Entry Survey (Instrument 1)

INSTRUMENT #1

PREP STUDIES OF PERFORMANCE MEASURES

AND ADULTHOOD PREPARATION SUBJECTS

PARTICIPANT ENTRY SURVEY

Form approved

OMB Control No:

Expiration Date:

PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP)

PARTICIPANT ENTRY SURVEY

Thank you for your help with this important study. This survey includes questions about your family, friends, school, and also your attitudes and behaviors. Your name will not be on the survey and your responses will remain private to the extent permitted by law.We want you to know that:

1. Your participation in this survey is voluntary.

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

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 8 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. The information collected will help policy makers, program providers and other stakeholders understand the experiences of youth today and identify ways to reduce risky behaviors. This information will also inform programs on how best to serve their participants. The collection of this information is voluntary and responses will be kept private to the extent allowed by law. The OMB number for this information collection is XXXX-XXXX and the expiration date is XX/XX/XXXX.

3. The answers you give will be kept private to the extent permitted by law.

General Instructions

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.

Based on your response to some of the questions, you may be instructed to skip over other questions:

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

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

EXAMPLE: QUESTION WITH A SKIP

1. Do you ever eat chocolate?

MARK (X) ONE

X

Yes

□ No GO TO QUESTION 3

2. Do you always brush your teeth after eating chocolate?

MARK (X) ONE

□ Yes

□ No

3. Did you do any of the following last week?

YOU MAY MARK (X) MORE THAN ONE ANSWER

□ Went to a play

□ Went to a movie

□ Attended a sporting event

Please answer the following questions as best you can. This first set of questions are about 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. 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 toward a GED

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

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

3. When you are at home or with your family, what language or languages do you usually speak?

mark all that apply

□ English

□ Spanish

□ Other (please specify)

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 Hispanic or Latino?

MARK YES OR NO

□ Yes

□ No

6. Which of the following best represents how you think of yourself?

MARK ONLY ONE ANSWER

□ Gay (or lesbian)

□ Straight, that is not gay (or lesbian)

□ Bisexual

□ Something else (specify) ___________________

□ Not sure

□ I don’t know the answer.

7. What sex were you assigned at birth, on your original birth certificate?

□ Male

□ Female

8. How do you describe your gender identity?

MARK ONLY ONE ANSWER

□ Male

□ Female

□ Transgender

□ Not Sure

□ Something else (specify) _________________

9. Are you currently…?

MARK ALL THAT APPLY

□ In foster care, living with a family

□ In foster care, living in a group home

□ Couch surfing or moving from house to house

□ Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle or in an abandoned building

□ Staying in an emergency shelter, transitional living program, or motel

□ In juvenile detention, jail, prison or another correctional facility, or under the supervision of a probation officer

□ None of the above

10. 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 or guardian?
c. resisted or said no to peer pressure?
d. managed conflict without causing more conflict?

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

[NOTE: middle school students will not be asked about oral sex or anal sex]

11. Have you ever had vaginal sex? Vaginal sex is when a penis is put in a vagina.

MARK ONLY ONE ANSWER

□ Yes

□ No GO TO QUESTION 11

a. In the past 3 months, how many times did you have vaginal sex? Vaginal sex is when a penis is put in a vagina.

MARK ONLY ONE ANSWER

□ I have never had vaginal sex

□ I have had vaginal sex, but not in the past 3 months GO TO QUESTION 11

□ Once

□ 2-3 times

□ 4 or more times

b. In the past 3 months, how many people did you have vaginal sex with? Vaginal sex is when a penis is put in a vagina.

MARK ONLY ONE ANSWER

□ I have never had vaginal sex

□ I have had vaginal sex, but not in the past 3 months

□ 1 person

□ 2-3 people

□ 4 or more people

c. When you had vaginal sex in the past 3 months, how often did you or a partner use a condom? Vaginal sex is when a penis is put in a vagina

MARK ONLY ONE ANSWER

□ I have never had vaginal sex

□ I have had vaginal sex, but not in the past 3 months

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

d. When you had vaginal sex in the past 3 months, how often did you or a partner use birth control OTHER than condoms? By birth control, we mean methods that can prevent pregnancy, like using birth control pills, the shot, the patch, the ring, IUD, or implant.

MARK ONLY ONE ANSWER

□ I have never had vaginal sex

□ I have had vaginal sex, but not in the past 3 months

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

e. When you had vaginal sex in the past 3 months, how often did you and your partner have sex without a condom or any form of birth control? By birth control, we mean methods that can prevent pregnancy, like using birth control pills, the shot, the patch, the ring, IUD, or implant.

MARK ONLY ONE ANSWER

□ I have never had vaginal sex

□ I have had vaginal sex, but not in the past 3 months

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

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

MARK ONLY ONE ANSWER

□ Yes

□ No GO TO QUESTION 12

a. To the best of your knowledge, how many times have you been pregnant or gotten someone pregnant, even if no child was born?

MARK ONLY ONE ANSWER

□ 0 times/ I have never been pregnant or gotten someone pregnant

□ 1 time

□ 2 times

□ 3 or more times

The next questions are about oral sex. Oral sex is when a mouth is put on a penis, vagina, or anus (another word for “anus” is “butt”).

13. Have you ever had oral sex?

MARK ONLY ONE ANSWER

□ Yes

□ No GO TO QUESTION 13

a. In the past 3 months, how many times did you have oral sex? Oral sex is when a mouth is put on a penis, vagina, or anus (another word for “anus” is “butt”).

MARK ONLY ONE ANSWER

□ I have never had oral sex

□ I have had oral sex, but not in the past 3 months GO TO QUESTION 13

□ Once

□ 2-3 times

□ 4 or more times

b. In the past 3 months, how many people did you have oral sex with? Oral sex is when a mouth is put on a penis, vagina, or anus (another word for “anus” is “butt”).

MARK ONLY ONE ANSWER

□ I have never had oral sex

□ I have had oral sex, but not in the past 3 months

□ 1 person

□ 2-3 people

□ 4 or more people

c. When you had oral sex in the past 3 months, how often did you or a partner use a condom or dental dam? Oral sex is when a mouth is put on a penis, vagina, or anus (another word for “anus” is “butt”).

MARK ONLY ONE ANSWER

□ I have never had oral sex

□ I have had oral sex, but not in the past 3 months

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

The next questions are about anal sex. Anal sex is when a penis is put in an anus (another word for “anus” is “butt”).

14. Have you ever had anal sex?

MARK ONLY ONE ANSWER

□ Yes

□ No GO TO QUESTION 14

a. In the past 3 months, how many times did you have anal sex? Anal sex is when a penis is put in an anus (another word for “anus” is “butt).

MARK ONLY ONE ANSWER

□ I have never had anal sex

□ I have had anal sex, but not in the past 3 months GO TO QUESTION 14

□ Once

□ 2-3 times

□ 4 or more times

b. In the past 3 months, how many people did you have anal sex with? Anal sex is when a penis is put in an anus (another word for “anus” is “butt”).

MARK ONLY ONE ANSWER

□ I have never had anal sex

□ I have had anal sex, but not in the past 3 months

□ 1 person

□ 2-3 people

□ 4 or more people

c. When you had anal sex in the past 3 months, how often did you or a partner use a condom? Anal sex is when a penis is put in an anus (another word for “anus” is “butt”).

MARK ONLY ONE ANSWER

□ I have never had anal sex

□ I have had anal sex, but not in the past 3 months

□ All of the time

□ Most of the time

□ Some of the time

□ None of the time

15. 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 toward others?

Thank you for participating in this survey!