New Instrument #1: Entry Survey (CPREP Participants)

INSTRUMENT #1
PARTICIPANT ENTRY 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 ENTRY SURVEY

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 5 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 family, friends, school, 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. Do you consider yourself to be one or more of the following?

MARK ALL THAT APPLY

□ Straight

□ Gay or Lesbian

□ Transgender

□ Bisexual

□ Something else/I have not decided

7. 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

8. In the past three months, how often would you say you…

MARK ONLY ONE ANSWER PER ROW
	All of the Time	Most of the Time	Some of the Time	None of the Time
a. cared about doing well in school?
b. shared ideas or talked about things that really matter with a parent/guardian?
c. resisted or said no to peer pressure?
d. managed conflict without causing more conflict?

The next questions ask about sexual intercourse and your risk of pregnancy and sexually transmitted diseases. Remember, all of your responses will be kept private.

9. If you have the chance, do you intend to have sexual intercourse in the next 6 months? By sexual intercourse, we mean the act that makes babies.

MARK ONLY ONE ANSWER

□ Yes, definitely

□ Yes, probably

□ No, probably not

□ No, definitely not

10. Have you ever had sexual intercourse? By sexual intercourse, we mean the act that makes babies.

MARK YES OR NO

□ Yes

□ No PLEASE GO TO Q.16 (PAGE 6)

11. To the best of your knowledge, have you ever been pregnant or gotten someone else pregnant, even if no child was born?

MARK YES OR NO

□ Yes

□ No

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

MARK ONLY ONE ANSWER

□ 0, I have never been pregnant or gotten someone pregnant

□ 1 pregnancy

□ 2 pregnancies

□ 3 or more pregnancies

13. In the past 3 months, with how many people did you have sexual intercourse, even if only one time?

MARK ONLY ONE ANSWER

□ 0, I did not have sexual intercourse in the past 3 months PLEASE GO TO Q.16 (PAGE 6)

□ 1 person

□ 2-3 people

□ 4 or more people

14. When you had sexual intercourse in the past 3 months, how often did you or a partner use birth control?

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

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

15. When you had sexual intercourse in the past 3 months, how often did you or a partner use a condom?

MARK ONLY ONE ANSWER

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

16. In the past 3 months, how often would you say you…

MARK ONLY ONE ANSWER PER ROW
	All of the Time	Most of the Time	Some of the Time	None of the Time
a. knew how to manage stress?
b. managed money carefully?
c. had friendships that kept you out of trouble
d. were respectful towards others?

Thank you for participating in this survey!