Chicago Public Schools

ATTACHMENT A
EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
FOLLOW- UP INSTRUMENT: CHICAGO PUBLIC SCHOOLS

The Chicago survey instrument is divided into three sections:
PART A – FOR ALL YOUTH (this section ends with a question on whether the adolescent has had sex, in
which case the adolescent chooses to continue to either PART B1 or B2)
PART B1 – FOR SEXUALLY-ACTIVE YOUTH
PART B2 – FOR NON-SEXUALLY-ACTIVE YOUTH

Form approved
OMB No. 0990-0382
Exp. Date: xx/xx/20xx

FOLLOW-UP QUESTIONNAIRE
PART A
CHICAGO
CONFIDENTIALITY
Thank you for your help with this important study. It will help us understand what
things are like for people your age today. Your answers are confidential and everything
you say will be kept private. Your name will not be on the questionnaire. Please answer
all questions as well as you can.
We want you to know that:
1.

We hope that you will answer all the questions, but you may skip any questions
you do not wish to answer.

2.

The answers you give will never be identified as yours. Your responses will be
combined with those of other people your age.
Mathematica Policy Research

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 0990-0382. The time
required to complete this information collection is estimated to average 36 minutes per response, including the time to review
instructions 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

GENERAL INSTRUCTIONS
1.

PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED! USE A PEN OR PENCIL.
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
X

Brown
Blue

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

Green
Another color
2.

EXAMPLE 2: MARK (X) ONE ANSWER and FILL IN THE BLANK
What is the color of your hair?
MARK (X) ONE

Brown
Black

If the color of your hair is purple, you would mark (X)
the last box and write the word “purple” in the blank as
shown. BE SURE TO WRITE CLEARLY.

Blond
Red
X

3.

Some other color PRINT OTHER COLOR

purple

EXAMPLE 3: SELECT ONE OR MORE
Do you plan to do any of the following next week?
SELECT ONE OR MORE
X

Rent a movie

X

Go to a baseball game

If you plan to rent a movie and go to a baseball game
next week, you would mark (X) both boxes.

Study at a friend’s house

PPA Study – Part A, Follow-Up 1 Concordance Version 10/13/11

1

4.

EXAMPLE 4: QUESTION WITH A SKIP
1. Do you ever eat chocolate?

Because you answered “Yes” to question 1, you would
continue to question 2 and then question 3.

MARK (X) ONE
X

If you answered “No” to question 1, you would skip
question 2 and go right to question 3.

Yes
GO TO 3

No

2. Do you always brush your teeth after eating chocolate?
MARK (X) ONE

Yes
X

No

3. Did you do any of the following last week?
SELECT ONE OR MORE
X

Went to a play

X

Went to a movie
Attended a sporting event

5.

EXAMPLE 5: FILL IN THE NUMBER
In the last seven (7) days, how many chocolate bars have you eaten?
0

2

NUMBER OF CHOCOLATE BARS – Your best guess is fine.
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.

6.

EXAMPLE 6: MARK (X) ONE ANSWER FOR EACH QUESTION
In the last 12 months, have you done any of the following?
MARK (X) ONE FOR EACH

a.
b.
c.
d.
e.
f.

YES
NO
Walked a dog on a leash? .......................................................................................................................... X
Played Frisbee? .......................................................................................................................................... X
X
Weeded a garden? .....................................................................................................................................
Eaten a piece of fresh fruit?........................................................................................................................ X
X
Played a piano? ..........................................................................................................................................
X
Watched a movie? ......................................................................................................................................
Mark (X) either “yes” or “no” for each of the six (6) questions (a–f)
by marking (X) one of the of two boxes in each row.

PPA Study – Part A, Follow-Up 1 Concordance Version 10/13/11

1

7.

EXAMPLE 7: MARK (X) ONE MONTH AND ONE YEAR
In what month and year did you finish elementary school?
MARK (X) ONE MONTH AND ONE YEAR

Month finished

Year finished

January
February

X

8.

2010
X

2009

March

2008

April

2007

May

2006

June

2005

July

2004

August

2003

September

2002

October

2001

November

2000

December

1999

If you finished elementary school in
June of 2009, you would mark (X) in the
box next to June and mark (X) in the
box next to 2009.

EXAMPLE 8: FOR GIRLS or FOR BOYS
1a. FOR GIRLS Do you want to be a mother someday?
MARK (X) ONE

Some questions are just for girls and some
questions are just for boys. These
GO TO 2
questions are marked with FOR GIRLS or
No
FOR BOYS. If a question is not marked
1b. FOR BOYS Do you want to be a father someday? specifically FOR GIRLS or FOR BOYS, then
it is a question for everyone to answer.
MARK (X) ONE
Yes

Yes
No

2. Do you have any brothers or sisters?
MARK (X) ONE

Yes

In the example, if you are a girl, you would
answer 1a (FOR GIRLS), skip 1b (FOR
BOYS), and then answer question 2, for
everyone. If you are a boy, you would skip
1a (FOR GIRLS), answer 1b (FOR BOYS),
and answer question 2, for everyone.

No

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

2

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

2002

February

2001

March

2000

April

1999

May

1998

June

1997

July

1996

August

1995

September

1994

October

1993

November

1992

December

1991

1.2. What grade are you in?
MARK (X) ONE

6th
7th
8th
9th
10th
11th
12th
Not currently in school

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

3

1.3. Are you male or female?
MARK (X) ONE

Male
Female

1.4. Are you Hispanic /Latino?
MARK (X) ONE

Yes
No

1.5. What is your race?
SELECT ONE OR MORE

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

1.6. In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH

YES

NO

a. Relationships, dating, marriage, or family life ................................................................................................
b. Abstinence from sex ......................................................................................................................................
c. Methods of birth control .................................................................................................................................
d. Where to get birth control ..............................................................................................................................
e. Sexually transmitted diseases, also known as STDs ....................................................................................
f.

How to talk to your partner about whether to have sex or whether to use birth control ................................

g. How to say no to sex......................................................................................................................................
h. How babies are made ....................................................................................................................................

1.6a. Did you say “yes” to any item a through h in question 1.6 above?
MARK (X) ONE

Yes
No

GO TO 1.9

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4

1.7. Thinking about the past 12 months, how many times did you get information on relationships,
abstinence, birth control, or sexually transmitted diseases at each of the following places?
MARK (X) ONE FOR EACH

Never

1-3 times

4-9 times

10 or more
times

a. School class ....................................................................................................................................................
b. Church, synagogue, mosque, or religious
classes outside of school ................................................................................................................................
c. Community center, youth organization, or
after-school activity .........................................................................................................................................
d. Doctor, nurse, or clinic ....................................................................................................................................
e. Friends ............................................................................................................................................................
f.

Parents or other relatives or family members .................................................................................................

g. Internet or media .............................................................................................................................................
h. Other LIST OTHER SOURCE

.................................................................................................................

1.8. Thinking about the past 12 months, where did you get information on relationships, abstinence,
birth control, or sexually transmitted diseases that was very helpful to you?
SELECT ONE OR MORE

School class
Church, synagogue, mosque or religious classes outside of school
Community center, youth organization, or after-school activity
Doctor, nurse, or clinic
Friends
Parents or other relatives or family members
Internet or media
Other PLEASE SPECIFY

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

5

1.9. How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. You can do things now that will help you to be
healthy when you are an adult .......................................................................................................................
b. Nothing you do as a teen will affect how healthy
you are as an adult ........................................................................................................................................
c.

Taking risks as a teen, like drinking and 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 .........................................................................................................................

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

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SECTION 2: FAMILY
The next questions are about where you live and who lives with you.
2.1a. Which of the following best describes where you live?
MARK (X) ONE

You live in one home

GO TO 2.2

You live in two or more homes, and go back and forth

GO TO 2.3

You are homeless, for example living on the street, in a car or shelter, or
staying with friends/relatives
GO TO 2.4

2.2. Who lives with you in your home?
MARK (X) ALL THAT APPLY

Your biological mother
Your biological father
A stepmother or adoptive mother
A foster mother
A stepfather or adoptive father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandfathers
Any older brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself

AFTER ANSWERING

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

GO TO 2.4

7

2.3. Who lives with you in each of your homes?
MARK (X) ALL THAT APPLY

MAIN HOME
Mark (X) all the people who live with you in your MAIN home

OTHER HOME(S)
Mark (X) all the people who live with you in your OTHER home(s)

Your biological mother

Your biological mother

Your biological father

Your biological father

A stepmother or adoptive mother

A stepmother or adoptive mother

A foster mother

A foster mother

A stepfather or adoptive father

A stepfather or adoptive father

A foster father

A foster father

Your parent’s partner, boyfriend, or girlfriend

Your parent’s partner, boyfriend, or girlfriend

Any grandmothers

Any grandmothers

Any grandfathers

Any grandfathers

Any older brothers or sisters

Any older brothers or sisters

Any younger brothers or sisters

Any younger brothers or sisters

Any aunts, uncles, or other relatives

Any aunts, uncles, or other relatives

Any other people you are not related to

Any other people you are not related to

You live by yourself

You live by yourself

MOTHER
2.4. 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 or adoptive mother
Your foster mother
Your grandmother
Your aunt or your older sister
Some other adult
You don’t have a mother or person you think of as your mother

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

GO TO 2.8

8

2.5. The following questions are about the person you marked as your mother or the person you think
of as your mother.
Is she working now?
MARK (X) ONE

She is not working at a paid job
Yes, she is working part-time or less than 30 hours a week
Yes, she is working full-time or at more than one job for 30 hours a week or more
Yes, she works, but you don’t know how many hours
Don’t know if she is working

2.6. Now thinking about your biological mother, that is, the woman who gave birth to you, how old is
she (or would she be if she were alive)?
NUMBER OF YEARS OLD – Your best guess is fine.
You do not know about your biological mother

GO TO 2.8

2.7. Again thinking about your biological mother and all the children she has ever had—how old is
the oldest one? If the oldest one is not alive, how old would that child be if still living?
NUMBER OF YEARS OLD – Your best guess is fine.
You do not know about your biological mother

FATHER
2.8. 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 or adoptive father
Your foster father
Your grandfather
Your uncle or your older brother
Some other adult
You don’t have a father or person you think of as your father

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

GO TO 2.10a

9

2.9. The following questions are about the person you marked as your father or the person you think
of as your father.
Is he working now?
MARK (X) ONE

He is not working at a paid job
Yes, he is working part-time or less than 30 hours a week
Yes, he is working full-time or at more than one job for 30 hours a week or more
Yes, he works, but you don’t know how many hours
Don’t know if he is working

2.10a. Which of the following best describes the relationship between your biological mother and
biological father? If one or both of your biological parents have passed away, please answer about their
relationship when both were alive.
MARK (X) ONE

They are married to each other
They used to be married to each other, but are now separated
They used to be married to each other, but are now divorced
They have never been married to each other
Don’t know
2.10b. Do your biological mother and biological father live together now?
MARK (X) ONE

Yes
No
One or both of your biological parents have passed away
Don’t know

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10

SECTION 3: VIEWS AND PERCEPTIONS
3.1. The next series of questions is about your views on sexual intercourse. In this survey, when we
ask about sexual intercourse, we mean a male putting his penis into a female’s vagina. How
strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. Having sexual intercourse is a good thing for you to
do at your age ................................................................................................................................................
b. At your age right now, having sexual intercourse
would create problems...................................................................................................................................
c. At your age right now, not having sexual intercourse is
important for you to be safe and healthy .......................................................................................................
d. At your age right now, it is okay for you to have sexual
intercourse if you use birth control, like a condom ........................................................................................
e. It is against your values to have sexual intercourse
before marriage .............................................................................................................................................

3.2. How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a. You have goals you want to accomplish before
you have a child ............................................................................................................................................
b. It is important for you to finish school before you
have a child ...................................................................................................................................................
c.

It is important for you to have a job and stable
income before you have a child.....................................................................................................................

d. Having a good marriage seems possible for you ..........................................................................................

3.3. FOR GIRLS
If you got pregnant now, how would you feel?
MARK (X) ONE

Very happy
A little happy
Neither happy nor upset
A little upset
Very upset

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11

3.4. FOR BOYS
If 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

3.5. Imagine you are alone with someone you like very much. How likely is it that you could…
MARK (X) ONE FOR EACH

NOT AT ALL
LIKELY

A LITTLE
BIT LIKELY

SOMEWHAT
LIKELY

VERY
LIKELY

a. Stop them if they wanted to touch your chest and
you did not want them to do that (FOR GIRLS)...............................................................................................
b. Stop them if they wanted to touch your private parts
below the waist, meaning the parts of the body covered
by underwear, and you did not want them to do that ......................................................................................
c. Avoid having sexual intercourse if you didn’t want to ......................................................................................

3.6. How likely is it that you will get pregnant (or get someone pregnant) between now and age 20?
MARK (X) ONE

Not at all likely
A little likely
Somewhat likely
Very likely

3.6a. How likely is it that you will get pregnant (or get someone pregnant) between now and when
you get married?
MARK (X) ONE

Not at all likely
A little likely
Somewhat likely
Very likely

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

12

3.7. The next series of questions is about condoms, birth control pills, pregnancy and sexually
transmitted diseases, also known as STDs.
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

GO TO 3.8

3.7a. How confident are you that your answer to the question above is correct?
MARK (X) ONE

Not at all confident
A little confident
Somewhat confident
Very confident

3.8. 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

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

13

3.9. 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

GO TO 3.10

3.9a. How confident are you that your answer to the question above is correct?
MARK (X) ONE

Not at all confident
A little confident
Somewhat confident
Very confident

3.10. 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

3.11. If birth control pills are used consistently and correctly, how much can they decrease the risk of getting
Chlamydia and gonorrhea?
MARK (X) ONE

Not at all
A little
A lot
Completely
Don’t know

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14

3.12. Can you get a sexually transmitted disease, or STD, from having oral sex?
MARK (X) ONE

Yes
No
Don’t know

GO TO 3.12a

3.12a. How confident are you that your answer to the question above is correct?
MARK (X) ONE

Not at all confident
A little confident
Somewhat confident
Very confident

3.13. The next series of questions is about condom use. How strongly do you agree or disagree
that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Condoms should always be used if a
person your age has sexual intercourse ........................................................................................................
b. Condoms are a hassle to use ........................................................................................................................
c. Condoms are pretty easy to get.....................................................................................................................
d. Condoms are important to make
sex safer. .......................................................................................................................................................
e. Using condoms means you don’t
trust your partner ...........................................................................................................................................
f.

Using condoms is morally wrong ...................................................................................................................

g. Condoms decrease sexual pleasure .............................................................................................................

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

15

3.14. The next series of questions is about other methods of birth control, NOT including condoms.
How strongly do you agree or disagree that…?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

NEITHER
AGREE
NOR
DISAGREE

DISAGREE

STRONGLY
DISAGREE

a. Birth control should always be used
if a person your age has sexual
intercourse .....................................................................................................................................................
b. Birth control is a hassle to use .......................................................................................................................
c. Birth control is pretty easy to get ...................................................................................................................
d. Birth control is important to make
sex safer ........................................................................................................................................................
e. Birth control has too many negative
side effects .....................................................................................................................................................
f.

Using birth control is morally wrong ...............................................................................................................

3.15. Read each statement below and check the answer that fits best.
MARK (X) ONE FOR EACH

I AM SURE
IT’S TRUE

I THINK IT’S
TRUE

I DON’T
KNOW

I THINK IT’S
FALSE

I AM SURE
IT’S FALSE

a. You can’t get AIDS if you have sex only
once or twice without a condom ....................................................................................................................
b. If condoms are used correctly and consistently,
they can reduce the risk of STDs such as
Chlamydia and gonorrhea .............................................................................................................................
c. Once you are infected with HIV, you are
infected for life ...............................................................................................................................................
d. If a young couple has had unprotected
sex a few times and a pregnancy did not
happen, then they do not have to worry
about her getting pregnant.............................................................................................................................
e. There is a vaccine or shot available to
prevent girls from becoming infected
with certain types of HPV (also known
as Human Papilloma virus) ............................................................................................................................

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

16

3.16. Thinking about the future, how likely do you think it is that you will get HIV/AIDS?
MARK (X) ONE

Not at all likely
A little likely
Somewhat likely
Very likely

3.17. How likely do you think it is that you will get an STD other than HIV/AIDS?
MARK (X) ONE

Not at all likely
A little likely
Somewhat likely
Very likely

3.18. Do you intend to have oral sex in the next year?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.19. Do you intend to have sexual intercourse in the next year?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

GO TO 3.22

3.20. If you have sexual intercourse in the next year, do you intend to use a condom?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

17

3.21. The next question is about your intention to use the following methods of birth control:
•
•
•
•
•
•
•

Condoms
Birth control pills
The shot (Depo-Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)

If you have sexual intercourse in the next year, do you intend to use any of these methods of
birth control?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not
3.22. Do you intend to have sexual intercourse without being married?
MARK (X) ONE

Yes, definitely
Yes, probably
No, probably not
No, definitely not

3.23. Right now, do you have a boyfriend or girlfriend—someone in particular you are going out with?
MARK (X) ONE

Yes
No

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

18

3.24. In the past 3 months, how many TIMES have you gone out on a date?
Zero or None

GO TO 3.26

NUMBER OF TIMES – Your best guess is fine.

3.25. Thinking about these dates in the past 3 months, how many DIFFERENT PEOPLE did you go out
on a date with?
NUMBER OF PEOPLE – Your best guess is fine.

3.26. Have you ever had sexual intercourse, oral sex, or anal sex?
Yes

GO TO PART B1

No

GO TO PART B2

PPA Study – Part A, Follow-Up 2 Chicago 11/22/11

19

Form approved
OMB No. 0990-0382
Exp. Date: xx/xx/20xx

FOLLOW-UP QUESTIONNAIRE
PART B1
CHICAGO
Please be sure that you have the correct Part B.
If you answered “Yes” to the last question of Part A, you have the correct version of
Part B. If you answered “No,” please put this version back in your envelope and fill out
Part B2 instead.
Thank you.
Mathematica Policy Research

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 0990-0382. The time
required to complete this information collection is estimated to average 36 minutes per response, including the time to review
instructions 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

PART B
4.1. The next questions are about your sexual behaviors and experiences. Please be as honest as
possible. Your answers are confidential and everything you say will be kept private.
Just to confirm, have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE

No

STOP AND GO TO PART B2.

Yes

CONTINUE WITH THIS BOOKLET.

4.2. 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
GO TO 4.13

No

4.3. The very first time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

Month of First Sexual
Intercourse

Year of First Sexual
Intercourse

January

2012

February

2011

March

2010

April

2009

May

2008

June

2007

July

2006

August

2005

September

2004

October

2003

November

2002

December

2001 or earlier

PPA Study – Part B1, Follow-Up 2 Chicago 11/22/2011

1

4.4. The very first time you had sexual intercourse, how old were you?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.

4.5. Have you had sexual intercourse more than one time?
MARK (X) ONE

Yes
GO TO 4.7

No

4.6. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
NUMBER OF PEOPLE – Your best guess is fine.

4.7. The most recent time you had sexual intercourse, what month and year was it?
MARK (X) ONE MONTH AND ONE YEAR

Month of Most Recent
Sexual Intercourse

Year of Most Recent Sexual
Intercourse

January

2012

February

2011

March

2010

April

2009

May

2008

June

2007

July

2006

August

2005

September

2004

October

2003

November

2002

December

2001 or earlier

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4.8. The most recent time you had sexual intercourse, did you or your partner use…?
MARK (X) ONE FOR EACH

YES
NO
a. Condoms........................................................................................................................................................
b. Birth control pills or the patch ........................................................................................................................
c. Depo-Provera or other injectable birth control ...............................................................................................
d. NuvaRing or the ring ......................................................................................................................................
e. Withdrawal or pulling out ...............................................................................................................................
f.

Another method? PRINT OTHER METHOD USED

...................................................................................

4.9. Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
sexual intercourse?
None

GO TO 4.13

NUMBER OF TIMES – Your best guess is fine.

4.10. 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.

4.11. In the past 3 months, of those times you used a condom during sexual intercourse, how many
times did the condom break or slip off during sex?
None
NUMBER OF TIMES – Your best guess is fine.

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4.12. 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)
Implants (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.

4.13. Now please think about the past 12 months.
In the past 12 months, how often have you had a relationship that was just sexual?
MARK (X) ONE

Never
Once
More than once

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4.14. 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
GO TO 4.19

No

4.15. The very first time you had oral sex, what month and year was it?
MARK (X) ONE MONTH AND MARK (X) ONE YEAR

Month of First Oral Sex

Year of First Oral Sex

January

2012

February

2011

March

2010

April

2009

May

2008

June

2007

July

2006

August

2005

September

2004

October

2003

November

2002

December

2001 or earlier

4.16. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.

4.17. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had oral sex?
None

GO TO 4.19

NUMBER OF TIMES – Your best guess is fine.

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4.18. 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.

4.19. 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
GO TO 5.1

No

4.20. How many DIFFERENT PEOPLE have you ever had anal sex with, even if only one time?
NUMBER OF PEOPLE – Your best guess is fine.

4.21. The very first time you had anal sex, what month and year was it?
MARK (X) ONE MONTH AND MARK (X) ONE YEAR

Month of First Oral Sex

Year of First Oral Sex

January

2012

February

2011

March

2010

April

2009

May

2008

June

2007

July

2006

August

2005

September

2004

October

2003

November

2002

December

2001 or earlier

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4.22. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had anal sex?
None

GO TO 5.1

NUMBER OF TIMES – Your best guess is fine.

4.23. 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.

PPA Study – Part B1, Follow-Up 2 Chicago Version 11/22/2011

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SECTION 5
5.1. Have you or your partner ever taken a pregnancy test?
MARK (X) ONE

Yes
No
Don’t know

5.2. a.

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 5.3

b. To the best of your knowledge, how many times have you been pregnant or gotten someone
pregnant?
NUMBER OF TIMES - Your best guess is fine.

c.

How old were you the first time you got pregnant or got someone pregnant?
NUMBER OF YEARS OLD YOU WERE – Your best guess is fine.

d. Have you ever had a baby or has anyone you got pregnant actually had the baby?
MARK (X) ONE

Yes
No
Don’t know

5.3. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted diseases, also known as STDs?
MARK (X) ONE

Yes
No

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5.4. In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
disease (also known as an STD), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE

Yes
No

5.5. In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted disease (also known as an STD)?
MARK (X) ONE

Yes
No

5.6. The next series of questions is about the types of sexually transmitted diseases (STDs) you have
had. In the past 12 months, did you have…?
MARK (X) ONE FOR EACH

YES

NO

DON’T
KNOW

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

PPA Study – Part B1, Follow-Up 2 Chicago Version 11/22/2011

...........................................................

9

SECTION 6: ALCOHOL AND DRUG USE
6.1. The next questions are about alcohol and drug use. Please remember, everything you tell us will
be kept private.
During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

GO TO 6.4

6.2. During the past 30 days, on how many days did you have 5 or more drinks in a row?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

6.3. During the past 30 days, on how many days did you get drunk or wasted?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

6.4. During the past 30 days, on how many days did you use marijuana, also called weed or pot?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

6.5. Have you ever used any other type of illegal drug, prescription drugs, or an inhalant that were not
prescribed for you?
MARK (X) ONE

Yes
No

PPA Study – Part B1, Follow-Up 2 Chicago Version 11/22/2011

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SECTION 7: FRIENDS
7.1. In general, how much pressure, if any, do you feel from your friends to have sexual intercourse?
MARK (X) ONE

A lot of pressure
Some pressure
A little pressure
No pressure

7.2. How often is each of the following statements true for you?
MARK (X) ONE FOR EACH

NEVER
TRUE

SOMETIMES
TRUE

OFTEN
TRUE

ALMOST
ALWAYS
TRUE

a. I can trust my friends .....................................................................................................................................
b. My friends want the best for me in my life .....................................................................................................
c. My friends care about me ..............................................................................................................................
d. My friends are there for me if I need them .....................................................................................................

Please put all three parts of the survey back
into the envelope and give the envelope back
to the moderator.
Thank you!

PPA Study – Part B1, Follow-Up 2 Chicago Version 11/22/2011

11

We thank you for
completing this survey!

PPA Study – Part B1, Follow-Up 2 Chicago Version 11/22/2011

12

Form approved
OMB No. 0990-0382
Expiration Date: xx/xx/20xx

FOLLOW-UP QUESTIONNAIRE
PART B2
CHICAGO
Please be sure that you have the correct PART B.
If you answered “No” to the last question of Part A, you have the correct Part B. If
you answered “Yes,” put this version back in your envelope and fill out Part B1
instead.
Thank you.
Mathematica Policy Research

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 0990-0382. The time
required to complete this information collection is estimated to average 36 minutes per response, including the time to review
instructions 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

PART B
4.1. This booklet is for youth who have not had sex. We want to be sure you are in the correct
booklet. We know we asked this before but…
Just to confirm, have you ever had sexual intercourse, oral sex, or anal sex?
Yes

STOP! GO TO PART B1 INSTEAD.

No

CONTINUE WITH THIS BOOKLET.

4.2. The first two questions in this part are about your schooling.
Do you expect that you will graduate from high school?
MARK (X) ONE

Yes

I already graduated from high school
GO TO 4.4

No

4.3. In what month and year do you expect to graduate from high school? If you already graduated, in
what month and year did you graduate from high school?
MARK (X) ONE MONTH AND ONE YEAR

Month of Graduation

Year of Graduation

January

2018 or later

February

2017

March

2016

April

2015

May

2014

June

2013

July

2012

August

2012

September

2010

October

2009

November

2008

December

2007 or earlier

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

1

4.4. Here are some reasons people your age might choose NOT to have sexual intercourse. How
important is each of these reasons to YOU?
MARK (X) ONE FOR EACH QUESTION

VERY
IMPORTANT

SOMEWHAT
IMPORTANT

NOT TOO
IMPORTANT

NOT AT ALL
IMPORTANT

a. I don’t want to get a sexually transmitted
disease, also known as an STD ..................................................................................................................
b. I don’t want to disappoint my parents ..........................................................................................................
c. I am too young to have sex .........................................................................................................................
d. My boyfriend or girlfriend doesn’t want
to have sex ..................................................................................................................................................
e. I want to wait until I’m married .....................................................................................................................
f.

It is against my personal values ..................................................................................................................

g. I haven’t met the right person yet ................................................................................................................
h. I haven’t had the chance..............................................................................................................................
i.

I don’t want to ..............................................................................................................................................

j.

FOR GIRLS I don’t want to get pregnant ...................................................................................................

k. FOR BOYS I don’t want to get a girl pregnant ...........................................................................................

4.5. What do you think are the benefits of waiting to have sexual intercourse?
MARK (X) ONE FOR EACH

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

a.

Respect for yourself ......................................................................................................................................

b.

Respect from parents ....................................................................................................................................

c.

Keeping true to religious values ....................................................................................................................

d.

Respect from friends .....................................................................................................................................

e.

Not having to worry about pregnancy ...........................................................................................................

f.

Not having to worry about sexually transmitted
diseases, also known as STDs .....................................................................................................................

g.

Better chance for a good marriage in the future ...........................................................................................

h.

Fewer distractions so you can focus on school work ....................................................................................

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

2

4.6. Do people need religion to have good values?
MARK (X) ONE

Yes
No

4.7. Should religious teachings be obeyed in every situation?
MARK (X) ONE

Yes
No

4.8. Do you pray every day?
MARK (X) ONE

Yes
No

4.9. Do you think it’s embarrassing for people your age to admit they are virgins?
MARK (X) ONE

Yes
No

4.10. Do you think it’s embarrassing for girls your age to get pregnant?
MARK (X) ONE

Yes
No

4.11. In the group you hang out with, how important is it to have a girlfriend or boyfriend or to be going
out with someone?
MARK (X) ONE

Very important
Not too important
Not important at all

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

3

4.12. The next few questions are about your access to and use of TV, cell phones, computers and
other forms of technology.
Do you personally have a phone, computer, or other device that can connect to the internet?
MARK (X) ONE

Yes
No

4.13. Do your parents have any rules about…?
MARK (X) ONE FOR EACH

YES

NO

NOT
APPLICABLE

a.

The amount of time or when you can text, talk on the phone,
watch TV or be on the computer ...................................................................................................................

b.

Whether or not you can have a profile on a social
networking site like MySpace or Facebook ...................................................................................................

4.14. Do your parents have any rules about what you are allowed to watch on TV?
MARK (X) ONE

Yes
No

4.15. Do your parents have any rules about what sites you can access on the internet?
MARK (X) ONE

Yes
No

4.16. Some people exchange sexy text messages, videos, or pictures of themselves or their friends.
How common would you say each of the following is among people your age?
MARK (X) ONE FOR EACH

NOT
COMMON
AT ALL

NOT
VERY
COMMON

FAIRLY
COMMON

VERY
COMMON

a.

Sending or posting sexy text messages............................................................................................................

b.

Sending or posting sexy pictures or video ........................................................................................................

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4.17. Have you ever sent a sexy message, picture, or video of yourself by email, IM or text (or posted
one to the internet)?
MARK (X) ONE

Yes
No

GO TO 4.19

4.18. Which of the following reasons did you have for sending or posting a sexy message, picture or
video of yourself?
MARK (X) ONE FOR EACH

YES

NO

a. To get or keep a guy’s or girl’s attention ......................................................................................................
b. Your boyfriend/girlfriend pressured you to do it ...........................................................................................
c.

As a “sexy” present for a boyfriend or girlfriend ...........................................................................................

d. To get back at someone or cause trouble ....................................................................................................
e. Pressure from friends ...................................................................................................................................
f.

To be fun or to flirt ........................................................................................................................................

g. Everybody does it .........................................................................................................................................
h. Another reason? PRINT REASON

...............................................................................................................

4.19. Have you ever received a sexy text message, or a picture or video of someone you know?
MARK (X) ONE

Yes
No

GO TO 5.1

4.20. Have you ever shared or forwarded a sexy text message, or picture or video of someone you
know?
MARK (X) ONE

Yes
No

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

5

SECTION 5
5.1. The next few questions ask about your community.
How often do you feel that there are teachers or other adults in your school who really know you
and care about you?
MARK (X) ONE

Never
Sometimes
Often
Very often

5.2. How often do you feel there are adults in your neighborhood, or in religious or youth
organizations, who really know you and care about you?
MARK (X) ONE

Never
Sometimes
Often
Very often

5.3. How often do you feel safe in your community or neighborhood?
MARK (X) ONE

Never
Sometimes
Usually
Always

5.4. How often do you feel safe at school?
MARK (X) ONE

Never
Sometimes
Usually
Always

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5.5. How often do you feel safe at home?
MARK (X) ONE

Never
Sometimes
Usually
Always

5.6. During the past 12 months, were you on a sports team or did you take sports lessons after school
or on weekends?
MARK (X) ONE

Yes
No

5.7. During the past 12 months, did you participate in any clubs or organizations after school or on
weekends, such as Scouts, a religious group, or Boy’s/Girl’s Club?
MARK (X) ONE

Yes
No

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SECTION 6: ALCOHOL AND DRUG USE
6.1. The next questions are about alcohol and drug use. Please remember, everything you tell us will
be kept private.
During the past 30 days, not including any times you just had a sip, on how many days did you
have one or more alcoholic beverages?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

GO TO 6.3

6.2. During the past 30 days, on how many days did you have 5 or more drinks in a row?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

6.3. During the past 30 days, on how many days did you get drunk or wasted?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

6.4. During the past 30 days, on how many days did you use marijuana, also called weed or pot?
MARK (X) ONE

More than 25 days
5 to 25 days
1 to 4 days
0 (zero) days

6.5. Have you ever used any other type of illegal drug, prescription drugs or an inhalant that were not
prescribed for you?
MARK (X) ONE

Yes
No

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

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SECTION 7: FRIENDS
7.1. In general, how much pressure, if any, do you feel from your friends to have sexual intercourse?
MARK (X) ONE

A lot of pressure
Some pressure
A little pressure
No pressure

7.2. How often is each of the following statements true for you?
MARK (X) ONE FOR EACH

NEVER
TRUE

SOMETIMES
TRUE

OFTEN
TRUE

ALMOST
ALWAYS
TRUE

a.

I can trust my friends .....................................................................................................................................

b.

My friends want the best for me in my life .....................................................................................................

c.

My friends care about me..............................................................................................................................

d.

My friends are there for me if I need them ....................................................................................................

Please put all three parts of the survey back
into the envelope and give the envelope back
to the moderator.
Thank you!

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

9

We thank you for
completing this survey!

PPA Study – Part B2, Follow-Up 2 Version 11/22/2011

10