Instrument 1_Youth Outcome Survey_CLEANrev

INSTRUMENT 1
YOUTH OUTCOME SURVEY

OMB Control No: 0990-0480

Expiration Date: 10/31/2024

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REA Study

Youth Outcome Survey

THE PAPERWORK REDUCTION ACT OF 1995

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0480. The time required to complete this information collection is estimated to average 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

How to complete the survey

• You may complete the survey all at once or save your responses and return at a later time.

• Please use the buttons and links on each page to move through the survey. Using “Enter” or your browser’s “Back” function may cause errors.

• If you have trouble accessing the survey, or if you have questions, please contact us at [STUDYADDRESS]@mathematica-mpr.com or [study toll-free telephone number].

INTRODUCTION

Thank you for your help with this important study. The purpose of this study is to learn about the components of programs like REA that matter most for promoting positive health behaviors and relationship skills in adolescents. The study is being conducted by the Office of Population Affairs in the U.S. Department of Health and Human Services. This survey includes questions about your background, your attitudes towards relationships, your social and emotional wellbeing, and your behaviors. Your name will not be on the questionnaire and your responses will remain private to the extent permitted by law. We want you to know that: 

1. Your participation in this survey is voluntary.

2. The survey will take about 40 minutes to complete.  

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

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

A. SOCIAL AND EMOTIONAL WELLBEING

These first questions ask about your attitudes and feelings.

A1. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Learning from people with different opinions from mine.	1 	2 	3 	4 	5 
b. Being patient when some students need extra help from the teacher.	1 	2 	3 	4 	5 
c. Understanding why people have different opinions from mine.	1 	2 	3 	4 	5 
d. Appreciating that some people do things differently than me.	1 	2 	3 	4 	5 
e. Appreciating that my classmates come from many different backgrounds.	1 	2 	3 	4 	5 
f. Appreciating that other students may learn differently than I do.	1 	2 	3 	4 	5 

A2. How much do you agree or disagree with the following?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. My actions affect my classmates.	1 	2 	3 	4 	5 
b. I don't think about how my actions might have potential consequences for me.	1 	2 	3 	4 	5 
c. I think about how my choices might affect others.	1 	2 	3 	4 	5 

A3. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Controlling my temper when I am upset.	1 	2 	3 	4 	5 
b. Being patient even when I am really excited.	1 	2 	3 	4 	5 
c. Calming myself down when I am nervous.	1 	2 	3 	4 	5 
d. Thinking carefully about what I want to say, before I speak.	1 	2 	3 	4 	5 

A4. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Not giving in to peer pressure at school.	1 	2 	3 	4 	5 
b. Saying "no" to a friend who wants me to do something I don't want to do.	1 	2 	3 	4 	5 
c. Sticking to my beliefs when making decisions.	1 	2 	3 	4 	5 
d. Telling a friend to stop if their behavior is making me uncomfortable.	1 	2 	3 	4 	5 

A5. Overall, how satisfied are you with life as a whole these days?

Please rate how satisfied you are with your life on a scale from 0 (not satisfied at all) to 10 (completely satisfied).

Not Satisfied At All										Completely Satisfied
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

A6. In general, how happy or unhappy do you usually feel? Please rate how happy you are with your life on a scale from 0 (extremely unhappy) to 10 (extremely happy).

Extremely Unhappy										Extremely Happy
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

B. COMMUNICATION SKILLS AND HEALTHY DECISION MAKING

The next questions are about your communication and decision-making skills.

B1. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Talking to my classmates about how I feel when I am upset with them.	1 	2 	3 	4 	5 
b. Talking to classmates about why they feel a certain way.	1 	2 	3 	4 	5 
c. Apologizing if I ever upset a classmate.	1 	2 	3 	4 	5 
d. Getting along with classmates even if I disagree with them.	1 	2 	3 	4 	5 
e. Stopping myself before I hurt someone's feelings.	1 	2 	3 	4 	5 
f. Forgiving classmates when they apologize to me.	1 	2 	3 	4 	5 

B2. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Admitting that you might be wrong during an argument.	1 	2 	3 	4 	5 
b. Avoiding saying things that could turn an argument into a big fight.	1 	2 	3 	4 	5 
c. Accepting another person's point of view even if you don't agree with it.	1 	2 	3 	4 	5 
d. Listening to another person's opinion during an argument.	1 	2 	3 	4 	5 
e. Working through problems without arguing.	1 	2 	3 	4 	5 

In the following items when we say trusted adult we mean a parent/guardian, other family member, teacher, counselor, coach, mentor, etc.

B3. How would you respond if someone you know was doing each of the following?

Select all that apply

	Laugh or go along with it	Not say or do anything	Confront the person in private about their behavior	Confront the person in public about their behavior	Talk to a trusted adult
a. Spreading rumors about another person	1 	2 	3 	4 	5 
b. Fighting with another person and the person you know began to threaten the other person	1 	2 	3 	4 	5 
c. Making fun of or teasing someone because of their race, ethnicity, gender identity, physical ability, or sexual orientation	1 	2 	3 	4 	5 
d. Making rude or disrespectful comments about another person’s body, clothing, or make-up	1 	2 	3 	4 	5 
e. Bullying within your own group of friends	1 	2 	3 	4 	5 

B4. How likely or unlikely is it that you would do each of the following?

Select one per row

	Very unlikely	Somewhat unlikely	Neither likely nor unlikely	Somewhat likely	Very likely
a. Talk to a trusted adult if someone you are dating or going out with makes you uncomfortable, hurts you, or pressures you to do things you don't want to do.	1 	2 	3 	4 	5 
b. Talk to a trusted adult if a friend or peer makes you uncomfortable, hurts you, or pressures you to do things you don't want to do.	1 	2 	3 	4 	5 
c. Talk to a trusted adult if a stranger makes you uncomfortable, hurts you, or pressures you to do things you don't want to do.	1 	2 	3 	4 	5 
d. Talk to a trusted adult when you are faced with a problem that you do not know how to fix yourself.	1 	2 	3 	4 	5 

B5. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. After carrying out a solution to a problem, you usually try to think about what went right and what went wrong.	1 	2 	3 	4 	5 
b. Difficult problems make you very frustrated.	1 	2 	3 	4 	5 
c. When making decisions, you generally have a plan for weighing your options.	1 	2 	3 	4 	5 
d. When making decisions, you usually go with your "gut feeling" without thinking too much about the consequences of each alternative.	1 	2 	3 	4 	5 
e. When you are attempting to solve a problem, you usually try to think of as many different approaches as possible.	1 	2 	3 	4 	5 
f. When you get what you want, it's usually because you worked hard for it.	1 	2 	3 	4 	5 
g. When you have a problem to solve, one of the first things you do is get as many facts about the problem as possible.	1 	2 	3 	4 	5 

The next questions are about skills for getting and maintaining a job.

B6. How confident are you in your ability to do each of the following activities by yourself?

Select one per row

	Not at all confident	A little confident	Somewhat confident	Confident	Very Confident
a. Prepare a resume.	1 	2 	3 	4 	5 
b. Answer questions in a job interview.	1 	2 	3 	4 	5 
c. Get along with coworkers or customers.	1 	2 	3 	4 	5 
d. Ask a manager or supervisor for changes to your schedule, time off, or other necessary accommodations.	1 	2 	3 	4 	5 
e. Act appropriately in professional situations.	1 	2 	3 	4 	5 

C. SOCIAL INFLUENCE

These next questions are about how you make decisions.

C1. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. In social situations, you tend not to follow the crowd, but instead behave in a way that suits your mood at the time.	1 	2 	3 	4 	5 
b. Your behavior often depends on how you think other people want you to behave.	1 	2 	3 	4 	5 
c. It is important for you to fit into the group you're with.	1 	2 	3 	4 	5 
d. You are confident saying no to drinking or drugs if your friends are using them and you don’t want to.	1 	2 	3 	4 	5 

These next questions are about social media and the internet.

C2. The following statements are about how sex is shown in media, such as TV shows, movies, video games, social media or books. How much do you agree or disagree with each statement?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. People expect to experience sex as it is portrayed in the media.	1 	2 	3 	4 	5 
b. The way that sex is shown in most media could happen in real life.	1 	2 	3 	4 	5 

C3. In the following items, advertisements can include commercials, ads on social media, products mentioned by celebrities or influencers.

How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Advertisers are interested in influencing people my age.	1 	2 	3 	4 	5 
b. Companies use sex appeal in their ads to help sell products to youth.	1 	2 	3 	4 	5 
c. People my age can trust what they see in advertisements.	1 	2 	3 	4 	5 

C4. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Watching sex on the Internet can impact your self-esteem.	1 	2 	3 	4 	5 
b. In reality, the sex people have is not like the sex that appears on the Internet.	1 	2 	3 	4 	5 
c. Watching sex on the Internet can be addictive.	1 	2 	3 	4 	5 

C5. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Anything you text, send or post online will never truly go away.	1 	2 	3 	4 	5 
b. No one can see my social media activity unless I give them permission.	1 	2 	3 	4 	5 
c. I sometimes decide not to post something online because I am concerned that it might reflect badly on me in the future.	1 	2 	3 	4 	5 
d. It is safe to share your location on social media posts.	1 	2 	3 	4 	5 
e. Even if someone only knows you by screen name, online profile, phone number or email address, they can probably find you if they try hard enough.	1 	2 	3 	4 	5 

C6. Now think about the past 3 months.

In the past 3 months, have you done any of the following?

	Yes	No
a. Sent a text message that you later regretted sending.	1 	0 
b. Posted something on social media that you later regretted.	1 	0 
c. Shared personal information with someone you only know online or virtually.	1 	0 
d. Sent or shared sexually suggestive content with friends or romantic partners.	1 	0 
e. Sent or shared sexually suggestive content with someone you only know online.	1 	0 

D. HEALTHY RELATIONSHIP SKILLS

The next questions are about relationships.

D1. My romantic and nonromantic relationships are as satisfying as I would want them to be.

Strongly Disagree										Strongly Agree
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

The next questions are about romantic relationships.

D2. Please answer the questions below even if you are not currently in a romantic relationship. How important is it that [FILL WITH A-K]?

Select one per row

	Not at all important	Not too important	Somewhat important	Important	Very important
a. you have a partner who listens when you share your thoughts	1 	2 	3 	4 	5 
b. you are able to trust a partner	1 	2 	3 	4 	5 
c. you are able to talk about your future dreams and goals with a partner	1 	2 	3 	4 	5 
d. you and a partner have shared values	1 	2 	3 	4 	5 
e. you and a partner have similar interests or like to do the same activities	1 	2 	3 	4 	5 
f. your friends like your partner	1 	2 	3 	4 	5 
g. your family likes your partner	1 	2 	3 	4 	5 
h. your partner is popular	1 	2 	3 	4 	5 
i. your partner is physically attractive	1 	2 	3 	4 	5 
j. your partner is supportive	1 	2 	3 	4 	5 
k. your partner is smart	1 	2 	3 	4 	5 

D3. How would you respond if someone you were in a romantic relationship with was doing each of the following?

Select all that apply

	Ignore it	Give them another chance	Talk with them about it	End the romantic relation-ship	Talk to a friend	Talk to a trusted adult
a. Checks your cell phone without permission	1 	2 	3 	4 	5 	6 
b. Tells you how to dress	1 	2 	3 	4 	5 	6 
c. Has an explosive temper	1 	2 	3 	4 	5 	6 
d. Makes negative comments about your body	1 	2 	3 	4 	5 	6 
e. Pressures you into sexual activities	1 	2 	3 	4 	5 	6 

D4. If you were to go on a date, how confident are you that you could [FILL A-D]?

Select one per row

	Not at all confident	Not too confident	Somewhat confident	Confident	Very confident
a. set physical intimacy boundaries for yourself before the date	1 	2 	3 	4 	5 
b. resist or say no to your partner if they want to move beyond your physical intimacy boundaries	1 	2 	3 	4 	5
c. avoid drinking alcohol or using drugs	1 	2 	3 	4 	5
d. come up with creative and healthy date ideas	1 	2 	3 	4 	5

E. SEXUAL HEALTH AND DRUG AND ALCOHOL USE

E1. In general, how would you rate your overall mental health?

Poor										Excellent
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

E2. In general, how would you rate your physical health?

Poor										Excellent
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

The next questions are about sexual health and tobacco, drug and alcohol use.

E3. The following statements are about sexually transmitted diseases or infections (STDs or STIs) and HIV, the virus that can lead to AIDS. Please select whether you think each statement is true, false, or you don’t know.

Select one per row

	True	False	Don’t know
a. If you have a STD your sexual partner probably has it too.	1 	2 	d 
b. You can have an STD and feel healthy.	1 	2 	d 
c. A person with HIV can give it to other people only if they look or feel sick.	1 	2 	d 
d. There is a good chance you will get HIV if you share a sink, shower, or toilet seat with someone who has HIV.	1 	2 	d 
e. The HIV virus is present in blood, semen, and vaginal fluid.	1 	2 	d 
f. You can get an STD from having oral sex.	1 	2 	d 

The next questions are about sexual consent. Sexual consent means that a person agrees to a sexual activity.

E4. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. It is important to ask for sexual consent in all relationships whether or not each person has had sex before.	1 	2 	3 	4 	5 
b. When initiating sexual activity, one should always assume they do not have sexual consent.	1 	2 	3 	4 	5 
c. Sexual consent should be asked before any kind of sexual behavior, including kissing or touching.	1 	2 	3 	4 	5 
d. Not asking for sexual consent some of the time is okay.	1 	2 	3 	4 	5 

E5. The next questions are about your sexual behaviors. Please be as honest as possible. Your answers will be kept private.

Have you ever had sex (this includes vaginal, oral, or anal sex)?

 Yes 1

 No 0 GO TO E8

answer IF QE5 = 1 (ever had sex)

E6. In the past 3 months, how many times have you had sex? Please answer "0" if you have not had sex in the past 3 months.

# of times you have had sex

(RANGE 0-100)

answer IF QE5 = 1 (ever had sex)

E7. In the past 3 months, how many times have you had sex without using a condom? Please answer "0" if you wore a condom every time.

# of times you have had sex without a condom

(RANGE 0-100)

E8. Do you intend to have sex (this includes vaginal, oral, or anal sex) in the next 3 months, if you have the chance?

Select one only

 Yes, definitely 1

 Yes, probably 2

 No, probably not 3

 No, definitely not 4

E9. If you were to have sex in the next 3 months, do you intend to use or have your partner use a condom?

Select one only

 Yes, definitely 1

 Yes, probably 2

 No, probably not 3

 No, definitely not 4

answer IF QE5 = 1 (ever had sex)

E10. Have you ever been told by a doctor, nurse, or some other health professional that you had a sexually transmitted diseases (STDs or STIs) like gonorrhea, Chlamydia, syphilis, genital herpes, human papilloma virus (HPV) or HIV?

Select one only

 Yes 1

 No 0

E11. The next questions are about tobacco, alcohol and drug use. Please be as honest as possible and remember that your answers will be kept private.

During the past 30 days, on how many days did you smoke cigarettes or use electronic vapor product?

Electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens, and mods.

Please provide your best guess.

Number of days

(RANGE 0-30)

E12. During the past 30 days, on how many days did you have at least one drink of alcohol?

Please provide your best guess.

Number of days

(RANGE 0-30)

E13. During the past 30 days, on how many days did you use marijuana?

Please provide your best guess.

Number of days

(RANGE 0-30)

E14. During the past 30 days, on how many days have you used any other type of drug?

This may include any form of cocaine, including powder, crack, heroin, methamphetamines (also called speed, crystal meth, crank, ice, or meth), ecstasy (also called MDMA or Molly), or sniffing glue, breathing contents of aerosol spray cans, or inhaling any paints or sprays to get high?

Please provide your best guess.

Number of days

(RANGE 0-30)

F. SELF ESTEEM, SELF AWARENESS, AND SELF IDENTITY

The next few questions ask about you, including how you would describe yourself and how easy or difficult things are for you.

F1. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. You feel like you are doing everything just about right.	1 	2 	3 	4 	5 
b. You have a lot of good qualities.	1 	2 	3 	4 	5 
c. You have a lot to be proud of.	1 	2 	3 	4 	5 
d. You like yourself just the way you are.	1 	2 	3 	4 	5 
e. You feel loved and wanted.	1 	2 	3 	4 	5 
f. You feel socially accepted.	1 	2 	3 	4 	5 

F2. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Accepting when I am not the best at everything I do.	1 	2 	3 	4 	5 
b. Knowing what I don't do well.	1 	2 	3 	4 	5 
c. Knowing how I learn best.	1 	2 	3 	4 	5 
d. Knowing which things make me feel nervous.	1 	2 	3 	4 	5 
e. Knowing what my strengths are.	1 	2 	3 	4 	5 
f. Knowing that I am a good person.	1 	2 	3 	4 	5 
g. Being okay with who I am.	1 	2 	3 	4 	5 
h. Knowing what kind of activities make me happy.	1 	2 	3 	4 	5 

F3. For the following statement, please select how true this is for you on the scale of 0 “Not True of Me” to 10 “Completely True of Me”.

I always act to promote good in all circumstances, even in difficult and challenging situations.

Not True of Me										Completely True of Me
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

F4. For the following statement, please select how true this is for you on the scale of 0 “Not True of Me” to 10 “Completely True of Me”.

I am always able to give up some happiness now for greater happiness later.

Not True of Me										Completely True of Me
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

F5. How easy or difficult are each of the following for you?

Select one per row

	Very difficult	Difficult	Moderate	Easy	Very easy
a. Understanding why I do what I do.	1 	2 	3 	4 	5 
b. Knowing when my mood affects how I treat others.	1 	2 	3 	4 	5 
c. Understanding how my feelings influence how I act.	1 	2 	3 	4 	5 
d. Knowing the emotions I feel.	1 	2 	3 	4 	5 
e. Communicating to others how I feel	1 	2 	3 	4 	5 

F6. Now we would like you to think about what is important to you in your life right now. How important is it that you [FILL A-H]?

Select one per row

	Not at all important	Not too important	Somewhat important	Important	Very important
a. Have the support of your family	1 	2 	3 	4 	5 
b. Make time to serve your community	1 	2 	3 	4 	5 
c. Have adults that encourage you to succeed	1 	2 	3 	4 	5 
d. Have the time to participate in clubs, sports or organizations in your community	1 	2 	3 	4 	5 
e. Stand up for your beliefs	1 	2 	3 	4 	5 
f. Feel optimistic about your future.	1 	2 	3 	4 	5 

G. GOAL SETTING AND PLANNING FOR THE FUTURE

The next questions are about your goals and the future.

G1. At this time in your life, how much do you agree or disagree with each of the following statements about you?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. I plan on delaying future sexual activity until I graduate high school or receive my GED.	1 	2 	3 	4 	5 
b. I plan on delaying future sexual activity until I graduate college or complete another education or training program.	1 	2 	3 	4 	5 
c. I plan on delaying future sexual activity until I am married.	1 	2 	3 	4 	5 
d. I plan to be married before I have a child.	1 	2 	3 	4 	5 
e. I plan to have a steady full-time job before I get married.	1 	2 	3 	4 	5 
f. I plan to have a steady full-time job before I have a child.	1 	2 	3 	4 	5 

G2. How much do you agree or disagree with each of the following statements?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Nothing you do as a teen will affect how healthy you are as an adult.	1 	2 	3 	4 	5 
b. You can do things now that will help you to be healthy when you are an adult.	1 	2 	3 	4 	5 
c. Taking unhealthy risks as a teen, like drinking and doing drugs, does not really matter for your health in the long run.	1 	2 	3 	4 	5 
d. The decisions you make as a teen will affect your health as an adult.	1 	2 	3 	4 	5 

G3. When making decisions about using drugs or alcohol, how important are the following?

Select one per row

	Not at all important	Not too important	Somewhat important	Important	Very important
a. How it might affect your schoolwork.	1 	2 	3 	4 	5 
b. How it might affect your future.	1 	2 	3 	4 	5 
c. How it might affect your ability to make decisions in the moment.	1 	2 	3 	4 	5 
d. How it might affect your physical health.	1 	2 	3 	4 	5 
e. How it might affect your ability to make decisions around sexual activity.	1 	2 	3 	4 	5 
f. How it might affect relationships with family and friends.	1 	2 	3 	4 	5 

G4. How important is it for people your age to think about the following when making decisions about doing something sexually with a partner?

Select one per row

	Not at all important	Not too important	Somewhat important	Important	Very important
a. How a pregnancy could impact their education/career goals.	1 	2 	3 	4 	5 
b. How an STD might affect their physical health.	1 	2 	3 	4 	5 
c. How an STD might affect their future relationships.	1 	2 	3 	4 	5 
d. How a pregnancy could impact their parent’s life.	1 	2 	3 	4 	5 
e. How a pregnancy or STD could impact their partner’s life.	1 	2 	3 	4 	5 

G5. Overall, to what extent do you feel the things you do in your life are worthwhile?

Not at All Worthwhile										Completely Worthwhile
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

G6. For the following statement, please select how much you agree on the scale of 0 “Strongly Disagree” to 10 “Strongly Agree.” I understand my purpose in life.

Strongly Disagree										Strongly Agree
0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	10 

H. SCHOOL INVOLVEMENT

The next questions are about your school.

H1. How much do you agree or disagree with the following statements about your school?

Select one per row

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. I feel proud of belonging to my school.	1 	2 	3 	4 	5 
b. I am treated with as much respect as other students.	1 	2 	3 	4 	5 
c. I feel very different from most other students.	1 	2 	3 	4 	5 
d. The teachers respect me.	1 	2 	3 	4 	5 
e. There’s at least one teacher or other adult in my school I can talk to if I have a problem.	1 	2 	3 	4 	5 

The next questions are about all of your classes in school.

H2. How much effort do you put into getting involved in discussions during class?

Select one only

 Almost no effort 1

 A little bit of effort 2

 Some effort 3

 Quite a bit of effort 4

 A great deal of effort 5

H3. When your teacher is speaking, how much effort do you put into trying to pay attention?

Select one only

 Almost no effort 1

 A little bit of effort 2

 Some effort 3

 Quite a bit of effort 4

 A great deal of effort 5

H4. How much effort do you put into your homework for your classes?

Select one only

 Almost no effort 1

 A little bit of effort 2

 Some effort 3

 Quite a bit of effort 4

 A great deal of effort 5

H5. Overall, how much effort do you put forth during your classes?

Select one only

 Almost no effort 1

 A little bit of effort 2

 Some effort 3

 Quite a bit of effort 4

 A great deal of effort 5

H6. How much effort do you put into learning all the material for your classes?

Select one only

 Almost no effort 1

 A little bit of effort 2

 Some effort 3

 Quite a bit of effort 4

 A great deal of effort 5

H7. How much do each of the following statements sound like you?

Select one per row

	Not at all like me	A little like me	Somewhat like me	A lot like me	Exactly like me
a. I develop step-by-step plans to reach my goals.	1 	2 	3 	4 	5 
b. I have financial goals.	1 	2 	3 	4 	5 
c. I have health and wellness goals.	1 	2 	3 	4 	5 
d. I have social goals.	1 	2 	3 	4 	5 
e. I have education goals.	1 	2 	3 	4 	5 
f. I have career goals.	1 	2 	3 	4 	5 
g. If I set goals, I take action to reach them.	1 	2 	3 	4 	5 
h. It is important to me that I reach my goals.	1 	2 	3 	4 	5 
i. I know how to make my plans happen.	1 	2 	3 	4 	5 

H8. How often do you make plans to achieve your goals?

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

H9. How often do you have trouble figuring out how to make your goals happen?

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

H10. How often would you say you skip school?

Select one only

 Never or almost never 1

 Sometimes, but less than once a week 2

 Not every day, but at least once a week 3

 Daily or almost every day 4

The next items ask about your thoughts on healthy relationship skills education. By healthy relationship skills, we mean things like communication, controlling emotions, and considering others in both romantic and non-romantic relationships.

H11. For me, being good at healthy relationships skills is…

Select one only

 Not at all important 1

 Not too important 2

 Somewhat important 3

 Important 4

 Very important 5

H12. In general, I think learning about healthy relationships skills [will be/is]?

Select one only

 Very boring 1

 A little boring 2

 Neither boring nor interesting 3

 A little interesting 4

 Very interesting 5

H13. How much [would/did] you like learning about healthy relationships skills?

Select one only

 Not at all 1

 A little 2

 Somewhat 3

 A lot 4

H14. Compared to other things you learn about in school, how important is learning about healthy relationships skills?

Select one only

 Not at all important 1

 Not too important 2

 Somewhat important 3

 Important 4

 Very important 5

THESE QUESTIONS (H15 & H16) ARE FOR THE IMMEDIATE POST SURVEY

H15. The next questions are about your experiences with the REAL Essentials program. Even if you didn’t attend all of the sessions or classes in this program, how often during REAL Essentials [FILL A-E]?

Select one per row

	None of the time	Some of the time	Half of the time	Most of the time	All of the time
a. did you feel interested in program sessions and classes	1 	2 	3 	4 	5 
b. did you feel the material presented was clear	1 	2 	3 	4 	5 
c. did discussions or activities help you to learn program lessons	1 	2 	3 	4 	5 
d. did you have a chance to ask questions about topics or issues that came up in the program	1 	2 	3 	4 	5 
e. did you feel respected as a person	1 	2 	3 	4 	5

H16. The next questions are about your experiences with the person teaching you the REAL Essentials program. We refer to this person as the REA facilitator. How much do you agree with the following statements about the REA facilitator?

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. The REA facilitator knows me.	1 	2 	3 	4 	5 
b. The REA facilitator and I connected.	1 	2 	3 	4 	5 
c. The REA facilitator and I formed a good working relationship.	1 	2 	3 	4 	5 
d. The REA facilitator responded to questions without judgement.	1 	2 	3 	4 	5 
e. The REA facilitator was enthusiastic about teaching the program.	1 	2 	3 	4 	5 

THIS QUESTION (H17) IS FOR THE IMMEDIATE POST SURVEY and 6 MONTH FOLLOW-UP SURVEY ONLY

H17. How much do you agree or disagree with the following statement?

I am starting to see opportunities to apply the ideas from REAL Essentials in my life.

Select one only

 Strongly disagree 1

 Disagree 2

 Neither agree nor disagree 3

 Agree 4

 Strongly agree 5

I. BACKGROUND

These last questions ask for some general background information.

I1. What is your date of birth?

Date of birth

MM/DD/YYYY

(Month (1-12)/Day (1-31)/Year (2006-2014))

I2. What is your race?

Select all that apply

 American Indian or Alaska Native 1

 Asian 2

 Black or African American 3

 Native Hawaiian or Other Pacific Islander 4

 White 5

 Don't know d

 Choose not to answer n

I3. What is your ethnicity?

Select only one

 Hispanic or Latino 1

 Not Hispanic or Latino 2

 Don't know 3

 Choose not to answer 4

I4. How do you describe yourself?

Select only one

 Male 1

 Female 2

 Transgender male 3

 Transgender female 4

 Another gender identity (for example, non-binary, genderqueer, gender fluid, or intersex) 5

 Don't know/Not sure d

 Choose not to answer n

I5. Which of the following best represents how you think of yourself?

Select only one

 Straight, that is, not lesbian or gay 1

 Lesbian 2

 Gay 3

 Bisexual 4

 Asexual 5

 Pansexual 6

 Demisexual 7

 I think of myself some other way (please specify) 8

 (SPECIFY) 99

Specify (STRING (NUM))

 Don't know d

 Choose not to answer n

I6. How would you define your current relationship status?

Select one only

m Seriously dating 1

m Casually dating 2

m Not currently in a relationship or dating 3

I7. What grade are you currently in?

Select only one

 9th 9

 10th 10

 11th 11

 12th 12

 Not currently enrolled in school 0

This completes the survey. Thank you for your participation in the REA Study.

[FOR IMMEDIATE POST TEST: As a reminder, we will contact you again in about 6 months to complete a similar survey. Thank-you again.]

J. UPDATED CONTACT INFORMATION

J1. Next, we would like to ask for some contact information. Mathematica will contact you in about 6 months to see how you are doing and conduct another survey.

What is your address?

Street Address 1: (STRING (NUM))

Street Address 2: (STRING (NUM))

City: (STRING (NUM))

State: (STRING (NUM))

Zip: (STRING (NUM))

J2. What is your personal email address?

EMAIL ADDRESS

(STRING 50)

m DON’T HAVE ONE 0

m DON’T KNOW d

m REFUSED r

J3. What is your home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

m NO LANDLINE 1

J4. Do you have a cell phone?

m YES 1

m NO 0

m DON’T KNOW d

m REFUSED r

J4=01

J5. What is your cell phone number?

CELL PHONE

(201-989) (200-999) (0000-9999)

J5a=01

J6. Is it okay for us to text you at this number? Message and data rates may apply.

m YES 1

m NO 0

J7. What is another phone number where you can be reached?

PHONE NUMBER

(201-989) (200-999) (0000-9999)