New Instrument #2: Exit Survey (CPREP Participants)

INSTRUMENT #2
participant exit survey (pas)

*Note. This instrument is identical to an instrument approved in the last ICR, which was approved on March 12, 2013 (OMB Control # 0970-0398). We are increasing the burden for this instrument and administering it to additional participants.

Form approved

OMB Control No:

PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP)

E xpiration Date:

PARTICIPANT EXIT SURVEY

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 10 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.

June 2012

General Instructions

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 peers, school, 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 kept private. Your responses will be combined with those of other people your age.

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.

• PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED.

• USE A PEN OR PENCIL.

Please answer the following questions to the best of your ability. This first set of questions has to do with you.

1. How old are you?

MARK ONLY ONE ANSWER

□ 10

□ 11

□ 12

□ 13

□ 14

□ 15

□ 16

□ 17

□ 18

□ 19

□ 20

□ 21 or older

2. Are you Hispanic or Latino?

MARK YES OR NO

□ Yes

□ No  PLEASE GO TO Q.4

3. Are you…?

MARK ONLY ONE ANSWER

□ Mexican, Mexican American, Chicano/a

□ Puerto Rican

□ Cuban

□ Another Hispanic, Latino/a, or Spanish origin

4. What is your race?

MARK ALL THAT APPLY

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White or Caucasian

5. Are you male or female?

MARK ONLY ONE ANSWER

□ Male

□ Female

6. What grade are you in? (If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)

MARK ONLY ONE ANSWER

□ 4th

□ 5th

□ 6th

□ 7th

□ 8th

□ 9th

□ 10th

□ 11th

□ 12th

□ My school does not assign grade levels

□ I dropped out of school, and I am not working on getting a high school diploma or GED

□ I am working towards a GED

□ I have a high school diploma/GED but I am not currently enrolled in college/technical school

□ I have a high school diploma/GED and I am currently enrolled in college/technical school

Please think about how the program that you just completed has affected you.

7. Even if your program didn’t cover a topic, would you say that being in the program has made you more likely, about the same, or less likely to…

MARK ONLY ONE ANSWER PER ROW
	Much More Likely	Somewhat More Likely	About the Same	Somewhat Less Likely	Much Less Likely
a. resist or say no to peer pressure?
b. know how to manage stress?
c. manage conflict without causing more conflict?
d. form friendships that keep you out of trouble?
e. be respectful toward others?
f. make plans to reach your goals?
g. care about doing well in school?
h. get a steady job after you finish school?
i. share ideas or talk about things that really matter with a parent/guardian?
j. make healthy decisions about drugs and alcohol?
k. get more education after high school?
l. manage money carefully, such as making a budget, saving, or investing?
m. be the best that you can be?

8. The next few questions refer to sexual intercourse and your risk of pregnancy and sexually transmitted diseases. Please respond, even if you are not planning on having sex in the next 6 months.

Would you say that being in the program has made you more likely, about the same, or less likely to…

a. have sexual intercourse in the next 6 months?

By sexual intercourse, we mean the act that makes babies.

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

b. use (or ask your partner to use) any of these methods of birth control, if you were to have sexual intercourse in the next 6 months?

By birth control, we mean using birth control pills, condoms, the shot (Depo Provera), the patch, the ring (NuvaRing), IUD (Mirena or Paragard), or implant (Implanon).

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from sexual intercourse (choose not to have sex) in the next 6 months

c. use (or ask your partner to use) a condom if you were to have sexual intercourse in the next 6 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from sexual intercourse (choose not to have sex) in the next 6 months

d. abstain from sexual intercourse (choose not to have sex) in the next 6 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

The next questions ask you about your experiences in the program that you just completed. Think about all of the sessions or classes of the program that you attended.

9. Even if you didn’t attend all of the sessions or classes in this program, how often in this program…

MARK ONLY ONE ANSWER PER ROW
	All of the Time	Most of the Time	Some of the Time	A Little of the Time	None of the Time
a. did you feel interested in program sessions and classes?
b. did you feel the material presented was clear?
c. did discussions or activities help you to learn program lessons?
d. did you feel respected as a person?
e. were you picked on, teased, or bullied in this program?
f. did you have a chance to ask questions about topics or issues that came up in the program?

10. Now thinking about all youth in this program, how often…

MARK ONLY ONE ANSWER PER ROW
	All of the Time	Most of the Time	Some of the Time	A Little of the Time	None of the Time
a. were youth in this program picked on, teased, or bullied because people thought they were lesbian, gay, bisexual, or transgender?
b. were youth in this program picked on, teased, or bullied because of their race or ethnic background?

Thank you for participating in this survey!