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Baseline Survey |
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OMB No. 0920-0861
Exp. Date: 08/31/2013
Public
Reporting burden of this collection
of information is estimated at 60 minutes per response, including
the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance
Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn:
PRA (0920-0861).
Instructions
We would like to ask you a few questions about your relationships. This is not a test, so there are no right or wrong answers.
Please read the directions and questions carefully and answer the questions as honestly as you can. The Expect Respect Facilitator will assist you if you need help.
Your answers are completely confidential. School personnel will not see your questionnaire. Your name will not appear on the survey.
By answering the questions you help us to understand what is important to teens like you and how we can improve programs for teens.
To be completed by SafePlace staff (Baseline Survey)
1. SafePlace ID |
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2. School Code
3. Facilitator Code
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4. Date
5. Age _________________
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Part 1: Are the following statements true for you?
6. I always speak out when someone is being harassed.
1 False
2True
7. I sometimes feel upset when I don’t get my way.
1 False
2True
8. I like to gossip sometimes.
1 False
2True
9. I’m always a good listener.
1 False
2True
10. I’m always willing to admit it when I make a mistake.
1 False
2True
11. I am always nice with people.
1 False
2True
12. I have never hurt someone’s feelings on purpose.
1 False
2True
Part 2: Dealing with Anger
Most of us feel angry sometimes. Do not spend a lot of time thinking about the questions – just give your first response.
In the past 3 months, how often have you … |
Never |
Rarely |
Sometimes |
Often |
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Part 3: Your Opinion
Is it OKAY if you do these things in a dating relationship? |
Definitely not okay |
Probably not okay |
Probably okay |
Definitely okay |
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How strongly do you agree or disagree with each statement? |
Strongly agree |
Agree somewhat |
Disagree somewhat |
Strongly disagree |
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Part 4: Relationships
By dating we’re talking about having a boyfriend or a girlfriend, going out or hanging out in a romantic way, or hooking up with one person. This can be a relationship of any length.
57. Have you ever dated someone? If NO, skip to question 140 (page 12). If YES, continue with the next questions. |
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58. How many dating partners have you had in your life? |
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59. How long was your longest dating relationship? |
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Look back at ALL of the dating relationships you have EVER had to answer these questions.
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66. Have you dated in the past 3 months? If NO, skip to question 140 (page 12). If YES, continue with the next questions. |
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67. How many people have you dated in the past 3 months? |
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When you answer the following questions, please think about all the dating relationship(s) you’ve had in the past 3 months.
By dating partner we’re talking about a boyfriend or girlfriend, someone you go out with or hang out with in a romantic way, or someone you hook up with.
In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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In the past 3 months, how often did the following things happen in your dating relationship(s)? |
Never
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Rarely |
Some- times |
Often |
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Part 5: About You
140. What grade are you in? |
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141. Are you? |
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142. What were your grades for the last semester or grading period you completed? (Mark one.)
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143. Which of the following best describes you? (Mark one.) |
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144. Have you participated in any of the following activities in the past 12 months? (Mark all that apply.)
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Thank you for your hard work in answering these questions.
File Type | application/msword |
File Title | Expect Respect Support Group Survey |
Author | User |
Last Modified By | its7 |
File Modified | 2011-03-24 |
File Created | 2011-03-04 |