Instrument 1 - Participant Entry Survey

Form approved

OMB Control No: 0970-0536

Expiration Date: 10/31/2022

SEXUAL RISK AVOIDANCE EDUCATION PROGRAM (SRAE)

PARTICIPANT ENTRY 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:

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.

   THE PAPERWORK REDUCTION ACT OF 1995

   Public reporting burden for this collection of information is estimated to average 8 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.

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

General Instructions

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

The next questions ask about alcohol, tobacco, and other substance use. Remember, all of your responses will be kept private.

8. In the past three months, have you ...

MARK ONLY ONE ANSWER PER ROW
	Yes	No
a. drunk alcohol (more than a few sips, including beer, wine, and liquor)?
b. smoked cigarettes or cigar products (cigars, cigarillos, or little cigars)?
c. used other tobacco products (such as chewing tobacco, snuff, dip, or snus)?
d. used 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. used marijuana (also called pot, weed, or cannabis)?
f. taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it?

9. In the past three months, how often would you say you…

	MARK ONLY ONE ANSWER PER ROW
		All of the time	Most of the time	Some of the time	None of the time
	a. resisted or said no to peer pressure?
	b. managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)?
	c. thought about the consequences before making a decision?
d. talked with your parent, guardian, or caregiver about sex?

10. For each of the items below, please mark how true each statement is of you.

MARK ONLY ONE ANSWER PER ROW
	Not true at all	Somewhat true of me	Very true of me
a. I make plans to reach my goals.
b. I care about doing well in school.
c. I save money to get things I want.
d. I would speak up or ask for help if I am being bullied in person or online, via text, while gaming, or through other social media.
e. I would speak up or ask for help if others are being bullied in person or online, via text, while gaming, or through other social media.

11. The next few questions are about relationships and dating. Please answer the questions below even if you are not currently dating or going out with someone.

For each of the items below, please mark how true each statement is of you.

MARK ONLY ONE ANSWER PER ROW
	Not true at all		Somewhat true of me	Very true of me
a. I understand what makes a relationship healthy
b. I would be able to resist or say no to someone if they pressured me to participate in sexual acts, such as kissing, touching private parts, or sex
c. I would talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes me uncomfortable, hurts me, or pressures me to do things I don’t want to do

Thank you for participating in this survey!

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