Form 0920-xxxx Sample Instrument: Youth Pre/Post Questionnaire

Form Approved

OMB No. 0920-new

Expiration Date: 00/00/0000

Attachment 4

Sample Instrument: Youth Pre/Post Questionnaire

Please note: This is the same example questionnaire provided in Attachment 3. It could be used both before and after an intervention to assess change between two time points. It is provided here as a separate attachment to prevent confusion on the part 2 worksheet documentation.

Public reporting burden of this collection of information is estimated to average 50 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New).

This survey is about your experiences in school. The survey asks about a number of things in your in school. The survey will include questions about topics taught in schools, experiences with harassment and bullying and about sexual behaviors that cause AIDS, other sexually transmitted disease, and pregnancy. The information will be used to improve the school environment at your school so that students feel safer and will help to improve health behavior.

Because the survey is anonymous, no one will know your answers. DO NOT write your name on this survey. The answers you give will be kept private. Again, no one will know what you write. Answer the questions based on what you really do and what you really think.

Completing this survey is voluntary. That means you do not have to take it. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank.

The questions that ask about your background will be used only to describe the types of students completing this survey. The information will NOT be used to find out your name. No names will ever be reported.

Make sure to read every question. Fill in the circles completely. When you are finished, follow the instructions of the person giving you the survey.

Thank you very much for your help!

DIRECTIONS

• Use a #2 pencil only.

• Make dark marks.

• Fill in a response like this:

• If you change your answer, erase your old answer completely.

	TELL US ABOUT YOURSELF
	How old are you?
	A. 12 years old or younger
	B. 13 years old
	C. 14 years old
	D. 15 years old
	E. 16 years old
	F. 17 years old
	G. 18 years old or older
	What is your sex?
	A. Female
	B. Male
	In what grade are you?
	A. 9th grade
	B. 10th grade
	C. 11th grade
	D. 12th grade
	E. Ungraded or other grade
	Are you Hispanic or Latino?
	A. Yes
	B. No
	What is your race? (Select one or more responses).
	A. American Indian or Alaska Native
	B. Asian
	C. Black or African American
	D. Native Hawaiian or Other Pacific Islander
	E. White
	Who would you say you are attracted to?
	A. Females
	B. Males
	C. Females and Males
	D. I don’t know
	Which of the following best describes you?
	A. Heterosexual (straight)
	B. Gay or Lesbian
	C. Bisexual
	D. I don’t know
	QUESTIONS ABOUT HEALTH EDUCATION & RELATED TOPICS
	Have you ever been taught about AIDS or HIV infection in school?
	A. Yes
	B. No
	C. I don't know
	Have you ever been taught in school about how to use condoms?
	A. Yes
	B. No
	C. I don't know
	Have you seen any posters or messages related to HIV or STD prevention education in your school in the last 30 days?
	A. Yes
	B. No
	C. I don't know
	Have you seen any posters or messages related to HIV or STD testing in your school in the last 30 days?
	A. Yes
	B. No
	C. I don't know
	Have you seen any posters or messages related to HIV or STD testing in your community in the last 30 days?
	A. Yes
	B. No
	C. I don't know
	QUESTIONS ABOUT SEXUAL BEHAVIOR AND SEXUAL HEALTH SERVICES
	The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex
	Have you ever had sexual intercourse?
	A. Yes
	B. No (if no, skip to #14)
		13a. During your life, with whom have you had sex?
		A. Females
		B. Males
		C. Females and Males
		13b. The last time you had sexual intercourse, did you or your partner use a condom?
		A. Yes
		B. No
	Have you ever been tested for HIV, the virus that causes AIDS? (Do not count tests done if you donated blood.)
	A. Yes
	B. No
	C. I don't know
	Have you ever been tested for other sexually transmitted diseases (STDs) such as genital herpes, chlamydia, syphilis, or genital warts?
	A. Yes
	B. No
	C. I don't know
	During this school year, did a staff member at your school (such as a teacher, counselor, nurse, coach or other school staff) provide you with a referral to HIV testing services or treatment?
	A. Yes
	B. No (if no, skip to #17)
		16a. Did you receive HIV testing because of the referral?
		A. Yes
		B. No
		C. I don't want to say
			16b. Did that person check to see that you received HIV testing?
			A. Yes
			B. No
			C. I don't want to say
	During this school year, did a staff member at your school (such as a teacher, counselor, nurse, coach or other school staff) provide you with a referral to STD testing services or treatment?
	A. Yes
	B. No (if no, skip to #18)
		17a. Did you receive STD testing because of the referral?
		A. Yes
		B. No
		C. I don't want to say
			17b. Did that person check to see that you received STD testing?
			A. Yes
			B. No
			C. I don't want to say
	During this school year, did a staff member at your school (such as a teacher, counselor, nurse, coach or other school staff) provide you with a referral to other sexual health services such as contraceptives like condoms or pills or HPV vaccine?
	A. Yes
	B. No (if no, skip to #19)
		18a. Did you receive other sexual health services because of the referral?
		A. Yes
		B. No
		C. I don't want to say
			18b. Did that person check to see that you received other sexual health services?
			A. Yes
			B. No
			C. I don't want to say
	During this school year, did a staff member at your school (such as a teacher, counselor, nurse, coach or other school staff) provide you with a referral to counseling, psychological, or social services?
	A. Yes
	B. No (if no, skip to #20)
		19a. Did you receive counseling, psychological, or social services because of the referral?
		A. Yes
		B. No
		C. I don't want to say
			19b. Did that person check to see that you received counseling, psychological, or social services?
			A. Yes
			B. No
			C. I don't want to say
	EXPERIENCES AT SCHOOL
	Please select the answer that best describes your experiences at your school.
	I feel close to people at this school.
	A. Strongly disagree
	B. Disagree
	C. Neither agree or disagree
	D. Agree
	E. Strongly agree
	I am accepted and feel like I belong at this school.
	A. Strongly disagree
	B. Disagree
	C. Neither agree or disagree
	D. Agree
	E. Strongly agree
	I feel happy at this school.
	A. Strongly disagree
	B. Disagree
	C. Neither agree or disagree
	D. Agree
	E. Strongly agree
	Staff (such as a teacher, counselor, nurse, coach or other school staff) at this school treats students fairly.
	A. Strongly disagree
	B. Disagree
	C. Neither agree or disagree
	D. Agree
	E. Strongly agree
	Staff (such as a teacher, counselor, nurse, coach or other school staff) at this school care about me.
	A. Strongly disagree
	B. Disagree
	C. Neither agree or disagree
	D. Agree
	E. Strongly agree
	Do you feel safe at your school?
	A. Yes (if yes, skip to #26)
	B. No
		25a. Do you feel unsafe at your school because of your sexual orientation?
		A. Yes
		B. No
	Do you avoid spaces at school because you feel uncomfortable or unsafe in the space?
	A. Yes
	B. No (if no, skip to #27)
		26a. Which of the following spaces at school do you avoid because you feel uncomfortable or unsafe in the space? Please mark all that apply.
		Cafeteria or lunch room
		Locker rooms
		Hallways/stairwells
		School athletic fields or facilities
		School buses
		Physical Education (PE) or gym class
		School grounds, not including athletic fields (example: parking lots)
		Another space not listed above
		I don’t avoid anywhere at school because of feeling uncomfortable or unsafe
	How often do you avoid school functions (dances, assemblies, etc.) because you feel uncomfortable or unsafe?
	A. Always
	B. Most of the time
	C. Some of the time
	D. Never
	During the past 30 days, on how many days did you not go to school?
	A. 0 days (If 0 days, skip to #30)
	B. 1 day
	C. 2 or 3 days
	D. 4 or more days
	During the past 30 days, on how many days did you not go to school because you felt unsafe at school or unsafe on your way to or from school?
	A. 0 days
	B. 1 day
	C. 2 or 3 days
	D. 4 or more days
	How often do you hear the word “gay” used in a negative way (such as “That’s so gay” or “You’re so gay”) in school?
	A. Always
	B. Most of the time
	C. Some of the time
	D. Never
	How many students do you hear make homophobic remarks?
	A. Most of the students
	B. Some of the students
	C. A few of the students
	D. None of the students
	When you hear homophobic remarks, how often does another student intervene or do something about it?
	A. Always
	B. Most of the time
	C. Some of the time
	D. Never
	When homophobic remarks are made and a teacher or other school staff person is present, how often does the teacher or staff person intervene or do something about it?
	A. Always
	B. Most of the time
	C. Some of the time
	D. Never
	How often do you hear homophobic remarks from teachers or school staff?
	A. Always
	B. Most of the time
	C. Some of the time
	D. Never
	How many teachers or other school staff at your school do you know who are openly LGBT?
	A. None
	B. One
	C. Between 2 and 5
	D. Between 6 and 10
	E. More than 10
	Does your school have a Gay-Straight Alliance (GSA) or another type of club that addresses Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) student issues?
	A. Yes
	B. No
	C. I don’t know
	This school year, have you seen a sticker or poster anywhere in your school promoting safe spaces?
	A. Yes
	B. No
	C. I don't know
	QUESTIONS ABOUT HARRASSMENT AND BULLYING
	Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.
	How many times have you seen or heard of students being bullied?
	A. 0 times
	B. 1 time
	C. 2-3 times
	D. 4-5 times E. 6 or more times
	Do students at school bully you:
	A. Always
	B. Most of the time
	C. Some of the time
	D. Never
	Has a teacher or another adult at school told our class about bullying this school year?
	A. Yes
	B. No
	C. I don’t know
	Do you know how to report a bullying incident?
	A. Yes
	B. No
	During the past 3 months, how many times on school property were you harassed or bullied?
	0 times (skip to question 46)
	1 time
	2-3 times
	4 or more times
	6 or more times
	During the past 3 months, how many times outside of school property were you harassed or bullied?
	0 times
	1 time
	2-3 times
	4 or more times
	6 or more times
	During the past 3 months, how many times did you experience cyber-bullying?
	0 times
	1 time
	2-3 times
	4 or more times
	6 or more times
	Do you think you were harassed or bullied during the past 3 months because of any of the following reasons? Please mark all that apply.
	Your race or ethnicity or because people think you are of a certain race or ethnicity
	Your family’s income or economic status
	Your religion or because people think you are of a certain religion
	Your disability or because people think you have a disability
	Your gender
	Your sexual orientation or what others think about your sexual orientation
	How you express your gender (how traditionally “masculine” or “feminine” you are in your appearance or in how you act)
	Other reason
	None of the above

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