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BASELINE SURVEY (IIS) –
MASTER BASELINE SURVEY
OMB Control No:
Expiration Date:
PERSONAL RESPONSIBILITY EDUCATION
PROGRAM (PREP)
BASELINE SURVEY
PART A
PRIVACY
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, community, 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 keep private. Your responses will be combined with
those of other people your age.
Mathematica Policy Research
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 45 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.
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: YOU MAY MARK (X) MORE THAN ONE ANSWER
Do you plan to do any of the following next week?
YOU MAY MARK (X) MORE THAN ONE ANSWER
X
Watch 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
PREP Baseline A 8-13-12
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
Yes
No
GO TO QUESTION 3
If you answered “No” to question 1, you would skip
question 2 and go right to question 3.
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?
YOU MAY MARK (X) MORE THAN ONE ANSWER
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 estimate 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 QUESTION
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.
PREP Baseline A 8-13-12
2
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
2010
X
2009
March
2008
April
2007
May
2006
June
2005
July
2004
August
2003
September
2002
October
2001
November
2000
December
1999
PREP Baseline A 8-13-12
If you finished elementary school in
June of 2009, you would mark (X)
the box next to June and mark (X)
the box next to 2009.
3
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. Are you male or female?
MARK (X) ONE
Male
Female
PREP Baseline A 8-13-12
4
1.3. Are you Hispanic/Latino/a?
MARK (X) ONE
Yes
No
GO TO QUESTION 1.5
1.4. Are you…?
MARK (X) ALL THAT APPLY
Mexican, Mexican American, Chicano/a
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
1.5. What is your race?
YOU MAY MARK (X) MORE THAN ONE ANSWER
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
1.6. What is the main language you speak at home?
MARK (X) ONE
English
Spanish
Some other language PRINT OTHER LANGUAGE
1.7. In the past 12 months, how often did you attend religious services or activities?
MARK (X) ONE
Never
Less than once a month
1-3 times per month
Once a week
More than once a week
PREP Baseline A 8-13-12
5
1.8. Are you currently enrolled in school? If you are currently on summer vacation but plan to return to
school, mark “yes.”
MARK (X) ONE
Yes
No
1.9. What is the highest grade you have completed?
MARK (X) ONE
Less than 7th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Higher than 12th grade
1.10. Do you have any of these?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a.
A high school diploma ...........................................................................................................
b.
A GED certificate ..................................................................................................................
c.
A certificate or license from a trade school or vocational training
program ................................................................................................................................
d.
A degree from a community college ......................................................................................
PREP Baseline A 8-13-12
6
1.11. What kind of grades do you or did you usually get in school? If you are not currently attending
school, answer based on the last school you attended.
MARK (X) ONE
My courses are not graded
Mostly As
About half As and half Bs
Mostly Bs
About half Bs and half Cs
Mostly Cs
About half Cs and half Ds
Mostly Ds
Mostly below Ds
1.12. For the last school you attended or the school you are now attending, how often did would you
say you cut classes?
MARK (X) ONE
Never or almost never
Sometimes, but less than once a week
Not every day, but at least once a week
Daily or almost every day
1.13. Thinking about all of the schools you have ever attended, how many times have you been
suspended or expelled from school?
MARK (X) ONE
Never
Once
More than once
1.14. How likely is it that you will do each of the following things?
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE
BIT LIKELY
SOMEWHAT
LIKELY
VERY
LIKELY
ALREADY
DID THIS
a. Graduate from high school .............................................................................................................
b. Graduate from a 4-year college ......................................................................................................
PREP Baseline A 8-13-12
7
1.15. How much do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE
DISAGREE
AGREE
STRONGLY
AGREE
a. I have specific goals for my future career ....................................................................................
b. I have a plan for achieving my future career goals ......................................................................
c. Planning for a career is not worth the effort.................................................................................
d. I haven’t thought much about my future career ...........................................................................
e. If I have a career, I won’t be able to enjoy
other things in life .......................................................................................................................
f. Going to college is important for getting a
good job......................................................................................................................................
1.16. How important do you think it is to do each of the following things?
MARK (X) ONE FOR EACH QUESTION
NOT THAT
IMPORTANT
SOMEWHAT
IMPORTANT
VERY
IMPORTANT
EXTREMELY
IMPORTANT
a. Keep track of your expenses .........................................................................................................
b. Compare prices when you shop ....................................................................................................
c. Set aside money for future purchases ...........................................................................................
PREP Baseline A 8-13-12
8
SECTION 2: FAMILY
2.1. 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
Your adoptive mother
Your foster mother
Your grandmother
Some other adult
Don’t have a mother or person you think of as your mother
GO TO 2.5
2.2. 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
2.3. How close do you feel to your mother or the person you think of as your mother?
MARK (X) ONE
Not at all close
Not very close
Somewhat close
Very close
2.4. How would she feel if you got pregnant or got someone pregnant at this time in your life?
MARK (X) ONE
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
PREP Baseline A 8-13-12
9
2.5. 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
Your adoptive father
Your foster father
Your grandfather
Some other adult
Don’t have a father or person you think of as your father
GO TO 2.9
2.6. 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
2.7. How close do you feel to your father or the person you think of as your father?
MARK (X) ONE
Not at all close
Not very close
Somewhat close
Very close
2.8.
How would he feel if you got pregnant or got someone pregnant at this time in your life?
MARK (X) ONE
Strongly approve
Approve
Neither approve nor disapprove
Disapprove
Strongly disapprove
PREP Baseline A 8-13-12
10
2.9. In the past 3 months, how many TIMES have you talked with your mother or your father about
each of the following things?
MARK (X) ONE FOR EACH QUESTION
NEVER
1-2
TIMES
3-9
TIMES
10 OR MORE
TIMES
a. How things are going with school work or
with your grades .........................................................................................................................
b. A personal problem you were having ..........................................................................................
c. Romantic relationships or dating.................................................................................................
d. How to resist pressures to have sex ...........................................................................................
e. Avoiding drugs or alcohol ...........................................................................................................
f. Whether you should be having sex at this
time in your life ...........................................................................................................................
2.10. The next few questions ask about your biological parents.
Do you live with your biological mother?
MARK (X) ONE
None of the time
Some of the time
Most of the time
All of the time
2.11. Do you live with your biological father?
MARK (X) ONE
None of the time
Some of the time
Most of the time
All of the time
PREP Baseline A 8-13-12
11
2.12. Which of the following best describes the relationship between your biological mother and
biological father?
MARK (X) ONE
They are married to each other
They were married to each other, but are now separated or divorced
They were never married to each other
One or both of my biological parents have died
Don’t know
2.13. In the past 12 months, how many times have you moved?
MARK (X) ONE
Never
Once
Twice
Three times
Four times or more
2.14. How long have you lived [where you live now1]?
MARK (X) ONE
Less than 1 month
1 month to 3 months
More than 3 months to 6 months
More than 6 months to 1 year
More than 1 year
2.15. All together, how many times have you run away from home for at least one night?
MARK (X) ONE
Never
Once
Twice
Three times or more
1
This wording may be adjusted slightly, depending on the program setting of the sites recruited into the study (foster care homes,
juvenile justice facilities, etc.).
PREP Baseline A 8-13-12
12
SECTION 3: YOUR RELATIONSHIPS
3.1. The next question is about how you deal with different situations.
How well can you do each of the following?
MARK (X) ONE FOR EACH QUESTION
I AM BAD
AT THIS
I AM
OKAY AT
THIS
I AM
GOOD AT
THIS
I AM
EXTREMELY
GOOD AT
THIS
a. Admit that you might be wrong during a
disagreement ..............................................................................................................................
b. Avoid saying things that could turn a disagreement
into a big fight..............................................................................................................................
c. Accept another person’s point of view even if you
don’t agree with it ........................................................................................................................
d. Listen to another person’s opinion during a
disagreement ..............................................................................................................................
e. Work through problems without arguing ......................................................................................
3.2. The next questions are about your experiences and attitudes toward romantic relationships and
dating.
How would you define your current relationship status?
MARK (X) ONE
Married
Engaged
Seriously dating
Casually dating
Not currently in a relationship or dating
PREP Baseline A 8-13-12
13
3.3. How much do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE
DISAGREE
AGREE
STRONGLY
AGREE
a. In a good dating relationship, you don’t always
get your own way. ......................................................................................................................
b. There are times when hitting or pushing between
people who are dating is okay. ...................................................................................................
c. A good dating relationship is based on mutual
respect, not just sex. ...................................................................................................................
d. People who make their dating partner jealous
deserve to be hit or pushed. .......................................................................................................
e. It would be easy to trust someone you are dating,
even when you’re apart. ..............................................................................................................
f. Avoiding a disagreement with someone you are
dating is always better than talking about your
problems. ...................................................................................................................................
3.4. Have you ever been fearful that someone you were dating or having sex with might physically
hurt you?
MARK (X) ONE
Yes
No
3.5. Do you consider yourself to be one or more of the following?
MARK (X) ALL THAT APPLY
Straight
Gay or Lesbian
Transgender
Bisexual
Something else/I have not decided
PREP Baseline A 8-13-12
14
SECTION 4: INFORMATION, THOUGHTS AND OPINIONS
4.1. In the past 12 months, did you attend any classes or sessions about the following?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Relationships, dating, or marriage ..................................................................................................
b. Abstinence from sex ......................................................................................................................
c. Methods of birth control, such as condoms, pills, etc......................................................................
d. Where to get birth control ...............................................................................................................
e. Sexually transmitted diseases, also known as STDs or STIs .........................................................
4.2. Where did you attend these classes or information sessions, for example, in health class at
school, or through a program at a community center such as the Boys Club or Girls Club, or the
YMCA? If you attended these classes or sessions at more than one place, please list all of these places
in the spaces provided below.
PLACE 1:
PLACE 2:
ADDITIONAL PLACES:
4.3. How strongly do you agree or disagree with each of the following statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE
DISAGREE
AGREE
STRONGLY
AGREE
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, the pill, etc. ......................................................................................................................
e. It is against your values to have sexual intercourse
before marriage .............................................................................................................................
PREP Baseline A 8-13-12
15
4.4.
Sometimes people don’t want to have sex but have difficulty saying “no.” How likely is it you
would be able to say “No” to having sexual intercourse…
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE
BIT LIKELY
SOMEWHAT
LIKELY
VERY
LIKELY
a. With someone you have known for a few days or less? ..................................................................
b. With someone you have dated for a long time?...............................................................................
c. With someone with whom you have already had
sexual intercourse? .........................................................................................................................
d. With someone who is pushing you to have sexual
intercourse? ....................................................................................................................................
e. With someone who does not want to use a condom?......................................................................
4.5. The next series of statements is about condom use. How strongly do you agree or disagree with
each of these statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE
DISAGREE
NEITHER
AGREE NOR
DISAGREE
AGREE
STRONGLY
AGREE
a. Condoms should always be used if a
person your age has sexual intercourse ..........................................................................................
b. Condoms are important to make sex
safer................................................................................................................................................
c. Using condoms means you don’t trust
your partner ....................................................................................................................................
d. Using condoms is morally wrong .....................................................................................................
4.6. 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
PREP Baseline A 8-13-12
16
4.7. 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
4.8. 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
4.9. 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
PREP Baseline A 8-13-12
17
4.10. If birth control pills are used correctly and consistently, how much can they decrease the risk of
getting gonorrhea?
MARK (X) ONE
Not at all
A little
A lot
Completely
Don’t know
4.11. Can you get a sexually transmitted disease, also known as an STD or STI, from having oral sex?
MARK (X) ONE
Yes
No
Don’t know
4.12. Have you ever had sexual intercourse, oral sex, or anal sex?
Yes
GO TO PART B1 AND PUT THIS BOOKLET BACK IN THE ENVELOPE
No
GO TO PART B2 AND PUT THIS BOOKLET BACK IN THE ENVELOPE
Complete the correct Part B (B1 or B2),
but not both.
PREP Baseline A 8-13-12
18
Put this booklet back in
the envelope and
Go to Part B1 or Part B2.
PREP Baseline A 8-13-12
19
OMB Control No:
Expiration Date:
PERSONAL RESPONSIBILITY EDUCATION
PROGRAM (PREP)
BASELINE SURVEY
PART B1
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
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 30 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.
PART B
5.1. The next questions are about your sexual behaviors and experiences. Please be as honest as
possible. Your answers will be kept private and will not be shared with anyone.
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.
5.2. The first questions are about sexual intercourse. By sexual intercourse, we mean a male putting
his penis into a female’s vagina2.
Have you ever had sexual intercourse?
MARK (X) ONE
Yes
No
GO TO 5.10
5.3. The very first time you had sexual intercourse, how old were you?
MARK (X) ONE
12 years old or younger
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older
2
Some sites may resist using the current definition of sexual intercourse. For these sites, sexual intercourse will be defined as “the
act that makes babies.”
PREP Baseline B 3-30-12
1
5.4. The first time you had sexual intercourse, did you or your partner use any of these methods of
birth control?
MARK (X) ONE FOR EACH QUESTION
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
................................................................
5.5. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
NUMBER OF PEOPLE – Your best estimate is fine.
5.6. Now please think about the past 3 months. In the past 3 months, have you had sexual
intercourse?
MARK (X) ONE
Yes
No
GO TO 5.10
5.7. In the past 3 months, how many TIMES have you had sexual intercourse?
NUMBER OF TIMES – Your best estimate is fine.
5.8. In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?
NUMBER OF TIMES – Your best estimate is fine.
PREP Baseline B 3-30-12
2
5.9. 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)
Implant (Implanon)
In the past 3 months, how many TIMES have you had sexual intercourse without using any of
these methods of birth control?
NUMBER OF TIMES – Your best estimate is fine.
5.10. Do you intend to have sexual intercourse in the next year, if you have the chance?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
5.11. 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
No
GO TO 5.16
5.12. The very first time you had oral sex, how old were you?
MARK (X) ONE
12 years old or younger
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older
PREP Baseline B 3-30-12
3
5.13. Now please think about the past 3 months. In the past 3 months, have you had oral sex?
MARK (X) ONE
Yes
No
GO TO 5.16
5.14. In the past 3 months, how many TIMES have you had oral sex?
NUMBER OF TIMES – Your best estimate is fine.
5.15. In the past 3 months, how many TIMES have you had oral sex without using a condom?
NUMBER OF TIMES – Your best estimate is fine.
5.16. 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
No
GO TO 5.21
5.17. The very first time you had anal sex, how old were you?
MARK (X) ONE
12 years old or younger
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older
5.18. Now please think about the past 3 months. In the past 3 months, have you had anal sex?
MARK (X) ONE
Yes
No
GO TO 5.21
5.19. In the past 3 months, how many TIMES have you had anal sex?
NUMBER OF TIMES – Your best estimate is fine.
PREP Baseline B 3-30-12
4
5.20. In the past 3 months, how many TIMES have you had anal sex without using a condom?
NUMBER OF TIMES – Your best estimate is fine.
5.21. Have you ever had oral sex or anal sex with a person the same sex as you?
MARK (X) ONE
Yes
No
PREP Baseline B 3-30-12
5
SECTION 6: HEALTHCARE AND PREGNANCY
6.1. In the past 12 months, did you receive information from a doctor, nurse, or clinic about any of the
following?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Methods of birth control, such as condoms, pills, etc................................................................
b. Where to get birth control .........................................................................................................
c. Sexually transmitted diseases, also known as STDs or STIs ...................................................
6.2. In the past 12 months, did you get any type of birth control from a doctor, nurse, or clinic, such
as condoms, pills, the shot, an implant, the ring, etc.?
MARK (X) ONE
Yes
No
6.3. In the past 12 months, have you been told by a doctor, nurse, or some other health professional
that you had any of the following sexually transmitted diseases?
MARK (X) ONE FOR EACH QUESTION
YES
NO
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
PREP Baseline B 3-30-12
......................................
6
6.4. These next few questions are about pregnancy. 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 6.7
6.5. To the best of your knowledge, how many TIMES have you been pregnant or gotten someone
pregnant?
NUMBER OF TIMES
6.6. Have you ever had a baby or has anyone you got pregnant actually had the baby?
MARK (X) ONE
Yes
No
Don’t know
6.7. If you got pregnant now or 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
PREP Baseline B 3-30-12
7
SECTION 7: ALCOHOL AND DRUG USE AND HEALTH
7.1. The next questions are about alcohol, drugs and general health. Please be as honest as possible,
and remember that your answers will be kept private and will not be shared with anyone.
During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.2. During the past 30 days, on how many days did you have one or more alcoholic beverages?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.3. During the past 30 days, on how many days did you have 5 or more drinks in a row, that is, within
a few hours?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
PREP Baseline B 3-30-12
8
7.4. During the past 30 days, on how many days did you use marijuana, also called weed or pot?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.5. During the past 30 days, on how many days did you use any other type of illegal drug, inhalant,
or a prescription drug in a way that was not prescribed?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.6. Now thinking about experiences throughout your life, how many times have you experienced the
following things?
MARK (X) ONE FOR EACH QUESTION
NEVER
ONCE
TWO OR
THREE
TIMES
FOUR OR
MORE
TIMES
a. Heard gunshots in your neighborhood........................................................................................
b. Witnessed a shooting .................................................................................................................
c. Been robbed or mugged ............................................................................................................
d. Been threatened with a gun or knife ..........................................................................................
e. Been beaten up badly enough that you needed to go to
the doctor, even if you did not end up going ...............................................................................
f. Been touched by someone or forced to touch someone
in a sexual way when you did not want to ..................................................................................
PREP Baseline B 3-30-12
9
7.7.
How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE
DISAGREE
AGREE
STRONGLY
AGREE
a. Nothing you do as a teen will affect how
healthy you are as an adult ......................................................................................................
b. You can do things now that will help you to
be healthy when you are an adult .............................................................................................
c. Taking risks as a teen, like drinking and doing
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 ......................................................................................
Please put all three parts of the survey (including
the part you didn’t fill out) back into the envelope
and give it to the moderator.
Thank you!
PREP Baseline B 3-30-12
10
Thank you for
completing this survey!
PREP Baseline B 3-30-12
11
OMB Control No:
Expiration Date:
PERSONAL RESPONSIBILITY EDUCATION
PROGRAM (PREP)
BASELINE SURVEY
PART B2
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 version of
Part B. If you answered “Yes,” please put this version back in your envelope and fill out
Part B1 instead.
Thank you.
Mathematica Policy Research
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 30 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.
PART B
5.1. 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?
MARK (X) ONE
Yes
STOP AND GO TO PART B1.
No
CONTINUE WITH THIS BOOKLET.
5.2. The first questions in this booklet are about your future plans.
Do you expect to get married in the future?
MARK (X) ONE
Yes
No
GO TO 5.5
5.3. If it were just up to you, what age would you like to get married?
MARK (X) ONE
Younger than 20 years old
20 to 24 years old
25 to 29 years old
30 to 34 years old
35 to 39 years old
40 to 44 years old
45 years old or older
5.4. If you met the right person, would you be willing to get married before these things happened?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. You had been dating for at least a year ........................................................................................
b. You had lived together .................................................................................................................
c. You had your family’s approval ....................................................................................................
d. You had graduated from high school............................................................................................
e. You had graduated from a four-year college ................................................................................
f. You had a full-time job .................................................................................................................
PREP Baseline – HFSA- 02/22/13
13
5.5. 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
5.6. How many of your friends who are your age think the following things? Your best guess is fine.
MARK (X) ONE FOR EACH
NONE
SOME
HALF
MOST
ALL
DON’T
KNOW
a. Having sexual intercourse is a
good thing for them to do at their
age ........................................................................................................................................................
b. It would be okay for them to
have sexual intercourse as long
as they used birth control, like a
condom .................................................................................................................................................
c. It would be okay for them to
have sexual intercourse if they
were dating the same person for
a long time ............................................................................................................................................
d. They should wait until they are
older to have sexual intercourse............................................................................................................
e. They should wait until marriage
to have sexual intercourse ....................................................................................................................
5.7. How many of your friends who are your age have had sexual intercourse? Your best guess is
fine.
MARK (X) ONE
None
Some
Half
Most
All
Don’t know
PREP Baseline B 3-30-12
14
5.8. 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 or an STI .................................................................................
b. I don’t want to disappoint my parents .........................................................................................
c. I am too young to have sex ........................................................................................................
d. I want to wait until I’m married ...................................................................................................
e. It is against my personal values .................................................................................................
f. I haven’t met the right person yet ...............................................................................................
g. I haven’t had the chance ............................................................................................................
h. I do not want to get pregnant or get
someone pregnant .....................................................................................................................
5.9. How strongly do you agree or disagree that each of the following statements are benefits to you
of waiting to have sexual intercourse?
MARK (X) ONE FOR EACH
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
a.
Respect for yourself ....................................................................................................................
b.
Keeping true to religious values ..................................................................................................
c.
Respect from friends...................................................................................................................
d.
Better chance for a good marriage in the future ..........................................................................
PREP Baseline B 3-30-12
15
5.10. Do you think it’s embarrassing for people your age to admit they are virgins?
MARK (X) ONE
Yes
No
5.11. Do you think it’s embarrassing for girls your age to get pregnant?
MARK (X) ONE
Yes
No
5.12. 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
5.13. Do you intend to have sexual intercourse in the next year, if you have the chance?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
PREP Baseline B 3-30-12
16
SECTION 6: HEALTHCARE AND PREGNANCY
6.1. In the past 12 months, did you receive information from a doctor, nurse, or clinic about any of the
following?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Methods of birth control, such as condoms, pills, etc................................................................
b. Where to get birth control .........................................................................................................
c. Sexually transmitted diseases, also known as STDs or STIs ...................................................
6.2. In the past 12 months, did you get any type of birth control, for example, condoms, birth control
pills, the shot, an implant, the ring, etc. from a doctor, nurse, or clinic?
MARK (X) ONE
Yes
No
6.3. In the past 12 months, did you receive information about any of the following sexually
transmitted diseases, also known as STDs or STIs?
MARK (X) ONE FOR EACH QUESTION
YES
NO
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.............................................
PREP Baseline B 3-30-12
17
6.4. These next few questions are about your future plans. Do you want to have children in the
future?
MARK (X) ONE
Yes
No
GO TO 6.7
6.5. If it were just up to you, what age would you like to have your first child?
YEARS OLD
6.6. If it were just up to you, how many children would you like to have?
MARK (X) ONE
One
Two
Three or more
6.7. If you got pregnant now or 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
PREP Baseline B 3-30-12
18
SECTION 7: ALCOHOL AND DRUG USE AND HEALTH
7.1. The next questions are about alcohol, drugs and general health. Please be as honest as possible,
and remember that your answers will be kept private and will not be shared with anyone.
During the past 30 days, on how many days did you smoke one or more cigarettes?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.2. During the past 30 days, on how many days did you have one or more alcoholic beverages?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.3. During the past 30 days, on how many days did you have 5 or more drinks in a row, that is, within
a few hours?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
PREP Baseline B 3-30-12
19
7.4. During the past 30 days, on how many days did you use marijuana, also called weed or pot?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.5. During the past 30 days, on how many days did you use any other type of illegal drug, inhalant,
or a prescription drug in a way that was not prescribed?
MARK (X) ONE
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
7.6. Now thinking about experiences throughout your life, how many times have you experienced the
following things?
MARK (X) ONE FOR EACH QUESTION
NEVER
ONCE
TWO OR
THREE
TIMES
FOUR OR
MORE
TIMES
a. Heard gunshots in your neighborhood........................................................................................
b. Witnessed a shooting .................................................................................................................
c. Been robbed or mugged ............................................................................................................
d. Been threatened with a gun or knife ..........................................................................................
e. Been beaten up badly enough that you needed to go to
the doctor, even if you did not end up going ...............................................................................
f. Been touched by someone or forced to touch someone
in a sexual way when you did not want to ..................................................................................
PREP Baseline B 3-30-12
20
7.7.
How strongly do you agree or disagree with the following statements?
MARK (X) ONE FOR EACH QUESTION
STRONGLY
DISAGREE
DISAGREE
AGREE
STRONGLY
AGREE
a. Nothing you do as a teen will affect how
healthy you are as an adult ......................................................................................................
b. You can do things now that will help you to
be healthy when you are an adult .............................................................................................
c. Taking risks as a teen, like drinking and doing
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 ......................................................................................
Please put all three parts of the survey (including
the part you did not fill out) back into the
envelope and give it to the moderator.
Thank you!
PREP Baseline B 3-30-12
21
Thank you for
completing this survey!
PREP Baseline B 3-30-12
22
| File Type | application/pdf |
| File Title | PREP BASELINE |
| Subject | SAQ |
| Author | Melissa Thomas |
| File Modified | 2013-02-28 |
| File Created | 2013-02-28 |