Youth survey for proof-of-concept study

INSTRUMENT 1a. YOUTH SURVEY

(Initial GenIC request: proof of concept study)

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide SRAE program development. Public reporting burden for the collection of information is estimated to average 30 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 OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/20XX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Melissa Thomas at mthomas@mathematica-mpr.com.

INTRODUCTION

Thank you for your help with this important study. The purpose of this study is to understand how well youth programs work in your community. The study is being conducted by the Administration for Children and Families in the U.S. Department of Health and Human Services. This survey includes questions about your background, your attitudes towards relationships and sexual activity, and your behaviors. Your name will not be on the survey. Your responses will remain private. We want you to know that: 

1. Your participation in this survey is voluntary.

2. The survey will take about 30 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. Your responses will be combined with other people your age.

How to complete the survey

Pre & immediate post only (Paper survey)

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.

• Please mark all answers within the boxes provided.

• Please use a pen or a pencil.

Section A. Background

Pre survey only

1. How old are you?

2. What grade did you finish in the [FILL PAST SCHOOL YEAR]?

Pre survey only

m 7th 3

m 8th 4

m 9th 5

m 10th 6

m 11th 7

m 12th 8

m Not enrolled in any school/home-schooled 9

m Some college 10

3. How likely do you think it is that you will do the following before you turn 25?

Pre survey, Immediate post survey, 6mo post survey
		SELECT ONE ONLY PER ROW
		Not at all likely	Somewhat likely	Very likely	Not sure
	a. Obtain a GED or high school diploma.	1 m	2 m	3 m	4 m
	b. Obtain a vocational certificate or vocational license (this could be related to a professional trade/business such as construction, carpentry, welding, plumbing).	1 m	2 m	3 m	4 m
	c. Complete some college	1 m	2 m	3 m	4 m
	d. Obtain an Associate’s degree.	1 m	2 m	3 m	4 m
	e. Obtain a Bachelor’s degree	1 m	2 m	3 m	4 m
	f. Obtain a graduate degree	1 m	2 m	3 m	4 m
	g. Start your own business at a flea market or farmer’s market.	1 m	2 m	3 m	4 m

4. Below are questions about ways people may feel or act. There are no right or wrong answers. Please do your best to answer honestly.

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY PER ROW
How easy or hard is it to…	Very hard	Hard	A little hard, a little easy	Easy	Very easy
a. Set goals for myself.	1 	2 	3 	4 	5 
b. Find a way to stick with my goals, even when it’s tough.	1 	2 	3 	4 	5 
c. Consider all the positives and negatives before making a decision.	1 	2 	3 	4 	5 

5. The following questions are about your attitudes and feelings. For each statement, please indicate how much or how little each statement feels like you.

Pre survey, Immediate post survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	Not at all like me	A little like me	Sort of like me	A lot like me	Very much like me
a. I learn from my mistakes.	1 	2 	3 	4 	5 
b. I believe I will be okay even when bad things happen.	1 	2 	3 	4 	5 
c. I do a good job of handling problems in my life.	1 	2 	3 	4 	5 
d. I try new things even if they are hard.	1 	2 	3 	4 	5 
e. When I have a problem, I come up with ways to solve it.	1 	2 	3 	4 	5 
f. I give up when things get hard.	1 	2 	3 	4 	5 
g. I deal with my problems in a positive way (like asking for help).	1 	2 	3 	4 	5 
h. I keep trying to solve problems even when things don’t go my way.	1 	2 	3 	4 	5 
i. Failure just makes me try harder.	1 	2 	3 	4 	5 
j. No matter how bad things get, I know the future will be better.	1 	2 	3 	4 	5 

6. In the last 6 months have you participated in any of the following extracurricular activities?

Pre survey & 6mo post survey

	SELECT ONE ONLY PER ROW
	Yes	No
a. School sports (ex. Volleyball, football, soccer, cross country, basketball, wrestling, softball, baseball, golf, track and field).	1 	2 
b. Out of school sports (ex. Martial arts, baseball, basketball, disc golf, golf, running, walking groups, hiking, pickleball, swimming, Zumba, spin class).	1 	2 
c. Arts (ex. band, theatre, dance, choir)	1 	2 
d. Leadership (ex. National Honor Society, Student Council, Future Farmers of America, Robotics, Debate, United National Indian Tribal Youth, JROTC, Gifted and Talented).	1 	2 
e. Volunteer (ex. Big Brothers Big Sisters, Awareness Walks, Earth Day Trash Pick-Up, High School Concession Volunteer, Community Service Learning Projects).	1 	2 
f. Faith-based (ex. religious/church groups).	1 	2 
g. Traditional (ex. Weaving, cultural ceremonies, beading, sash belt making, pow wows, male sweats, female sweats, song and dance, winter shoe games, basket weaving)	1 	2 

Section B. Peer relationships and support networks

7. For the following statements, think about the person you live with that is the main person who takes care of you. That can be a parent, grandparent, auntie/uncle, cousin, older sibling, etc. For these questions we are calling this person a parent/caregiver/trusted adult. For each of the following statements, please answer how often this happens.

Pre survey, Immediate post survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	Never	Rarely	Sometimes	Often	Almost always
a. My parent/caregiver/trusted adult shows me they are proud of me.	1 	2 	3 	4 	5 
b. My parent/caregiver/trusted adult takes an interest in my activities.	1 	2 	3 	4 	5 
c. My parent/caregiver/trusted adult listens to me when I talk to them. .	1 	2 	3 	4 	5 
d. I can count on my parent/caregiver/trusted adult to be there when I need them.	1 	2 	3 	4 	5 
e. My parent/caregiver/trusted adult and I talk about the things that really matter.	1 	2 	3 	4 	5 

8. This question is related to your relationships with your peers and friends. Please mark how strongly you agree or disagree about each sentence.

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY PER ROW
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. My friends support and care about me.	1 	2 	3 	4 	5 
b. My friends think I am a positive person.	1 	2 	3 	4 	5 
c. My friends are people who I can trust.	1 	2 	3 	4 	5 
d. My friends do nice things for other people.	1 	2 	3 	4 	5 

9. Now we want you to think about the past 3 months. In the past 3 months, how often would you say you talked about things that really matter with a peer or a friend?

Pre survey, 6mo post survey

 None of the time 1

 Some of the time 2

 Most of the time 3

m All of the time 4

10. How many of your friends who are your age think the following things?

Pre survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	None	Some	Half	Most	All
a. Having sex is a good thing for them to do at their age.	1 	2 	3 	4 	5 
b. It would be okay for them to have sex if they were dating the same person for a long time.	1 	2 	3 	4 	5 
c. They should wait until they are older to have sex.	1 	2 	3 	4 	5 
d. They should wait until marriage to have sex.	1 	2 	3 	4 	5

11. Do most of your friends follow the rules their parents make for them?

Pre survey, 6mo post survey

 Almost never 1

 Some of the time 2

 Usually 3

 Almost always 4

12. Do most of your friends stay out of trouble?

Pre survey, 6mo post survey

 Almost never 1

 Some of the time 2

 Usually 3

 Almost always 4

13. Do most of your friends choose healthy behaviors or activities?

Pre survey, 6mo post survey

 Almost never 1

 Some of the time 2

 Usually 3

 Almost always 4

14. Are most of your friends responsible?

Pre survey, 6mo post survey

 Almost never 1

 Some of the time 2

 Usually 3

 Almost always 4

Section C. Native identity

The next questions ask about Native American/Indigenous identity and customs.

15. I plan on trying to find out more about my Native American/Indigenous culture, such as its history, my Tribal Identity, traditions, customs, arts and language.

Pre survey, Immediate post survey, 6mo post survey

 Yes 1

 No 0

16. Please mark how strongly you agree or disagree about each sentence.

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY PER ROW
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. I have spent time trying to find out more about being Native American/Indigenous, such as my Tribe’s history, Tribal Identity, traditions, customs, arts and language	1 	2 	3 	4 	5 
b. I have a strong sense of belonging to my Native American/Indigenous family, community, Tribe, or Nation.	1 	2 	3 	4 	5 
c. I have done things that will help me understand my Native American/Indigenous background better.	1 	2 	3 	4 	5 
d. I have talked to community members or other people in order to learn more about being Native American/Indigenous	1 	2 	3 	4 	5 
e. When I learn something about my Native American/Indigenous culture, history or ceremonies, I will ask someone, research it, look it up, or find resources to learn more about it.	1 	2 	3 	4 	5 
f. I feel a strong attachment towards my Native American community or Tribe	1 	2 	3 	4 	5 
g. If a traditional person, counselor or Elder who is knowledgeable about my culture spoke to me about being Native American/Indigenous, I would listen to them carefully	1 	2 	3 	4 	5 
h. I feel a strong connection to my ancestors and those who came before me	1 	2 	3 	4 	5 
i. Being Native American means I sometimes have a different perception or way of looking at the world	1 	2 	3 	4 	5 
j. It is important to me that I know my Native American/Indigenous or Tribal language(s)	1 	2 	3 	4 	5 

Section D. Romantic relationships

The next questions are about romantic relationships. Please answer the questions below even if you are not currently in a romantic relationship.

17. How would you define your current romantic relationship status?

Pre survey, Immediate post survey, 6mo post survey

m Seriously dating 1

m Casually dating 2

m Not currently in a relationship or dating 3

18. In healthy romantic relationships, how important is it that…?

Pre survey, Immediate post survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	Not at all important	Not too important	Somewhat important	Important	Very important
a. you have a partner/boyfriend/girlfriend who listens when you share your thoughts.	1 	2 	3 	4 	5 
b. you can trust a partner/boyfriend/girlfriend	1 	2 	3 	4 	5 
c. you can talk about your future dreams and goals with a partner/boyfriend/girlfriend.	1 	2 	3 	4 	5 
d. you and a partner/boyfriend/girlfriend have shared values.	1 	2 	3 	4 	5 
e. you and a partner/boyfriend/girlfriend have similar interests or like to do the same activities.	1 	2 	3 	4 	5 
f. your friends like your partner/boyfriend/girlfriend.	1 	2 	3 	4 	5 
g. your family likes your partner/boyfriend/girlfriend	1 	2 	3 	4 	5 
h. you give each other gifts.	1 	2 	3 	4 	5 
i. you encourage each other when life is hard.	1 	2 	3 	4 	5 
j. you do not cheat on each other.	1 	2 	3 	4 	5 
k. you do not call each other names.	1 	2 	3 	4 	5 
l. you do not push, shove, hit, slap, or grab each other.	1 	2 	3 	4 	5 

19. How strongly do you agree or disagree with the following statements?

Pre survey, Immediate post survey, 6mo post survey

SELECT ONE ONLY

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Violence between partners/boyfriends/girlfriends can improve the relationship.	1 	2 	3 	4 	5 
b. There are times when violence between partners/boyfriends/girlfriends is ok.	1 	2 	3 	4 	5
c. It’s okay to stay in a relationship even if you’re afraid of your partner/boyfriend/girlfriend.	1 	2 	3 	4 	5
d. Sometimes violence is the only way to express your feelings.	1 	2 	3 	4 	5
e. Some couples must use violence to solve their problems.	1 	2 	3 	4 	5
f. Violence between partners/boyfriends/girlfriends is a personal matter and people should not interfere.	1 	2 	3 	4 	5

20. How strongly do you agree or disagree with the following statements?

Pre survey, Immediate post survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. I am able to recognize the warning signs in a bad relationship early on.	1 	2 	3 	4 	5 
b. I know what to do when I recognize the warning signs in a bad relationship.	1 	2 	3 	4 	5

Section E. Attitudes, opinions and knowledge related to sexual activity

The next series of questions ask your attitudes and opinions about sexual activity. Remember, this survey is private and there are no right or wrong answers. Please do your best to answer honestly.

The first set of questions are about sexual consent. Sexual consent means that a person agrees to a sexual activity.

21. How strongly do you agree or disagree with each of the following statements?

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY 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 

22. Many people find it difficult to make decisions about sex. Whether you have or have not had sex, how confident are you that you could…?

Pre survey, Immediate post survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	Not at all confident	A little confident	Somewhat confident	Confident	Very confident
a. consider all the positives and negatives before making a decision about whether to have sex.	1 m	2 m	3 m	4 m	5 m
b. think carefully before making a decision about sex.	1 m	2 m	3 m	4 m	5 m
c. stop yourself from acting on your feelings when it comes to decisions about sex.	1 m	2 m	3 m	4 m	5 m
d. tell your partner/boyfriend/girlfriend what you do and do not want to do sexually.	1 m	2 m	3 m	4 m	5 m
e. know what you are feeling when faced with a decision about sex.	1 m	2 m	3 m	4 m	5 m

23. How confident are you that you could say "no" to having sex in the following situations?

Pre survey, Immediate post survey, 6mo post survey

	SELECT ONE ONLY PER ROW
	Not at all confident	A little confident	Somewhat confident	Confident	Very confident
a. With someone you have known for a few days or less.	1 	2 	3 	4 	5 
b. With someone you have dated for a long time.	1 	2 	3 	4 	5 
c. With someone with whom you have already had sex.	1 	2 	3 	4 	5 
d. With someone who is pushing you to have sex.	1 	2 	3 	4 	5 
e. With someone who does not want to use a condom.	1 	2 	3 	4 	5 
f. If your partner/boyfriend/girlfriend wanted to have sex but you didn’t.	1 	2 	3 	4 	5 

24. The following statements are about condoms. Please select whether you think each statement is true, false, or you don’t know.

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY PER ROW
	True	False	Don’t know
a. It is okay to use the same condom more than once.	1 	2 	d 
b. Condoms have an expiration date.	1 	2 	d 
c. When putting on a condom, it is important to leave a space at the tip.	1 	2 	d 
d. When using a condom, it is important for the man to pull out right after ejaculation.	1 	2 	d 
e. Wearing two latex condoms will provide extra protection.	1 	2 	d 

25. 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.

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY PER ROW
	True	False	Don’t know
a. If you have an 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 

26. The following statements are about pregnancy. Please select whether you think each statement is true, false, or you don’t know.

Pre survey, Immediate post survey, 6mo post survey
	SELECT ONE ONLY PER ROW
	True	False	Don’t know
a. The very first time a woman has sex, she cannot get pregnant. ………….	1 	2 	d 
b. During a woman’s monthly cycle, there are certain days when she is more likely to become pregnant if she has sex. …………………………….	1 	2 	d 
c. Pregnancy is much less likely to occur if a couple has sex standing up. ...	1 	2 	d 
d. The only way to completely prevent pregnancy is by not having sex. ……	1 	2 	d 

Section F. Sexual behaviors

[For entire section] Pre survey, 6mo post survey

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

27. In the past 3 months have you hung out alone with someone you were attracted to?

 Yes 1

 No 0

28. In the past 3 months have you laid down alone with someone you were attracted to?

 Yes 1

 No 0

29. In the past 3 months have you kissed someone you were attracted to on the mouth?

 Yes 1

 No 0

30. In the past 3 months have you tongue kissed or French kissed someone?

 Yes 1

 No 0

31. In the past 3 months have you touched someone’s private parts?

Private parts are the parts of the body covered by underwear or a bra.

 Yes 1

 No 0

32. Other than a doctor or a nurse, in the past 3 months have you let someone touch your private parts?

 Yes 1

 No 0

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

 Yes, definitely 1

 Yes, probably 2

 No, probably not 3

 No, definitely not 4

.

34. Have you ever had sex?

 Yes 1

 No 0

35. In the past 6 months, have you had sex?

 Yes 1

 No 0

36. In the past 6 months, how many times have you had sex? Please answer "0" if you have not had sex in the past 6 months.

# of times you have had sex

(RANGE 0-100)

37. If yes to ever sex: 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?

 Yes 1

 No 0

38. If yes to ever sex: To the best of your knowledge, are you currently or have you ever been pregnant, or have you ever gotten someone pregnant?

 Yes 1

 No 0

 Don’t know D

Section G. Drug & alcohol use

The next items are about drug and alcohol use.

39. How confident are you that you could say "no" to drinking or using drugs when you don’t want to?

	Pre survey, Immediate post survey, 6mo post survey

m Not at all confident 1

m A little confident 2

m Confident 3

m Very confident 4

m Completely confident 5

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

	Pre survey, Immediate post survey, 6mo post survey

SELECT ONE ONLY

	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 

[For remaining items in this section] Pre survey, 6mo post survey

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

m 0 days 1

m 1-2 days 2

m 3-5 days 3

m 6-9 days 4

m 10-19 days 5

m 20-29 days 6

m All 30 days 7

42. During the past 30 days, on how many days did you have 4 or more drinks of alcohol in a row, that is, within a couple of hours?

m 0 days 1

m 1-2 days 2

m 3-5 days 3

m 6-9 days 4

m 10-19 days 5

m 20-29 days 6

m All 30 days 7

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

m 0 days 1

m 1-2 days 2

m 3-5 days 3

m 6-9 days 4

m 10-19 days 5

m 20-29 days 6

m All 30 days 7

44. The next question asks about the use of prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it. For this question, count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet.

During your life, how many times have you taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it?

m 0 times 1

m 1-2 times 2

m 3-9 times 3

m 10-19 times 4

m 20-39 times 5

m 40 or more times 6

Section H. Demographics

The next questions are going to ask some questions about you.

45. What is your race and/or ethnicity?

Pre survey only

Select all that apply

□ American Indian or Alaska Native 1

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

□ Asian 2

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

□ Black or African American 3

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

□ Hispanic or Latino 4

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

□ Middle Eastern or North African 5

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

□ Native Hawaiian or other Pacific Islander 6

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijan, Marshallese, etc.

□ White 7

For example, English, German, Irish, Italian, Polish, Scottish, etc.

46. What is your sex?

Pre survey only

Select only one

m Female 1

m Male 2

m I prefer not to answer n

THANK YOU FOR TAKING TIME TO COMPLETE THIS SURVEY!

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