Baseline Survey

OMB Control No: 0970-0398

Expiration Date: 03/31/2016

Personal Responsibility Education Program (PREP)

BASELINE SURVEY

NEW YORK

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

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

1. PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED! USE A BLACK PEN.

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

Brown

Blue

Green

Another color

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.

2. EXAMPLE 2: FILL IN THE NUMBER

In the last seven (7) days, how many chocolate bars have you eaten?

NUMBER OF CHOCOLATE BARS – Your best estimate is fine.

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		2004
February		2003
March		2002
April		2001
May		2000
June		1999
July		1998
August		1997
September		1996
October		1995
November		1994
December		1993

1.2. Are you male or female?

MARK (X) ONE

Male

Female

1.3. Are you Hispanic/Latino?

MARK (X) ONE

Yes

No

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. What kind of grades do you or did you usually get in school?

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

1.7. How oftenwould 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

1.8. 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

One time

Two times

More than two times

1.9. How likely is it that you will do each of the following things? MARK (X) ONE FOR EACH QUESTION
	NOT AT ALL LIKELY	A LITTLE BIT LIKELY	SOMEWHAT LIKELY	VERY LIKELY
a. Graduate from high school
b. Graduate from a 4-year college

1.10. 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

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 2.4

2.2. 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

Don’t have a mother or person I think of as my mother

2.3. How would she feel if you got pregnant or got someone pregnant at this time in your life?

MARK (X) ONE

Strongly approve

Approve

Neither approve nor disapprove

Disapprove

Strongly disapprove

Don’t have a mother or person I think of as my mother

2.4. 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 2.7

2.5. 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

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

2.6. How would he feel if you got pregnant or got someone pregnant at this time in your life? MARK (X) ONE Strongly approve Approve Neither approve nor disapprove Disapprove Strongly disapprove Don’t have a father or person I think of as my father
2.7. In the past 3 months, how many TIMES have you talked with your mother or your father about each of the following things? MARK (X) ONE FOR EACH QUESTION
		NEVER	1-2 TIMES	3-9 TIMES	10 OR MORE TIMES
	a. How things are going with school work or with your grades
	b. A personal problem you were having
	c. Romantic relationships or dating
	d. How to resist pressures to have sex
	e. Avoiding drugs or alcohol
	f. Whether you should be having sex at this time in your life

2.8. In the past 12 months, how many times have you moved?

MARK (X) ONE

Never

One time

Two times

Three times

Four times or more

2.9. All together, how many times have you run away from home for at least one night?

MARK (X) ONE

Never

One time

Two times

Three times or more

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 questions are about your experiences and attitudes toward romantic relationships and dating.

How would you define your current relationship status?

MARK (X) ONE

Married

Engaged

Seriously dating

Casually dating

Not currently in a relationship or dating

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 dating relationship, you don’t always get your own way.
b. There are times when hitting or pushing between people who are dating is okay.
c. A good dating 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 dating, even when you’re apart.
f. Avoiding a disagreement with someone you are dating is always better than talking about your problems.

3.4. Do you consider yourself to be one or more of the following?

YOU MAY MARK (X) MORE THAN ONE ANSWER

Straight

Gay or Lesbian

Transgender

Bisexual

Something else/I have not decided

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.

I did not attend any classes or sessions

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?

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

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. 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

SECTION 5: BEHAVIOR

5.1. The next questions are about your sexual behaviors and experiences. Please be as honest as possible. Your answers will be kept private and will not be shared with anyone.

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?

MARK (X) ONE

Yes

No GO TO 5.7

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

MARK (X) ONE

I have never had sexual intercourse

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 or older

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

I have never had sexual intercourse

NUMBER OF PEOPLE – Your best guess is fine.

5.4. 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.

5.5. 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.

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 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.

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

MARK (X) ONE

Yes, definitely

Yes, probably

No, probably not

No, definitely not

5.8. 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

Yes

No GO TO 5.11

5.9. 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.

5.10. 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.

5.11. 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

Yes

No GO TO 6.1

5.12. In the past 3 months, how many TIMES have you had anal sex?

None

NUMBER OF TIMES – Your best guess is fine.

5.13. 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.

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. In the past 12 months, have you 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

6.4. These next few questions are about pregnancy. 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 6.7

6.5. To the best of your knowledge, how many TIMES have you been pregnant or gotten someone pregnant?

NUMBER OF TIMES

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

MARK (X) ONE

Yes

No

Don’t know

6.7. If you got pregnant now or 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

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

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 or inhale something to get high?

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

7.7. 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
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