Young Adult 12 Month Follow-Up Survey
Transition Living Program Evaluation
D. TLP_YouthFollowUpSurvey_forNSchange_withBCF_CLEAN_20180502
Young Adult 12 Month Follow-Up Survey
OMB: 0970-0383
TLP OUTCOMES STUDY
YOUNG ADULT FOLLOW-UP SURVEY
[6-Month/12-Month Follow Up]
TLP Outcomes Study Young Adult Follow-Up Survey
[6-Month/12-Month Follow Up]
Contents
Section A: Housing Experiences 14
Section C: TLP and Service Experiences 8
Section D: Your Feelings and Health 17
Supportive Relationships with Adults 19
Supportive Peer Relationships 19
Section E: Education and Training 23
Programming Notes
Display “back” “next” “or" buttons and on each screen.
Display a reminder not to use the forward and back buttons in the internet browser but to use the survey forward and back buttons.
Display a progress bar on each screen.
Time out after 7 minutes of inactivity. Display a one-minute timeout warning enabling user to extent time out period another 7 minutes.
Unless otherwise specified (by “select all that apply”), only one answer is permitted per item.
Participants may skip any item.
For select questions, if a response/answer is not provided, after respondent clicks “continue,” the following pop-up warning should appear confirming that they want to skip. It should read: “We didn’t get an answer to one or more of the last questions. Please provide your best answer(s), even if you're not completely sure. If you prefer to skip this question(s), you can click "Next".
Special codes:
Code a legitimate (planned) skip as -101
Code unplanned skips as -9999
Code “don’t know” as -98
Code refusals (i.e., “rather not say”) as -99
Code not applicable (i.e., “does not apply to me”) as -100
Item-specific programming notes appear in Blue Font throughout the survey.
Notations regarding the construct being measured and/or its source are shown in Red Font. These must NOT be displayed on the programmed survey.
Yellow Highlighting indicates information that is pending and will be updated.
Section headings (in black font) may be displayed if desired.
Welcome
WELCOME TO THE TLP OUTCOMES STUDY [6-MONTH/12-MONTH] FOLLOW-UP SURVEY!
You are part of an important study called the TLP Outcomes Study. You signed up for it at [insert TLP name].
What’s the study about?
The study is learning about how communities can help young adults like you develop the skills they need to build strong futures. Participation in this study is voluntary.
What will happen?
When you joined the study, you were asked to take part in three surveys over 12 months. Now, we’re asking you to take the [second/third] survey. You will get a [$30/$40] electronic gift card to Amazon.com for your time completing it.
[In paragraph above pipe in “second” and “$30” for 6 month survey. Pipe in “third” and “$40” for 12-month survey]
The questions in this survey take about 37 minutes to answer. You will be asked to check and update your contact information. You will be asked about the places you’ve stayed, your experiences, thoughts and feelings. You may skip questions or stop answering questions at any time.
What happens to my answers?
Only the study team and authorized study team members can see your answers. Your answers will be combined and reported with the answers of all the other people in the study.
Who should I contact if I have any questions about the study?
If you have any questions about the study, you can email or call the people who are doing the study at XXX@abtassoc.com or (855) 579-6654. This is a free call.
Tracking and Verification
To help us make sure we are giving you the right survey, please enter your name and date of birth below.
Name. : First Name: ______________ Middle Initial: _____ Last Name: ______________
Date of birth: __/__/____ [MM/DD/YYYY format, provide dropdown]
Where were you born? _________________________________
City State Country
Continue
[Use name and DOB or birthplace to confirm respondent’s identity, check for match in sample file, and confirm ID match with prior wave(s) of data.]
OMB Control No: 0970-0383
Expiration Date: XX/XX/XXXX
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden of this collection of information is estimated to average 0.61 hours 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 [Contact Name]; [Contact Address]; Attn: OMB-PRA (xxxx-xxxx).
Gift Card Information
First, we want to make sure we know where to send your electronic gift card after you complete this survey.
Gift1. After you finish and submit your survey, we will email or text you an electronic gift card to Amazon.com. How would you like us to send you the gift card?
(Select only one answer)
Email it to me [ ] 01
Text it to my cell phone [ ] 02
I do not have an email address or cell phone you can text to [ ] 00
[If Gift1 = 0, present Gift1b. Else skip to Contact1]
Gift1b. Instead of emailing or texting you your electronic gift card, we can send the information by mail. We will ask for the address to send it to a little later in the survey.
Contact1. Is your contact information shown below correct?
Yes [ ] 01
No [ ] 00
[Insert current contact info from sample file.]
First Name _________________ Middle Initial ______ Last Name ________________
Street Address
City State Zip Code
Cell Phone Number Other Phone Number
[If Contact1=0, allow to correct contact info Change Information : Continue ]
Contact Info Check: If missing any piece of contact information in Contact1, present a pop-up that reads: We do not seem to have a <contact info item> for you. Would you like to go back and provide that information so we can be sure to reach you for future surveys and to provide you with your electronic gift card from completing this survey? Go Back Continue ]
[Check that email in standard form, containing @ and .com, .net, .biz, .edu, etc. If not, present error message that reads: “The email address you entered is not in standard form. Please re-enter your email address.”]
[If Gift1 = 0, ask Gift3.]
[If Gift1 = 1 or 2, ask Gift2]
[If Gift1 skipped, ask Gift2c]
[If Gift1=1 and no email in contact form, ask to Gift 2c_alt]Gift1=2 and no cell in contact form, ask to Gift 2c_alt]
Gift2. Earlier you told us to send your electronic gift card to you by [if Gift1 = 1 insert “email” if Gift1 = 2 insert “text”]. Please confirm where to send your electronic gift card
|
Yes (01) |
No (00) |
[if Gift1 = 1 present:
|
|
|
[if Gift1 = 2 present:
|
|
|
[If Gift2a=1, skip to Contact 3, If Gift2b=1, ask Gift2d]
Gift2c]
Gift2c. Please tell us how to send you your electronic gift card:
(Select only one answer)
|
|
Enter the [email address/ cell phone number] we should use here: |
|
|
Email it to me at: |
|
01 |
|
Text it to my cell phone: |
|
02 |
|
I do not have an email address or cell phone you can send it to |
03 |
|
[If Gift2c = 3, Go to Gift3]
[If no response is selected = “Please select Email it to me at, Text it to my cell phone, or I do not have an email address or cell phone you can send it to.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c = 2 and cell phone number is left blank = “Please enter your 10 digit cell phone number.” IF STILL NOT ANSWERED: Go to Gift3]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Gift3]
[If not all ten digits or if letters are entered for the cell phone number = “Phone Number must be 10 digits (numbers only). The first three are the Area Code. Please re-enter the 10 digit cell phone number.” IF STILL NOT CORRECTED: Go to Gift3]
Gift2c_alt. Please provide your [if Gift1=1 email address/ Gift1=2 cell phone], so we can send you your electronic gift card:
(Select only one answer)
|
|
Enter the [email address/ cell phone number] we should use here: |
|
|
|
Email it to me at: |
|
01 |
|
|
Text it to my cell phone: |
|
02 |
|
|
I do not have an email address or cell phone you can send it to |
|
03 |
|
[If Gift2c_alt= 3, Go to Gift3]
[If no response is selected = “Please select Email it to me at, Text it to my cell phone, or I do not have an email address or cell phone you can send it to.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c_alt = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c_alt = 2 and cell phone number is left blank = “Please enter your 10 digit cell phone number.” IF STILL NOT ANSWERED: Go to Gift3]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Gift3]
[If not all ten digits or if letters are entered for the cell phone number = Phone Number must be 10 digits (numbers only). The first three are the Area Code. Please re-enter the 10 digit cell phone number. IF STILL NOT CORRECTED: Go to Gift3]
[If Gift1, Gift2c or Gift2c_alt = 2 (text), ask Gift 2d]
Gift2d. In order to text you your gift card codes, we need to know which company provides your cell phone service (Please select one):
|
AT&T |
[Insert provider logo] |
|
Boost Mobile |
[Insert provider logo] |
|
Cricket |
[Insert provider logo] |
|
Sprint |
[Insert provider logo] |
|
T-Mobile |
[Insert provider logo] |
|
US Cellular |
[Insert provider logo] |
|
Verizon |
[Insert provider logo] |
|
Virgin Mobile |
[Insert provider logo] |
|
Company Not Listed |
|
|
I Don’t Know |
|
[If Gift2d = “AT&T” “Boost Mobile” “Cricket” “Sprint” “T-Mobile” “US Cellular” “Verizon” or “Virgin Mobile” go to Contact 2]
[If Gift2d = “company not listed” or “don’t know” show the following prompt and redirect the participant to provide an email or mailing address. “We can only send a text message to the companies that are listed on screen. If the company that provides your cell phone service is not listed or you do not know the name of your cell provider, we will not be able to text your gift card information to you.”, Go to Gift2e]
Gift2e. Please tell us how to send you your electronic gift card:
(Select only one answer)
|
|
Enter the [email address/mailing address] we should use here: |
|
|
|
Email it to me at: |
|
01 |
|
|
Mail it to me: |
|
02 |
|
|
I do not have an email address or mailing address you can send it to |
|
03 |
|
[If Gift2e = 2, Go to Gift 3]
[If Gift2e = 3, Go to Gift4]
[If no response is selected = “Please select Email it to me at, Mail it to me or I do not have an email address or mailing address you can send it to.” IF STILL NOT ANSWERED: Go to Gift4]
[If Gift2e = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Gift4]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Gift3]
Gift3. Earlier you told us that you do not have an email address or a cell phone where we can text your electronic gift card. We can mail it to you instead.
[If Gift2c or Gift2c_alt = 3 or skipped or Gift2e = 2 or skipped or the email or cell entered at Gift2c, Gift2c_alt, Gift2e is not valid, present this text instead: “You did not provide an email address or a cell phone where we can text your electronic gift card. We can mail it to you instead.”]
[If has address in Contact1, present Gift3a]
Gift3a. Is the address below where we should send it?
[Insert contact info from above. If no address is provided, Go to Gift 3b.]
Street Address
City ____________________ State ________ Zip Code
Yes [ ] 01
No [ ] 00
[If Gift3a =0 or skipped, ask Gift3b]
[If NO address in Contact1, present Gift3b]
Gift3b. Please tell us where to mail your electronic gift card:
|
|
Street Address |
_______________________________ |
City |
_______________________________ |
State |
_______________________________ |
Zip Code |
_______________________________ |
[If Gift3b left blank (skipped), Go to Gift4]
[Apt# can be left blank]
[If Street Address is left blank = “Please enter your street address.” IF STILL NOT ANSWERED: Go to Gift4]
[If City is left blank = “Please enter your city.” IF STILL NOT ANSWERED; Go to Gift4]
[If numeric values are entered for the City = “Only letters may be entered for your city. We need a valid address.” IF STILL NOT CORRECTED: Go to Gift4]
[If Zip Code is left blank = “Please enter your zip code.” IF STILL NOT ANSWERED: Go to Gift4]
[If letters are entered in the zip = “Zip code must be 5 digits (numbers only). We need a valid address.” IF STILL NOT CORRECTED: Go to Gift4]
[If no contact information provided for gift card (no email, no cell, no mailing address), present the following statement
Gift4. Because you did not provide an email address, a cell phone number to send a text, or a mailing address, we cannot send you an electronic gift card. If you have any questions, please email XXX@abtassoc.com or call (855) 579-6654. This is a free call.
I would like to provide contact information…………………………………………….……………....[ ] 01
I understand I will not receive an electronic gift card ………………………………………..……....[ ] 02
[If Gift4 = 1, Go to Gift1]
[If Gift4 = 2, Go to Contact 4]
[If cell phone provided in Contact1, ask Contact2 and Contact3, else skip to Contact4]
Contact2. Is it OK for us to text your cell phone about the study?
(Please keep in mind that your cell phone carrier may charge a fee to receive or send text messages, depending on your plan.)
Yes [ ] 01
No [ ] 00
Contact3. Is it OK for us to leave a message on your cell phone about the study?
Yes [ ] 01
No [ ] 00
[If other phone provided in Contact1, ask Contact4, else skip to Contact5]
Contact4. Is it OK for us to leave a message on your other phone about the study?
Yes [ ] 01
No [ ] 00
[If other phone
[If Twitter handle provided in Contact1 or Contact2, ask Contac6a-6b, else skip to Contact7]
Contact6a. Is it OK for us to contact you about [insert informal study name] on Twitter? We would only contact you on Twitter with a private message and never Tweet at you publicly.
Yes [ ] 01
No [ ] 00
Contact6b. If you would like us to contact you on Twitter, you will need to follow us. Now’s a
great time to do that! Our Twitter Handle is: [insert study Twitter handle]
[If Facebook screen name provided in Contact1 or Contact2, ask Contact6, else skip to Contact7a]
Contact7. Is it OK for us to contact you about [insert informal study name]on Facebook? We would only contact you on Facebook with a private message and never post anything to your wall.
Yes [ ] 01
No [ ] 00
To be sure we can reach you about your gift card [AT 6 MONTHS ADD: and the next survey], we ask you to provide contact information for people who will always know where you are and how to reach you. We will NOT discuss or share any of your personal information or survey answers with anyone you list as a contact. Your personal information and answers are confidential.
Contact8. Below is the information you gave us for a trusted friend, family member, or other person who will always know where you are and how to reach you in the future in case we have difficulty. Is the contact information we have correct?
Yes [ ] 01
No [ ] 00
[Insert current contact info from sample file.]
First name
Last name
Email address
Home address
Cell phone number
Home phone number
[If Contact5=0, allow to correct contact info Change Information : Continue ]
Contact9. Below is the information you gave us for another trusted friend, family member, or other person who will always know where you are and how to reach you in the future in case we have difficulty. Is the contact information we have correct?
Yes [ ] 01
No [ ] 00
[Insert current contact info from sample file.]
First name of
Last name of
Email address
Home address
Cell phone number
Home phone number
[If Contact6=0, allow to correct contact info Change Information : Continue ]
Section A: Housing Experiences
We want to start by asking about the places you’ve stayed and your experiences with homelessness. By homeless we mean that you had a period of time in your life when you:
|
A1. Since [insert baseline date], have you ever been homeless?
Yes [ ] 01
No [ ] 00
[If A1 =1 (homeless since baseline), ask A2, else skip to Section B]
A2. Since [insert baseline date], including right now, about how many nights in total have you been homeless? Your best guess is fine.
About 1 to 3 nights [ ] 01
More than 3 nights but less than 1 week [ ] 02
About 1 week (7 nights) [ ] 03
More than a week, but less than a month [ ] 04
About a month [ ] 05
2 to 6 months [ ] 06
More than 6 months, but less than a year [ ] 07
A year or more [ ] 08
Section B: Where You Stay
The next questions ask about the places you have stayed in the time from [insert baseline date] (the day you enrolled in the study) to today. This includes times when you were in a shelter or residential program for people who are homeless or homeless in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned building).
For each place that you have stayed, we will ask you about when you started and stopped staying there and what kind of a place it was.
We will ask you to think backwards in time – from last night until [insert baseline date].
B1a. Where did you stay last night? If the place has a name please tell us the name.
________________ [open ended, tag response as: name situation #a, used in later items. If B1a is left blank, pipe in “the place you stayed last night” for B2a through B11a.]
B2a. When did you start staying at [name situation #a]?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date, present this prompt once: “Please review the date you entered.”]
[Items B3a – B4a intentionally removed]
B5a. How would you describe [name situation #a]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) [ ] 01
Another Transitional Living Program (TLP) [ ] 02
Another residential program for people who are homeless that provides a long-term
place to stay and services [ ] 03
In a shelter (for example, emergency shelter or basic center program) [ ] 04
In an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) [ ] 05
Foster home or group home [ ] 06
Room, apartment or house (not as part of a homeless program) [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) [ ] 08
School or college dormitory (or dorm) [ ] 09
Military setting (for example, base camp, deployment, combat zone) [ ] 10
Other (please specify) [ ] 94
[If B5a is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
B6a. When you started staying in [name situation #a], did you think it would be temporary? By temporary, we mean it would only last a short time (for example, couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary [ ] 01
No, I thought I would be there a while [ ] 00
I was not sure [ ] 02
I don’t remember [ ] -98
[If B5a = 7 (room/apt/house), present B7a – B8a, else skip to B9a]
B7a. At [name situation #a], are you staying…
(Select all that apply.)
Alone [ ] 01
With one or more family members [ ] 02
With one or more friends [ ] 03
Other (please specify) [ ] 94
B8a. At [name situation #a], are you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid (pay) rent [ ] 02
Yes, I sometimes paid (pay) rent [ ] 01
No, I never paid (pay) rent [ ] 00
B9a. Do you feel safe in [name situation #a]?
Yes [ ] 01
No [ ] 00
Don’t know…………………………………………………………………………………….[ ] -98
[Item B10a intentionally removed]
B11a. Have you stayed anywhere else in the time from [insert baseline date] to today?
Yes [ ] 01
No [ ] 00
[If B11a is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
[If B11a = 1, continue to housing history loop. If B11a = 0 or skipped, skip to next section]
Note the questions asked in the loop are (nearly) identical to B1a – B11a
[B1b begins Housing History Loop: First turn through loop is B1b – B11b and occurs if B11a = 1 (stayed somewhere else since baseline). The loop is repeated again (B1c-B11c) if B11b = 1 (stayed somewhere else since baseline). The loop continues to be repeated until B11# = 0 with a maximum of 3 times through the loop (ending with B11d). Thus, we capture up to 4 living situations in the housing history series.]
B1b. What is the name of the place you stayed just before [name situation #a]? If this is a program, please use its official name.
Remember you can include times when you were in a shelter or residential program for people who are homeless or homeless in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned building).
________________ [open ended, tag response as: name situation #b, used in later items. If B1b is left blank, pipe in “the place you stayed just before [name situation #a]” for B2a through B11b.]
B2b. When did you start staying at [name situation #b]?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or after the date provided at B2a, present this prompt once: “Please review the date you entered.”]
[Item B3b intentionally removed]
B4b. When did you stop staying there? Your best guess is fine.
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or after the date provided at B2a or before the date provided at B2b, present this prompt once: “Please review the date you entered.”]
B5b. How would you describe [name situation #b]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) [ ] 01
Another Transitional Living Program (TLP) [ ] 02
Another residential program for people who are homeless that provides a long-term
place to stay and services [ ] 03
Homeless in a shelter (for example, emergency shelter or basic center program) [ ] 04
Homeless in an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) [ ] 05
Foster home or group home [ ] 06
Room, apartment or house (not as part of a homeless program) [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) [ ] 08
School or college dormitory (or dorm) [ ] 09
Military setting (for example, base camp, deployment, combat zone) [ ] 10
Other (please specify) [ ] 94
[If B5b is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
B6b. When you started staying in [name situation #b], did you think it would be temporary? By temporary, we mean it would only last a short time (for example, couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary [ ] 01
No, I thought I would be there a while [ ] 00
I was not sure [ ] 02
I don’t remember [ ] -98
[If B5b = 4 (room/apt/house), present B7b – B8b, else skip to B9b]
B7b. In [name situation #b], were you staying…
(Select all that apply.)
Alone [ ] 01
With one or more family members [ ] 02
With one or more friends [ ] 03
Other (please specify) [ ] 94
B8b. In [name situation #b], were you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid rent [ ] 02
Yes, I sometimes paid rent [ ] 01
No, I never paid rent [ ] 00
B9b. Did you feel safe in [name situation #b]?
Yes [ ] 01
No [ ] 00
Don’t know…………………………………………………………………………………….[ ] -98
B10b. Why did you leave [name situation #b]?
(Select all that apply.)
[If B5b = in {1, 2, 3, 6, 7, 9, 10} (TLP, room/apt/house, foster, school, military) present response options a – i & m.]
[If B5b = 4 (homeless sheltered), present response options a, c, e - i, & m.]
[If B5b = 5 (homeless unsheltered), present response options c, e - i, & m.]
[If B5b = 8 (institution), present response options a, c, e - h & j – m.]
[If B5b = 94, present response options a – m.]
[Randomly order/rotate all options presented for B10b]
I was no longer eligible to stay there (for example, I became too old or
reached my time limit) [ ] 01
I graduated or successfully completed the program [ ] 02
I went back home [ ] 03
I was evicted or kicked out for not keeping up with my rent/mortgage [ ] 04
I was evicted or kicked out because of problems with alcohol or drugs [ ] 05
I was evicted or kicked out because of problems getting along or fighting [ ] 06
I was evicted or kicked out for some other reason [ ] 07
I left because my living situation was unsafe [ ] 08
I found somewhere else to live that I liked better [ ] 09
I completed my sentence in a corrections facility/jail or detention center [ ] 10
I left a residential treatment facility after completing a substance abuse recovery plan [ ]11
I left a mental health hospital or psychiatric residential treatment facility after
completing treatment [ ] 12
Other (Please specify) [ ] 94
B11b. So far, you have told us about [insert name(s) of previously identified situation(s): name situation #a, name situation #b, etc.].
Have you stayed anywhere else in the time from [insert baseline date] to today?
Yes [ ] 01
No [ ] 00
[If B11b is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
[End of Loop. If B11b = 1, loop back and begin with B1c. If B11b = 0, exit loop and continue to next question. Looping continues until B11#=0 with a maximum of 3 times through the loop, ending with B11d. (Thus, we capture up to 4 living situations in the housing history series.)
If B1# is left blank, pipe in the place you stayed just before [name situation #-1]” for B2# through B11#.
After 3 times through the loop, if B11d = 1 or skipped then present B12 - B13. Else if B11d=0 skip to next section]
B12. How many other places have you stayed from [insert baseline date] to today?
________________ # places [Valid range: 0-100]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -100.’]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
[If B12 is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
[If B11d = 1 and B12 > 0 then present B13]
B13. What types of places were they?
(Select all that apply)
[Randomly order/rotate all options presented for B13]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Section C: TLP and Service Experiences
[Items C1-C3 intentionally removed]
The next few questions are about programs and services you may have participated in.
C4. At any time from [insert baseline date] to today, have you participated in or received any of the following assessments?
|
Yes (01) |
No (00) |
Don’t Know (-98) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C5. At any time from [insert baseline date] to today, have you received any of the following services?
(Select all that apply)
[Items have been partitioned into four groupings. Present the main question stem before each grouping. Randomly order/rotate the items within each grouping.]
[C5 Grouping #1.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
[C5 Grouping #2.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
[C5 Grouping #3.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
[C5 Grouping #4.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
[If two or more services in C5 = Yes, then ask C6]
C6. Of the services you received in the time from [insert baseline date] to today, which three (3) were most helpful to you?
(Please select up to three (3) services.)
[Only present services selected in C5 (=Yes). Do not group – simply list those selected in C5. Randomly order/rotate the items.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
[If ‘no’ (i.e., not selected) to any services in C5, ask C7]
C7. You said you did not receive any of the following services, in the time from [insert baseline date] to today, have you been offered any of them but decided not to participate?
[Only list services in C5 = No. Randomly order/rotate the items within each grouping. Present the main question stem before each grouping.].
[Grouping #1.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
[Grouping #2.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
[Grouping #3.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
[Grouping #4.]
|
Yes (01) |
|
|
|
|
|
|
|
|
|
|
C8. People have different goals. On a scale of 1 to 3, where 1 = Not At All Important to Me and 3 = Very Important to Me, how important are each of the following goals for you?
[Randomly order/rotate the items]
|
Not at all important to me 1 |
Somewhat important to me 2 |
Very important to me 3 |
Does not apply to me (-100) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C9. In the time from [insert baseline date] to today, how much progress do you feel you’ve made toward your goals? To answer, please use a scale of 1 to 5, where 1 = None and 5 = A Whole Lot.
[Randomly order/rotate the items]
|
None 1 |
2 |
3 |
4 |
A Whole Lot 5 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Section D: Your Feelings and Health
The next few questions are about your feelings.
D1. Thinking about yourself, how accurate is each of these statements?
To answer, please use a scale of 1 to 4, where 1 = Not at All True and 4 = Exactly True.
|
Not at all true 1 |
Hardly true 2 |
Moderately true 3 |
Exactly true 4 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D2. Below is a list of the ways you might have felt or behaved. How often you have felt this way during the past week?
During the past week… |
Hardly ever or never (00) |
Some of the time (01) |
Much or most of the time (02) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D3. The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are: “not at all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.
|
Not at all (01) |
A little bit (02) |
Moderately (03) |
Quite a bit (04) |
Extremely (05) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Supportive Relationships with Adults
D4. Currently, in your life, are there responsible adults or mentors who…
(Select yes or no for each).
|
Yes (01) |
No (00) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D5. Currently, in your life, are there people about your same age who...
(Select yes or no for each).
|
Yes (01) |
No (00) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
[Present D6 and D7 on the same screen]
D6. How many friends would you consider to be close friends? These are friends who you see more than once a week. These are friends who you spend time with and enjoy doing things with.
_______ # friends [Valid range: 0-30]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -30.’]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
[If D6 is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
D7. Now, in the past 3 months how many of these friends have…
|
None of them (00) |
Very few of them (01) |
Some of them (02) |
Most of them (03) |
All of them (04) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
The next few questions are about your health and the health care you may have received.
D8. At any time from [insert baseline date] to today, did you THINK YOU SHOULD SEE a doctor, nurse, or other health professional for any of the following reasons?
By THINK YOU SHOULD SEE, we mean you thought about, needed or wanted to see a doctor, nurse, or other health professional – even if you never actually went.
(Select yes or no for each).
|
Yes (01) |
No (00) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D9. At any time from [insert baseline date] to today, did you RECEIVE care from a doctor, nurse, or other health professional for any of the following reasons?
(Select yes or no for each.)
|
Yes (01) |
No (00) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Section E: Education and Training
The next few questions are about your education and training experiences.
E1a. What is the highest level of education you have completed? (By completed we mean the grade or level you have actually finished, not the grade or level you are currently in. If you are in high school, and it is summer, what grade did you complete this spring?)
(Select one response.)
6th grade or less [ ] 01
7th grade [ ] 02
8th grade [ ] 03
9th grade [ ] 04
10th grade [ ] 05
11th grade [ ] 06
GED or high school equivalency [ ] 07
High school diploma (12th grade) [ ] 08
Some vocational or trade school after graduating high school or getting your GED [ ] 09
Earned a credential from a vocational or trade school after graduating high school
or getting your GED [ ] 10
Associate's degree (community or two-year college) [ ] 11
Some college [ ] 12
Four-year college degree or higher [ ] 13
E1b. In the time from [insert baseline date] to today, have you received any training certificate, trade license, diploma, degree, or passed any type of qualifying exam?
Yes [ ] 01
No [ ] 00
[If E1b = 0 (no) skip to E2]
E1c. Which have you received since [insert baseline date]?
Regular High School Diploma [ ] 01
GED [ ] 02
Trade License/Certificate [ ] 03
Associates Degree [ ] 04
College Degree [ ] 05
E2. In the time from [insert baseline date] to today, have you repeated a grade or been held back?
Yes [ ] 01
No [ ] 00
Does not apply to me [ ] -100
E3. In the time from [insert baseline date] to today, have you been suspended from school?
Yes [ ] 01
No [ ] 00
[if in high school since baseline ask:]
E4. In the time from [insert baseline date] to today, have you been expelled from school?
Yes [ ] 01
No [ ] 00
E5. In the time from [insert baseline date] to today, have you dropped out of school?
Yes [ ] 01
No [ ] 00
[Begin with E6a- then follow skip patterns.]
[E7a – E7f, If value entered is out of range, please present the following prompt once, “Please enter a value between 0 to 60.”]
[E8a – E8f, If value entered is out of range, please present the following prompt once, “Please enter a value between 0 to 12.”]
[E7a – E7f and E8a – E8f, If letters are entered, please present the following prompt, “Please enter numbers only.”]
E6. At any time from [insert baseline date] to today have you taken…? |
E7. While you were taking… |
E8. Altogether for how many… |
E9. Which months were you enrolled in… |
E6a.Adult Basic Education (ABE) By adult basic education (ABE), we mean classes to improve basic reading and math skills. This is not high school or college classes Yes [Go to E7a] No [Go to E6b] [If skipped Go to E6b]
|
E7a. Adult basic education, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8a] |
E8a. Months since [month, year of baseline] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9a] |
E9a. Adult basic education? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6b] |
E6b. English as a Second Language (ESL) classes Yes [Go to E7b] No[Go to E6c] [If skipped Go to E6c]
|
E7b. ESL classes, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8b] |
E8b. Months since [month, year of baseline] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9b] |
E9b. ESL classes? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6c] |
E6c. GED classes By GED classes, we mean classes to prepare for the GED test Yes [Go to E7c] No [Go to E6d] [If skipped Go to E6d]
|
E7c. GED classes, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8c] |
E8c. Months since [month, year of baseline] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9c] |
E9c. GED classes? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6d] |
E6d. High school or classes toward a regular high school diploma (do not include ABE, GED, or ESL classes) Yes [Go to E7d] No [Go to E6e] [If skipped Go to E6e]
|
E7d. High school or classes toward a regular high school diploma, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8d] |
E8d. Months since [month, year of baseline] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9d] |
E9d. High school or classes toward a regular high school diploma? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6e] |
E6e. College or classes toward an Associate’s degree or Bachelor’s degree at a 2-year or 4-year college (Do not count recreational classes like exercise or hobbies, courses for the GED, or any courses that don’t provide credit toward a degree) Yes [Go to E7e] No [Go to E6f] [If skipped Go to E6f]
|
E7e. College or classes toward an Associate’s degree or Bachelor’s degree at a 2-year or 4-year college, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8c] |
E8e. Months since [month, year of baseline] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9c] |
E9e. College or classes toward an Associate’s degree or Bachelor’s degree at a 2-year or 4-year college? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6d] |
E6f. Vocational, career, or technical training at a community or private college By vocational, career, or technical training, we mean training for a specific job, trade, or occupation. This is not training you get in college courses. It is also not on-the-job training or unpaid work experience Yes [Go to E7f] No [Go to next section] [If skipped Go to next section]
|
E7f. Vocational, career, or technical training at a community or private college, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8f] |
E8f. Months since [month, year of baseline] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9f] |
E9f. . Vocational, career, or technical training at a community or private college? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
|
Section F: Employment
The next few questions are about your work experiences.
F1. At any time from [insert baseline date] to today, have you worked at a job or business for pay?
By worked at a job or business for pay, we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. It does not include odd jobs, informal work, illegal or “off-the-books” work, or work where you did not get paid.
Yes [ ] 01
No [ ] 00
[If F1=1 (yes) or skipped- skip to employment history series (F3a), If F1=0 (not employed) ask F2a]
F2a. Which of the following best describes the reason you have not worked in the time from [insert baseline date] to today
(Select one)
I was in school [ ] 01
I was looking for work but could not find it [ ] 02
I did not want to work [ ] 03
I was not able to work [ ] 04
I was working informally, illegally, “off-the-books,” or not for pay [ ] 05
[If F2a=04 (unable to work), then ask F2b]
F2b. Why have you been unable to work?
Physical or other type of disability [ ] 01
Other (Please specify) [ ] 94
[If F1=1 (employed) or skipped present employment history series, else skip to next section]
We’d like to ask you about work or employment
since [insert baseline date].
We will ask you to think backwards in time from now until [insert
baseline date]. Sometimes people
have more than one job at a time. If you had more than one job at a
time, please answer the following questions for each job
separately—one at a time
F3a. Thinking about the time from [insert baseline date], what is the name of the place you currently work or most recently worked?
Remember we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. This does not include odd jobs, informal, illegal, or “off-the-books” work, volunteer work, or work where you did not get paid
________________ [open ended, tag response as: employer #a, used in later items. If F3a is left blank, pipe in “your first employer” for F4a through F8a.]
F4a. What did you do at [insert employer #a]?
________________ [open ended, tag response as: occupation #a]
F5a. When did you start working at [insert employer #a]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date, present this prompt once: “Please review the date you entered.”]
F6a. Are you still working at [insert employer #a]?
Yes [ ] 01
No [ ] 00
[If F6a=0, ask F7a, else skip to F8a]
F7a. When did you stop working at [insert employer #a]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or before the date entered at F5a, present this prompt once: “Please review the date you entered.”]
F8a. In an average week, how many hours do you or did you usually work at [insert employer #a]?
________________ # hours per week [Valid range: 0-168]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -168.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
F9a. Have you worked anywhere else in the time from [insert baseline date] to today?
Yes [ ] 01
No [ ] 00
[If F9a=1, continue to employment history loop. F9a=2 or skipped, skip to next section]
Note the questions asked in the loop are (nearly) identical to F3a – F9a
[F3b begins Employment History Loop: First turn through loop is F3b – F9b and occurs if F9a = 1 (worked somewhere else since baseline). The loop is repeated again (F3c-F9c) if F9b = 1 (worked somewhere else since baseline). The loop continues to be repeated until F9# = 0 with a maximum of three times through the loop (ending with F9d). Thus, we capture up to 4 jobs in the employment history series.]
F3b. What is the name of the place you worked just before [insert name of previously identified employer]? You can give it any name that makes sense to you.
Remember we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. This does not include odd jobs, informal, illegal, or “off-the-books” work, volunteer work, or work where you did not get paid
________________ [open ended, tag response as: employer #b, used in later items. If F3b is left blank, pipe in “your second employer” for F4b through F8b.]
F4b. What did you do at [insert employer #b]?
________________ [open ended, tag response as: occupation #b]
F5b. When did you start working at [insert employer #b]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or the date entered at F5a, present this prompt once: “Please review the date you entered.”]
F6b. Are you still working at [insert employer #b]?
Yes [ ] 01
No [ ] 00
[If F6b=0, ask F7b, F6b=1 or skipped, skip to F8b]
F7b. When did you stop working at [insert employer #b]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or before the date entered at F5b, present this prompt once: “Please review the date you entered.”]
F8b. In an average week, how many hours did you usually work at [insert employer #b]?
________________ # hours per week [Valid range: 0-168]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -168.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
F9b. So far, you have told us about [insert names of all previously identified employers: employer #a, employer #b, etc.].
Have you worked anywhere else in the time from [insert baseline date] to today?
Yes [ ] 01
No [ ] 00
[If F9b=1, continue to employment history loop, F9b=0 or skipped, skip to next section]
[End of Loop. If F9b = 1, loop back and begin with F3c. If F9b = 0 or skipped, exit loop and continue to next section. Looping continues until F9#=0 with a maximum of three times through the loop, ending with F9d. Thus, we capture up to 4 jobs in the employment history series. If F3# is left blank, pipe in “your [third, fourth…] employer” for F4# through F8#.]
F10. At the end of the month do you usually have…
(Select One.)
Some money left over [ ] 03
Just enough money to make ends meet [ ] 02
Not enough money to make ends meet [ ] 01
F11. Do you currently have a savings account?
Yes [ ] 01
No [ ] 00
F12. Do you currently have a checking account?
Yes [ ] 01
No [ ] 00
Section G. Activities
The next few questions are about things you do or activities you’ve participated in
G1. In the time from [insert baseline date], to today, have you volunteered to help local community organizations or groups?
Yes [ ] 01
No [ ] 00
[If E6d, E6e, and/or E6f = Yes (i.e., enrolled in HS or college since baseline), ask G2; else skip to G3]
G2. In the time from [insert baseline date], to today, have you participated in any organized activities sponsored by your school or college, such as sports teams, band, or clubs?
Yes [ ] 01
No [ ] 00
G3. In the time from [insert baseline date], to today, have you participated in any organized activities or groups that meet on a regular basis [If enrolled in HS or college since baseline insert the following: and are not sponsored by your school or college]? These could be organizations or clubs, such as Boy or Girl Scouts, or community service groups.
Yes [ ] 01
No [ ] 00
Section H: Your Experiences
The next few questions ask things like drug use, sex, and violence. Remember your answers are confidential, and you don't have to answer any question you don't want to.
H1. During the past 12 months, that is since [calculate current date minus 12 months], how often did each of the following things happen?
|
Never [0] |
Once [1] |
More than Once [2] |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H2. In the past 12 months, that is since [calculate current date minus 12 months], how often did you do each of the following things?
|
Never [00] |
1 or 2 Times [01] |
3 or 4 Times [02] |
5 or More Times [03] |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products. |
[For this section, if a value entered is out of range, please present the following prompt once, “Please enter a value between 0 – 30.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
H3a. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Include menthol and regular cigarettes and loose tobacco rolled into cigarettes)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
H3b. During the past 30 days, on how many days did you use other tobacco products? (Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next question is about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. However, this may not be true for your religious, cultural, or ethnic group. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you consumed alcohol. |
H4a. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish. |
H4b. During the past 30 days, on how many days did you use marijuana or hashish?
[Present Options 0-30 days, Don’t know, or Rather not say]
-
Days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish, which include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or to get high), heroin, crack or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and report on how many days, if any, you used other illegal drugs. |
H5a. During the past 30 days, on how many days did you use any other illegal drug?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
Now we would like to ask about your use of several specific drugs. |
H5b. During the past 30 days, on how many days did you use cocaine or crack?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
H5c. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
H5d. During the past 30 days, on how many days did you inject any drugs? (Count only injections without a doctor’s orders, those you had just to feel good or to get high.)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next questions are about your sexual behaviors and experiences.
H6. Sexual intercourse is when a male puts his penis into a female’s vagina.
At any time from [current date minus 3 months] to today, have you had sexual intercourse, even once?
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H6=1 ask H7, else skip to H8]
H7. At any time from [current date minus 3 months] to today, have you had sexual intercourse without you or your partner using a condom, even just once?
Yes, I have had sexual intercourse without using a condom [ ] 01
No, I have used a condom each time I had sexual intercourse [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
H8. 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.
At any time from [current date minus 3 months] to today, have you had anal sex, even once?
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H8=1,ask H9, else skip to skip to H10a]
H9. In the time from [current date minus 3 months] to today, have you had anal sex without you or your partner using a condom, even just once?
Yes, I have had anal sex without using a condom [ ] 01
No, I have used a condom each time I had anal sex [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H6=1 or H8=1 ask H10a, if H6 or H8 skipped ask H10a; else skip to H11a]
H10a. At any time from [current date minus 3 months] to today, have you received anything in exchange for having sexual relations with another person, such as money, food, drugs, or shelter? By sexual relations we mean sexual intercourse, anal sex, or oral sex.
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H10a=1 ask H10b, if H10a skipped ask H11a]
H10b. In the time from [current date minus 3 months] to today, how many times have you received something in exchange for having sexual relations with another person, such as money, food, drugs, or shelter? Your best guess is fine.
______ # times [valid range 1 – 99]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
H11. In the time from [insert baseline date] to today, have you ever gone to civilian or military court for any criminal offense (not including court appearances for minor traffic violations)?
Yes [ ] 01
No [ ] 00
H12. In the time from [insert baseline date] to today, have you been convicted of a criminal offense?
Yes [ ] 01
No [ ] 00
H13. In the time from [insert baseline date] to today, have you spent one or more nights in jail, a correctional facility, or a juvenile detention center?
Yes [ ] 01
No [ ] 00
[Item H14 intentionally removed]
The next questions are about situations that may have happened during your life and the ways your caregivers may have mistreated you in the past. By caregivers, we mean the adults who were responsible for taking care of you in the past. Remember, your answers are confidential, and you don't have to answer any question you don't want to.
H15. In the time from [insert baseline date] to today, did any of your caregivers fail to give you regular meals so that you had to go hungry or ask other people for food?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H16. In the time from [insert baseline date] to today, did any of your caregivers ever throw or push you? For example, push you down a staircase or push you into a wall?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H17. In the time from [insert baseline date] to today, did any of your caregivers ever hit you hard with a fist, or kick you or slap you really hard?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H18. In the time from [insert baseline date] to today, did any of your caregivers ever beat you up such as hitting or kicking you repeatedly?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H19. In the time from [insert baseline date] to today, did you ever have a serious illness or injury or physical disability, but your caregivers ignored it or failed to get you medical care or other treatment for it?
Some examples are an infection that became serious because it was not treated soon enough, a broken bone that did not get fixed, or problems seeing or hearing that were not treated with glasses or hearing aids?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H20. In the time from [insert baseline date] to today, did any of your caregivers ever abandon you?
By “abandon,” we mean leave you, walk out on you, ditch or dump you.
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H21. In the time from [insert baseline date] to today, did any of your caregivers ever touch or kiss you against your will?
By “against your will,” we mean when you did not want them to or without your permission.
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
H22. In the time from [insert baseline date] to today, did any of your caregivers ever have sexual intercourse, oral sex, or anal sex with you against your will?
By “against your will,” we mean when you did not want them to or without your permission
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Rather not say [ ] -99
Section I: About You
We’re almost done. There are just a few more questions about your background.
I1a. What is your current marital status?
(Select only one answer.)
Never Married [ ] 01
Married [ ] 02
Separated [ ] 03
Divorced [ ] 04
Widowed [ ] 05
I1b. Are you currently living with a romantic partner (boyfriend or girlfriend), spouse (husband or wife) or someone who is like a spouse to you?
(Select only one answer.)
Yes [ ] 01
No [ ] 00
I1c. At any time from [insert baseline date] to today, has your marital status changed?
(Select all that apply.)
No change [ ] 00
Yes, I got married [ ] 01
Yes, I separated from my wife/husband [ ] 02
Yes, I got divorced [ ] 03
Yes, I got became widowed (my wife/husband died) [ ] 04
Yes, I stopped living with a romantic partner [ ] 05
I2a. Do you have any children (even if they don’t live with you)?
Yes [ ] 01
No [ ] 00
[If I2a=0, skip to I3]
I2b. At any time from [insert baseline date] to today, have you had any new biological children or adopted any children?
Yes [ ] 01
No [ ] 00
I2c. How many children do you have (even if they don’t live with you)?
________# children [Valid range 0-10]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 – 10.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
I3. Are you currently pregnant or expecting to become a father in the next 9 months?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… [ ] -98
Closing Screen
[If contact information was provided present Closing1, if not present Closing2b]
Closing1.
Thank you for taking this survey and being part of the study!
After you submit your survey, we will [insert mode selected: email/text] your electronic gift card to:
[insert gift card contact]
Closing 1a. If this information is correct, click here to submit your survey: SUBMIT [Go to Closing2]
(Once you submit your survey, you cannot go back and change your answers.)
Closing1. If this information is wrong, click here: CHANGE INFORMATION
Closing1b. Please tell us how to send you your electronic gift card:
(Select only one answer)
|
|
Enter the [email address/cell phone number/mailing address] we should use here: |
|
||||||||||||
|
Email it to me at: |
|
01 |
||||||||||||
|
Text it to my cell phone: |
|
02 |
||||||||||||
|
Mail it to me: |
|
03 |
||||||||||||
|
I do not have an email address, cell phone or mailing address you can send it to (Without an email address, cell phone number or mailing address we cannot send you an electronic gift card.) |
|
04 |
||||||||||||
[If Closing1b = 4, Go to Closing2b]
[If no response is selected = “Please select Email it to me at, Text it to my cell phone, Mail it to me or I do not have an email address, cell phone or mailing address you can send it to.” IF STILL NOT ANSWERED: Go to Closing2b]
[If Closing1b = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Closing2b]
[If Closing1b = 2 and cell phone number is left blank = “Please enter your 10 digit cell phone number.” IF STILL NOT ANSWERED: Go to Closing2b]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Closing2b]
[If not all ten digits or letters are entered for the cell phone number = “Phone Number must be 10 digits (numbers only). The first three are the Area Code. Please re-enter the 10 digit cell phone number.” IF STILL NOT CORRECTED: Go to Closing2b]
[Apt# can be left blank]
[If Street Address is left blank = “Please enter your street address.” IF STILL NOT ANSWERED: Go to Closing2b]
[If City is left blank = “Please enter your city.” IF STILL NOT ANSWERED: Go to Closing2b]
[If numeric values are entered for the City = “Only letters may be entered for your city. We need a valid address.” IF STILL NOT CORRECTED: Go to Closing2b]
[If Zip Code is left blank = “Please enter your zip code.” IF STILL NOT ANSWERED: Go to Closing2b]
[If letters are entered in the zip = “Zip code must be 5 digits (numbers only). We need a valid address.” IF STILL NOT CORRECTED: Go to Closing2b]
Closing2.
If email selected present, “You will receive your electronic gift card within 24 hours. Please check your Inbox and Spam/Junk folder for the email.”
If text selected present, “You will receive your electronic gift card within 1 business day.”
If mail selected, present, “You will receive your electronic gift card within 10 days.”
If you have any questions about the study, you can email or call the people who are doing the research at XXX@abtassoc.com or (855) 579-6654. This is a free call.
Thanks again!
You are a very important part of the study!
Closing2b.
Thank you for taking this survey and being part of the study!
Because you did not provide an email address, a cell phone number to send a text or a complete mailing address we cannot send you an electronic gift card. If you have any questions, please email XXXX@abtassoc.com or call (855) 579-6654. This is a free call.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jessica Walker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |
© 2024 OMB.report | Privacy Policy