New Instrument 6: Baseline Survey

INSTRUMENT #6
BASELINE SURVEY (IIS) –
HEALTHY FAMILIES SAN ANGELO (HFSA) BASELINE SURVEY

OMB Control No:
Expiration Date:

PERSONAL RESPONSIBILITY EDUCATION
PROGRAM (PREP)
BASELINE SURVEY
Healthy Families San Angelo
PRIVACY
Thank you for your help with this important study. It will help us understand what
things are like for people your age today and help to identify effective ways to reduce
risk behaviors. This survey includes questions about your family, community, future
goals, and also your attitudes and behaviors. Your answers and everything you say will
be kept private. Your name will not be on the survey. Please answer all questions as
well as you can.
We want you to know that:
1.

Your participation in this survey is voluntary.

2

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

3.

The answers you give will be keep private. Your responses will be combined with
those of other people your age.
Mathematica Policy Research
THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number.

GENERAL INSTRUCTIONS
1.

PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED! USE A PEN OR PENCIL.
PLEASE READ EACH QUESTION CAREFULLY. There are different ways to answer the questions
in this survey. It is important that you follow the instructions when answering each kind of
question. Here are some examples.
EXAMPLE 1: MARK (X) ONE ANSWER
What is the color of your eyes?
MARK (X) ONE
X

Brown
Blue

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

Green
Another color

2.

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

Brown
Black

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

Blond
Red
X

3.

Some other color PRINT OTHER COLOR

purple

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

Watch a movie

X

Go to a baseball game

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

Study at a friend’s house

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4.

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

MARK (X) ONE
X

Yes
No

GO TO QUESTION 3

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

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

Yes
X

No

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

Went to a play

X

Went to a movie
Attended a sporting event

5.

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

2

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

6.

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

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

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

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7.

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

Month finished

Year finished

January
February

X

2010
X

2009

March

2008

April

2007

May

2006

June

2005

July

2004

August

2003

September

2002

October

2001

November

2000

December

1999

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

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

Month born

Year born

January

2002

February

2001

March

2000

April

1999

May

1998

June

1997

July

1996

August

1995

September

1994

October

1993

November

1992

December

1991

1.2. Are you Hispanic/Latina?
MARK (X) ONE

Yes
No

GO TO QUESTION 1.4

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1.3. Are you…?
MARK (X) ALL THAT APPLY

Mexican, Mexican American, Chicana
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin

1.4. 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
1.5. What is the main language you speak at home?
MARK (X) ONE

English
Spanish
Some other language PRINT OTHER LANGUAGE

1.6. 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

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1.7. Are you currently enrolled in school? If you are currently on summer vacation or taking a short break
to have your baby but plan to return to school, mark “yes.”
MARK (X) ONE

Yes
No

1.8. What is the highest grade you have completed?
MARK (X) ONE

Less than 7th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Higher than 12th grade

1.9. Do you have any of these?
MARK (X) ONE FOR EACH QUESTION

YES

NO

a.

A high school diploma.................................................................................................................

b.

A GED certificate ........................................................................................................................

c.

A certificate or license from a trade school or vocational training program ..................................

d.

A degree from a community college ............................................................................................

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1.10. What kind of grades do you or did you usually get in school? If you are not currently attending
school, answer based on the last school you attended.
MARK (X) ONE

My courses are not graded
Mostly As
About half As and half Bs
Mostly Bs
About half Bs and half Cs
Mostly Cs
About half Cs and half Ds
Mostly Ds
Mostly below Ds

1.11. For the last school you attended or the school you are now attending, how often would you say
you cut classes?
MARK (X) ONE

Never or almost never
Sometimes, but less than once a week
Not every day, but at least once a week
Daily or almost every day

1.12. Thinking about all of the schools you have ever attended, how many times have you been
suspended or expelled from school?
MARK (X) ONE

Never
Once
More than once

1.13. 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

ALREADY
DID THIS

a. Graduate from high school .............................................................................................................
b. Graduate from a 4-year college ......................................................................................................

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1.14. How much do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE

DISAGREE

AGREE

STRONGLY
AGREE

a. I have specific goals for my future career ....................................................................................
b. I have a plan for achieving my future career goals ......................................................................
c. Planning for a career is not worth the effort.................................................................................
d. I haven’t thought much about my future career ...........................................................................
e. If I have a career, I won’t be able to enjoy
other things in life .......................................................................................................................
f. Going to college is important for getting a
good job......................................................................................................................................
1.15. How important do you think it is to do each of the following things?
MARK (X) ONE FOR EACH QUESTION

NOT THAT
IMPORTANT

SOMEWHAT
IMPORTANT

VERY
IMPORTANT

EXTREMELY
IMPORTANT

a. Keep track of your expenses ......................................................................................................
b. Compare prices when you shop .................................................................................................
c. Set aside money for future purchases ........................................................................................

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SECTION 2: FAMILY
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
Your adoptive mother
Your foster mother
Your grandmother
Some other adult
Don’t have a mother or person you think of as your mother

GO TO 2.5

2.2. 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 you don’t know how many hours
Don’t know if she is working
2.3. How close do you feel to your mother or the person you think of as your mother?
MARK (X) ONE

Not at all close
Not very close
Somewhat close
Very close
2.4. How would she feel if you got pregnant again in the next year?
MARK (X) ONE

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

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2.5. 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
Your adoptive father
Your foster father
Your grandfather
Some other adult
Don’t have a father or person you think of as your father

GO TO 2.9

2.6. 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 you don’t know how many hours
Don’t know if he is working
2.7. How close do you feel to your father or the person you think of as your father?
MARK (X) ONE

Not at all close
Not very close
Somewhat close
Very close
2.8. How would he feel if you got pregnant again in the next year?
MARK (X) ONE

Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove

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2.9. The next few questions ask about your biological parents.
Do you live with your biological mother?
MARK (X) ONE

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

2.10. Do you live with your biological father?
MARK (X) ONE

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

2.11. Which of the following best describes the relationship between your biological mother and
biological father?
MARK (X) ONE

They are married to each other
They were married to each other, but are now separated or divorced
They were never married to each other
One or both of my biological parents have died
Don’t know
2.12. In the past 12 months, how many times have you moved?
MARK (X) ONE

Never
Once
Twice
Three times
Four times or more

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2.13. How long have you lived where you live now?
MARK (X) ONE

Less than 1 month
1 month to 3 months
More than 3 months to 6 months
More than 6 months to 1 year
More than 1 year

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SECTION 3: YOUR RELATIONSHIPS
3.1. The next question is about how you deal with different situations.
How well can you do each of the following?
MARK (X) ONE FOR EACH QUESTION

I AM BAD
AT THIS

I AM
OKAY AT
THIS

I AM
GOOD AT
THIS

I AM
EXTREMELY
GOOD AT
THIS

a. Admit that you might be wrong during a
disagreement ..............................................................................................................................
b. Avoid saying things that could turn a disagreement
into a big fight..............................................................................................................................
c. Accept another person’s point of view even if you
don’t agree with it ........................................................................................................................
d. Listen to another person’s opinion during a
disagreement ..............................................................................................................................
e. Work through problems without arguing ......................................................................................

3.2. The next question is about your relationship with the father of the child you just gave birth to, or
are about to give birth to.
How would you define your current relationship status with the father of your baby?
MARK (X) ONE

Married to each other
Living together, but not married
Dating, but not living together
Not currently in a romantic relationship, but in regular contact
No longer in regular contact

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3.3. How much do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
DISAGREE

DISAGREE

AGREE

STRONGLY
AGREE

a. In a good couple relationship, you don’t always
get your own way ........................................................................................................................
b. There are times when hitting or pushing between
people who are a couple is okay .................................................................................................
c. A good couple relationship is based on mutual
respect, not just sex. ...................................................................................................................
d. People who make their dating partner jealous
deserve to be hit or pushed .........................................................................................................
e. It would be easy to trust someone you are
romantically involved with, even when you’re apart .....................................................................
f. Avoiding a disagreement with someone you are
romantically involved with is always better than
talking about your problems ........................................................................................................

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SECTION 4: INFORMATION, THOUGHTS AND OPINIONS
4.1. In the past 12 months, did you attend any classes or sessions about the following?
MARK (X) ONE FOR EACH QUESTION

YES

NO

a. Relationships, dating, or marriage ..................................................................................................
b. Abstinence from sex ......................................................................................................................
c. Methods of birth control, such as condoms, pills, etc......................................................................
d. Where to get birth control ...............................................................................................................
e. Sexually transmitted diseases, also known as STDs or STIs .........................................................
4.2. Where did you attend these classes or information sessions, for example, in health class at
school, or through a program at a community center such as the Boys Club or Girls Club, or the
YMCA? If you attended these classes or sessions at more than one place, please list all of these places
in the spaces provided below.
PLACE 1:
PLACE 2:
ADDITIONAL PLACES:

4.3. Sometimes people don’t want to have sex, but have difficulty saying “no.” How likely is it you
would be able to say “no” to having sexual intercourse …
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY

A LITTLE
BIT LIKELY

SOMEWHAT
LIKELY

VERY
LIKELY

a. With someone you have known for a few days or less? ..................................................................
b. With someone you have dated for a long time?...............................................................................
c. With someone with whom you have already had
sexual intercourse? .........................................................................................................................
d. With someone who is pushing you to have sexual intercourse? ......................................................
e. With someone who does not want to use a condom?......................................................................

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4.4. The next series of statements is about condom use. How strongly do you agree or disagree with
each of these statements?
MARK (X) ONE FOR EACH QUESTION

STRONGLY
DISAGREE

DISAGREE

NEITHER
AGREE NOR
DISAGREE

AGREE

STRONGLY
AGREE

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

4.5. 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
Completely
Don’t know
4.6. 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
Completely
Don’t know

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4.7. 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
4.8. 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
4.9. If birth control pills 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

4.10. Can you get a sexually transmitted disease, also known as an STD or STI, from having oral sex?
MARK (X) ONE

Yes
No
Don’t know

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SECTION 5
5.1. The next questions are about sexual intercourse. In this survey, by sexual intercourse we mean a
male putting his penis into a female’s vagina.
The very first time you had sexual intercourse, how old were you?
MARK (X) ONE

12 years old or younger
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old
20 years old or older

5.2. The first time you had sexual intercourse, did you or your partner use any of these methods of
birth control?
MARK (X) ONE FOR EACH QUESTION

YES

NO

a. Condoms .....................................................................................................................................
b. Birth control pills or the patch .......................................................................................................
c. Depo-Provera or other injectable birth control ..............................................................................
d. NuvaRing or the ring ....................................................................................................................
e. Withdrawal or pulling out ..............................................................................................................
f. Another method PRINT OTHER METHOD USED

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

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

5.4. Now please think about the 3 months before you found out you were pregnant. In the 3 months
before you found out you were pregnant, how many TIMES did you have sexual intercourse?
NUMBER OF TIMES – Your best estimate is fine.

5.5. Again thinking about the 3 months before you found out you were pregnant, how many TIMES did
you have sexual intercourse without using a condom?

NUMBER OF TIMES – Your best estimate is fine.
5.6. 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)
In the 3 months before you found out you were pregnant, how many TIMES did you have sexual
intercourse without using any of these methods of birth control?
NUMBER OF TIMES – Your best estimate is fine.

5.7. Do you intend to have sexual intercourse in the next year?
MARK (X) ONE

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

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SECTION 6: HEALTHCARE AND PREGNANCY
6.1. In the past 12 months, did you receive information from a doctor, nurse, or clinic about any of the
following?
MARK (X) ONE FOR EACH QUESTION

YES

NO

a. Methods of birth control, such as condoms, pills, etc................................................................
b. Where to get birth control .........................................................................................................
c. Sexually transmitted diseases, also known as STDs or STIs ...................................................

6.2. In the past 12 months, did you get any type of birth control from a doctor, nurse, or clinic, such
as condoms, pills, the shot, an implant, the ring, etc.?
MARK (X) ONE

Yes
No
6.3. Have you ever been told by a doctor, nurse, or some other health professional that you had any
of the following sexually transmitted diseases?
MARK (X) ONE FOR EACH QUESTION

YES

NO

a. Chlamydia ..................................................................................................................................
b. Gonorrhea..................................................................................................................................
c. Genital herpes............................................................................................................................
d. Syphilis ......................................................................................................................................
e. HIV infection or AIDS .................................................................................................................
f. Human Papilloma virus, also known as HPV or genital warts .....................................................
g. Another sexually transmitted disease (STD) PRINT OTHER STD

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6.4. These next few questions are about pregnancy. Are you currently pregnant?
MARK (X) ONE

Yes
No

6.5. Counting your current or most recent pregnancy, how many times have you EVER been
pregnant, even if no baby was born?
NUMBER OF TIMES PREGNANT

6.6. How many children do you have? Please do not include children who have not been born yet.
NUMBER OF CHILDREN

6.7. If you got pregnant again in the next year, how would you feel?
MARK (X) ONE

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

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SECTION 7: ALCOHOL AND DRUG USE AND HEALTH
7.1. The next questions are about alcohol, drugs and general health. Please be as honest as possible,
and remember that your answers will be kept private and will not be shared with anyone.
During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

7.2. During the past 30 days, on how many days did you have one or more alcoholic beverages?
MARK (X) ONE

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

7.3. During the past 30 days, on how many days did you have 5 or more drinks in a row, that is, within
a few hours?
MARK (X) ONE

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

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7.4. During the past 30 days, on how many days did you use marijuana, also called weed or pot?
MARK (X) ONE

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

7.5. During the past 30 days, on how many days did you use any other type of illegal drug, inhalant,
or a prescription drug in a way that was not prescribed?
MARK (X) ONE

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

7.6. Now thinking about experiences throughout your life, how many times have you experienced the
following things?
MARK (X) ONE FOR EACH QUESTION

NEVER

ONCE

TWO OR
THREE
TIMES

FOUR OR
MORE
TIMES

a. Heard gunshots in your neighborhood........................................................................................
b. Witnessed a shooting .................................................................................................................
c. Been robbed or mugged.............................................................................................................

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

STRONGLY
DISAGREE

DISAGREE

AGREE

STRONGLY
AGREE

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

Please put the survey back into the envelope
and give it to the moderator.
Thank you!

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Thank you for
completing this survey!

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