Instrument 2b_SRAE IMPACT HS Exit Survey_110321_clean

Form approved

OMB Control No: 0970-0536

Expiration Date: 10/31/2022

SEXUAL RISK AVOIDANCE EDUCATION PROGRAM (SRAE)

PARTICIPANT EXIT SURVEY

HIGH SCHOOL AND OLDER

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:

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.

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.

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

General Instructions

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

□ 17

□ 18

□ 19

□ 20

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

□ 9th

□ 10th

□ 11th

□ 12th

□ My school does not assign grade levels

□ I dropped out of school, and I am not working on getting a high school diploma or GED

□ I am working toward a GED

□ I have a high school diploma or GED but I am not currently enrolled in college or technical school

□ I have a high school diploma or GED and I am currently enrolled in college or technical 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 (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

The next questions ask about some personal behaviors, including sex and pregnancy. Remember, all of your responses will be kept private.

8. As a result of being in the program, are you planning to abstain from sexual intercourse (choose to not have sexual intercourse)?

□ Yes GO TO QUESTION 9

□ No GO TO QUESTION 10, NEXT PAGE

□ Not sure GO TO QUESTION 10, NEXT PAGE

9. How important are each of these reasons in your decision to not have sexual intercourse? (Note: Do not answer this question if you responded “No” or “Not sure” to question 8.)

MARK ONLY ONE ANSWER PER ROW
	Not at all important	Not too important	Somewhat important	Very important
a. how it might affect your plans for the future …
b. the possible emotional and social consequences (for example, feeling sadness or regret, disappointing your parent(s) or guardian(s), and/or negative reactions from your peers) ………….
c. the risk of getting a sexually transmitted infection (STI) ……………………………………
d. the risk of getting pregnant or getting someone pregnant………………………………………….

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.

10. 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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