Instrument 2 - Participant Exit Survey

Form approved

OMB Control No: 0970-0536

Expiration Date: 10/31/2022

SEXUAL RISK AVOIDANCE EDUCATION PROGRAM (SRAE)

PARTICIPANT EXIT SURVEY

MIDDLE SCHOOL

Thank you for your help with this important study. This survey includes questions about your family, friends, school, and also your attitudes and behaviors. Your name will not be on the survey and your responses will remain private to the extent permitted by law. We want you to know that:

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The information collected will help policy makers, program providers and other stakeholders understand the experiences of youth today and identify ways to reduce risky behaviors. This information will also inform programs on how best to serve their participants. The collection of this information is voluntary and responses will be kept private to the extent allowed by law. The OMB number for this information collection is 0970-0536 and the expiration date is 10/31/2022.

1. Your participation in this survey is voluntary.

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

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

General Instructions

If the color of your eyes is brown, you would mark (X) the first box as shown.

PLEASE READ EACH QUESTION CAREFULLY: There are different ways to answer the questions in this survey. It is important that you follow the instructions when answering each kind of question. Here are some examples.

• PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED.

• USE A PEN OR PENCIL.

1. EXAMPLE 1: MARK ONLY ONE ANSWER

What is the color of your eyes?

MARK ONLY ONE ANSWER

Brown

Blue

Green

Another color

2. EXAMPLE 2: MARK ALL THAT APPLY

Do you plan to do any of the following next week?

If you plan to watch a movie and go to a baseball game next week, you would mark (X) both boxes.

MARK ALL THAT APPLY

Watch a movie

Go to a baseball game

Study at a friend’s house

Please answer the following questions as best you can. This first set of questions are about you.

1. How old are you?

MARK ONLY ONE ANSWER

□ 10

□ 11

□ 12

□ 13

□ 14

□ 15

□ 16

2. What grade are you in? (If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)

MARK ONLY ONE ANSWER

□ 5th

□ 6th

□ 7th

□ 8th

□ 9th

□ My school does not assign grade levels

□ I am not currently enrolled in school

3. When you are at home or with your family, what language or languages do you usually speak?

MARK ALL THAT APPLY

□ English

□ Spanish

□ Other (please specify):

4. Are you Hispanic or Latino?

MARK ONLY ONE ANSWER

□ Yes

□ No

5. What is your race?

MARK ALL THAT APPLY

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White or Caucasian

□ Other (please specify):

6. What is your sex?

MARK ONLY ONE ANSWER

□ Male

□ Female

7. Are you currently …?

MARK ALL THAT APPLY

□ Living with family [parent(s), guardian, grandparents, or other relatives]

□ In foster care, living with a family

□ In foster care, living in a group home

□ Couch surfing or moving from home to home

□ Living outside, in a tent city or homeless camp, in a car, in an abandoned vehicle or in an abandoned building

□ Staying in an emergency shelter or transitional living program

□ Staying in a hotel or motel

□ In juvenile detention center, juvenile group home, and/or under the supervision of a probation officer

□ None of the above

For questions 8 – 12, please think about how the program you just completed has affected you, even if your program did not cover the topic.

8. Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do any of the following, choose “About the same.”)

MARK ONLY ONE ANSWER PER ROW
	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely
a. make decisions to not drink alcohol?
b. make decisions to not smoke cigarettes or cigar products (cigars, cigarillos, or little cigars)? .
c. make decisions to not use other tobacco products (such as chewing tobacco, snuff, dip, or snus)?
d. make decisions to not use electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? (electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, hookahs, hookah pens, and mods)
e. make decisions to not use marijuana (also called pot, weed, or cannabis)?
f. make decisions to not take prescription pain medicine without a doctor’s prescription or differently than how a doctor told you to use it?...

9. Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same.”)

MARK ONLY ONE ANSWER PER ROW
	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely
a. resist or say no to peer pressure?
b. manage your emotions in healthy ways (for example, ways that are not hurtful to you or others)?
c. think about the consequences before making a decision?

10. Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same”.)

MARK ONLY ONE ANSWER PER ROW
	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely
a. make plans to reach your goals?
b. care about doing well in school?

11. Has being in the program made you more likely, about the same, or less likely to… (Note: If the program has not affected your likelihood to do the following, choose “About the same.”)

MARK ONLY ONE ANSWER PER ROW
	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely
better understand what makes a relationship healthy?
resist or say no to someone if they pressure you to participate in sexual acts, such as kissing, touching private parts, or sexual intercourse?
talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes you uncomfortable, hurts you, or pressures you to do things you don’t want to do?

12 . Has being in the program made you more likely, about the same, or less likely to…

MARK ONLY ONE ANSWER PER ROW
	Much more likely	Somewhat more likely	About the same	Somewhat less likely			Much less likely
a. plan to delay having sexual intercourse until you graduate high school or receive your GED
b. plan to delay having sexual intercourse until you graduate college or complete another education or training program
c. plan to delay having sexual intercourse until you are married
d. plan to be married before you have a child
e. plan to have a steady full-time job before you get married
f. plan to have a steady full-time job before you have a child

The next questions ask you about your experiences in the program that you just completed. Think about all of the sessions or classes of the program that you attended.

13. Even if you didn’t attend all of the sessions or classes in this program, how often in this program…

MARK ONLY ONE ANSWER PER ROW
	All of the time	Most of the time	Some of the time	None of the time
a. did you feel interested in program sessions and classes?
b. did you feel the material presented was clear?
c. did discussions or activities help you to learn program lessons?
d. did you have a chance to ask questions about topics or issues that came up in the program?
e. did you feel respected as a person?

Thank you for participating in this survey!

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