modifications for follow-up

The next series of questions is about condom use. How strongly do you
agree or disagree that …

Dropped “neither agree nor disagree”

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. Condoms are a hassle to use
c. Condoms are pretty easy to get
d. Condoms are important to make sex safer
e. Using condoms means you don’t trust your partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure
h. Condoms make sex less exciting

12

Follow-up #

OICA Baseline #

3.4

3.4

OICA Baseline Question Text

Modifications for follow-up

The next series of questions is about other methods of birth control, NOT
including condoms. How strongly do you agree or disagree that…

Dropped “neither agree nor disagree”

MARK (X) ONE FOR EACH QUESTION
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

13

Follow-up #

OICA Baseline #

3.5

3.5

OICA Baseline Question Text

Modifications for follow-up

Please tell us how sure or unsure you are that you could do the
following things:
MARK (X) ONE FOR EACH QUESTION
a. Find a place in your community to obtain methods of protection
b. Tell your partner your feelings about what you do and do not want to
do sexually
c. Say “no” if your partner puts pressure on you to be involved sexually,
and you do not want that
d. Talk with your partner about methods of protection if you have sex
with him/her
e. Insist on using a method of protection if you have sex and want to use
a method of protection
f. Stop and use a method of protection once you are turned on
g. Plan ahead to have some method of protection available
h. Resist having sex with your partner if he/she did not want to use a
method of protection

14

Follow-up #

OICA Baseline #

3.6

3.6

OICA Baseline Question Text

Modifications for follow-up

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.
b.

4.1

4.1

Having sexual intercourse is a good thing for you to do at your age
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
The first questions are about sexual intercourse. By sexual intercourse,
we mean a male putting his penis into a female’s vagina.
Have you ever had sexual intercourse?

4.2

4.2

MARK (X) ONE
□
Yes
□
No
Have you had sexual intercourse more than one time?
MARK (X) ONE
□ I have never had sexual intercourse
□ Yes
□ No
GO TO 4.14

15

Follow-up #

OICA Baseline #

4.3

4.3

OICA Baseline Question Text
How many DIFFERENT PEOPLE have you ever had sexual intercourse with,
even if only one time?
□
|

4.4

4.4

Modifications for follow-up

I have never had sexual intercourse
|

| NUMBER OF PEOPLE - Your best guess is fine.

These next few questions ask about the first time you had sexual
intercourse. The very first time you had sexual intercourse, how old were
you?
□I have never had sexual intercourse
□ 9 years old
□10 years old
□11 years old
□12 years old
□13 years old
□14 years old
□15 years old
□16 years old
□17 years old
□18 years old

16

Follow-up #

OICA Baseline #

4.5

4.5

OICA Baseline Question Text

Modifications for follow-up

Birth control methods are something used to reduce the risk of
pregnancy, and some can reduce the risk of sexually transmitted
infections, also called STis.
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
□
□
□

4.6

4.6

I have never had sexual intercourse
Yes
No
GO TO 4.9

The first time you had sexual intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
YES, NO
□ I have never had sexual intercourse
a.
b.
c.
d.
e.
f.

4.7

4.7

Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
Nuva ring or the ring
Withdrawal or pulling out
Another method (PRINT OTHER METHOD USED):

Now please think about the past 3 months. In the past 3 months, how
many TIMES have you had sexual intercourse?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

17

Follow-up #

OICA Baseline #

4.8

4.8

OICA Baseline Question Text

Modifications for follow-up

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.

4.9

4.9

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.

4.10

N/A

In the past 3 months, with how many people have you had sex?
MARK (X) ONE
□ 1 person
□ 2 people
□ 3 people
□ 4 people
□ 5 people
□ 6 or more people

18

Follow-up #

OICA Baseline #

OICA Baseline Question Text

4.11

4.10

Do you intend to have sexual intercourse in the next year?

Modifications for follow-up

MARK (X) ONE
o
o
o
o
4.12

4.11

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

If you have sexual intercourse in the next year, do you intend to use a
condom?
MARK (X) ONE
o
o
o
o

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

19

Follow-up #

OICA Baseline #

4.13

4.12

OICA Baseline Question Text

Modifications for follow-up

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 have sexual intercourse in the next year, do you intend to use any
of these other methods of birth control?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not

4.14

4.13

To the best of your knowledge, have you ever been pregnant or gotten
someone pregnant, even if no child was born? Be sure to answer ‘yes’ if
you are currently pregnant or had any pregnancy that ended in a birth, an
abortion, stillbirth, miscarriage, or live birth after which the baby died.

.

MARK (X) ONE
□ Yes
□
No

20

Follow-up #

OICA Baseline #

4.15

4.14

OICA Baseline Question Text

Modifications for follow-up

Have you been pregnant or gotten someone pregnant during the past 3
months? Be sure to answer ‘yes’ if you are currently pregnant or had any
pregnancy that ended in a birth, an abortion, stillbirth, miscarriage, or
live birth after which the baby died.
MARK (X) ONE
□ Yes
□
No

4.16

4.15

To the best of your knowledge, how many TIMES have you been
pregnant or gotten someone pregnant?
□
None
| | | NUMBER OF TIMES

4.17

4.16

Have you ever had a baby or has anyone you got pregnant actually had
the baby?
MARK (X) ONE
□
I have never been pregnant or gotten anyone pregnant
□
Yes
□
No
□
Don’t know

4.18

4.17

When you or your partner got pregnant, were you trying to become
pregnant?
MARK (X) ONE
□ I have never been pregnant or gotten anyone pregnant
□ Yes
□ No

21

Follow-up #

OICA Baseline #

4.19

4.18

OICA Baseline Question Text

Modifications for follow-up

If you got pregnant now or got someone pregnant now, how would you
feel?
MARK (X) ONE
□
□
□
□
□

4.20

4.19

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

Oral sex is when someone puts his or her mouth on another person’s
penis or vagina, OR lets someone else put his or her mouth on their penis
or vagina.
Have you ever had oral sex?
MARK (X) ONE
□
□

4.21

4.20

Yes
No

How many DIFFERENT PEOPLE have you ever had oral sex with, even if
only one time?
□ I have never had oral sex
|

|

| NUMBER OF PEOPLE - Your best guess is fine.

22

Follow-up #

OICA Baseline #

4.22

4.21

OICA Baseline Question Text

Modifications for follow-up

Now think about the first time you had oral sex. The very first time you
had oral sex, how old were you?
MARK (X) ONE
□I have never had oral sex
□ 9 years old
□10 years old
□11 years old
□12 years old
□13 years old
□14 years old
□15 years old
□16 years old
□17 years old
□18 years old

4.23

4.22

Now please think about the past 3 months. In the past 3 months, how
many TIMES have you had oral sex?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

4.24

4.23

Do you intend to have oral sex in the next year?
o
o
o
o

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

23

Follow-up #

OICA Baseline #

4.25

4.24

OICA Baseline Question Text

Modifications for follow-up

The next few questions ask about sex. By sex, we mean ALL types of sex –
including vaginal, oral, and anal sex.
Have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
□Yes
□No

4.26

4.25

These next few questions ask about the last time you had sex (sexual
intercourse, oral sex or anal sex).
The last time you had sex did you or your partner use a method of
protection?
MARK (X) ONE
□ I have never had sex
□ Yes
□ No

4.27

4.26

The last time you had sex did you or your partner use a condom?
MARK (X) ONE
□ I have never had sex
□ Yes
□ No

24

Follow-up #

OICA Baseline #

4.28

4.27

OICA Baseline Question Text

Modifications for follow-up

The last time you had sex, did you or your partner use the following
methods to prevent pregnancy or STIs?
MARK (X) ONE FOR EACH QUESTION
□ I have never had sex
a.
b.
c.
d.
e.
f.
g.

4.29

4.28

Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
NuvaRing or the ring
Withdrawal or pulling out
Not sure
Another method (PRINT OTHER METHOD USED):

Which one of these statements best describes you now?
MARK (X) ONE
□
□
□
□

I have not had sex and am not even thinking about having sex
I have not had sex, however I am thinking about having sex
I have not had sex, but I am seriously thinking about having sex in
the near future
I have had sex in the past but I am not having sex now

□

I am currently having sex

25

Follow-up #

OICA Baseline #

4.30

4.29

OICA Baseline Question Text

Modifications for follow-up

Which of the following categories best describes your use of methods of
protection now? Please choose just one category.
MARK (X) ONE
□ I do not use any methods of protection because I am not sexually
active
□ I do not use a method of protection
□ I do not use any methods of protection, but am considering using a
method of protection
□ I use a method of protection sometimes, but I am thinking about using
a method of protection every time I have sex
□ I use a method of protection every time, but it has been less than 6
months since I started using a method of protection every time
□ I use a method of protection every time, and it has been more than 6
months since I started using a method of protection every time

4.31

4.30

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

Yes
No

26

Follow-up #

OICA Baseline #

4.32

4.31

OICA Baseline Question Text

Modifications for follow-up

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

4.33

4.32

Yes
No

In the past 12 months, have you been told by a doctor or nurse that you
had a sexually transmitted infection (STI)?

.

MARK (X) ONE
□
□
□

Yes
No
Don’t know

27

Follow-up #

OICA Baseline #

4.34

4.33

OICA Baseline Question Text

Modifications for follow-up

The next series of questions is about the types of sexually transmitted
infections or STIs you have had. In the past 12 months, did you have…
Yes, No, Don’t know
□ I have not had an STI in the past 12 months

5.1

4.34

a. Chlamydia
b. Gonorrhea
c. Genital herpes
d. Syphilis
e. HIV infection or AIDS
Human papilloma virus, also called HPV or genital warts
f.
g. Another sexually transmitted disease (STD) PRINT OTHER STD:
Were you in the POWER Through Choices program at any previous
time?
MARK (X) ONE
□
□

Yes
No

28

Follow-up #

OICA Baseline #

5.2

N/A

OICA Baseline Question Text

Modifications for follow-up
For the next few questions, please think about POWER ThroughChoices
and how it may have influenced you.
Would you say that being in this program has made you more or less
likely to have sexual intercourse in the next year?
MARK (X) ONE
□
□
□
□
□

5.3

N/A

Much more likely
More likely
About the same
Less likely
Much less likely

If you were to have sexual intercourse in the next year, would you say
that being in POWER Through Choices has made you more or less likely
to use a condom?
MARK (X) ONE
□
□
□
□
□

29

Much more likely
More likely
About the same
Less likely
Much less likely

Follow-up #

OICA Baseline #

5.4

N/A

OICA Baseline Question Text

Modifications for follow-up
The next question is about how likely you are to use other methods of
birth control (NOT including condoms) if you have sexual intercourse in
the next year:
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, would you say
that being in POWER Through Choices has made you more or less likely
to use one of these other methods of birth control?
MARK (X) ONE
□ Much more likely
□ More likely
□ About the same
□ Less likely
□ Much less likely

30

Follow-up #

OICA Baseline #

5.5

N/A

OICA Baseline Question Text

Modifications for follow-up
How helpful do you feel the material presented in Power Through
Choices has been to you personally?
MARK (X) ONE
□
□
□
□
□

5.6

N/A

Extremely helpful
Very helpful
Neutral
Not very helpful
Not helpful at all

Compared to other teachers you have had, how would you rate the
instructor who presented the Power Through Choices program?
MARK (X) ONE
□
□
□
□
□

31

Outstanding
Above average
Average
Below average
Poor

SUMMARY OF DIFFERENCES BETWEEN THE ENGENDER HEALTH BASELINE AND FOLLOW-UP INSTRUMENTS

Engender Health
Baseline #

Engender Health First
Follow-up #

Items are listed in the order in which they appear on the Engender Health follow-up instrument. The number for the corresponding baseline item is
listed in the “Engender Health Baseline #” column. Items in Part A are listed first, followed by items in Section 4, Part B1 (for sexually active
respondents), items in Section 4, Part B2 (for non-sexually active respondents) and items in Sections 5 and 6, Parts B1 and B2 (these sections are
the same for sexually active and non-sexually active respondents). Items found on the baseline instrument that are not on the follow-up instrument
are listed at the bottom of the table.
Modifications to an existing baseline item are listed in the “Modifications for Follow-up” column; otherwise, the question text on the followup instrument is the same as that on the baseline instrument.
If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “Engender Health Baseline #” column and the text is
noted in the “Modifications for Follow-up” column.

Engender Health Baseline Question Text

Modifications for Follow-up

PART A (Sections 1 – 3): All items in Part A are the same for sexually active and non-sexually active respondents.
1.1

1.1

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1

Engender Health First
Follow-up #

Engender Health
Baseline #

1.2

1.2

Engender Health Baseline Question Text

Modifications for Follow-up

What is the last grade you completed?
MARK (X) ONE
□
6th
□
7th
□
8th
□
9th
□
10th
□
11th
□
12th

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

Survey will be administered to respondents during the summer

1.3

N/A

1.4

1.3

1.5

1.4

□
College/technical school
□
Not currently in school
What high school do you attend?
MARK (X) ONE
□
Will obtain list of high schools
□
Other (PRINT NAME OF SCHOOL):
Are you male or female?
MARK (X) ONE
□
Male
□
Female
Are you Hispanic/Latino?
MARK (X) ONE
□
Yes
□
No

2

Engender Health First
Follow-up #

Engender Health
Baseline #

1.6

1.5

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

1.10

In the past 12 months, have you received any information or learned about any of the
following?
MARK (X) ONE FOR EACH QUESTION
Yes, No

Engender Health Baseline Question Text

Modifications for Follow-up
Removed answer category:
□
Some other race PRINT OTHER RACE

a.
b.
c.
d.
e.
f.
g.
h.

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or whether to use birth
control
How to say no to sex
How babies are made

3

Engender Health First
Follow-up #

Engender Health
Baseline #

1.8

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
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 QUESTION
Never, 1-3 times, 4-9 times, 10 or more times
a.
b.
c.
d.
e.
f.
g.
h.
i.

1.9

N/A

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

Was ANY of the information you received helpful to
you?
MARK (X) ONE
□
Yes
□
No

4

Engender Health First
Follow-up #

Engender Health
Baseline #

1.10

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
Thinking about the past 12 months, where did you get
information on relationships, abstinence, birth control,
or sexually transmitted diseases that was very helpful
to you?
SELECT ONE OR MORE
□ School class, workshop, or event
□ Church, synagogue, mosque or religious
classes outside of school
□ Community center, youth organization, or
after-school activity
□ Doctor, nurse, or clinic
□ Friends or other students
□ Parents and other relatives or family
members
□ Internet and media
□ Summer youth program
□ Other (Please specify)

5

Engender Health First
Follow-up #

Engender Health
Baseline #

1.11

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
How strongly do you agree or disagree with the
following statements?
MARK (X) ONE FOR EACH
Strongly agree, Agree, Disagree, Strongly
disagree
a.
b.
c.

d.
1.12

1.11

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.
b.
c.
d.
e.

Graduate from high school
Go to a technical or vocational school after high school
Go to college
Graduate from a 2-year or community college program
Graduate from a 4-year college program

6

You can do things now that will help you
to be healthy when you are an adult
Nothing you do as a teen will affect how
healthy you are as an adult
Taking risks as a teen, like drinking and
drugs, does not really matter for your
health in the long run
The good and bad decision you make as a
teen will affect your health as an adult

Engender Health First
Follow-up #

Engender Health
Baseline #

1.13

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
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
□
□
□
□
□

1.14

N/A

Never
Almost never
Sometimes
Fairly often
Very often

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
□
□
□
□
□

7

Never
Almost never
Sometimes
Fairly often
Very often

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

2.1

2.1

The next questions are about where you live and who lives with you.

Modifications for Follow-up

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

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

8

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

2.3

2.3

Who lives with you in each of your homes?

Modifications for Follow-up

Mark (X) all of the people who live with you in your MAIN home, and then mark (X) all
of the people who live with you in your OTHER home(s).
MARK ALL THAT APPLY (List appears for both the MAIN home and the 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

9

Engender Health First
Follow-up #

Engender Health
Baseline #

2.4

2.4

Engender Health Baseline Question Text

Modifications for Follow-up

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

2.5

2.7

2.6

N/A

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 a mother
GO TO 2.14

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

Added intro text: 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.

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

10

Engender Health First
Follow-up #

Engender Health
Baseline #

2.7

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
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)?
| |
fine
□

2.8

N/A

□
2.12

I do not know about my biological mother

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
| |
fine

2.9

| NUMBER OF YEARS OLD –Your best guess is

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
Don’t have a father or person I think of as a father GO TO 2.22a

11

| NUMBER OF YEARS OLD –Your best guess is

I do not know about my biological mother

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

2.10

2.15

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

N/A

Modifications for Follow-up
Added intro text: 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.

How comfortable are you 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

12

Engender Health First
Follow-up #

Engender Health
Baseline #

2.12a

2.20a

Engender Health Baseline Question Text

Modifications for Follow-up

Which of the following best describes the relationship between your biological
mother and biological father? If one or both of your biological parents have passed
away, please answer about their relationship when both were alive.

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
□
□
□
□
□

They are married to each other
They used to be married to each other, but are now separated
They used to be married to each other, but are now divorced
They have never been married to each other
I don’t know

MARK (X) ONE
□
□
□
□
□

2.12b

2.20b

Do your biological mother and biological father live together now?
MARK (X) ONE
□
□
□
□

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

13

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

Engender Health First
Follow-up #

Engender Health
Baseline #

2.13

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
The next questions ask about 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

N/A

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

14

Engender Health First
Follow-up #

Engender Health
Baseline #

2.15

N/A

2.16

Engender Health Baseline Question Text

Modifications for Follow-up
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
If you were going to be home late, would your parents
expect you to call?

N/A

MARK (X) ONE
□
Yes
□
No
3.1

3.6

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

15

Engender Health First
Follow-up #

Engender Health
Baseline #

3.2

3.1

Engender Health Baseline Question Text

Modifications for Follow-up

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 QUESTION
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.
d.
e.
f.

3.3

3.8

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

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.
b.

c.

Stop them if they wanted to touch your chest and you did not want them to do
that (FOR GIRLS)
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
Avoid having sexual intercourse if you didn’t want to

16

Engender Health First
Follow-up #

Engender Health
Baseline #

3.4

3.7

Engender Health Baseline Question Text

Modifications for Follow-up

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.
b.
c.
d.

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

17

Engender Health First
Follow-up #

Engender Health
Baseline #

3.5

3.4

Engender Health Baseline Question Text

Modifications for Follow-up

FOR BOYS ONLY: These questions are about how boys feel and behave. How strongly do
you agree or disagree that:

(This question is asked of both boys and girls in the
follow-up)

MARK (X) ONE FOR EACH QUESTION

Question wording changed to:

Strongly Agree, Agree, Disagree, Strongly Disagree

These questions are about boys and girls. How strongly
do you agree or disagree that:

a.
b.
c.
d.
3.6

3.2

The best way for a boy to show he is strong is to act tough
Boys should let it show when their feelings are hurt
In a good dating relationship the boy gets his way most of the time
It’s embarrassing for a boy when he needs to ask for help

FOR GIRLS ONLY: These questions are about how girls feel about boys. How strongly do
you agree or disagree that:

FOR GIRLS ONLY: These questions are about how girls
feel. How strongly do you agree or disagree that:

MARK (X) ONE FOR EACH QUESTION

MARK (X) ONE FOR EACH QUESTION

Strongly Agree, Agree, Disagree, Strongly Disagree

Strongly Agree, Agree, Disagree, Strongly Disagree

a.
b.
c.
d.

Teenage girls who have a boyfriend feel better about themselves than girls
who don’t have a boyfriend
When a teenage girl has a boyfriend, other girls look up to her
A girl is likely to feel bad about herself if she has never had a boyfriend
A girl who really likes a guy needs to have sex with him to prevent him from
finding someone else

18

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

Engender Health First
Follow-up #

Engender Health
Baseline #

3.7

3.3

Engender Health Baseline Question Text

Modifications for Follow-up

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

3.8

3.5

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

FOR BOYS
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

19

Engender Health First
Follow-up #

Engender Health
Baseline #

3.9

3.9

Engender Health Baseline Question Text

Modifications for Follow-up

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

3.10

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?

If a condom is used correctly, how much can it decrease the risk of pregnancy?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Completely
□ Don’t know

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

GO TO 3.6

20

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

3.10a

3.10a

How confident are you that your answer is correct?

3.11

3.11

Modifications for Follow-up

MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If a condom is used correctly, how much can it decrease the risk of getting HIV, the virus
that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.12

3.12

If birth control pills are used correctly, how much can they decrease the risk of
pregnancy?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

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
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 3.10

21

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

3.12a

3.12a

How confident are you that your answer is correct?

3.13

3.13

Modifications for Follow-up

MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If birth control pills are used correctly, how much can they decrease the risk of getting
HIV, the virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.14

3.14

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

The next series of questions is about methods of birth control, NOT including condoms.
How strongly do you agree or disagree that…
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

22

Engender Health First
Follow-up #

Engender Health
Baseline #

3.15

3.15

Engender Health Baseline Question Text

Modifications for Follow-up

The following questions are about how you can get birth control where you live. How
true do you think it is that:

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
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 clinic or health clinic without their parent’s permission
b. I would know where to go if I wanted (or my girlfriend wanted) to get a birth control
method like the pill or the shot
c. I would know where to go if I wanted to get tested for a sexually transmitted disease
(STD)
d. If I/my girlfriend wanted birth control pills, I would have enough money to pay for
them

3.16

3.16

In the past 3 months, how many TIMES have you gone out on a date?
□ Zero or None
GO TO 3.15
| | | NUMBER OF TIMES - Your best guess is fine

3.17

3.17

Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you
go out on a date with?
□
Zero or None
| | | NUMBER OF PEOPLE - Your best guess is fine.

23

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
clinic 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

Engender Health First
Follow-up #

Engender Health
Baseline #

3.18

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
In the past 6 months, have you had a boyfriend or
girlfriend?
MARK (X) ONE
□
Yes
□
No

3.19

N/A

In the past 6 months, how many different boyfriends or
girlfriends have you had?
|

3.20

3.18

Do you intend to have sexual intercourse in the next year?

|

| NUMBER OF PEOPLE - Your best guess is fine.

Do you intend to have sexual intercourse in the next
year, if you have the chance?

MARK (X) ONE
MARK (X) ONE
□
□
□
□

Yes, definitely
Yes, probably
No, probably not
No, definitely not GO TO 3.19

□
□
□
□

24

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

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

3.21

3.19

If you have sexual intercourse in the next year, do you intend to use a condom?
MARK (X) ONE
□
□
□
□

3.22

3.20

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

Modifications for Follow-up
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
□
□
□
□

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 have sexual intercourse in the next year, do you intend to use any of these other
methods of birth control?
MARK (X) ONE
□ Yes, definitely
□ Yes, probably
□ No, probably not
□ No, definitely not

25

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

The next question is about your intention to use the
following 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 methods of birth control?
MARK (X) ONE
□ Yes, definitely
□ Yes, probably
□ No, probably not
□ No, definitely not

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

3.23

3.21

Do you intend to have sexual intercourse without being married?
□
□
□
□

3.24

3.22

Modifications for Follow-up

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

Have you ever had sexual intercourse?

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

□ YES: GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
□ NO: GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE

26

Engender Health
Baseline #

Engender Health First
Follow-up #

Engender Health Baseline Question Text

Modifications for Follow-up

PART B1: The items in Section 4, Part B1 are specifically for sexually active respondents. Items in Sections 5 and 6, Part B1 are the same
as the items in Sections 5 and 6, Part B2 (for non-sexually active respondents).
4.1
Part
B1

4.1
Part
B1

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 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.

Just to confirm, have you ever had sexual intercourse?
Have you ever had sexual intercourse?

The first questions are about sexual intercourse. By
sexual intercourse, we mean a man putting his penis
into a female’s vagina.

MARK (X) ONE
□
Yes
□
No - GO TO 4.15

Just to confirm, have you ever had sexual intercourse?
MARK (X) ONE
□
Yes – STOP AND GO TO PART B2
□
No - CONTINUE WITH THIS BOOKLET
(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
Part
B1
4.3
Part
B1

4.2
Part
B1
4.3
Part
B1

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

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

27

Engender Health First
Follow-up #

Engender Health
Baseline #

4.4
Part
B1

4.4
Part
B1

Engender Health Baseline Question Text

Modifications for Follow-up

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
□
□
□

4.5
Part
B1

4.6
Part
B1

4.5
Part
B1

4.6
Part
B1

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

The very first time you had sexual intercourse, would you say that it was voluntary or
not voluntary?
MARK (X) ONE
□ Voluntary
□ Not voluntary
Birth control methods are something used to reduce the risk of pregnancy, and some
can reduce the risk of sexually transmitted diseases, also called 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 4.9

28

Engender Health First
Follow-up #

Engender Health
Baseline #

4.7
Part
B1

4.7
Part
B1

Engender Health Baseline Question Text

Modifications for Follow-up

The first time you had sexual intercourse, did you or your partner use …

Changed wording for:

MARK (X) ONE FOR EACH ITEM

c.

YES, NO
a.
b.
c.
d.
e.
f.
4.8
Part
B1

4.8
Part
B1

4.9
Part
B1

4.9
Part
B1

4.10
Part
B1

4.10
Part
B1

Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
NuvaRing or the ring
Withdrawal or pulling out
Another method (PRINT OTHER METHOD USED):

Have you had sexual intercourse more than one time?
MARK (X) ONE
□ Yes
□ No
GO TO 4.14
How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only
one time?
| | | NUMBER OF PEOPLE - Your best guess is fine.
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.

29

Depo-Provera or other injectable birth control

Engender Health First
Follow-up #

Engender Health
Baseline #

4.11
Part
B1

4.11
Part
B1

Engender Health Baseline Question Text

Modifications for Follow-up

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
Part
B1

4.12
Part
B1

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.

4.13
Part
B1

4.13
Part
B1

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.

30

Engender Health First
Follow-up #

Engender Health
Baseline #

4.14a
Part
B1

4.14a
Part
B1

Engender Health Baseline Question Text

Modifications for Follow-up

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

4.14b
Part
B1

4.14b
Part
B1

Yes
No

To the best of your knowledge, how many TIMES have you been pregnant or gotten
someone pregnant?
□
None
| | | NUMBER OF TIMES

4.14c
Part
B1

4.14c
Part
B1

Have you ever had a baby or has anyone you got pregnant actually had the baby?

4.15
Part
B1

4.15
Part
B1

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
□
Don’t know

MARK (X) ONE
□
□

Yes
No

31

Engender Health First
Follow-up #

Engender Health
Baseline #

4.16
Part
B1

4.16
Part
B1

Engender Health Baseline Question Text

Modifications for Follow-up

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
□
□

4.17
Part
B1

4.17
Part
B1

Yes
No

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
□
□

4.18
Part
B1

4.18
Part
B1

Yes
No

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

32

Engender Health First
Follow-up #

Engender Health
Baseline #

4.19
Part
B1

4.19
Part
B1

Engender Health Baseline Question Text

Modifications for Follow-up

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

PART B2: The items in Section 4, Part B2 are specifically for non-sexually active respondents. Items in Sections 5 and 6, Part B1 are the
same as the items in Sections 5 and 6, Part B2 (for non-sexually active respondents).
4.1
Part
B2

4.1
Part
B2

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

4.2
Part
B2

4.2
Part
B2

□ Yes STOP AND GO TO PART B1
□ No CONTINUE WITH THIS BOOKLET
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

33

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

Engender Health First
Follow-up #

Engender Health
Baseline #

4.3
Part
B2

4.3
Part
B2

Engender Health Baseline Question Text

Modifications for Follow-up

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

4.4
Part
B2

4.4
Part
B2

The next questions are about where you live.
In the last 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
□
□

4.5
Part
B2

4.5
Part
B2

Yes GO TO 4.11
No

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
Part
B2

4.6
Part
B2

Do you consider one of these homes to be your main home?
MARK (X) ONE
□ Yes
□ No

34

Engender Health First
Follow-up #

Engender Health
Baseline #

4.7
Part
B2

4.7
Part
B2

4.8
Part
B2

4.8
Part
B2

Engender Health Baseline Question Text
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.

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

4.9
Part
B2

4.9
Part
B2

Modifications for Follow-up

Yes
No

Is your home or any of your homes a group home or halfway house?
MARK (X) ONE□ Yes
□ No

35

Engender Health First
Follow-up #

Engender Health
Baseline #

4.10
Part
B2

4.10
Part
B2

Engender Health Baseline Question Text

Modifications for Follow-up

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?
|

4.11
Part
B2

4.11
Part
B2

|

| NUMBER OF PEOPLE

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

4.12
Part
B2

4.12
Part
B2

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
How strongly do you agree or disagree that . . .?
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree
a.
b.
c.
d.

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

36

Engender Health First
Follow-up #

Engender Health
Baseline #

4.13
Part
B2

4.13
Part
B2

Engender Health Baseline Question Text

Modifications for Follow-up

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.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

4.14
Part
B2

4.14
Part
B2

I don’t want to get a sexually transmitted disease, also known as an STD
I don’t want to disappoint my parents
I am too young to have sex
My boyfriend or girlfriend doesn’t want to have sex
I want to wait until I’m married
It is against my personal values
I haven’t met the right person yet
I haven’t had the chance
I don’t want to
FOR GIRLS: I do not want to get pregnant
FOR BOYS: I do not want to get a girl pregnant

Have you ever done any of the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
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

37

Engender Health First
Follow-up #

Engender Health
Baseline #

Engender Health Baseline Question Text

4.15
Part
B2

4.15
Part
B2

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?

Modifications for Follow-up

MARK (X) ONE
□
□
4.16
Part
B2

4.16
Part
B2

4.16
Part
B2

4.17
Part
B2

Yes
No

Have you ever been fearful that someone you were dating might physically hurt you?
MARK (X) ONE
□ Yes
□ No
□ I have never dated anyone
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

38

Engender Health First
Follow-up #

Engender Health
Baseline #

4.18
Part
B2

4.18
Part
B2

Engender Health Baseline Question Text

Modifications for Follow-up

If you decided to have sexual intercourse outside of marriage, how likely is it 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

Sections 5 and 6 (Parts B1 and B2) – these items are the same for sexually active and non-sexually active respondents.
5.1

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
□
□

5.2

5.2

Yes
No GO TO 5.8

The very first time you had an alcoholic drink, how old were you?
|

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

39

Engender Health First
Follow-up #

Engender Health
Baseline #

5.3

5.3

Engender Health Baseline Question Text

Modifications for Follow-up

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
□
□
□
□

5.4

5.5

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?

5.5

MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used marijuana, also called weed or pot?
MARK (X) ONE
□
□

Yes
No GO TO 5.10

40

Engender Health First
Follow-up #

Engender Health
Baseline #

5.6

5.7

Engender Health Baseline Question Text

Modifications for Follow-up

Have you ever used any other type of illegal drug, for example Methamphetamine,
speed, PCP, ecstasy, or any form of cocaine, such as crack?

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

5.8

MARK (X) ONE
□
Yes
□
No

Have you ever used any prescription pills or other prescription drugs that were not
prescribed for you?
MARK (X) ONE
□
Yes
□
No

5.9

Have you ever used an inhalant, such as sniffed glue, breathed the contents of spray
cans, or inhaled any paints or solvents to get high?
MARK (X) ONE
□
Yes
□
No

41

Engender Health First
Follow-up #

Engender Health
Baseline #

6.1

6.1

Engender Health Baseline Question Text

Modifications for Follow-up

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.

6.2

6.2

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.
How many of your friends who are your age have had sexual intercourse?

MARK (X) ONE
□
□
□
□
□
□

None
Some
Half
Most
All
Don’t know

42

Engender Health First
Follow-up #

Engender Health
Baseline #

6.3

6.3

Engender Health Baseline Question Text

Modifications for Follow-up

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

6.4

6.5

A lot of pressure
Some pressure
A little pressure
No pressure

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

Treatment group questions (Part B1 and B2): These items are the same for sexually active and non-sexually active respondents. The
questions in this section will only be asked of those respondents that were in the treatment group. 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.
1

N/A

How many other people do you know of at your high
school who participated in Gen.M this past summer?
□
None
| | | NUMBER OF PEOPLE – Your best guess is fine.

43

Engender Health First
Follow-up #

Engender Health
Baseline #

2

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
How often do you hang out with any of those kids?
MARK (X) ONE
□
A lot
□
Sometimes
□
Rarely
□
Never

3

N/A

Did you attend an even sponsored by Gen.M after you
completed your summer Gen.M group?

MARK (X) ONE
□
□
4

N/A

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

44

Engender Health First
Follow-up #

Engender Health
Baseline #

5

N/A

Engender Health Baseline Question Text

Modifications for Follow-up
How many times have you done the following things in
the past six months?
MARK (X) ONE FOR EACH QUESTION
0, 1-2, 3-5, 6-10
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

45

Engender Health
Baseline #

Engender Health First
Follow-up #

DROPPED: The questions listed below are part of the baseline concordance instrument, but are not part of this site-specific baseline
instrument.

1.6

Modifications for Engender Health First Followup

Engender Health Baseline Question Text
When you are at home or with your family, what language or languages do you usually
speak?
YOU MAY MARK (X) MORE THAN ONE ANSWER
□ English
□ Spanish
□ Chinese language such as Mandarin or Cantonese
□ Some other language PRINT OTHER LANGUAGE(S) ____________________________

1.7

What is the main language you speak at home?
MARK (X) ONE
□
□
□
□

English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE ____________________________

46

1.8

In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
□
□
□
□
□

1.9

How important is religion in your life?
MARK (X) ONE
□
□
□

1.11

Never
Less than once a month
1-3 times per month
Once a week
More than once a week

Not at all important
Somewhat important
Very important

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

2.5

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
The following questions are about the person you marked as your mother or the person you
think of as your mother.
Did she graduate from high school?
MARK (X) ONE
□
□
□

2.6

Yes
No
Don’t know

Did she graduate from a 4-year college?
MARK (X) ONE
□

Yes

47

□
□

2.8

No
Don’t know

How close do you feel to your mother or the person you think of as your mother?
MARK (X) ONE
□
□
□
□

2.9

Not at all close
A little close
Somewhat close
Very close

In general, how much do you think she cares about you?
MARK (X) ONE
□
□
□
□

2.10

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would she feel about you having sex at this time in
your life?
MARK (X) ONE

2.11

□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove
How would she feel about you having a baby at this time in your life?
MARK (X) ONE
□
□
□
□
□

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

48

2.13

The following questions are about the person you marked as your father or the person you
think of as your father.
Did he graduate from high school?
MARK (X) ONE
□
□
□

2.14

2.16

Yes
No
Don’t know

Did he graduate from a 4-year college?
MARK (X) ONE
□
Yes
□
No
□
Don’t know
How close do you feel to your father or the person you think of as your father?
MARK (X) ONE
□ Not at all close
□ A little close
□ Somewhat close
□ Very close

2.17

In general, how much do you think he cares about you?
MARK (X) ONE
□
□
□
□

2.18

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would he feel about you having sex at this time in
your life?
MARK (X) ONE
□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove

49

2.19

How would he feel about you having a baby at this time in your life?
MARK (X) ONE

2.21

□ Strongly approve
□ Approve
□ Neither approve nor disapprove
□ Disapprove
□ Strongly disapprove
In the past 12 months, how many times have you talked with at least one of your parents or
guardians about . . .?
MARK (X) ONE FOR EACH QUESTION
Never, 1-2 Times, 3-9 Times, 10 or more times

5.6

6.4

a. How things are going with school work or with your grades
b. A personal problem you were having
c. How to have good romantic relationships
d. Strategies for safe dating
e. How to resist pressures to have sex
f.
Avoiding drugs and alcohol
g. Pregnancy or birth
h. Sexually transmitted diseases (also called STDs), HIV, or AIDS
During the past 30 days, on how many days did you use marijuana?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
People are different in their sexual attraction to other people. Which of the following best
describes you?
MARK (X) ONE
□
□
□
□
□

I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure

50

SUMMARY OF DIFFERENCES BETWEEN THE LIVE THE LIVE BASELINE AND FOLLOW-UP INSTRUMENTS

Baseline #

Follow-up #

Items are listed in the order in which they appear on the Live the Life follow-up instrument. The number for the corresponding baseline item is
listed in the “Baseline #” column. Items in Part A are listed first, followed by items in Section 4, Part B1 (for sexually active respondents), items in
Section 4, Part B2 (for non-sexually active respondents) and items in Sections 5 and 6, Parts B1 and B2 (these sections are the same for sexually
active and non-sexually active respondents). Items found on the baseline instrument that are not on the follow-up instrument are listed at the
bottom of the table.
Modifications to an existing baseline item are listed in the “Modifications” column; otherwise, the question text on the follow-up
instrument is the same as that on the baseline instrument.
If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “Baseline #” column and the question text is noted in the
“Modifications” column.

Live the Life Baseline text

Modified for Live the Life Follow-up

PART A (Sections 1 – 3): All items in Part A are the same for sexually active and non-sexually active respondents.

1.1

1.1

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1

Follow-up #

Baseline #

1.2

1.2

1.3

1.4

Live the Life Baseline text

Modified for Live the Life Follow-up

What grade are you in?
MARK (X) ONE

1.3

□
6th
□
7th
□
8th
□
9th
□
10th
□
11th
□
12th
□
Not currently in school
Are you male or female?

1.4

MARK (X) ONE
□
Male
□
Female
Are you Hispanic/Latino?
MARK (X) ONE
□
Yes
□
No

2

Follow-up #

Baseline #

Live the Life Baseline text

1.5

1.5

What is your race?

Modified for Live the Life Follow-up

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

1.6

1.6

What is the main language you speak at home?
□
□
□

1.7

1.7

English
Spanish
Some other language PRINT OTHER LANGUAGE

In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
□
□
□
□
□

Never
Less than once a month
1-3 times per month
Once a week
More than once a week

3

Follow-up #

Baseline #

1.8

1.8

Live the Life Baseline text
How important is religion in your life?
MARK (X) ONE
□
□
□

1.9

1.9

Modified for Live the Life Follow-up

Not at all important
Somewhat important
Very important

In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.

1.10

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or whether to use birth control
How to say no to sex
How babies are made

N/A

Did you say “yes” to any item a through h in
question 1.9 above?
MARK (X) ONE
□
Yes
□
No – GO TO 1.13

4

Follow-up #

Baseline #

1.11

N/A

Live the Life Baseline text

Modified for Live the Life Follow-up
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 QUESTION
Never, 1-3 times, 4-9 times, 10 or more times
a.
b.
c.

d.
e.
f.
g.
h.

5

School class, workshop, or event
Church, synagogue, mosque or
religious classes outside of school
Community
center,
youth
organization, or after-school
activity
Doctor, nurse, or clinic
Friends or other students
Parents and other relatives or
family members
Internet or media
Other (List other source)

Follow-up #

Baseline #

1.12

N/A

Live the Life Baseline text

Modified for Live the Life Follow-up
Thinking about the past 12 months, where did
you get information on relationships,
abstinence, birth control, or sexually
transmitted diseases that was very helpful to
you?
SELECT ONE OR MORE
□ School class, workshop, or event
□ Church, synagogue, mosque or
religious classes outside of school
□ Community
center,
youth
organization, or after-school
activity
□ Doctor, nurse, or clinic
□ Friends or other students
□ Parents or other relatives or
family members
□ Internet and media
□ Other (Please specify)

1.13

1.10

How likely is it that you will do each of the following things?
MARK (X) ONE
Not at all likely, A little bit likely, Somewhat likely, Very likely
a.
b.
c.
d.
e.

Graduate from high school
Go to a technical or vocational school after high school
Go to college
Graduate from a 2-year or community college program
Graduate from a 4-year college program

6

Follow-up #

Baseline #

Live the Life Baseline Question text

2.1

2.1

The next question is about where you live and who lives with you.

Modified for follow-up

Which of the following best describes where you live?
□ 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, staying with friends/relatives) –
GO
TO 2.4
2.2

2.2

Who lives with you in your home?
MARK 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

7

Follow-up #

Baseline #

Live the Life Baseline Question text

2.3

2.3

Who lives with you in each of your homes?

Modified for follow-up

Mark all of the people who live with you in your MAIN home, and then mark all of the people
who live with you in your OTHER homes.
MARK ALL THAT APPLY (List appears for both the MAIN home and the 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

8

Follow-up #

Baseline #

2.4

2.4

Live the Life Baseline Question text

Modified for follow-up

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

2.5

2.7

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 a mother
GO TO 2.12

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

Is the person you marked as your mother or the
person you think of as your mother 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

9

Follow-up #

Baseline #

2.6

2.12

Live the Life Baseline Question text

Modified for follow-up

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

2.7

2.15

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
□
Don’t have a father or person I think of as a father GO TO 2.8
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

10

Is the person you marked as your father or the
person you think of as your father 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

Follow-up #

Baseline #

2.8

2.20

Live the Life Baseline Question text

Modified for follow-up

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

2.9

2.21

They are married to each other
They used to be married to each other, but are now separated
They used to be married to each other, but are now divorced
They have never been married to each other
I don’t know

Do your biological mother and biological father live together now?
MARK (X) ONE
o
o
o
o

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

11

Follow-up #

Baseline #

3.1

3.1

Live the Life Baseline Question text

Modified for follow-up

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
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.
d.
e.
f.
g.
h.

Having sexual intercourse is a good thing for you to do at your age
At your age right now, having sexual intercourse would create problems
At your age right now, not having sexual intercourse is important for you to be safe and
healthy
At your age right now, it is okay for you to have sexual intercourse if you use birth control,
like a condom
If you have sexual intercourse as a teen, it will not do any harm
You would feel guilty having sexual intercourse as a teen
You would feel embarrassed to say no to a boyfriend or girlfriend who wanted to have
sexual intercourse with you
You would not want to disappoint a boyfriend or girlfriend who wanted to have sexual
intercourse with you

12

Follow-up #

Baseline #

3.2

3.2

Live the Life Baseline Question text

Modified for follow-up

The next series of questions is about your views on sexual intercourse before marriage. How
strongly do you agree or disagree that…

h.

MARK (X) ONE FOR EACH
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.

3.3

3.3

You intend to wait until marriage to have sexual intercourse
It would be good for you to wait until marriage to have sexual intercourse
Whether or not you wait until marriage to have sexual intercourse is completely up to
you
d. It would be difficult for you to wait until marriage to have sexual intercourse
e.
It is against your values to have sexual intercourse before marriage
f.
You think people who wait until marriage to have sexual intercourse are being safe
and responsible
g.
It would be unpleasant for you to wait until marriage to have sexual intercourse
Most people who are important to you think that you should wait until marriage to
have sexual intercourse
FOR GIRLS
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

13

Follow-up #

Baseline #

3.3

3.3

Live the Life Baseline Question text

Modified for follow-up

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

3.4

3.4

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

Imagine you are alone with someone you like very much. How likely is it that you could . . .
MARK (X) ONE FOR EACH
Not at all Likely, A Little Bit Likely, Somewhat Likely, Very Likely
a.
b.
c.

Stop them if they wanted to touch your chest and you did not want them to do that (FOR
GIRLS)
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
Avoid having sexual intercourse if you didn’t want to

14

Follow-up #

Baseline #

Live the Life Baseline Question text

3.5

3.5

The next series of questions is about condom use. How strongly do you agree or disagree that …

Modified for follow-up

MARK (X) ONE FOR EACH
Strongly agree, Agree, Neither agree nor disagree, Disagree, Strongly disagree
a.
b.
c.
d.
e.
f.
g.
3.6

3.6

Condoms should always be used if a person your age has sexual intercourse
Condoms are a hassle to use
Condoms don ont protect from the emotional impact of sexual intercourse
Condoms are important to make sex safer
Using condoms means you don’t trust your partner
Using condoms is morally wrong
Condoms decrease sexual pleasure

If a condom is used correctly, how much can it decrease the risk of pregnancy
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.6a

3.6a

If condoms are used correctly and consistently,
how mych can they decrease the risk of
pregnancy?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know GO TO 3.7

GO TO 3.7

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident

15

Follow-up #

Baseline #

3.7

3.7

Live the Life Baseline Question text

Modified for follow-up

If a condom is used correctly, how much can it decrease the risk of getting HIV, the virus that
causes AIDS?

If condoms are used correctly and consistently,
how much can it decrease the risk of getting
HIV, the virus that causes AIDS?

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.8

3.8

MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

If a condom is used correctly, how much can it decrease the risk of getting Chlamydia and
gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.9

3.9

If condoms are used correctly and consistently,
how much can they decrease the risk of getting
gonorrhea?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

The next series of questions is about birth control pills.
If birth control pills are used correctly, how much can they decrease the risk of pregnancy?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know – GO TO 3.10

If birth control pills are used correctly and
consistently, how much can they decrease the
risk of pregnancy?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

16

Follow-up #

Baseline #

Live the Life Baseline Question text

3.9a

3.9a

How confident are you that your answer is correct?

3.10

3.10

Modified for follow-up

MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If birth control pills are used correctly, how much can they decrease the risk of getting HIV, the
virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.11

3.11

If birth control pills are used correctly, how much can they decrease the risk of getting
Chlamydia and gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

If birth control pills are used correctly and
consistently, how much can they decrease the
risk of getting HIV, the virus that causes AIDS?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know
If birth control pills are used correctly and
consistently, how much can they decrease the
risk of getting Chlamydia and gonorrhea?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Completely
□ Don’t know

17

Follow-up #

Baseline #

3.12

3.12

Live the Life Baseline Question text
Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
□
□
□

3.12a

3.12a

3.13

3.13

Modified for follow-up

Yes
No
Don’t know

GO TO 3.13

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
In the past 3 months, how many TIMES have you gone out on a date?
□ Zero or None
GO TO 3.15
| | | NUMBER OF TIMES - Your best guess is fine

3.14

3.14

Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you go out
on a date with?
□
Zero or None
| | | NUMBER OF PEOPLE - Your best guess is fine.

3.15

3.15

Do you intend to have oral sex in the next year?
o
o
o
o

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

18

Follow-up #

Baseline #

Live the Life Baseline Question text

3.16

3.16

Do you intend to have sexual intercourse in the next year?
o
o
o
o

3.17

3.17

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

Do you intend to have sexual intercourse in the
next year, if you have the chance?
o
o
o
o

If you have sexual intercourse in the next year, do you intend to use a condom?
o
o
o
o

Modified for follow-up

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

If you were to have sexual intercourse in the
next year, do you intend to use (or have your
partner use) a condom?
o
o
o
o

19

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

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

Follow-up #

Baseline #

3.18

3.18

Live the Life Baseline Question text

Modified for follow-up

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 (Implanaon)

The next question is about your intention to use
any of these methods of birth control:
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanaon)

If you have sexual intercourse in the next year, do you intend to use any of these other
methods of birth control?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not

3.19

3.19

Do you intend to have sexual intercourse without being married?
o
o
o
o

3.20

3.20

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

Have you ever had sexual intercourse or oral sex?
□ YES: GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
□ NO: GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE

20

If you have sexual intercourse in the next year,
do you intend to use (or have your partner use)
any of these methods of birth control?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not

Baseline #

Follow-up #

Live the Life Baseline Question text

Modified for follow-up

PART B1: The items in Section 4, Part B1 are specifically for sexually active respondents. Items in Sections 5 and 6, Part B1 are the same as the items in Sections 5
and 6, Part B2 (for non-sexually active respondents).
4.1
Part
B1

4.1
Part
B1

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.
Just to confirm, have you ever had sexual intercourse or oral sex?

4.2
Part
B1

4.2
Part
B1

□ No STOP AND GO TO PART B2
□ Yes CONTINUE WITH THIS BOOKLET.
The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Have you ever had sexual intercourse?

4.3
Part
B1

4.3
Part
B1

4.4
Part
B1

4.4
Part
B1

MARK (X) ONE
□
Yes
□
No
GO TO 4.14
The very first time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

The very first time you had sexual intercourse, how old were you?
|

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

21

Follow-up #

Baseline #

4.5
Part
B1

4.6
Part
B1

Live the Life Baseline Question text
The very first time you had sexual intercourse, would you say that it was voluntary or not
voluntary?
MARK (X) ONE
□
□

4.6
Part
B1

4.7
Part
B1

Modified for follow-up

Voluntary
Not voluntary

Birth control methods are something used to reduce the risk of pregnancy, and some can
reduce the risk of sexually transmitted diseases, also called 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
□
□

4.7
Part
B1

4.8
Part
B1

Yes
No

GO TO 4.9

The first time you had sexual intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
YES, NO
a.
b.
c.
d.
e.
f.

Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
Nuva ring or the ring
Withdrawal or pulling out
Another method PRINT OTHER METHOD USED

22

Follow-up #

Baseline #

4.8
Part
B1

4.9
Part
B1

4.9
Part
B1

4.10
Part
B1

4.10
Part
B1

4.11
Part
B1

Live the Life Baseline Question text

Modified for follow-up

Have you had sexual intercourse more than one time?
MARK (X) ONE
□ Yes
□ No
GO TO 4.14
How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
| | | NUMBER OF PEOPLE - Your best guess is fine.
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
Part
B1

4.12
Part
B1

In the past 3 months, how many TIMES did have sexual intercourse without using a condom?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

23

Follow-up #

Baseline #

4.12
Part
B1

4.13
Part
B1

Live the Life Baseline Question text

Modified for follow-up

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 (Implanaon)
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.

4.13
Part
B1

4.14
Part
B1

Oral sex is when someone puts his or her mouth on another person’s penis or vagina, OR lets
someone else put his or her mouth on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE
□
□

4.14
Part
B1

4.15
Part
B1

Yes
No

GO TO 4.18

The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

24

Follow-up #

Baseline #

4.15
Part
B1

4.16
Part
B1

How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?

4.16
Part
B1

4.17
Part
B1

Now please think about the past 3 months. In the past 3 months, how many TIMES have you
had oral sex?

Live the Life Baseline Question text

|

|

Modified for follow-up

| NUMBER OF PEOPLE - Your best guess is fine.

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
4.17
Part
B1

4.19a
Part
B1

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
□
No GO TO 4.26

4.18
Part
B1

4.19,
Part
B1

To the best of your knowledge, how many times have you been pregnant or gotten someone
pregnant?
|

4.19
Part
B1

4.19c,
Part
B1

|

| NUMBER OF TIMES

Have you ever had a baby or has anyone you got pregnant actually had the baby?
MARK (X) ONE
□
Yes
□
No
□
Don’t know

25

Follow-up #

Baseline #

4.20
Part
B1

4.20
Part
B1

Live the Life Baseline Question text

Modified for follow-up

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
□
□

4.21
Part
B1

4.21
Part
B1

Yes
No

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
□
□

4.22
Part
B1

4.22
Part
B1

Yes
No

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
Don’t know

26

Removed “don’t know” option

Follow-up #

Baseline #

4.23
Part
B1

4.23
Part
B1

Live the Life Baseline Question text

Modified for follow-up

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

PART B2: The items in Section 4, Part B2 are specifically for non-sexually active respondents. Items in Sections 5 and 6, Part B1 are the
same as the items in Sections 5 and 6, Part B2 (for non-sexually active respondents).
4.1
Part
B2

4.1
Part
B2

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 or oral sex?
MARK (X) ONE

4.2
Part
B2

4.2
Part
B2

□ Yes STOP AND GO TO PART B1
□ No CONTINUE WITH THIS BOOKLET
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

27

Follow-up #

Baseline #

4.3
Part
B2

4.3
Part
B2

Live the Life Baseline Question text

Modified for follow-up

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

4.4
Part
B2

4.4
Part
B2

The next questions are about where you live.
In the last 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
□
□

4.5
Part
B2

4.5
Part
B2

Yes GO TO 4.8
No

In how many homes, places, or households do you live: one, two, or three or more?
MARK (X) ONE
□ 1 home GO TO 4.8
□ 2 homes
□ 3 or more homes

4.6
Part
B2

4.6
Part
B2

Do you consider one of these homes to be your main home?
MARK (X) ONE
□ Yes
□ No

28

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
consistent, regular place to stay?

Follow-up #

Baseline #

4.7
Part
B2

4.7
Part
B2

4.8
Part
B2

4.8
Part
B2

Live the Life Baseline Question text

Modified for follow-up

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.

These next few questions are about you and your friends.
How strongly do you agree or disagree that you have friends who will give you good advice?
MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree
4.9
Part
B2

4.9
Part
B2

How strongly do you agree or disagree that you have a friend who cares about you?
MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree

29

Follow-up #

Baseline #

4.10
Part
B2

4.10
Part
B2

Live the Life Baseline Question text

Modified for follow-up

How strongly do you agree or disagree that you have a friend you can talk to when you need
to?
MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree
4.11
Part
B2

4.11
Part
B2

How strongly do you agree or disagree that you have someone who you can call your best
friend?
MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree
4.12
Part
B2

4.12
Part
B2

These next few questions are about you.
How strongly do you agree or disagree that when you start a project, you finish it?
MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree

30

Follow-up #

Baseline #

4.13
Part
B2

4.13
Part
B2

Live the Life Baseline Question text

Modified for follow-up

How strongly do you agree or disagree that that you only work as hard as you have to?
MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree
4.14
Part
B2

4.14
Part
B2

How strongly do you agree or disagree that you are someone people can count on?

4.15
Part
B2

4.15
Part
B2

How strongly do you agree or disagree that when you do work, you do a good job?

MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree

MARK (X) ONE

□ Strongly Agree
□ Agree
□ Disagree
□ Strongly disagree

31

Follow-up #

Baseline #

4.16
Part
B2

4.16
Part
B2

Live the Life Baseline Question text

Modified for follow-up

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.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

4.17
Part
B2

4.19
Part
B2

I believe it is better for my long-term health and well-being
I don’t want to get a sexually transmitted disease, also known as an STD
I don’t want to disappoint my parents
I am too young to have sex
My boyfriend or girlfriend doesn’t want to have sex
I want to wait until I’m married
It is against my personal values
I haven’t met the right person yet
I haven’t had the chance
I don’t want to
FOR GIRLS: I do not want to get pregnant
FOR BOYS: I do not want to get a girl pregnant

Have you ever kissed someone on the lips?
MARK (X) ONE
□ Yes

4.18
Part
B2

4.20
Part
B2

□ No GO TO 4.21
Have you ever French kissed, that is put your tongue in someone’s mouth while kissing?
MARK (X) ONE
□ Yes
□ No

32

Follow-up #

Baseline #

4.19
Part
B2

4.21
Part
B2

Live the Life Baseline Question text

Modified for follow-up

Have you ever touched another person’s private parts?
MARK (X) ONE
□ Yes
□ No

4.20
Part
B2

4.22
Part
B2

Have you ever let someone touch your private parts?
MARK (X) ONE

□ Yes
4.21
Part
B2

4.23
Part
B2

□ No
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

4.22
Part
B2

4.24
Part
B2

□ Yes
□ No
If you decided to have sexual intercourse outside of marriage, how likely is it you would use a
condom or other contraceptive method?
MARK (X) ONE
□
Don’t plan to have sexual intercourse outside of marriage
□
Not at all likely
□
A little bit likely
□
Somewhat likely
□
Very likely

33

If you decided to have sexual intercourse
outside of marriage, how likely is it you would
use a condom or other method of birth control?

Follow-up #

Baseline #

4.23

N/A

Live the Life Baseline Question text

Modified for follow-up
Have you made a decision not ot have sexual
intercourse until you get married?

MARK (X) ONE
□
□
4/24

N/A

Yes
No – GO TO 5.1

Here are some statements about how you
might feel about your decision NOT to have
sexual intercourse until you get married. How
much does each statement reflect how you
feel? (Not at all like me, Somewhat like me,
Like me, Very much like me)
a.
b.
c.
d.

My decision to NOT have sex is good
for me
I am confortale with my decision to
NOT have sex
My decisionto NOT have sex makes me
feel good about myself
At this stage in my life, sex is NOT
important to me

Sections 5 and 6 (Parts B1 and B2) – these items are the same for sexually active and non-sexually active respondents.

34

Follow-up #

Baseline #

5.1

5.1

Live the Life Baseline Question text

Modified for follow-up

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
□
□

5.2

5.2

The very first time you had an alcoholic drink, how old were you?
|

5.3

5.3

Yes
No GO TO 5.8

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

During the past 30 days, on how many days did you have one or more alcoholic drink, such as
beer, wine or other liquor, NOT counting any times you just had a sip?
MARK (X) ONE
□
□
□
□

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

35

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?

Follow-up #

Baseline #

Live the Life Baseline Question text

5.4

5.4

During the past 30 days, on how many days did you have 5 or more drinks in a row?

5.5

MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used marijuana, also called weed or pot?

5.5

Modified for follow-up

MARK (X) ONE
□
□
5.6

5.6

Yes
No GO TO 5.10

During the past 30 days, on how many days did you use marijuana?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days

5.7

N/A

Have you ever used amy pther type of illegal
drug, prescription drugs or an inhalant that
were not prescribed for you?
MARK (X) ONE
□
Yes
□
No

36

Follow-up #

Baseline #

Live the Life Baseline Question text

6.1

6.1

How many of your friends who are your age think the following things? Your best guess is fine

Modified for follow-up

MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know
a.
b.

Having sexual intercourse is a good thing for them to do at their age.
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.
f. It is more important to finish high school than to have sexual intercourse
6.2

6.2

How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know

6.3

6.3

a. Had sexual intercourse.
b. Had oral sex.
c. Have decided to delay having sexual intercourse until later in life
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

37

Follow-up #

Baseline #

Live the Life Baseline Question text

6.4

6.4

How much do you feel that your friends care about you?

Modified for follow-up

MARK (X) ONE
□
Do not care at all
□
Care a little bit
□
Care somewhat
□
Care very much

DROPPED: The questions listed below are part of the baseline instrument, but are not part of the follow-up instrument.
N/A

2.5

The following questions are about the person you marked as your mother or the person you
think of as your mother.

DROP

Did she graduate from high school?
MARK (X) ONE
□
□
□
N/A

2.6

Yes
No
Don’t know

Did she graduate from a 4-year college?

DROP

MARK (X) ONE
□
□
□

Yes
No
Don’t know

38

Baseline #

Follow-up #
N/A

2.8

Live the Life Baseline Question text

Modified for follow-up

How close do you feel to your mother or the person you think of as your mother?

DROP

MARK (X) ONE
□
□
□
□
N/A

2.9

Not at all close
A little close
Somewhat close
Very close

In general, how much do you think she cares about you?

DROP

MARK (X) ONE
□
□
□
□
N/A

2.10

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would she feel about you having sex at this time in your
life?
MARK (X) ONE
□
□
□
□
□

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

39

DROP

Follow-up #

Baseline #

N/A

2.11

Live the Life Baseline Question text

Modified for follow-up

How would she feel about you having a baby at this time in your life?

DROP

MARK (X) ONE
□
□
□
□
□
N/A

2.13

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

The following questions are about the person you marked as your father or the person you think
of as your father.

DROP

Did he graduate from high school?
MARK (X) ONE
□
□
□
N/A

2.14

Yes
No
Don’t know

Did he graduate from a 4-year college?

DROP

MARK (X) ONE
□
□
□

Yes
No
Don’t know

40

Follow-up #

Baseline #

N/A

2.16

Live the Life Baseline Question text

Modified for follow-up

How close do you feel to your father or the person you think of as your father?

DROP

MARK (X) ONE
□ Not at all close
□ A little close
□ Somewhat close
□ Very close
N/A

2.17

In general, how much do you think he cares about you?

DROP

MARK (X) ONE
□
□
□
□
N/A

2.18

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would he feel about you having sex at this time in your
life?
MARK (X) ONE
□
□
□
□
□

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

41

DROP

Follow-up #

Baseline #

N/A

2.19

Live the Life Baseline Question text

Modified for follow-up

How would he feel about you having a baby at this time in your life?

DROP

MARK (X) ONE
□
□
□
□
□
N/A

2.22

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

The next questions are about 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?

DROP

MARK (X) ONE
□
Always
□
Usually
□
Sometimes
□
Rarely
□
Never
N/A

2.23

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

42

DROP

Follow-up #

Baseline #

N/A

2.24

Live the Life Baseline Question text

Modified for follow-up

In the past 12 months, how many times have you talked with at least one of your parents or
guardians about . . .
MARK (X) ONE FOR EACH QUESTION

DROP

Never, 1-2 Times, 3-9 Times, 10 or more times

N/A

4.5
Part
B1

a. How things are going with school work or with your grades
b. A personal problem you were having
c. How to have good romantic relationships
d. Strategies for safe dating
e. How to resist pressures to have sex
f.
Avoiding drugs and alcohol
g. Pregnancy or birth
h. Sexually transmitted diseases (also called STDs), HIV, or AIDS
The very first time you had sexual intercourse, how old was your partner?
MARK (X) ONE
□
□
□
□
□

N/A

4.18a
Part
B1

DROP

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

FOR GIRLS
a. Have you ever had your period, that is, your menstrual period?

DROP

MARK (X) ONE
□ Yes
□ No GO TO 4.27

43

N/A

Baseline #

Follow-up #
N/A

Live the Life Baseline Question text

Modified for follow-up

4.18b
Part
B1

How old were you when you had your first period, that is, your first menstrual period?

4.18a
Part
B1

FOR BOYS

|

|

DROP

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.
DROP

People reach puberty at different ages. Signs of puberty for males include physical changes such
as developing pubic or facial hair, or the voice cracking or lowering. Which of the following best
describes these changes for you?
MARK (X) ONE
□ These changes have not yet started GO TO 4.27
□ These changes have barely started
□ These changes are definitely underway
□ These changes seem complete

N/A

N/A

N/A

4.18b
Part
B1

How old were you when these changes started?

4.17 a
Part
B2

FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual period?

4.17b
Part
B2

|

|

DROP

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

MARK (X) ONE
□ Yes
□ No GO TO 4.19
FOR GIRLS ONLY- How old were you when you had your first period, that is, your first menstrual
period?
|

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

44

DROP

DROP

Baseline #

Follow-up #
N/A

4.18a
Part
B2

Live the Life Baseline Question text

Modified for follow-up

FOR BOYS ONLY

DROP

People reach puberty at different ages. Signs of puberty for males include physical changes such
as developing pubic or facial hair, or the voice cracking or lowering. Which of the following best
describes these changes for you?
MARK (X) ONE
□
□
□
□

N/A

N/A

These changes have not yet started
These changes have barely started
These changes are definitely underway
These changes seem complete

GO TO 4.19

4.18b
Part
B2

FOR BOYS: How old were you when these changes started?

5.7

Have you ever used any other type of illegal drug, for example Methamphetamine, speed, PCP,
ecstasy, or any form of cocaine, such as crack?

|

|

DROP

| NUMBER OF YEARS OLD YOU WERE

MARK (X) ONE
□
Yes
□
No

45

DROP

SUMMARY OF DIFFERENCES BETWEEN THE TEEN PEP BASELINE AND FOLLOW-UP INSTRUMENTS

Teen PEP Baseline #

Teen PEP Follow-up #

Items are listed in the order in which they appear on the Teen PEP follow-up instrument. The number for the corresponding
baseline item is listed in the “Baseline #” column. Items in Part A are listed first, followed by items in Section 4, Part B1 (for
sexually active respondents), items in Section 4, Part B2 (for non-sexually active respondents) and items in Sections 5 and 6,
Parts B1 and B2 (these sections are the same for sexually active and non-sexually active respondents). Items found on the
baseline instrument that are not on the follow-up instrument are listed at the bottom of the table.
Modifications to an existing baseline item are listed in the “Modifications” column; otherwise, the question text on the
follow-up instrument is the same as that on the baseline instrument.
If an item is specific to the follow-up instrument, it is indicated by an “N/A” in the “Baseline #” column and the question
text is noted in the “Modifications” column.

Teen PEP Baseline Text

Modifications for follow-up

PART A (Sections 1 – 3): All items in Part A are the same for sexually active and non-sexually active respondents.
1.1

1.1

In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

1

Teen PEP Follow-up #

Teen PEP Baseline #

1.2

1.2

1.3

1.4

Teen PEP Baseline Text

Modifications for follow-up

What grade are you in?
MARK (X) ONE

1.3

□
6th
□
7th
□
8th
□
9th
□
10th
□
11th
□
12th
□
Not currently in school
Are you male or female?

1.4

MARK (X) ONE
□
Male
□
Female
Are you Hispanic/Latino?
MARK (X) ONE
□
Yes
□
No

2

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

1.5

1.5

What is your race?

Modifications for follow-up

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

1.6

1.9

In the past 12 months, have you any received information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION
Yes, No
a.
b.
c.
d.
e.
f.
g.
h.

Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or whether to use birth control
How to say no to sex
How babies are made

3

Teen PEP Follow-up #

Teen PEP Baseline #

1.6a

N/A

Teen PEP Baseline Text

Modifications for follow-up
Did you say “yes” to any item a through h in
question 1.6 above?
MARK (X) ONE
□
Yes
□
No

4

Teen PEP Follow-up #

Teen PEP Baseline #

1.7

N/A

Teen PEP Baseline Text

Modifications for follow-up
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 QUESTION
Never, 1-3 times, 4-9 times, 10 or more times
a.
b.
c.

d.
e.
f.
g.
h.

5

School class, workshop, or event
Church, synagogue, mosque or
religious classes outside of school
Community
center,
youth
organization,
or
after-school
activity
Doctor, nurse, or clinic
Friends or other students
Parents and other relatives or
family members
Internet and media
Other (List other source)

Teen PEP Follow-up #

Teen PEP Baseline #

1.8

N/A

Teen PEP Baseline Text

Modifications for follow-up
Thinking about the past 12 months, where did
you get information on relationships,
abstinence, birth control, or sexually
transmitted diseases that was very helpful to
you?
SELECT ONE OR MORE
□ School class, workshop, or event
□ Church, synagogue, mosque or
religious classes outside of school
□ Community
center,
youth
organization,
or
after-school
activity
□ Doctor, nurse, or clinic
□ Friends or other students
□ Parents and other relatives or
family members
□ Internet and media
□ Other (Please specify)

6

Teen PEP Follow-up #

Teen PEP Baseline #

1.9

N/A

Teen PEP Baseline Text

Modifications for follow-up
For the next question, please indicate how
often you do the item listed. How often have
you talked about each of the topics listed below
with your partner in the last month?
□

I didn’t have a partner in the last
month

MARK (X) ONE FOR EACH
Often, Sometimes, Never
a.
b.
c.
d.
e.
f.

7

Expectations in the relationship
Pregnancy
Birth control
Sexually Transmitted Infections
(STIs)
What you feel comfortable doing
sexually
What you do not feel comfortable
doing sexually

Teen PEP Follow-up #

Teen PEP Baseline #

1.10

N/A

Teen PEP Baseline Text

Modifications for follow-up
For the next question, please answer how often
you do each of the statements below. When
you have to make a decision about your sexual
behavior, how often do you…
MARK (X) ONE FOR EACH
Very Often, Often, Not often, Never
a.
b.
c.

8

Think of the consequences of each
possible choice
First get as much information as
you can
Make it on the spot without
worrying about the consequences

Teen PEP Follow-up #

Teen PEP Baseline #

1.11

N/A

Teen PEP Baseline Text

Modifications for follow-up
How strongly do you agree or disagree with the
following statements?
MARK (X) ONE FOR EACH
Strongly agree, Agree,
Strongly disagree
a.

b.

c.

d.

9

Disagree,

You can do things now that will
help you to be healthy when you
are an adult
Nothing you do as a teen will
affect how healthy you are as an
adult
Taking risks as a teen, like
drinking and drugs, does not
really matter for your health in
the long run
The good and bad decision you
make as a teen will affect your
health as an adult

Teen PEP Follow-up #

Teen PEP Baseline #

1.12

N/A

Teen PEP Baseline Text

Modifications for follow-up
How strongly do you agree or disagree with the
following statements?
MARK (X) ONE FOR EACH
Strongly agree, Agree,
Strongly disagree

Disagree,

a. If my partner refused to use
condoms, I could refuse to have
sex
b. I would have sex now if someone I
cared about pressured me to have
sex
c. I believe I could go to a clinic if I
needed to get tested for HIV/AIDS
or another sexually transmitted
infection (STI)
2.1a

2.1

The next questions are about where you live and who lives with you.
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

10

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

2.2

2.2

Who lives with you in your home?

Modifications for follow-up

MARK (X) ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
□
□
□
□
2.3

2.3

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

Who lives with you in each of your homes?
Mark (X) all of the people who live with you in your MAIN home, and then mark (X) all of the
people who live with you in your OTHER homes.
MARK ALL THAT APPLY (List appears for both the MAIN home and the 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

11

Teen PEP Baseline #

Teen PEP Follow-up #

Teen PEP Baseline Text
□
□
□
□
□
□
□
□

2.4

2.6

Modifications for follow-up

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

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

2.5

2.9

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 a mother
GO TO 2.14

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

Added: The following questions are about the
person you marked as your mother or the
person you think of as your mother.

12

Teen PEP Follow-up #

Teen PEP Baseline #

2.6

N/A

2.7

Teen PEP Baseline Text

Modifications for follow-up
How well can you and your mother or the
person you think of as your mother share ideas
or talk about things that are important to you?
MARK (X) ONE
□ Not at all well
□ Not very well
□ Somewhat well
□ Very well
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)?

N/A

| | | NUMBER OF YEARS OLD –Your best
guess is fine
□
2.8

N/A

I do not know about my biological
mother

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

13

I do not know about my biological
mother

Teen PEP Follow-up #

Teen PEP Baseline #

2.9

2.14

Teen PEP Baseline Text

Modifications for follow-up

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

2.10

2.17

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
□
Don’t have a father or person I think of as my father GO TO 2.22a
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

N/A

Added: The following questions are about the
person you marked as your father or the person
you think of as your father.

How well can you and your father or the person
you think of as your father share ideas or talk
about things that are important to you?
MARK (X) ONE
□ Not at all well
□ Not very well
□ Somewhat well
□ Very well

14

Teen PEP Follow-up #

Teen PEP Baseline #

2.12a

2.22a

Teen PEP Baseline Text

Modifications for follow-up

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

2.12b

2.22b

They are married to each other
They used to be married to each other, but are now separated
They used to be married to each other, but are now divorced
They have never been married to each other
I don’t know

Do your biological mother and biological father live together now?
MARK (X) ONE
o
o
o
o

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

15

Teen PEP Follow-up #

Teen PEP Baseline #

3.1

3.1

Teen PEP Baseline Text

Modifications for follow-up

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.
b.
c.
d.
e.

3.2

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

N/A

How strongly do you agree or disagree with the
following statements?
MARK (X) ONE FOR EACH
Strongly agree, Agree, Disagree, Strongly
disagree
a. You have goals you want to accomplish
before you have a child
b. It is important for you to finish school
before you have a child
c. It is important for you to have a job and
stable income before you have a child
d. Having a good marriage seems possible
for you

16

Teen PEP Follow-up #

Teen PEP Baseline #

3.3

3.2

Teen PEP Baseline Text

Modifications for follow-up

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

3.4

3.2

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

FOR BOYS
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

17

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

3.5

3.3

Imagine you are alone with someone you like very much. How likely is it that you could . . .

Modifications for follow-up

MARK (X) ONE FOR EACH QUESTION
Not at all Likely, a Little Bit likely, Somewhat Likely, Very Likely
a.
b.
c.
3.6

Stop them if they wanted to touch your chest and you did not want them to do that (FOR
GIRLS)
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
Avoid having sexual intercourse if you didn’t want to

N/A

How likely is it that you will get pregnant (or get
someone pregnant) between now and age 20?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely

18

Teen PEP Follow-up #

Teen PEP Baseline #

3.7

3.5

Teen PEP Baseline Text

Modifications for follow-up

The next series of questions is about condoms, birth control pills, pregnancy and sexually
transmitted diseases, also known as STDs.

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 it decrease the risk of pregnancy
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.7a

3.8

3.5a

3.6

If condoms are used correctly and consistently,
how much can they decrease the risk of
pregnancy?

GO TO 3.6

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Completely
□
Don’t know

GO TO 3.6

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Completely
□
Don’t know

GO TO 3.6

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If condoms are used correctly and consistently, how much can it decrease the risk of getting
HIV, the virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

19

Teen PEP Follow-up #

Teen PEP Baseline #

3.9

3.8

Teen PEP Baseline Text
If birth control pills are used correctly and consistently, how much can they decrease the risk of
pregnancy?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

3.9a

3.10

3.11

3.8a

3.9

3.10

Modifications for follow-up
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Completely
□
Don’t know

GO TO 3.6

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Completely
□
Don’t know

GO TO 3.6

MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Completely
□
Don’t know

GO TO 3.6

GO TO 3.10

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
If birth control pills are used correctly and consistently, how much can they decrease the risk of
getting HIV, the virus that causes AIDS?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
If birth control pills are used correctly and consistently, how much can they decrease the risk of
getting Chlamydia and gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know

20

Teen PEP Follow-up #

Teen PEP Baseline #

3.12

3.12

Teen PEP Baseline Text
Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE
□
□
□

3.12a

3.12a

3.13

3.4

Modifications for follow-up

Yes
No
Don’t know

GO TO 3.12

How confident are you that your answer is correct?
MARK (X) ONE
□
Not at all confident
□
A little confident
□
Somewhat confident
□
Very confident
The next series of questions is about condom use. How strongly do you agree or disagree that …
MARK (X) ONE FOR EACH QUESTION

The next series of questions is about condom
use. How strongly do you agree or disagree that
…

Strongly agree, Agree, Neither agree nor disagree, Disagree, Strongly disagree

MARK (X) ONE FOR EACH QUESTION

a. Condoms should always be used if a person your age has
sexual intercourse
b. Condoms are a hassle to use
c. Condoms are pretty easy to get
d. Condoms are important to make sex safer
e. Using condoms means you don’t trust your partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure

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. Condoms are a hassle to use
c. It would not be too hard for me to carry a
condom and have it with me if I needed it
d. Condoms are important to make sex safer
e. Using condoms means you don’t trust your
partner
g. Condoms decrease sexual pleasure

21

Teen PEP Follow-up #

Teen PEP Baseline #

3.14

3.11

Teen PEP Baseline Text

Modifications for follow-up

The next series of questions is about other methods of birth control, NOT including condoms.
How strongly do you agree or disagree that…

Deleted item:

Strongly agree, Agree, Neither agree nor disagree, Disagree, Strongly disagree

f. Using birth control is morally wrong

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

22

Teen PEP Follow-up #

Teen PEP Baseline #

3.15

N/A

Teen PEP Baseline Text

Modifications for follow-up
Read each statement below and check the
answer that fits best.
MARK (X) ONE FOR EACH
I am sure it’s true, I think it’s true, I don’t know,
I think it’s false, I am sure it’s false
a. You can’t get AIDS if you have sex only once
or twice without a condom
b. If condoms are used correctly and
consistently, they can reduce the risk of STDs
such as Chlamydia and gonorrhea
c. Once you are infected with HIV, you are
infected for life
d. If a young couple has had unprotected sex a
few times and a pregnancy did not happen,
they do not have to worry about her getting
pregnant
e. There is a vaccine or shot available to prevent
girls from becoming infected with certain types
of HPV (also known as Human Papilloma virus)

23

Teen PEP Follow-up #

Teen PEP Baseline #

3.16

N/A

Teen PEP Baseline Text

Modifications for follow-up
Thinking about the future, how likely do you
think it is that you will get HIV/AIDS?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely

3.17

N/A

How likely do you think it is that you will get an
STD other than HIV/AIDS?

MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely
3.18

3.18

Do you intend to have oral sex in the next year?
MARK (X) ONE
o
o
o
o

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

24

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

3.19

3.15

Do you intend to have sexual intercourse in the next year?
o
o
o
o

3.20

3.16

3.21

3.17

Do you intend to have sexual intercourse in the
next year, if you have the chance?

Yes, definitely
Yes, probably
No, probably not
No, definitely not GO TO QUESTION 3.19

If you have sexual intercourse in the next year, do you intend to use a condom?
o
o
o
o

Modifications for follow-up

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

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

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)

The next question is about your intention to use
following other methods of birth control:
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)

If you have sexual intercourse in the next year, do you intend to use any of these other methods
of birth control?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not

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?
o Yes, definitely
o Yes, probably
o No, probably not
o No, definitely not

25

Teen PEP Follow-up #

Teen PEP Baseline #

3.22

N/A

Teen PEP Baseline Text

Modifications for follow-up
Right now, do you have a boyfriend or
girlfriend- someone in particular you are going
out with?
MARK (X) ONE
□
Yes
□
No

3.23

3.13

In the past 3 months, how many TIMES have you gone out on a date?
□ Zero or None
GO TO 3.15
| | | NUMBER OF TIMES - Your best guess is fine

3.24

3.14

Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you go out
on a date with?
|

3.25

3.20

|

| NUMBER OF PEOPLE - Your best guess is fine.

Have you ever had sexual intercourse, oral sex, or anal sex?

Have you ever had sexual intercourse, oral sex,
or anal sex?

□ YES: GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE
□ NO: GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE
ENVELOPE

□ YES: GO TO PART B1
□ NO: GO TO PART B2

PART B2: The items in Section 4, Part B2 are specifically for non-sexually active respondents. Items in Sections 6 and 7, Part B1 are the
same as the items in Sections 6 and 7, Part B2 (for non-sexually active respondents).

26

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

4.1
B1

4.1
B1

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.

Modifications for follow-up

Just to confirm, have you ever had sexual intercourse, oral sex, or anal sex?

4.2
B1

4.2
B1

□ No STOP AND GO TO PART B2
□ Yes CONTINUE WITH THIS BOOKLET.
The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina.
Have you ever had sexual intercourse?

4.3
B1

4.3
B1

MARK (X) ONE
□
Yes
□
No
GO TO 4.15
The very first time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

4.4
B1

4.4
B1

The very first time you had sexual intercourse, how old were you?
|

4.5
B1

4.9
B1

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

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

Yes
No

GO TO 4.14

27

Teen PEP Follow-up #

Teen PEP Baseline #

4.6
B1

4.10
B1

4.7
B1

N/A

4.8
B1

N/A

Teen PEP Baseline Text

Modifications for follow-up

How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one time?
|

|

| NUMBER OF PEOPLE - Your best guess is fine.
The most recent time you had sexual
intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR
The most recent time you had sexual
intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
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):

4.9
B1

4.11
B1

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.

28

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

4.10
B1

4.12
B1

In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?

Modifications for follow-up

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
4.11
B1

N/A

In the past 3 months, of those times you used a
condom during sexual intercourse, how many
times did the condom break or slip off during
sex?
□
None
| | | NUMBER OF TIMES - Your best guess
is fine.

4.12
B1

4.13
B1

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.

29

Teen PEP Baseline #

Teen PEP Follow-up #
4.13
B1

Teen PEP Baseline Text

Modifications for follow-up

N/A

Now please think about the past 12 months.
In the past we months, how often have you had
a relationship that was just sexual?
MARK (X) ONE
□
□
□

4.14
B1

4.14
B1

Oral sex is when someone puts his or her mouth on another person’s penis or vagina, OR lets
someone else put his or her mouth on their penis or vagina.
Have you ever had oral sex?
MARK (X) ONE
□
□

4.15
B1

4.15
B1

Yes
No

GO TO 4.19

The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

4.16
B1

4.16
B1

How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
|

|

| NUMBER OF PEOPLE - Your best guess is fine.

30

Never
Once
More than once

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

4.17
B1

4.17
B1

Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
oral sex?

Modifications for follow-up

□
None
| | | NUMBER OF TIMES - Your best guess is fine.
4.18
B1

4.18
B1

In the past 3 months, how many TIMES have you had oral sex without using a condom?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

4.19
B1

4.19
B1

Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a
male put his penis in their anus or butt. Have you ever had anal sex?
MARK (X) ONE
□
□

4.20
B1

4.20
B1

GO TO 4.23

How many DIFFERENT PEOPLE have you ever had anal sex with, even if only one time?
|

4.21
B1

Yes
No

|

| NUMBER OF PEOPLE - Your best guess is fine.

N/A

The very first time you had anal sex, what
month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

31

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

4.22
B1

4.21
B1

Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
anal sex?

Modifications for follow-up

□
None
GO TO 4.23
| | | NUMBER OF TIMES - Your best guess is fine.
4.23
B1

4.22
B1

In the past 3 months, how many TIMES have you had anal sex without using a condom?
□
None
| | | NUMBER OF TIMES - Your best guess is fine.

5.1
B1

N/A

Have you or your partner ever taken a
pregnancy test?
MARK (X) ONE
□
Yes
□
No
□
Don’t know

5.2a
B1

4.26A
B1

FOR BOYS AND GIRLS
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
□
No GO TO 4.27

5.2b
B1

4.26b
B1

To the best of your knowledge, how many TIMES have you been pregnant or gotten someone
pregnant?
□
None
| | | NUMBER OF TIMES

32

Teen PEP Baseline #

Teen PEP Follow-up #
5.2c
B1

Teen PEP Baseline Text

Modifications for follow-up

N/A

How old were you the first time you got
pregnant or got someone pregnant?
| | | NUMBER OF YEARS OLD YOU WERE –
Your best guess is fine.

5.2d
B1

4.26c
B1

Have you ever had a baby or has anyone you got pregnant actually had the baby?
MARK (X) ONE
□
Yes
□
No
□
Don’t know

5.3
B1

4.27
B1

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
□
□

5.4
B1

4.28
B1

Yes
No

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

33

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

5.5
B1

4.29
B1

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

Modifications for follow-up

MARK (X) ONE
□
□
5.6
B1

4.30
B1

Yes
No

The next series of questions is about the types of sexually transmitted diseases (STDs) you have
had. In the past 12 months, did you have…
Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.

Chlamydia
Gonorrhea
Genital herpes
Syphilis
HIV infection or AIDS
Human papilloma virus, also called HPV or genital warts
Another sexually transmitted disease (STD) PRINT OTHER STD:

PART B2: The items in Section 4, Part B2 are specifically for non-sexually active respondents. Items in Sections 5 and 6, Part B1 are the
same as the items in Sections 5 and 6, Part B2 (for non-sexually active respondents).
4.1
B2

4.1
B2

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, oral sex, or anal sex?
MARK (X) ONE
□ Yes STOP AND GO TO PART B1
□ No CONTINUE WITH THIS BOOKLET

34

Teen PEP Follow-up #

Teen PEP Baseline #

4.2
B2

4.2
B2

Teen PEP Baseline Text

Modifications for follow-up

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

4.3
B2

4.3
B2

Yes
I already graduated from high school
No
GO TO 4.4

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

35

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

4.4
B2

4.13
B2

Here are some reasons people your age might choose NOT to have sexual intercourse. How
important is each of these reasons to YOU?

Modifications for follow-up

MARK (X) ONE FOR EACH QUESTION
Very Important, Somewhat Important, Not Too Important, Not At All Important
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

I don’t want to get a sexually transmitted disease, also known as an STD
I don’t want to disappoint my parents
I am too young to have sex
My boyfriend or girlfriend doesn’t want to have sex
I want to wait until I’m married
It is against my personal values
I haven’t met the right person yet
I haven’t had the chance
I don’t want to
FOR GIRLS: I do not want to get pregnant
FOR BOYS: I do not want to get a girl pregnant

36

Teen PEP Baseline #

Teen PEP Follow-up #
4.5
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

What do you think are the benefits of waiting to
have sexual intercourse?
MARK (X) ONE FOR EACH
Strongly agree, Agree, Disagree, Strongly
disagree
a.
b.
c.
d.
e.
f.

g.
h.

4.6
B2

N/A

Respect for yourself
Respect from parents
Keeping true to religious values
Respect from friends
Not having to worry about
pregnancy
Not having to worry about sexually
transmitted diseases, also known
as STDs
Better chance for a good marriage
in the future
Fewer distractions so you can
focus on school work

Do people need religion to have good values?
MARK (X) ONE
□ Yes
□
No

37

4.8
B2

4.9
B2

4.10
B2

4.11
B2

Teen PEP Baseline #

Teen PEP Follow-up #
4.7
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

Should religious teachings be obeyed in every
situation?
MARK (X) ONE
□ Yes
□
No
Do you pray every day?

N/A

MARK (X) ONE
□ Yes
□
No
Do you think it’s embarrassing for people your
age to admit they are virgins?

N/A

MARK (X) ONE
□ Yes
□
No
Do you think it’s embarrassing for girls your age
to get pregnant?

N/A

MARK (X) ONE
□ Yes
□
No
In the group you hang out with, how important
is it to have a girlfriend or boyfriend or to be
going out with someone?

N/A

MARK (X) ONE
□ Very important
□
Not too important
□ Not important at all

38

Teen PEP Baseline #

Teen PEP Follow-up #
4.12
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

The next few questions are about your access to
and use of TV, cell phones, computers and
other forms of technology.
Do you personally have a phone, computer, or
other device that can connect to the internet?

4.13
B2

MARK (X) ONE
□ Yes
□
No
Do your parents have any rules about…?

N/A

MARK (X) ONE FOR EACH
a. The amount of time or when you
can text, talk on the phone, watch
TV or be on the computer
b. Whether or not you can have a
profile on a social networking site
like MySpace or Facebook
4.14
B2

4.15
B2

N/A

Do your parents have any rules about what you
are allowed to watch on TV?
MARK (X) ONE
□ Yes
□
No
Do your parents have any rules about what sites
you can access on the internet?

N/A

MARK (X) ONE
□ Yes
□
No

39

Teen PEP Baseline #

Teen PEP Follow-up #
4.16
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

Some people exchange sexy text messages,
videos, or pictures of themselves or their
friends. How common would you say each of
the following is among people your age?
MARK (X) ONE FOR EACH
Not common at all, Not very common, Fairly
common, Very common
a. Sending or posting sexy text
messages
b. Sending or posting sexy pictures or
video

4.17
B2

N/A

Have you ever sent or posted a sex message,
picture, or video of yourself by email, IM or
text?
MARK (X) ONE
□ Yes
□
No

40

4.19
B2

4.20
B2

Teen PEP Baseline #

Teen PEP Follow-up #
4.18
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

Which of the following reasons did you have for
sending or posting a sexy message, picture or
video of yourself?
MARK (X) ONE FOR EACH
Yes, No
a. To get or keep a guy’s or girl’s
attention
b. Your boyfriend/girlfriend
pressured you to do it
c. As a “sexy” present for a boyfriend
or girlfriend
d. To get back at someone or cause
trouble
e. Pressure from friends
f. To be fun or to flirt
g. Everybody does it
h. Another reason? (Print reason)
Have you ever received a sexy text message, or
a picture or video of someone you know?

N/A

MARK (X) ONE
□ Yes
□
No
Have you ever shared or forwarded a sexy text
message, or picture or video of someone you
know?

N/A

MARK (X) ONE
□ Yes
□
No

41

Teen PEP Baseline #

Teen PEP Follow-up #
5.1
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

The next few questions ask about your
community.
How often do you feel that there are teachers
or other adults in your school who really know
and care about you?
MARK (X) ONE
□
□
□
□

5.2
B2

N/A

Never
Sometimes
Often
Very often

How often do you feel there are adult s in your
neighborhood, or in religious or youth
organizations, who really know you and care
about you?
MARK (X) ONE
□
□
□
□

42

Never
Sometimes
Often
Very often

Teen PEP Baseline #

Teen PEP Follow-up #
5.3
B2

Teen PEP Baseline Text

Modifications for follow-up

v

How often do you feel safe in your community
or neighborhood?
MARK (X) ONE
□
□
□
□

5.4
B2

N/A

Never
Sometimes
Often
Very often

How often do you feel safe at school?
MARK (X) ONE
□
□
□
□

5.5
B2

N/A

Never
Sometimes
Often
Very often

How often do you feel safe at home?
MARK (X) ONE
□
□
□
□

43

Never
Sometimes
Often
Very often

Teen PEP Baseline #

Teen PEP Follow-up #
5.6
B2

Teen PEP Baseline Text

Modifications for follow-up

N/A

During the past 12 months, were you on a
sports team or did you take sports lessons after
school or on weekends?
MARK (X) ONE
□
□

5.7
B2

N/A

Yes
No

During the past 12 months, did you participate
in any clubs or organizations after school or on
weekends, such as Scouts, a religious group, or
Boy’s/Girl’s Club?
MARK (X) ONE
□
□

Yes
No

Sections 6 and 7 (Parts B1 and B2) – these items are the same for sexually active and non-sexually active respondents.
6.1

5.6

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

44

Added: The next questions are about alcohol
and drug use. Please remember, everything
you tell us will be kept private.

Teen PEP Follow-up #

Teen PEP Baseline #

Teen PEP Baseline Text

6.2

5.7

During the past 30 days, on how many days did you have 5 or more drinks in a row?

Modifications for follow-up

MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
6.3

6.4

6.5

N/A

5.9

5.10

During the past 30 days, on how many days did
you get drunk or wasted?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
During the past 30 days, on how many days did
you use marijuana, also called weed or pot?

During the past 30 days, on how many days did you use marijuana?
MARK (X) ONE
□
More than 25 days
□
5 to 25 days
□
1 to 4 days
□
0 (zero) days
Have you ever used any other type of illegal drug, for example Methamphetamine, speed, PCP,
ecstasy, or any form of cocaine, such as crack?
MARK (X) ONE
□
Yes
□
No

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

45

Teen PEP Baseline #

Teen PEP Follow-up #

5.11

Teen PEP Baseline Text

Modifications for follow-up

Have you ever used any prescription pills or other prescription drugs that were not prescribed
for you?
MARK (X) ONE
□
Yes
□
No

5.12

7.1

6.3

Have you ever used an inhalant, such as sniffed glue, breathed the contents of spray cans, or
inhaled any paints or solvents to get high?
MARK (X) ONE
□
Yes
□
No
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

46

Teen PEP Follow-up #

Teen PEP Baseline #

7.2

N/A

Teen PEP Baseline Text

Modifications for follow-up
How often is each of the following statements
true for you?
MARK (X) ONE FOR EACH
Never true, Sometimes true, Often true, Almost
always true
a.
b.
c.
d.

47

I can trust my friends
My friends want the best for me in my life
My friends care about me
My friends are there for me if I need them

DROPPED: The questions listed below are part of the baseline instrument, but are not part of the follow-up instrument.
1.6

When you are at home or with your family, what language or languages do you usually speak?
YOU MAY MARK (X) MORE THAN ONE ANSWER
□ English
□ Spanish
□ Chinese language such as Mandarin or Cantonese
□ Some other language PRINT OTHER LANGUAGE(S) ____________________________

1.6a

What is the main language you speak at home?
□
□
□
□

1.7

In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
□
□
□
□
□

1.8

English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language PRINT OTHER LANGUAGE(S) ____________________________

Never
Less than once a month
1-3 times per month
Once a week
More than once a week

How important is religion in your life?
MARK (X) ONE
□
□
□

Not at all important
Somewhat important
Very important

48

1.10

In an average week last month, including weekends, about how many hours did you spend
participating in each of the following?
MARK (X) ONE FOR EACH QUESTION
Zero Hours Per Week, More Than Zero but Less Than 2 Hours Per Week, 2-5 Hours Per Week,
More Than 5 Hours Per Week
a.
b.
c.

2.4

2.5

Sports-related clubs, teams, or organizations
Lessons, clubs, or performances for art, music, or drama
Other clubs, teams, and organizations, such as academic
clubs, Scouts, chess clubs, or debating teams
d. Services or programs at a church, temple, synagogue,
mosque, or other place of worship
e. Working at a paid job
f.
Volunteering
On how many days last week did all the family members who live in your household sit down
together for a meal?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7
On how many days last week did you do something with at least one adult in your family like play
a game, watch a movie, go to a sporting event, or work on something you enjoy doing together?
MARK (X) ONE
□0
□1
□2
□3
□4
□5
□6
□7

49

2.7

The following questions are about the person you marked as your mother or the person you
think of as your mother.
Did she graduate from high school?
MARK (X) ONE
□
□
□

2.8

Yes
No
Don’t know

Did she graduate from a 4-year college?
MARK (X) ONE
□
□
□

2.10

Yes
No
Don’t know

How close do you feel to your mother or the person you think of as your mother?
MARK (X) ONE
□
□
□
□

2.11

Not at all close
A little close
Somewhat close
Very close

In general, how much do you think she cares about you?
MARK (X) ONE
□
□
□
□

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

50

2.12

Whether you have done this or not, how would she feel about you having sex at this time in your
life?
MARK (X) ONE
□
□
□
□
□

2.13

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

How would she feel about you having a baby at this time in your life?
MARK (X) ONE
□
□
□
□
□

2.15

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

The following questions are about the person you marked as your father or the person you think
of as your father.
Did he graduate from high school?
MARK (X) ONE
□
□
□

2.16

Yes
No
Don’t know

Did he graduate from a 4-year college?
MARK (X) ONE
□
□
□

2.18

Yes
No
Don’t know

How close do you feel to your father or the person you think of as your father?
MARK (X) ONE
□ Not at all close

51

□
□
□
2.19

A little close
Somewhat close
Very close

In general, how much do you think he cares about you?
MARK (X) ONE
□
□
□
□

2.20

Does not care at all
Cares a little bit
Cares somewhat
Cares very much

Whether you have done this or not, how would he feel about you having sex at this time in your
life?
MARK (X) ONE
□
□
□
□
□

2.21

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

How would he feel about you having a baby at this time in your life?
MARK (X) ONE
□
□
□
□
□

2.23

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

The next questions ask about 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

52

□
2.24

Never

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

2.25

2.26

2.27

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
If you were going to be home late, would your parents expect you to call?
MARK (X) ONE
□
Yes
□
No
In the past 12 months, how many times have you talked with at least one of your parents or
guardians about . . .
MARK (X) ONE FOR EACH QUESTION
Never, 1-2 Times, 3-9 Times, 10 or more times
a.
b.
c.
d.
e.
f.
g.

How things are going with school work or with your grades
A personal problem you were having
How to have good romantic relationships
Strategies for safe dating
How to resist pressures to have sex
Avoiding drugs and alcohol
Pregnancy or birth

53

3.7

3.19

h. Sexually transmitted diseases (also called STDs), HIV, or AIDS
i. Whether you should be having sex at this time in your life
If a condom is used correctly, how much can it decrease the risk of getting Chlamydia and
gonorrhea?
MARK (X) ONE
□
Not at all
□
A little
□
A lot
□
Don’t know
Do you intend to have sexual intercourse without being married?
MARK (X) ONE
o
o
o
o

4.5
B1

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

4.6
B1

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

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

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

4.7
B1

Voluntary
Not voluntary

Birth control methods are something used to reduce the risk of pregnancy, and some can reduce
the risk of sexually transmitted diseases, also called 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?

54

MARK (X) ONE
□
□
4.8
B1

Yes
No

GO TO 4.9

The first time you had sexual intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
YES, NO
a.
b.
c.
d.
e.
f.

4.23
B1

Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
Nuva ring or the ring
Withdrawal or pulling out
Another method (PRINT OTHER METHOD USED):

Have you ever had oral sex or anal sex with a person the same sex as you?
MARK (X) ONE
□ Yes
□ No

4.24a
B1

4.24b
B1

FOR GIRLS ONLY- Have you ever had your period, that is, your menstrual period?
MARK (X) ONE
□ Yes
□ No GO TO 4.27
FOR GIRLS ONLY- How old were you when you had your first period, that is, your first menstrual
period?
|

4.25a
B1

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

FOR BOYS ONLY
People reach puberty at different ages. Signs of puberty for males include physical changes such
as developing pubic or facial hair, or their voices cracking or lowering. Which of the following
best describes these changes for you?
MARK (X) ONE

55

□
□
□
□
4.25b
B1

FOR BOYS: How old were you when these changes started?
|

4.31
B1

These changes have not yet started
These changes have barely started
These changes are definitely underway
These changes seem complete

|

| NUMBER OF YEARS OLD YOU WERE

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
□
□

4.32
B1

Yes
No

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

4.4
B2

Yes
No
I have never dated anyone

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
□
□

4.5
B2

Yes GO TO 4.11
No

In how many homes, places, or households do you live: one, two, or three or more?
MARK (X) ONE
□ 1 home
□ 2 homes

GO TO 4.9

56

□ 3 or more homes
4.6
B2

Do you consider one of these homes to be your main home?
MARK (X) ONE
□ Yes
□ No

4.7
B2

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

4.8
B2

|

|

| 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.

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

4.9
B2

4.10
B2

Yes
No

Is your home or any of your homes a group home or halfway house?
MARK (X) ONE
□ Yes
□ No
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

57

4.11
B2

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

4.12
B2

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
How strongly do you agree or disagree that . . .
MARK (X) ONE FOR EACH QUESTION
Strongly agree, Agree, Disagree, Strongly disagree

4.14a
B2

4.14b
B2

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 work, you do a good job
FOR GIRLS - Have you ever had your period, that is, a menstrual period?
MARK (X) ONE
□ Yes
□ No GO TO 4.16
FOR GIRLS - How old were you when you had your first period, that is, your first menstrual
period?
|

4.15a
B2

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine. GO TO 4.16

FOR BOYS ONLY
People reach puberty at different ages. Signs of puberty for males include physical changes such
as developing pubic or facial hair, or their voices cracking or lowering. Which of the following
best describes these changes for you?
MARK (X) ONE
□ These changes have not yet started
□ These changes have barely started
□ These changes are definitely underway
□ These changes seem complete

58

4.15b
B2

FOR BOYS: How old were you when these changes started?
|

4.16
B2

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

Have you ever done any of the following?
Yes, No

4.17
B2

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
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

4.18
B2

□ Yes
□ No
Have you ever been fearful that someone you were dating might physically hurt you?
MARK (X) ONE
□
□
□

4.19
B2

Yes
No
I have never dated anyone

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

4.20
B2

□
Yes
□
No
If you decided to have sexual intercourse, how likely is it you would use a condom or other
contraceptive method?
MARK (X) ONE
□ Not at all likely
□ A little bit likely
□ Somewhat likely
□ Very likely

59

5.1

The next questions are about tobacco, alcohol and drugs. Please be as honest as possible, and
remember that everything you tell us will be kept private.
Have you ever smoked a cigarette?
MARK (X) ONE
□
□

5.2

The very first time you smoked a cigarette, how old were you?
|

5.3

Yes
No GO TO 5.4

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
□
□
□
□

5.4

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

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
□
□

5.5

The very first time you had an alcoholic drink, how old were you?
|

5.8

Yes
No GO TO 5.8

|

| NUMBER OF YEARS OLD YOU WERE - Your best guess is fine.

Have you ever used marijuana, also called weed or pot?
MARK (X) ONE
□
Yes
□
No GO TO 5.10

60

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 QUESTION
None, Some, Half, Most, All, Don’t Know
a.
b.
c.
d.
e.

6.2

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

How many of your friends who are your age have done the following things?
MARK (X) ONE FOR EACH QUESTION
None, Some, Half, Most, All, Don’t Know

6.4

a. Had sexual intercourse.
b. Had oral sex.
People are different in their sexual attraction to other people. Which of the following best
describes you?
MARK (X) ONE
□
□
□
□
□

6.5

I am only attracted to males
I am attracted to both males and females
I am only attracted to females
I am not attracted to either males or females
I am not sure

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

61