Exit Survey (Instrument 2)

INSTRUMENT #2

PREP STUDIES OF PERFORMANCE MEASURES

AND ADULTHOOD PREPARATION SUBJECTS

PARTICIPANT EXIT SURVEY

Form approved

OMB Control No:

Expiration Date:

PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP)

PARTICIPANT EXIT 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 15 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

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

10. Even if your program didn’t cover a topic, would you say that being in the program has made you much more likely, somewhat more likely, about the same, somewhat less likely or much 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. be the best you can be?
b. resist or say no to peer pressure?
c. know how to manage stress?
d. manage conflict without causing more conflict?
e. form friendships that keep you out of trouble?
f. be respectful toward others?
g. make plans to reach your goals?
h. care about doing well in school?
i. get more education after high school?
j. get a steady job after you finish high school?
k. share ideas or talk about things that really matter with a parent or guardian?
l. make healthy decisions about drugs and alcohol?
m. manage money carefully, such as making a budget, saving, or investing?

11. The next few questions refer to vaginal sex and your risk of pregnancy and sexually transmitted diseases. Please respond, even if you are not planning on having sex in the next 3 months. Vaginal sex is when a penis is put in a vagina.

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

a. have vaginal sex in the next 3 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ Not at all likely

b. use (or ask your partner to use) a condom if you were to have vaginal sex in the next 3 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from vaginal sex
(choose not to have vaginal sex) in the next 3 months

c. use (or ask your partner to use) birth control OTHER than condoms if you were to have vaginal sex in the next 3 months? 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

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from vaginal sex (choose not to have vaginal sex) in the next 3 months

d. use (or ask your partner to use) a condom or other form of birth control if you were to have vaginal sex in the next 3 months ? 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

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from vaginal sex (choose not to have vaginal sex) in the next 3 months

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

12. The next few questions refer to oral sex and your risk of sexually transmitted diseases. Please respond, even if you are not planning on having oral sex in the next 3 months. Oral sex is when a mouth is put on a penis, vagina, or anus

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

a. have oral sex in the next 3 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ Not at all likely

b. use (or have your partner use) a condom or dental dam if you were to have oral sex in the next 3 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from oral sex (choose not to have oral sex) in the next 3 months

13. The next few questions refer to anal sex and your risk sexually transmitted diseases. Please respond, even if you are not planning on having anal sex in the next 3 months. Anal sex is when a penis is put in an anus (another word for “anus” is “butt”).

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

a. have anal sex in the next 3 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ Not at all likely

b. use (or have your partner use) a condom if you were to have anal sex in the next 3 months?

MARK ONLY ONE ANSWER

□ Much more likely

□ Somewhat more likely

□ About the same

□ Somewhat less likely

□ Much less likely

□ I will abstain from anal sex (choose not to have anal sex) in the next 3 months

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.

14. 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	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 have a chance to ask questions about topics or issues that came up in the program?
e. did you feel respected as a person?
f. were you picked on, teased, or bullied in this program?

15. 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	None of the Time
a. were any youth in this program picked on, teased, or bullied because people thought they were lesbian, gay, bisexual, or transgender?
b. were any youth in this program picked on, teased, or bullied because of their race or ethnic background?

Thank you for participating in this survey!