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pdfEVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES
SITE- SPECIFIC FIRST FOLLOW- UP INSTRUMENT AND SUMMARY TABLE:
OICA
The OICA survey instrument is for foster care youth and is not divided into separate parts for sexually
active and non-sexually active youth.
OMB Control No:
Expiration Date:
FIRST FOLLOW-UP QUESTIONNAIRE
OICA
CONFIDENTIALITY
Thank you for your help with this important study. It will help us understand what things are like for
people your age today. Your answers are confidential and everything you say will be kept private.
Your name will not be on the questionnaire. Please answer all questions as well as you can.
We want you to know that:
1.
We hope that you will answer all the questions, but you may skip any questions you do not
wish to answer.
2.
The answers you give will never be identified as yours. Your responses will be combined
with those of other people your age.
Mathematica Policy Research
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this 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.
PPA Study – OICA – 06/20/11
1
SECTION 1: DEMOGRAPHICS
1.1. Are you male or female?
MARK (X) ONE
Male
Female
1.2. What is the last grade you completed?
MARK (X) ONE
6th
7th
8th
9th
10th
11th
12th
1.3. How old were you when you entered the foster care system?
MARK (X) ONE
<1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
1.4. Do you currently live in a group home?
MARK (X) ONE
Yes
No – GO TO 1.6
1.5. In what month and year did you start living in this group home?
MARK (X) ONE MONTH AND ONE YEAR
Month started living in this
group home
January
2008
February
2009
March
2010
April
2011
May
2012
June
2013
July
2014
August
September
October
November
December
1.6. Are you Hispanic/Latino?
MARK (X) ONE
Yes
No
Year started living in this
group home
1.7
What is your race?
YOU MAY MARK (X) MORE THAN ONE ANSWER
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Some other race PRINT OTHER RACE
1.8. What is the second letter of your first
name?
1.9. What is the last letter of your first name?
MARK (X) ONE
MARK (X) ONE
A
N
A
N
B
O
B
O
C
P
C
P
D
Q
D
Q
E
R
E
R
F
S
F
S
G
T
G
T
H
U
H
U
I
V
I
V
J
W
J
W
K
X
K
X
L
Y
L
Y
M
Z
M
Z
1.10. In which month were you
born?
MARK (X) ONE
1.11. On which day were you
born?
MARK (X) ONE
1.12. In which year were you
born?
MARK (X) ONE
January
1
17
1991
February
2
18
1992
March
3
19
1993
April
4
20
1994
May
5
21
1995
June
6
22
1996
July
7
23
1997
August
8
24
1998
September
9
25
1999
October
10
26
2000
November
11
27
2001
December
12
28
13
29
14
30
15
31
16
1.13. How likely is it that you will do each of the following?
MARK (X) ONE FOR EACH QUESTION
NOT AT ALL
LIKELY
A LITTLE
BIT LIKELY
SOMEWHAT
LIKELY
VERY
LIKELY
a. Graduate from high school ............................................................................................................................
b. Go to a technical or vocational school after high school ...............................................................................
c. Go to college ..................................................................................................................................................
d. Graduate from a 2-year or community college program ................................................................................
e. Graduate from a 4-year college program.......................................................................................................
1.14. In the past 12 months, have you received any information or learned about any of the following?
MARK (X) ONE FOR EACH QUESTION
YES
NO
a. Relationships, dating, marriage, or family life ................................................................................................
b. Abstinence from sex ......................................................................................................................................
c. Methods of birth control .................................................................................................................................
d. Where to get birth control ..............................................................................................................................
e. Sexually transmitted infections, also known as STIs .....................................................................................
f.
How to talk to your partner about whether to have sex or whether to use birth control ................................
g. How to say no to sex......................................................................................................................................
h. How babies are made ....................................................................................................................................
1.15. Thinking about the past 12 months, how many times did you get information on relationships, abstinence,
birth control, or sexually transmitted diseases at each of the following places?
MARK (X) ONE FOR EACH
NEVER
1-3 TIMES
4-9 TIMES
10 OR MORE TIMES
a. School class ............................................................................................................................................
b. Church, synagogue, mosque, or religious classes
outside of school .....................................................................................................................................
c.
Community center, youth organization, or
after-school activity .................................................................................................................................
d. Doctor, nurse, or clinic ............................................................................................................................
e. Friends ....................................................................................................................................................
f.
Parents and other relatives or family members ......................................................................................
g. Internet and media ..................................................................................................................................
h. Other
LIST OTHER SOURCE
...................................................................................................
1.16. Thinking about the past 12 months, where did you get information on relationships, abstinence, birth
control, or sexually transmitted diseases that was very helpful to you?
YOU MAY MARK (X) MORE THAN ONE
School class
Church, synagogue, mosque or religious classes outside of school
Community center, youth organization, or after-school activity
Doctor, nurse, or clinic
Friends
Parents and other relatives or family members
Internet and media
Other
SECTION 2: KNOWLEDGE
These next questions ask about the body, sexually transmitted infections (STIs), and methods of
protection.
2.1. The body part of the female body where a baby grows during pregnancy is the:
MARK (X) ONE
Cervix
Uterus
Vagina
Ovary
2.2. The part of the male’s body that produces sperm is the:
MARK (X) ONE
Testicles
Urethra
Penis
Prostate
2.3. When is it possible for a female to become pregnant?
MARK (X) ONE
The first time she has sex
When she is ovulating
When her partner withdraws (pulls out) before ejaculating
All of the above
2.4. Of the following statements about methods of protection, which one is false?
MARK (X) ONE
You can get them with a prescription from a doctor
You can buy them at a local store in the drug or pharmacy section
Some require a prescription and others do not, depending on the type of method
You must have your parent’s/guardian’s permission to get them if you are under age 18
2.5. Please mark whether each statement is true, false, or you don’t know.
MARK (X) ONE FOR EACH QUESTION
TRUE
FALSE
DON’T
KNOW
a. A sexually active girl can become pregnant if she forgets to take
her birth control pills for several days in a row ............................................................................................
b. Using a condom can help prevent HIV ........................................................................................................
c. A condom can be used more than once ......................................................................................................
d. If a condom is used, a young man should be careful how he
pulls out........................................................................................................................................................
e. If a young couple has had unprotected sex a few times and a
pregnancy did not occur, then they do not have to worry about
her getting pregnant .....................................................................................................................................
f.
HIV destroys the immune system’s ability to fight off infections
and diseases ................................................................................................................................................
g. You cannot tell if a person has HIV by looking at them ...............................................................................
h. HIV is the only sexually transmitted infection that is incurable ....................................................................
i.
All sexually active individuals are at risk for getting HIV .............................................................................
j.
Latex condoms are 100% effective in preventing pregnancy
and STIs (including HIV) ..............................................................................................................................
k. All sexually transmitted infections (STIs) can be cured ..............................................................................
l.
You can get the same sexually transmitted infection (STI) twice ...............................................................
m. You can get a sexually transmitted infection (STI) from having oral sex ...................................................
2.6. Which of the following methods of protection offers the most protection against HIV and other
STIs?
MARK (X) ONE
Depo-Provera (the shot)
Vaginal film
Condom (rubber)
Birth control pill
2.7. What is the safest and most effective method for avoiding pregnancy and sexually transmitted
infections (STIs)?
MARK (X) ONE
Birth control pill
Condom (rubber)
Depo-Provera (the shot)
Abstinence (not having sex)
2.8. Which one of the following methods listed below do you think is most effective for preventing
pregnancy?
MARK (X) ONE
Condom (rubber)
Depo-Provera (the shot)
Rhythm (safe period by calendar)
Patch (Ortho evra)
Birth control pill
Withdrawal method
2.9. Which one of the following methods listed below do you think is least effective for preventing
pregnancy?
MARK (X) ONE
Condom (rubber)
Depo-Provera (the shot)
Rhythm (safe period by calendar)
Patch (Ortho evra)
Birth control pill
Withdrawal method
SECTION 3: ATTITUDES AND SELF-EFFICACY
The following questions are about your views on sex and protection.
3.1. Two people having vaginal intercourse should use some method of protection if they are not
ready for a child.
MARK (X) ONE
Strongly agree
Agree
Disagree
Strongly disagree
3.2. Using a method of protection is very important.
MARK (X) ONE
Strongly agree
Agree
Disagree
Strongly disagree
3.3. The next questions are about condom use. How strongly do you agree or disagree that…
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
NEITHER
AGREE
NOR
DISAGREE
DISAGREE
STRONGLY
DISAGREE
a. Condoms should always be used if a
person your age has sexual intercourse ........................................................................................................
b. Condoms are a hassle to use ........................................................................................................................
c. Condoms are pretty easy to get.....................................................................................................................
d. Condoms are important to make sex safer....................................................................................................
e. Using condoms means you don’t trust
your partner....................................................................................................................................................
f.
Condoms are morally wrong ..........................................................................................................................
g. Condoms decrease sexual pleasure .............................................................................................................
h. Condoms make sex less exciting ..................................................................................................................
3.4.
The next questions are about other methods of birth control, NOT including condoms. How
strongly do you agree or disagree that…
MARK (X) ONE FOR EACH
STRONGLY
AGREE
AGREE
NEITHER
AGREE
NOR
DISAGREE
DISAGREE
STRONGLY
DISAGREE
a. Birth control should always be used if
a person your age has sexual
intercourse .....................................................................................................................................................
b. Birth control is a hassle to use .......................................................................................................................
c. Birth control is pretty easy to get ...................................................................................................................
d. Birth control is important to make sex
safer ...............................................................................................................................................................
e. Birth control has too many negative
side effects .....................................................................................................................................................
f.
Using birth control is morally wrong ...............................................................................................................
3.5. Please tell us how sure or unsure you are that you could do the following things:
MARK (X) ONE FOR EACH QUESTION
VERY SURE
SOMEWHAT
SURE
SOMEWHAT
UNSURE
VERY
UNSURE
a. Find a place in your community to obtain
methods of protection from pregnancy and STIs ..........................................................................................
b. Tell your partner your feelings about what
you do and do not want to do sexually ..........................................................................................................
c. Say “no” if your partner puts pressure on you
to be involved sexually, and you do not want
to be involved sexually...................................................................................................................................
d. Talk with your partner about methods of
protection if you have sex with him/her ........................................................................................................
e. Insist on using a method of protection if you
have sex and want to use a method of
protection ......................................................................................................................................................
f.
Stop and use a method of protection once
you are turned on ..........................................................................................................................................
g. Plan ahead to have some method of protection
available .........................................................................................................................................................
h. Resist having sex with your partner if he/she
did not want to use a method of protection ...................................................................................................
3.6. The next questions are about your views on sexual intercourse. In this survey, when we ask
about sexual intercourse, we mean a male putting his penis into a female’s vagina. How strongly
do you agree or disagree that…
MARK (X) ONE FOR EACH QUESTION
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
a. Having sexual intercourse is a good
thing for you to do at your age .......................................................................................................................
b. At your age right now, having sexual
intercourse would create problems ................................................................................................................
c. At your age right now, not having sexual
intercourse is important for you to be
safe and healthy ............................................................................................................................................
d. At your age right now, it is okay for you
to have sexual intercourse if you use
birth control, like a condom ............................................................................................................................
e. It is against your values to have sexual
intercourse before marriage...........................................................................................................................
SECTION 4: BEHAVIOR AND INTENTIONS
NOTE: The following questions are about behaviors. Questions on this survey only mean behaviors
that you choose to participate in - do not count behaviors you were forced to do against your will.
SEXUAL INTERCOURSE
4.1. These first questions are about sexual intercourse. By sexual intercourse, we mean a male
putting his penis into a female’s vagina.
Have you ever had sexual intercourse?
MARK (X) ONE
Yes
No
4.2. Have you had sexual intercourse more than one time?
MARK (X) ONE
I have never had sexual intercourse
Yes
No
4.3. How many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one
time?
I have never had sexual intercourse
NUMBER OF PEOPLE – Your best guess is fine.
4.4. These next few questions ask about the first time you had sexual intercourse. The very first time
you had sexual intercourse, how old were you?
I have never had sexual intercourse
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
4.5. Birth control methods are something used to reduce the risk of pregnancy, and some can reduce
the risk of sexually transmitted infections, also known as STIs.
The first time you had sexual intercourse, did you or your partner use any type of birth control—
including condoms or any other method?
MARK (X) ONE
I have never had sexual intercourse
Yes
No
4.6. The first time you had sexual intercourse, did you or your partner use…?
MARK (X) ONE FOR EACH QUESTION
I have never had sexual intercourse
YES
NO
a. Condoms........................................................................................................................................................
b. Birth control pills or the patch ........................................................................................................................
c. Depo-Provera or other injectable birth control ...............................................................................................
d. NuvaRing or the ring ......................................................................................................................................
e. Withdrawal or pulling out ...............................................................................................................................
f.
Another method PRINT OTHER METHOD USED
................................................................................
4.7. Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had sexual intercourse?
None
NUMBER OF TIMES – Your best guess is fine.
4.8. In the past 3 months, how many TIMES have you had sexual intercourse without using a
condom?
None
NUMBER OF TIMES – Your best guess is fine.
4.9. The next question is about your use of the following methods of birth control:
•
•
•
•
•
•
•
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implant (Implanon)
In the past 3 months, how many TIMES have you had sexual intercourse without using any of
these methods of birth control?
None
NUMBER OF TIMES – Your best guess is fine.
4.10. In the past 3 months, with how many people have you had sex?
MARK (X) ONE
1 person
2 people
3 people
4 people
5 people
6 or more people
4.11. The next few questions are about your intentions for the next year.
Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
4.12. If you have sexual intercourse in the next year, do you intend to use a condom?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
4.13. The next question is about your intention to use other methods of birth control, NOT including
condoms:
•
Birth control pills
•
The shot (Depo Provera)
•
The patch
•
The ring (NuvaRing)
•
IUD (Mirena or Paragard)
•
Implants (Implanon)
If you have sexual intercourse in the next year, do you intend to use any of these other methods
of birth control?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
PREGNANCY
4.14. To the best of your knowledge, have you ever been pregnant or gotten anyone pregnant, even if
no child was born? Be sure to answer ‘yes’ if you are currently pregnant or had any pregnancy
that ended in a birth, an abortion, stillbirth, miscarriage, or live birth after which the baby died.
MARK (X) ONE
Yes
No
4.15. Have you been pregnant or gotten someone pregnant during the past 3 months? Be sure to
answer ‘yes’ if you are currently pregnant or had any pregnancy that ended in a birth, an
abortion, stillbirth, miscarriage, or live birth after which the baby died.
MARK (X) ONE
Yes
No
4.16. To the best of your knowledge, how many times have you been pregnant or gotten someone
pregnant?
None
NUMBER OF TIMES PREGNANT
4.17. Have you ever had a baby or has anyone you got pregnant had the baby?
MARK (X) ONE
I have never been pregnant or gotten anyone pregnant
Yes
No
Don’t know
4.18. When you or your partner got pregnant, were you trying to become pregnant?
MARK (X) ONE
I have never been pregnant or gotten anyone pregnant
Yes
No
4.19. If you got pregnant now or got someone pregnant now, how would you feel?
MARK (X) ONE
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
ORAL SEX
4.20. The next questions are about oral sex. Oral sex is when someone puts his or her mouth on
another person’s penis or vagina, OR lets someone else put his or her mouth on their penis or
vagina.
Have you ever had oral sex?
MARK (X) ONE
Yes
No
4.21. How many DIFFERENT PEOPLE have you ever had oral sex with, even if only one time?
I have never had oral sex
NUMBER OF PEOPLE – Your best guess is fine.
4.22. Now think about the first time you had oral sex. The very first time you had oral sex, how old were
you?
MARK (X) ONE
I have never had oral sex
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
4.23. Now please think about the past 3 months. In the past 3 months, how many TIMES have you had
oral sex?
None
NUMBER OF TIMES – Your best guess is fine.
4.24. Do you intend to have oral sex in the next year?
MARK (X) ONE
Yes, definitely
Yes, probably
No, probably not
No, definitely not
SEX – VAGINAL, ORAL, AND ANAL SEX
The next few questions ask about sex. By sex, we mean ALL types of sex – including vaginal,
oral, and anal sex.
4.25. Have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
Yes
No
4.26. These next few questions ask about the last time you had sex (sexual intercourse, oral sex or
anal sex). The last time you had sex did you or your partner use a method of protection?
MARK (X) ONE
I have never had sex
Yes
No
4.27. The last time you had sex did you or your partner use a condom?
MARK (X) ONE
I have never had sex
Yes
No
4.28. The last time you had sex, did you or your partner use the following methods to prevent
pregnancy or STIs?
MARK (X) ONE FOR EACH QUESTION
I have never had sex
YES
NO
a. Condoms........................................................................................................................................................
b. Birth control pills or the patch ........................................................................................................................
c. Depo-Provera or other injectable birth control ...............................................................................................
d. NuvaRing or the ring ......................................................................................................................................
e. Withdrawal or pulling out ...............................................................................................................................
f.
Not sure ........................................................................................................................................................
g. Another method PRINT OTHER METHOD USED
................................................................................
4.29. Which one of these statements best describes you now?
MARK (X) ONE
I have not had sex and am not even thinking about having sex
I have not had sex, however I am thinking about having sex
I have not had sex, but I am seriously thinking about having sex in the near future
I have had sex in the past but I am not having sex now
I am currently having sex
4.30. Which of the following categories best describes your use of methods of protection now? Please
choose just one category.
MARK (X) ONE
I do not use any methods of protection because I am not sexually active
I do not use a method of protection
I do not use any methods of protection, but am considering using a method of protection
I use a method of protection sometimes, but I am thinking about using a method of protection every time I have
sex
I use a method of protection every time, but it has been less than 6 months since I started using a method of
protection every time
I use a method of protection every time, and it has been more than 6 months since I started using a method of
protection every time
SEXUALLY TRANSMITTED INFECTIONS (STIs)
The next questions ask about sexually transmitted infections (STIs.)
4.31. In the past 12 months, have you spoken with a doctor or nurse about sex, birth control or
sexually transmitted infections, also known as STIs?
MARK (X) ONE
Yes
No
4.32. In the past 12 months, have you been tested by a doctor or nurse for a sexually transmitted
infection (STI), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE
Yes
No
4.33. In the past 12 months, have you been told by a doctor or nurse that you had a sexually
transmitted infection (STI)?
MARK (X) ONE
Yes
No
4.34. This question is about the types of sexually transmitted infections (STIs) you have had. In the
past 12 months, did you have…?
MARK (X) ONE FOR EACH QUESTION
I have not had an STI in the last 12 months
DON’T
YES
NO
KNOW
a. Chlamydia ......................................................................................................................................................
b. Gonorrhea ......................................................................................................................................................
c. Genital herpes ...............................................................................................................................................
d. Syphilis...........................................................................................................................................................
e. HIV infection or AIDS .....................................................................................................................................
f.
Human Papilloma virus, also known as HPV or genital warts .......................................................................
g. Another sexually transmitted infection (STI) PRINT OTHER STI.................................................................
SECTION 5: POWER THROUGH CHOICES
5.1. Were you in the POWER Through Choices program at any previous time?
MARK (X) ONE
Yes
No
For the next few questions, please think about POWER Through Choices and how it may have
influenced you.
5.2. Would you say that being in this program has made you more or less likely to have sexual
intercourse in the next year?
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
5.3. If you were to have sexual intercourse in the next year, would you say that being in POWER
Through Choices has made you more or less likely to use a condom?
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
5.4. The next question is about how likely you are to use other methods of birth control (NOT
including condoms) if you have sexual intercourse in the next year:
•
Birth control pills
•
The shot (Depo Provera)
•
The patch
•
The ring (NuvaRing)
•
IUD (Mirena or Paragard)
•
Implants (Implanon)
If you were to have sexual intercourse in the next year, would you say that being in POWER
Through Choices has made you more or less likely to use one of these other methods of birth
control?
MARK (X) ONE
Much more likely
More likely
About the same
Less likely
Much less likely
5.5. How helpful do you feel the material presented in Power Through Choices has been to you
personally?
MARK (X) ONE
Extremely helpful
Very helpful
Neutral
Not very helpful
Not helpful at all
5.6. Compared to other teachers you have had, how would you rate the instructor who presented the
Power Through Choices program?
MARK (X) ONE
Outstanding
Above average
Average
Below average
Poor
SUMMARY OF DIFFERENCES BETWEEN THE FIRST FOLLOW-UP CONCORDANCE INSTRUMENT AND THE OICA FIRST FOLLOW-UP SURVEY
OICA #
Concordance #
Items are listed in the order in which they appear on the OICA first follow-up instrument. The number for the corresponding follow-up
concordance item is listed in the “Concordance #” column. There are no separate sections for sexually active and non-sexually active
respondents. Items found on the concordance instrument that are not on the OICA instrument are listed at the bottom of the table.
• Modifications to an existing follow-up concordance item are listed in the “Modifications” column; otherwise, the question text on the
OICA instrument is the same as that on the follow-up concordance instrument.
• If an item is specific to the OICA instrument, it is indicated by an “N/A” in the “Concordance #” column and the question text is noted
on the “Modifications” column.
1.1
1.3
Concordance Follow-up Question Text
Modifications for OICA
Are you male or female?
MARK (X) ONE
□
□
Male
Female
1
OICA #
Concordance #
1.2
1.2
Concordance Follow-up Question Text
What grade are you in?
MARK (X) ONE
□
□
□
□
□
□
□
□
6th
7th
8th
9th
10th
11th
Modifications for OICA
What is the last grade you completed?
MARK (X) ONE
□
□
□
□
□
□
□
12th
Not currently in school
2
6th
7th
8th
9th
10th
11th
12th
OICA #
Concordance #
1.3
N/A
1.4
N/A
Concordance Follow-up Question Text
Modifications for OICA
How old were you when you entered the foster care system?
MARK (X) ONE
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
<1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
Do you currently live in a group home?
MARK (X) ONE
□
Yes
□
No GO TO 1.6
3
OICA #
Concordance #
1.5
N/A
1.6
1.4
Concordance Follow-up Question Text
Modifications for OICA
In what month and year did you start living in this group home?
MARK (X) ONE MONTH AND ONE YEAR
Are you Hispanic/Latino?
MARK (X) ONE
□
□
1.7
1.5
N/A
No
What is your race?
□
□
□
□
□
□
1.8
Yes
YOU MAY MARK (X) MORE THAN ONE ANSWER
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some other race PRINT OTHER RACE
What is the second letter of your first name?
MARK (X) ONE
4
OICA #
Concordance #
1.9
N/A
Concordance Follow-up Question Text
Modifications for OICA
What is the last letter of your first name?
MARK (X) ONE
1.10
1.1
1.11
N/A
1.12
1.1
1.13
1.12
In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
In which month were you born?
MARK (X) ONE
On which day were you born?
MARK (X) ONE
In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR
In which year were you born?
MARK (X) ONE
How likely is it that you will do each of the following things?
MARK (X) ONE FOR EACH
Not at all likely, A little bit likely, Somewhat likely, Very likely
A. Graduate from high school
B. Go to a technical or vocational school after high school
C. Go to college
D. Graduate from a 2-year or community college program
E. Graduate from a 4-year college program
5
OICA #
Concordance #
1.14
1.6
Concordance Follow-up Question Text
In the past 12 months, have you received any information or learned
about any of the following?
Modifications for OICA
Refers to STIs and sexually transmitted infections instead of STDs and sexually
transmitted diseases.
MARK (X) ONE FOR EACH
Yes/No
a.
b.
c.
d.
e.
f.
g.
h.
Relationships, dating, marriage, or family life
Abstinence from sex
Methods of birth control
Where to get birth control
Sexually transmitted diseases, also known as STDs
How to talk to your partner about whether to have sex or
whether to use birth control
How to say no to sex
How babies are made
6
OICA #
Concordance #
1.15
1.7
Concordance Follow-up Question Text
Thinking about the past 12 months, how many times did you get
information on relationships, abstinence, birth control, or sexually
transmitted diseases at each of the following places?
MARK (X) ONE FOR EACH
Modifications for OICA
Refers to STIs and sexually transmitted infections instead of STDs and sexually
transmitted diseases.
Added:
g. Internet and media
Never/1-3 times/4-9 times/10 or more times
a)
b)
c)
d)
e)
f)
g)
School class
Church, synagogue, mosque, or religious classes outside
of school
Community center, youth organization, or after-school
activity
Doctor, nurse, or clinic
Friends
Parents and other relatives or family members
Other LIST OTHER SOURCE
7
OICA #
Concordance #
1.16
1.8
Concordance Follow-up Question Text
Thinking about the past 12 months, where did you get information on
relationships, abstinence, birth control, or sexually transmitted diseases
that was very helpful to you?
Modifications for OICA
Refers to STIs and sexually transmitted infections instead of STDs and sexually
transmitted diseases.
YOU MAY MARK (X) MORE THAN ONE
□
□
□
School class
Church, synagogue, mosque or religious classes outside of
school
Community center, youth organization, or after-school
activity
2.1
N/A
□
□
□
□
□
Doctor, nurse or clinic
Friends
Parents and other relatives or family members
Internet and media
Other (Please specify)
The next questions ask about the body, sexually transmitted infections (STIs),
and methods of protection.
The body part of the female body where a baby grows during pregnancy is the:
□
□
□
□
8
Cervix
Uterus
Vagina
Ovary
OICA #
Concordance #
2.2
N/A
Concordance Follow-up Question Text
Modifications for OICA
The part of the male’s body that produces sperm is the:
MARK (X) ONE
2.3
2.4
N/A
N/A
□ Testicles
□ Urethra
□ Penis
□ Prostate
When is it possible for a female to become pregnant?
MARK (X) ONE
□ The first time she has sex
□ When she is ovulating
□ When her partner withdraws (pulls out) before ejaculating
□ All of the above
Of the following statements about methods of protection, which one is false?
MARK (X) ONE
□ You can get them with a prescription from a doctor
□ You can buy them at a local store in the drug or pharmacy section
□ Some require a prescription and othersdo not, depending on the type of
method
□ You must have your parent’s/ guardian’s permission to get them if you are
under age 18
9
Concordance #
OICA #
2.5
N/A
Concordance Follow-up Question Text
Modifications for OICA
Please mark whether each statement is true, false, or you don’t know.
MARK (X) ONE FOR EACH QUESTION
True, False, Don’t Know
a.
A sexually active girl can become pregnant if she forgets to take
her birth control pills for several days in a row
b. Using a condom can help prevent HIV
c. A condom can be used more than once
d. If a condom is used, a young man should be careful how he
pulls out
e. If a young couple has had unprotected sex a few times and a
pregnancy did not occur, then they do not have to worry about
her getting pregnant
f. HIV destroys the immune system’s ability to fight off infections
and diseases
g. You cannot tell if a person has HIV by looking at them
h. HIV is the only sexually transmitted infection that is incurable
i.
All sexually active individuals are at risk for getting HIV
j.
Latex condoms are 100% effective in preventing pregnancy
and STIs (including HIV)
k. All sexually transmitted infections (STIs) can be cured
l. You can get the same sexually transmitted infection (STI) twice
m. You can get a sexually transmitted infection (STI) from having
oral sex
10
OICA #
Concordance #
2.6
N/A
Concordance Follow-up Question Text
Modifications for OICA
Which of the following methods of protection offers the most protection against
HIV and other STIs?
MARK (X) ONE
2.7
N/A
□ Depo-Provera (the shot)
□ Vaginal film
□ Condom (rubber)
□ Birth control pill
What is the safest and most effective method for avoiding pregnancy and
sexually transmitted infections (STIs)?
MARK (X) ONE
2.8
N/A
□ Birth control pill
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Abstinence (not having sex)
Which one of the following methods listed below do you think is most effective
for preventing pregnancy?
MARK (X) ONE
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Rhythm (safe period by calendar)
□ Patch (Ortho evra)
□ Birth control pill
□ Withdrawal method
11
OICA #
Concordance #
2.9
N/A
3.1
N/A
Concordance Follow-up Question Text
Modifications for OICA
Which one of the following methods listed below do you think is
least effective for preventing pregnancy?
MARK (X) ONE
□ Condom (rubber)
□ Depo-Provera (the shot)
□ Rhythm (safe period by calendar)
□ Patch (Ortho evra)
□ Birth control pill
□ Withdrawal method
The following questions are about your views on sex and protection.
Two people having vaginal intercourse should use some method of protection if
they are not ready for a child.
MARK (X) ONE
3.2
N/A
□ Strongly agree
□ Agree
□ Disagree
□ Strongly disagree
Using a method of protection is very important.
MARK (X) ONE
□ Strongly agree
□ Agree
□ Disagree
□ Strongly disagree
12
OICA #
Concordance #
3.3
3.14
Concordance Follow-up Question Text
Modifications for OICA
The next series of questions is about condom use. How Added:
strongly do you agree or disagree that…?
h. Condoms make sex less exciting
MARK (X) ONE FOR EACH
Strongly Agree, Agree, Neither agree nor disagree,
Disagree, Strongly Disagree
a. Condoms should always be used if a person your age has
sexual intercourse
b. Condoms are a hassle to use
c. Condoms are pretty easy to get
d. Condoms are important to make sex safer
e. Using condoms means you don’t trust your partner
f. Using condoms is morally wrong
g. Condoms decrease sexual pleasure
13
OICA #
Concordance #
3.4
3.15
Concordance Follow-up Question Text
Modifications for OICA
The next series of questions is about other methods of
birth control, NOT including condoms. How strongly do
you agree or disagree that…?
MARK (X) ONE FOR EACH
Strongly Agree, Agree, Neither agree nor disagree,
Disagree, Strongly Disagree
a. Birth control should always be used if a person your age has
sexual intercourse
b. Birth control is a hassle to use
c. Birth control is pretty easy to get
d. Birth control is important to make sex safer
e. Birth control has too many negative side effects
f. Using birth control is morally wrong
14
OICA #
Concordance #
3.5
N/A
Concordance Follow-up Question Text
Modifications for OICA
Please tell us how sure or unsure you are that you could do the
following things:
MARK (X) ONE FOR EACH QUESTION
a. Find a place in your community to obtain methods of protection
b. Tell your partner your feelings about what you do and do not want to do
sexually
c. Say “no” if your partner puts pressure on you to be involved sexually, and you
do not want to be involved sexually
d. Talk with your partner about methods of protection if you have sex with
him/her
e. Insist on using a method of protection if you have sex and want to use a
method of protection
f. Stop and use a method of protection once you are turned on
g. Plan ahead to have some method of protection available
h. Resist having sex with your partner if he/she did not want to use a method of
protection
15
OICA #
Concordance #
3.6
3.1
Concordance Follow-up Question Text
Modifications for OICA
The next series of questions is about your views on sexual intercourse.
In this survey, when we ask about sexual intercourse, we mean a male
putting his penis into a female’s vagina. How strongly do you agree or
disagree that…?
MARK (X) ONE FOR EACH
Strongly Agree, Agree, Disagree, Strongly Disagree
a.
b.
c.
d.
e.
4.1
4.2
Having sexual intercourse is a good thing for you to do at
your age
At your age right now, having sexual intercourse would
create problems
At your age right now, not having sexual intercourse is
important for you to be safe and healthy
At your age right now, it is okay for you to have sexual
intercourse if you use birth control, like a condom
It is against your values to have sexual intercourse before
marriage
The first questions are about sexual intercourse. By sexual
intercourse, we mean a male putting his penis into a
female’s vagina.
Have you ever had sexual intercourse?
MARK (X) ONE
□
□
Yes
No
16
OICA #
Concordance #
4.2
4.5
Concordance Follow-up Question Text
Have you had sexual intercourse more than one time?
Added the option:
MARK (X) ONE
□
□
□
4.3
4.6
Modifications for OICA
I have never had sexual intercourse
Yes
No
How many DIFFERENT PEOPLE have you ever had sexual Added the option:
intercourse with, even if only one time?
□
|
|
| NUMBER OF PEOPLE - Your best guess is fine.
17
I have never had sexual intercourse
OICA #
Concordance #
4.4
4.4
Concordance Follow-up Question Text
The very first time you had sexual intercourse, how old
were you?
| | | NUMBER OF YEARS OLD YOU WERE - Your best
guess is fine.
Modifications for OICA
These next few questions ask about the first time you had sexual intercourse.
The very first time you had sexual intercourse, how old were you?
□I have never had sexual intercourse
□ 9 years old
□10 years old
□11 years old
□12 years old
□13 years old
□14 years old
□15 years old
□16 years old
□17 years old
□18 years old
4.5
N/A
Birth control methods are something used to reduce the risk of pregnancy, and
some can reduce the risk of sexually transmitted infections, also called STIs.
The first time you had sexual intercourse, did you or your partner use any type of
birth control, including condoms or any other method?
MARK (X) ONE
□
□
□
18
I have never had sexual intercourse
Yes
No
OICA #
Concordance #
4.6
N/A
Concordance Follow-up Question Text
Modifications for OICA
The first time you had sexual intercourse, did you or your partner use …
MARK (X) ONE FOR EACH ITEM
YES, NO
□
a.
b.
c.
d.
e.
f.
4.7
4.9
Now please think about the past 3 months. In the past 3
months, how many TIMES have you had sexual
intercourse?
□
|
4.8
4.10
None
| | NUMBER OF TIMES - Your best guess is fine.
In the past 3 months, how many TIMES did you have
sexual intercourse without using a condom?
□
|
None
|
| NUMBER OF TIMES - Your best guess is fine.
19
I have never had sexual intercourse
Condoms
Birth control pills or the patch
Depo-Provera or other injectable birth control
Nuva ring or the ring
Withdrawal or pulling out
Another method (PRINT OTHER METHOD USED):
OICA #
Concordance #
4.9
4.12
Concordance Follow-up Question Text
Modifications for OICA
The next question is about your use of the
following methods of birth control:
•
•
•
•
•
•
•
Condoms
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
In the past 3 months, how many TIMES have you had sexual
intercourse without using any of these methods of birth control?
□None
NUMBER OF TIMES – Your best guess is fine.
20
OICA #
Concordance #
4.10
N/A
Concordance Follow-up Question Text
Modifications for OICA
In the past 3 months, with how many people have you had sex?
MARK (X) ONE
□
□
□
□
□
□
4.11
3.20
Do you intend to have sexual intercourse in the next year?
MARK (X) ONE
□
□
□
□
1 person
2 people
3 people
4 people
5 people
6 or more people
Added introduction: The next few questions are about your intentions for the
next year.
Yes, definitely
Yes, probably
No, probably not
No, definitely not
21
OICA #
Concordance #
4.12
3.21
Concordance Follow-up Question Text
Modifications for OICA
If you have sexual intercourse in the next year, do you
intend to you a condom?
MARK (X) ONE
□
□
□
□
Yes, definitely
Yes, probably
No, probably not
No, definitely not
22
OICA #
Concordance #
4.13
3.22
Concordance Follow-up Question Text
Modifications for OICA
The next question is about your intention to use other
methods of birth control, NOT including condoms:
•
•
•
•
•
•
Birth control pills
The shot (Depo Provera)
The patch
The ring (NuvaRing)
IUD (Mirena or Paragard)
Implants (Implanon)
If you have sexual intercourse in the next year, do you
intend to use any of these other methods of birth control?
MARK (X) ONE
□
□
□
□
Yes, definitely
Yes, probably
No, probably not
No, definitely not
23
OICA #
Concordance #
4.14
5.2a
Concordance Follow-up Question Text
Modifications for OICA
To the best of your knowledge, have you ever been Added: Be sure to answer ‘yes’ if you are currently pregnant or had any
pregnant or gotten someone pregnant, even if no child pregnancy that ended in a birth, an abortion, stillbirth, miscarriage, or live birth
after which the baby died.
was born?
MARK (X) ONE
□
□
4.15
Yes
No
N/A
Have you been pregnant or gotten someone pregnant during the past 3
months? Be sure to answer ‘yes’ if you are currently pregnant or had any
pregnancy that ended in a birth, an abortion, stillbirth, miscarriage, or live birth
after which the baby died.
MARK (X) ONE
□
□
4.16
5.2b
Yes
No
To the best of your knowledge, how many times have you Added the option:
been pregnant or gotten someone pregnant?
|
|
| NUMBER OF TIMES
□
24
None
OICA #
Concordance #
4.17
5.2d
Concordance Follow-up Question Text
Have you ever had a baby or has anyone you got pregnant Deleted “actually”
actually had the baby?
MARK (X) ONE
□
□
□
4.18
Modifications for OICA
Yes
No
Don’t Know
N/A
Added the option:
□ I have never been pregnant or gotten anyone pregnant
When you or your partner got pregnant, were you trying to become pregnant?
MARK (X) ONE
□ I have never been pregnant or gotten anyone pregnant
□ Yes
□ No
4.19
3.3 for FOR GIRLS
If you got pregnant now, how would you feel?
girls;
3.4 for
FOR BOYS
boys
If you got someone pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
If you got pregnant now or got someone pregnant now, how would you feel?
MARK (X) ONE
□
□
□
□
□
25
Very happy
A little happy
Neither happy nor upset
A little upset
Very upset
OICA #
Concordance #
4.20
4.14
Concordance Follow-up Question Text
Oral sex is when someone puts
his or her mouth on another person’s
penis or vagina, OR lets someone else
put his or her mouth on their penis or
vagina.
Modifications for OICA
Added introduction: “The next questions are about oral sex.”
Have you ever had oral sex?
MARK (X) ONE
□
□
4.21
4.16
Yes
No
How many DIFFERENT PEOPLE have you ever had oral sex
with, even if only one time?
|
|
Added the option:
□ I have never had oral sex
| NUMBER OF PEOPLE - Your best guess is fine.
26
OICA #
Concordance #
4.22
4.15
Concordance Follow-up Question Text
Modifications for OICA
The very first time you had oral sex, what month and year Now think about the first time you had oral sex. The very first time you had oral
sex, how old were you?
was it?
MARK (X) ONE
MARK (X) ONE MONTH AND ONE YEAR
□I have never had oral sex
□ 9 years old
□10 years old
□11 years old
□12 years old
□13 years old
□14 years old
□15 years old
□16 years old
□17 years old
□18 years old
4.23
4.17
Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had oral
sex?
□
|
None
|
| NUMBER OF TIMES - Your best guess is fine.
27
OICA #
Concordance #
4.24
3.19
Concordance Follow-up Question Text
Do you intend to have oral sex in the next year?
MARK (X) ONE
□
□
□
□
4.25
Modifications for OICA
N/A
Yes, definitely
Yes, probably
No, probably not
No, definitely not
The next few questions ask about sex. By sex, we mean ALL types of sex including vaginal, oral and anal sex.
Have you ever had sexual intercourse, oral sex, or anal sex?
MARK (X) ONE
□
□
4.26
N/A
Yes
No
These next few questions ask about the last time you had sex (sexual
intercourse, oral sex or anal sex).
The last time you had sex did you or your partner use a method of protection?
MARK (X) ONE
□ I have never had sex
□ Yes
□ No
28
OICA #
Concordance #
4.27
N/A
Concordance Follow-up Question Text
Modifications for OICA
The last time you had sex did you or your partner use a condom?
MARK (X) ONE
□ I have never had sex
□ Yes
□ No
4.28
N/A
The last time you had sex, did you or your partner use the following
methods to prevent pregnancy or STIs?
MARK (X) ONE FOR EACH QUESTION
□ I have never had sex
a.
b.
c.
d.
e.
f.
g.
29
Condoms
Birth control pills or the patch
Depo-Provera, the shot, or other injectable birth control
NuvaRing or the ring
Withdrawal or pulling out
Not sure
Another method (PRINT OTHER METHOD USED):
OICA #
Concordance #
4.29
N/A
Concordance Follow-up Question Text
Modifications for OICA
Which one of these statements best describes you now?
MARK (X) ONE
□
□
□
4.30
N/A
□
I have not had sex and am not even thinking about having sex
I have not had sex, however I am thinking about having sex
I have not had sex, but I am seriously thinking about having sex in the near
future
I have had sex in the past but I am not having sex now
□
I am currently having sex
Which of the following categories best describes your use of methods of
protection now? Please choose just one category.
MARK (X) ONE
□ I do not use any methods of protection because I am not sexually active
□ I do not use a method of protection
□ I do not use any methods of protection, but am considering using a method of
protection
□ I use a method of protection sometimes, but I am thinking about using a
method of protection every time I have sex
□ I use a method of protection every time, but it has been less than 6 months
since I started using a method of protection every time
□ I use a method of protection every time, and it has been more than 6 months
since I started using a method of protection every time
30
OICA #
Concordance #
4.31
5.3
Concordance Follow-up Question Text
In the past 12 months, have you spoken with a doctor or Added to introduction: “ The next questions ask about sexually
nurse about sex, birth control or sexually transmitted transmitted infections (STIs).
diseases, also known as STDs?
MARK (X) ONE
□
□
4.32
5.4
Modifications for OICA
Yes
Question refers to STIs and sexually transmitted infections instead of STDs and
sexually transmitted diseases.
No
In the past 12 months, have you been tested by a doctor or Question refers to STIs and sexually transmitted infections instead of STDs and
nurse for a sexually transmitted disease (also known as an sexually transmitted diseases.
STD), like gonorrhea, Chlamydia, syphilis, or HIV?
MARK (X) ONE
□
□
4.33
5.5
Yes
No
In the past 12 months, have you been told by a doctor or Question refers to STIs and sexually transmitted infections instead of STDs and
nurse that you had a sexually transmitted disease (also sexually transmitted diseases.
known as an STD)?
MARK (X) ONE
□
□
Yes
No
31
OICA #
Concordance #
4.34
5.6
Concordance Follow-up Question Text
The next series of questions is about the types of sexually Question refers to STIs and sexually transmitted infections instead of STDs and
transmitted diseases (STDs) you have had. In the past 12 sexually transmitted diseases.
months, did you have…
MARK (X) ONE FOR EACH
Yes, No, Don’t know
a.
b.
c.
d.
e.
f.
g.
5.1
N/A
Modifications for OICA
Added the option:
□ I have not had an STI in the past 12 months
Chlamydia
Gonorrhea
Genital herpes
Syphilis
HIV infection or AIDS
Human Papilloma virus, also called HPV or genital
warts
Another sexually transmitted disease (STD)? PRINT
OTHER STD
Were you in the POWER Through Choices program at any previous
time?
MARK (X) ONE
□
□
32
Yes
No
OICA #
Concordance #
5.2
N/A
Concordance Follow-up Question Text
Modifications for OICA
For the next few questions, please think about POWER Through Choices and how
it may have
influenced you.
Would you say that being in this program has made you more or less likely to
have sexual intercourse in the next year?
MARK (X) ONE
□ Much more likely
□ More likely
□ About the same
□ Less likely
□ Much less likely
5.3
N/A
If you were to have sexual intercourse in the next year, would you say that being
in POWER Through Choices has made you more or less likely to use a condom?
MARK (X) ONE
□ Much more likely
□ More likely
□ About the same
□ Less likely
□ Much less likely
33
OICA #
Concordance #
5.4
N/A
Concordance Follow-up Question Text
Modifications for OICA
The next question is about how likely you are to use other methods of birth
control (NOT including condoms) if you have sexual intercourse in the next year:
•
Birth control pills
•
The shot (Depo Provera)
•
The patch
•
The ring (NuvaRing)
•
•
IUD (Mirena or Paragard)
Implants (Implanon)
If you were to have sexual intercourse in the next year, would you say that being
in POWER Through Choices has made you more or less likely to use one of these
other methods of birth control?
MARK (X) ONE
□ Much more likely
□ More likely
□ About the same
□ Less likely
□ Much less likely
34
OICA #
Concordance #
5.5
N/A
Concordance Follow-up Question Text
Modifications for OICA
How helpful do you feel the material presented in Power Through Choices has
been to you personally?
MARK (X) ONE
□ Extremely helpful
□ Very helpful
□ Neutral
□ Not very helpful
□ Not helpful at all
5.6
N/A
Compared to other teachers you have had, how would you rate the instructor
who presented the Power Through Choices program?
MARK (X) ONE
□ Outstanding
□ Above average
□ Average
□ Below average
□ Poor
DROPPED: The questions listed below are part of the follow-up concordance instrument, but are not part of this site-specific follow-up instrument.
35
OICA #
Concordance #
N/A
1.6a
Did you say “yes” to any item a through h in question 1.6
above?
MARK (X) ONE
□ Yes
□ No (GO TO QUESTION 1.9)
N/A
1.9
In the past 30 days, how often have you felt that you were
unable to control the important things in your life?
MARK (X) ONE
□ Never
□ Almost never
□ Sometimes
□ Fairly often
□ Very often
Concordance Follow-up Question Text
Modifications for OICA
36
OICA #
Concordance #
N/A
1.10
In the past 30 days, how often have you felt difficulties
were piling up so high that you could not overcome them?
MARK (X) ONE
□ Never
□ Almost never
□ Sometimes
□ Fairly often
□ Very often
N/A
1.11
How strongly do you agree or disagree with the following
statements?
MARK (X) ONE FOR EACH
Strongly Agree, Agree, Disagree, Strongly Disagree
Concordance Follow-up Question Text
Modifications for OICA
a. You can do things now that will help you to be healthy
when you are an adult
b. Nothing you do as a teen will affect how healthy you
are as an adult
c. Taking risks as a teen, like drinking and drugs, does
not really matter for your health in the long run
d. The good and bad decisions you make as a teen will
affect your health as an adult
37
OICA #
Concordance #
N/A
2.1
Concordance Follow-up Question Text
Modifications for OICA
The next questions are about where you live and who lives
with you.
Which of the following best describes where you live?
MARK (X) ONE
□ You live in one home
GO TO 2.2
□ You live in two or more homes, and go back
and forth
GO TO 2.3
□
You are homeless (living on the street, in a car or
shelter, or staying with friends/relatives)
GO TO 2.4
38
OICA #
Concordance #
N/A
2.2
Concordance Follow-up Question Text
Modifications for OICA
2. 2. Who lives with you in your home?
MARK (X) ALL THAT APPLY
□ Your biological mother
□ Your biological father
□ A stepmother or adoptive mother
□ A foster mother
□ A stepfather or adoptive father
□ A foster father
□ Your parent’s partner, boyfriend, or girlfriend
□ Any grandmothers
□ Any grandfathers
□ Any older brothers or sisters
□ Any younger brothers or sisters
□ Any aunts, uncles, or other relatives
□ Any other people you are not related to
□ You live by yourself
AFTER ANSWERING
GO TO 2.4
39
OICA #
Concordance #
N/A
2.3
Concordance Follow-up Question Text
Modifications for OICA
Who lives with you in each of your homes? MARK (X)
BOTH COLUMNS
Mark (X) all the people who live with you in your MAIN
home
Mark (X) all the people who live with you in your OTHER
home(s)
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Your biological mother
Your biological father
A stepmother or adoptive mother
A foster mother
A stepfather or adoptive father
A foster father
Your parent’s partner, boyfriend, or girlfriend
Any grandmothers
Any grandfathers
Any older brothers or sisters
Any younger brothers or sisters
Any aunts, uncles, or other relatives
Any other people you are not related to
You live by yourself
40
OICA #
Concordance #
N/A
2.4
Now we have some questions about your mother, or the
person you think of as your mother. Is this person…
MARK (X) ONE
□ Your biological mother, that is, the woman who gave
birth to you
□ Your stepmother or adoptive mother
□ Your foster mother
□ Your grandmother
□ Your aunt or your older sister
□ Some other adult
□ You don’t have a mother or person you think
of
as your mother
GO TO QUESTION 2.9
N/A
2.5
The following questions are about the person you marked
as your mother or the person you think of as your mother.
Is she working now?
MARK (X) ONE
□ She is not working at a paid job
□ Yes, she is working part-time or less than 30 hours a
week
□ Yes, she is working full-time or at more than one job
for 30 hours a week or more
□ Yes, she works, but I don’t know how many hours
□ Don’t know if she is working
Concordance Follow-up Question Text
Modifications for OICA
41
OICA #
Concordance #
N/A
2.6
Concordance Follow-up Question Text
Modifications for OICA
How well can you and she share ideas or talk about things
that are important to you?
MARK (X) ONE
□ Not at all well
□ Not very well
□ Somewhat well
□ Very well
N/A
2.7
Now thinking about your biological mother, that is, the
woman who gave birth to you, how old is she (or would
she be if she were alive)?
NUMBER OF YEARS OLD-your best guess is fine
□ I do not know about my biological mother Go To 2.9
42
OICA #
Concordance #
N/A
2.8
Concordance Follow-up Question Text
Modifications for OICA
Again thinking about your biological mother and all the
children she has ever had- how old is the oldest one? If the
oldest one is not alive, how old would that child be if still
living?
NUMBER OF YEARS OLD-your best guess is fine
□ I do not know about my biological mother
N/A
2.9
Next we have some questions about your father, or the
person you think of as your father. Is this person…
MARK (X) ONE
□ Your biological father, that is, the man who is
genetically related to you
□ Your stepfather or adoptive father
□ Your foster father
□ Your grandfather
□ Your uncle or your older brother
□ Some other adult
□ You don’t have a father or person you think of as your
father
GO TO 2.12a
43
OICA #
Concordance #
N/A
2.10
Concordance Follow-up Question Text
Modifications for OICA
The following questions are about the person you marked
as your father or the person you think of as your father.
Is he working now?
MARK (X) ONE
□ He is not working at a paid job
□ Yes, he is working part-time or less than 30
hours a week
□ Yes, he is working full-time or at more than one job
for 30 hours a week or more
□ Yes, he works, but I don’t know how many hours
□ Don’t know if he is working
N/A
2.11
How well can you and he share ideas or talk about things
that are important to you?
MARK (X) ONE
□ Not at all well
□ Not very well
□ Somewhat well
□ Very well
44
OICA #
Concordance #
N/A
2.12a
Concordance Follow-up Question Text
Modifications for OICA
Which of the following best describes the relationship
between your biological mother and biological father? If
one or both of your biological parents have passed away,
please answer about their relationship when both were
alive.
MARK (X) ONE
□ They are married to each other
□ They used to be married to each other, but are now
separated
□ They used to be married to each other, but are now
divorced
□ They have never been married to each other
□ I don’t know
45
OICA #
Concordance #
N/A
2.12b
Concordance Follow-up Question Text
Modifications for OICA
Do your biological mother and biological father
live together now?
MARK (X) ONE
□ Yes
□ No
□ One or both of my biological parents have passed
away
□ I don’t know
46
OICA #
Concordance #
N/A
2.13
Concordance Follow-up Question Text
Modifications for OICA
The next questions ask what your parents know about
your activities. By parents, we mean the parents or
guardians you live with most of the time.
Thinking about the past month, how often did your
parents know where you were after school?
MARK (X) ONE
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never
N/A
2.14
Thinking about the past month, how often did your
parents know who you were going to be with before you
went out?
MARK (X) ONE
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never
□ I did not go out
47
OICA #
Concordance #
N/A
2.15
Concordance Follow-up Question Text
Modifications for OICA
Thinking about the past month, how often did your
parents know where you were when you went out at
night?
MARK (X) ONE
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never
□ I did not go out at night
N/A
2.16
If you were going to be home late, would your parents
expect you to call?
MARK (X) ONE
□ Yes
□ No
48
OICA #
Concordance #
N/A
3.2
Concordance Follow-up Question Text
Modifications for OICA
How strongly do you agree or disagree with the following
statements?
MARK (X) ONE FOR EACH
Strongly Agree, Agree, Disagree, Strongly Disagree
a. You have goals you want to accomplish before you
have a child
b. It is important for you to finish school before you
have a child
c. It is important for you to have a job and stable income
before you have a child
d. Having a good marriage seems possible for you
49
OICA #
Concordance #
N/A
3.5
Concordance Follow-up Question Text
Modifications for OICA
Imagine you are alone with someone you like very much.
How likely is it that you could . . .
MARK (X) ONE FOR EACH
Not at all Likely, a Little Bit likely, Somewhat Likely, Very
Likely
a. Stop them if they wanted to touch your chest and you
did not want them to do that (FOR GIRLS)
b. Stop them if they wanted to touch your private parts
below the waist, meaning the parts of the body covered by
underwear, and you did not want them to do that
c. Avoid having sexual intercourse if you didn’t want to
N/A
3.6
How likely is it that you will get pregnant (or get someone
pregnant) between now and age 20?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely
50
OICA #
Concordance #
N/A
3.6a
Concordance Follow-up Question Text
Modifications for OICA
How likely is it that you will get pregnant (or get someone
else pregnant) between now and when you get married?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely
N/A
3.7
The next series of questions is
about condoms, birth control pills,
pregnancy and sexually transmitted
diseases, also known as STDs.
If a condom is used correctly, how much can it decrease
the risk of pregnancy?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Don’t know
GO TO QUESTION 3.8
51
OICA #
Concordance #
N/A
3.7a
How confident are you that your answer to the question
above is correct?
MARK (X) ONE
□ Not at all confident
□ A little confident
□ Somewhat confident
□ Very confident
N/A
3.8
If a condom is used correctly, how much can it decrease
the risk of getting HIV, the virus that causes AIDS?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Don’t know
N/A
3.9
If a condom is used correctly, how much can it decrease
the risk of getting Chlamydia and gonorrhea?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Don’t know
Concordance Follow-up Question Text
Modifications for OICA
52
OICA #
Concordance #
N/A
3.10
Concordance Follow-up Question Text
Modifications for OICA
If birth control pills are used correctly, how much can they
decrease the risk of pregnancy?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Don’t know
GO TO 3.11
N/A
3.10a
How confident are you that your answer to the question
above is correct?
MARK (X) ONE
□ Not at all confident
□ A little confident
□ Somewhat confident
□ Very confident
N/A
3.11
If birth control pills are used correctly, how much can they
decrease the risk of getting HIV, the virus that causes
AIDS?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Don’t know
53
OICA #
Concordance #
N/A
3.12
If birth control pills are used correctly, how much can they
decrease the risk of getting Chlamydia and gonorrhea?
MARK (X) ONE
□ Not at all
□ A little
□ A lot
□ Don’t know
N/A
3.13
Can you get a sexually transmitted disease, or STD, from
having oral sex?
MARK (X) ONE
□ Yes
□ No
□ Don’t know
GO TO 3.14
N/A
3.13a
How confident are you that your answer to the question
above is correct?
MARK (X) ONE
□ Not at all confident
□ A little confident
□ Somewhat confident
□ Very confident
Concordance Follow-up Question Text
Modifications for OICA
54
OICA #
Concordance #
N/A
3.16
Concordance Follow-up Question Text
Modifications for OICA
Read each statement below and check the answer that fits
best.
MARK (X) ONE FOR EACH
I am sure it’s true, I think it’s true, I don’t know, I think it’s false, I
am sure it’s false
a.
b.
c.
d.
e.
You can’t get AIDS if you have sex only
once or twice without a condom
Condoms are 100% effective in preventing
HIV
Once you are infected with HIV, you are
infected for life
If a young couple has had unprotected sex
a few times and a pregnancy did not
happen, then they do not have to worry
about her getting pregnant
There is a vaccine or shot available to prevent girls from
becoming infected with certain types of HPV (also known
as Human
Papilloma virus).
55
OICA #
Concordance #
N/A
3.17
Concordance Follow-up Question Text
Modifications for OICA
Thinking about the future, how likely do you think it is that
you will get HIV/AIDS?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely
N/A
3.18
How likely do you think it is that you will get an STD other
than HIV/AIDS?
MARK (X) ONE
□ Not at all likely
□ A little likely
□ Somewhat likely
□ Very likely
N/A
3.23
Do you intend to have sexual intercourse without being
married?
MARK (X) ONE
□ Yes, definitely
□ Yes, probably
□ No, probably not
□ No, definitely not
56
OICA #
Concordance #
N/A
3.24
Concordance Follow-up Question Text
Right now, do you have a boyfriend or girlfriend –
someone in particular you are going out with?
MARK (X) ONE
□
□
N/A
3.25
Modifications for OICA
Yes
No
In the past 3 months, how many TIMES have you gone out
on a date?
□ Zero or None
GO TO 3.27
| | | NUMBER OF TIMES - Your best guess is fine
57
OICA #
Concordance #
N/A
3.26
Concordance Follow-up Question Text
Thinking about these dates in the past 3 months, how
many DIFFERENT PEOPLE did you go out on a date with?
|
N/A
3.27
Modifications for OICA
|
| NUMBER OF PEOPLE - Your best guess is fine.
Have you ever had sexual intercourse, oral sex, or anal
sex?
□ YES: GO TO PART B1
□ NO: GO TO PART B2
58
OICA #
Concordance #
N/A
4.1
Concordance Follow-up Question Text
Modifications for OICA
The next questions are about your sexual behaviors and
experiences. Please be as honest as possible. Your answers
are confidential and everything you say will be kept
private.
Just to confirm, have you ever had sexual intercourse, oral
sex, or anal sex?
MARK (X) ONE
□ No
□ Yes
N/A
4.3
STOP AND GO TO PART B2.
CONTINUE WITH THIS BOOKLET.
The very first time you had sexual intercourse, what month
and year was it?
MARK (X) ONE MONTH AND ONE YEAR
59
OICA #
Concordance #
N/A
4.7
Concordance Follow-up Question Text
Modifications for OICA
The most recent time you had sexual intercourse, what
month and year was it?
MARK (X) ONE MONTH AND ONE YEAR
N/A
4.8
The most recent time you had sexual intercourse, did you
or your partner use …?
MARK (X) ONE FOR EACH
Yes or no
a. Condoms
b. Birth control pills or the patch
c. Depo-Provera or other
injectable birth control
d. NuvaRing or the ring
e. Withdrawal or pulling out
f. Another method PRINT OTHER METHOD USED
60
OICA #
Concordance #
N/A
4.11
N/A
4.13
Concordance Follow-up Question Text
Modifications for OICA
In the past 3 months, of those times you used a condom
during sexual intercourse, how many times did the
condom break or slip off during sex?
□
None
|
|
| NUMBER OF TIMES- Your best guess is fine.
Now please think about the past 12 months.
In the past 12 months, how often have you had a
relationship that was just sexual?
MARK (X) ONE
□ Never
□ Once
□ More than once
61
OICA #
Concordance #
N/A
4.18
Concordance Follow-up Question Text
Modifications for OICA
In the past 3 months, how many TIMES have you had oral
sex without using a condom?
□ None
| | | NUMBER OF TIMES – Your best guess is fine.
N/A
4.19
Anal sex is when a male puts his penis in someone else’s
anus, or their butt, or someone lets a male put his penis in
their anus or butt.
Have you ever had anal sex?
MARK (X) ONE
□ Yes
□ No
GO TO QUESTION 5.1
62
OICA #
Concordance #
N/A
4.20
Concordance Follow-up Question Text
How many DIFFERENT PEOPLE have you ever had anal sex
with, even if only one time?
|
N/A
4.21
Modifications for OICA
|
| NUMBER OF PEOPLE - Your best guess is fine.
The very first time you had anal sex, what month and year
was it?
MARK (X) ONE MONTH AND ONE YEAR
63
OICA #
Concordance #
N/A
4.22
Concordance Follow-up Question Text
Modifications for OICA
Now please think about the past 3 months.
In the past 3 months, how many TIMES have you had anal
sex?
□ None
| | |
fine.
N/A
4.23
GO TO 5.1
NUMBER OF TIMES – Your best guess is
In the past 3 months, how many TIMES have you had anal
sex without using a condom?
□ None
| | | NUMBER OF TIMES - Your best guess is fine.
64
OICA #
Concordance #
N/A
5.1
Have you or your partner ever taken a pregnancy test?
MARK (X) ONE
□ Yes
□ No
□ Don’t Know
N/A
5.2c
How old were you the first time you got pregnant or got
someone pregnant?
Concordance Follow-up Question Text
Modifications for OICA
| | | NUMBER OF YEARS OLD YOU WERE - Your best
guess is fine.
N/A
4.1
This booklet is for youth who have not had sex. We want
to be sure you are in the correct booklet. We know we
have asked this before but…
Just to confirm, have you ever had sexual intercourse, oral
sex, or anal sex?
□ Yes STOP! GO TO PART B1 INSTEAD.
□ Yes
CONTINUE WITH THIS BOOKLET.
65
OICA #
Concordance #
N/A
4.2
N/A
4.3
Concordance Follow-up Question Text
Modifications for OICA
The first two questions in this part are about your
schooling.
Do you expect that you will graduate from high school?
Mark (X) ONE
□ Yes
□ I already graduated from high school
□ No GO TO QUESTION 4.4
In what month and year do you expect to graduate from
high school? If you already graduated, in what month and
year did you graduate from high school?
MARK (X) ONE MONTH AND ONE YEAR
Year Range 2007 or earlier to 2018 or later
Month Range January to December
66
OICA #
Concordance #
N/A
4.4
Concordance Follow-up Question Text
Modifications for OICA
Here are some reasons people your age might choose
NOT to have sexual intercourse. How important is each of
these reasons to YOU?
MARK (X) ONE FOR EACH QUESTION
VERY IMPORTANT, SOMEWHAT IMPORTANT, NOT TOO
IMPORTANT, NOT AT ALL IMPORTANT
a. I don’t want to get a sexually transmitted disease, also
known as an STD
b. I don’t want to disappoint my parents
c. I am too young to have sex
d. My boyfriend or girlfriend doesn’t want to have sex
e. I want to wait until I’m married
f. It is against my personal values
g. I haven’t met the right person yet
h. I haven’t had the chance
i. I don’t want to
j. FOR GIRLS I do not want to get pregnant
k. FOR BOYS I do not want to get a girl pregnant
67
OICA #
Concordance #
N/A
4.5
N/A
4.6
Concordance Follow-up Question Text
Modifications for OICA
What do you think are the benefits of waiting to
have sexual intercourse?
Strongly Agree, Agree, Disagree, Strongly Disagree
Mark (X) ONE FOR EACH QUESTION
a. Respect for yourself
b. Respect from parents
c. Keeping true to religious values
d. Respect from friends
e. Not having to worry about pregnancy
f. Not having to worry about sexually transmitted diseases,
also known as STDs
g. Better chance for a good marriage in the future
h. Fewer distractions so you can focus on school work
Do people need religion to have good values?
Mark (X) ONE
□ Yes
□ No
68
OICA #
Concordance #
N/A
4.7
Should religious teachings be obeyed in every situation?
Mark (X) ONE
□ Yes
□ No
N/A
4.8
Do you pray every day?
Mark (X) ONE
□ Yes
□ No
N/A
4.9
Do you think it’s embarrassing for people your age to
admit they are virgins?
Concordance Follow-up Question Text
Modifications for OICA
Mark (X) ONE
□ Yes
□ No
69
OICA #
Concordance #
N/A
4.10
Do you think it’s embarrassing for girls your age to get
pregnant?
Mark (X) ONE
□ Yes
□ No
N/A
4.11
In the group you hang out with, how important is it to
have a girlfriend or boyfriend or to be going out with
someone?
Concordance Follow-up Question Text
Modifications for OICA
MARK (X) ONE
□ Very important
□ Not too important
□ Not important at all
N/A
4.12
The next few questions are about your access to and use
of TV, cell phones, computers and other forms of
technology.
Do you personally have a phone, computer, or other
device that can connect to the internet?
Mark (X) ONE
□ Yes
□ No
70
OICA #
Concordance #
N/A
4.13
Concordance Follow-up Question Text
Modifications for OICA
Do your parents have any rules about…?
MARK (X) ONE FOR EACH
Yes, No, Not Applicable
a. The amount of time or when you can text, talk on the
phone, watch TV or be on the computer?
c. Whether or not you can have a profile on a social
networking site like MySpace or Facebook
N/A
4.14
Do your parents have any rules about what you are
allowed to watch on TV?
Mark (X) ONE
□ Yes
□ No
71
OICA #
Concordance #
N/A
4.15
Do your parents have any rules about what sites you can
access on the internet?
Mark (X) ONE
□ Yes
□ No
N/A
4.16
Some people exchange sexy text messages, videos, or
pictures of themselves or their friends. How common
would you say each of the following is among people your
age?
Concordance Follow-up Question Text
Modifications for OICA
MARK (X) ONE FOR EACH
Not Common at all, Not very Common, Fairly Common,
Very Common
a. Sending or posting sexy text messages
b. Sending or posting sexy pictures or video
72
OICA #
Concordance #
N/A
4.17
Concordance Follow-up Question Text
Modifications for OICA
Have you ever sent or posted a sexy message, picture, or
video of yourself by email, IM or text?
MARK (X) ONE
□ Yes
□ No
GO TO QUESTION 4.19
N/A
4.18
Which of the following reasons did you have for sending or
posting a sexy message, picture or video of yourself?
MARK (X) ONE FOR EACH
Yes, No
a. To get or keep a guy’s or girl’s attention
b. Your boyfriend/girlfriend pressured you to do it
c. As a “sexy” present for a boyfriend or girlfriend
d. To get back at someone or cause trouble
e. Pressure from friends
f. To be fun or to flirt
g. Everybody does it
h. Another reason? PRINT REASON
73
OICA #
Concordance #
N/A
4.19
Have you ever received a sexy text message, or a picture or
video of someone you know?
MARK (X) ONE
□ Yes
□ No
GO TO QUESTION 5.1
N/A
4.20
Have you ever shared or forwarded a sexy text message, or
picture or video of someone you know?
MARK (X) ONE
□ Yes
□ No
Concordance Follow-up Question Text
Modifications for OICA
74
OICA #
Concordance #
N/A
5.1
Concordance Follow-up Question Text
Modifications for OICA
The next few questions ask about your community.
How often do you feel that there are teachers or other
adults in your school who really know you and care about
you?
MARK (X) ONE
□ Never
□ Sometimes
□ Often
□ Very often
N/A
5.2
How often do you feel there are adults in your
neighborhood, or in religious or youth organizations, who
really know you and care about you?
MARK (X) ONE
□ Never
□ Sometimes
□ Often
□ Very often
75
OICA #
Concordance #
N/A
5.3
Concordance Follow-up Question Text
Modifications for OICA
How often do you feel safe in your community or
neighborhood?
MARK (X) ONE
□ Never
□ Sometimes
□ Usually
□ Always
N/A
5.4
How often do you feel safe at school?
MARK (X) ONE
□ Never
□ Sometimes
□ Usually
□ Always
N/A
5.5
How often do you feel safe at home?
MARK (X) ONE
□ Never
□ Sometimes
□ Usually
□ Always
76
OICA #
Concordance #
N/A
5.6
Concordance Follow-up Question Text
Modifications for OICA
During the past 12 months, were you on a sports team or
did you take sports lessons after school or on weekends?
MARK (X) ONE
□ Yes
□ No
N/A
5.7
During the past 12 months, did you participate in any clubs
or organizations after school or on weekends, such as
Scouts, a religious group, or Boy’s/Girl’s Club?
MARK (X) ONE
□ Yes
□ No
77
OICA #
Concordance #
N/A
6.1
Concordance Follow-up Question Text
Modifications for OICA
The next questions are about alcohol and
drug use. Please remember, everything you
tell us will be kept private.
During the past 30 days, not including any times you just
had a sip, on how many days did you have one or more
alcoholic beverages?
MARK (X) ONE
□ More than 25 days
□ 5 to 25 days
□ 1 to 4 days
□ 0 (zero) days
GO TO QUESTION 6.4
N/A
6.2
During the past 30 days, on how many days did you have 5
or more drinks in a row?
MARK (X) ONE
□ More than 25 days
□ 5 to 25 days
□ 1 to 4 days
□ 0 (zero) days
78
OICA #
Concordance #
N/A
6.3
During the past 30 days, on how many days did you get
drunk or wasted?
MARK (X) ONE
□ More than 25 days
□ 5 to 25 days
□ 1 to 4 days
□ 0 (zero) days
N/A
6.4
During the past 30 days, on how many days did you use
marijuana, also called weed or pot?
N/A
6.5
Concordance Follow-up Question Text
Modifications for OICA
MARK (X) ONE
□ More than 25 days
□ 5 to 25 days
□ 1 to 4 days
□ 0 (zero) days
Have you ever used any other type of illegal drug,
prescription drugs, or an inhalant that were not prescribed
for you?
MARK (X) ONE
□ Yes
□ No
79
OICA #
Concordance #
N/A
7.1
In general, how much pressure, if any, do you feel from
your friends to have sexual intercourse?
MARK (X) ONE
□ A lot of pressure
□ Some pressure
□ A little pressure
□ No pressure
N/A
7.2
How often is each of the following statements true for
you?
MARK (X) ONE FOR EACH
Concordance Follow-up Question Text
Modifications for OICA
Never True, Sometimes True, Often True, Almost Always
True
a.
b.
c.
d.
I can trust my friends
My friends want the best for me in my life
My friends care about me
My friends are there for me if I need them
80
| File Type | application/pdf |
| Author | MThomas |
| File Modified | 2011-07-01 |
| File Created | 2011-07-01 |