Instrument 1
Perceived impact questions
New data collection for Tier 1 A/B grantees. Questions have previously been approved by OMB #0990-0382.
Date ______/_______/______
Demographic Questions
1. In what month and year were you born?
MARK (X) ONE Month and One Year
January 2002
February 2001
March 2000
April 1999
May 1998
June 1997
July 1996
August 1995
September 1994
October 1993
November 1992
December 1991
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX . The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
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 ANSWER
6th
7th
8th
9th
10th
11th
12th
Ungraded
College/Technical school
Not currently in school
Are you male or female?
MARK (X) ONE ANSWER
Male
Female
Are you Hispanic or Latino?
MARK (X) ONE ANSWER
Yes
No
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
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: _________________________
Perceived Impact of Program
For the next few questions, please think about [NAME OF PROGRAM] and how it may have influenced you. You may not have thought about these situations before, but please still answer the questions. Think about what you would do and answer as best you can.
1. Would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to have sexual intercourse in the next year?
Much more likely
More likely
About the same
Less likely
Much less likely
2. Would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to abstain (abstain means choose not to have sex) from sexual intercourse in the next year?
Much more likely
More likely
About the same
Less likely
Much less likely
3. If you were to have sexual intercourse in the next year, would you say that being in [NAME OF PROGRAM] has made you more likely or less likely 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)
Implant (Implanon)
Much more likely
More likely
About the same
Less likely
Much less likely
4. If you were to have sexual intercourse in the next year, would you say that being in [NAME OF PROGRAM] has made you more likely or less likely to use a condom?
Much more likely
More likely
About the same
Less likely
Much less likely
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | ewilson |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |