Form Youth Questionnair Youth Questionnair Youth Questionnaire
Minority Substance Abuse/HIV Prevention Initiative
HIV Youth Questionnaire_120321
Youth
OMB: 0930-0298
Form Approved
OMB No.: 0930-0298
Expiration Date: XX/XX/XXXX
National Minority SA/HIV Prevention Initiative
Youth Questionnaire |
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Participant ID #: ________________________ |
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RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.
National Minority SA/HIV Prevention Initiative
Youth Questionnaire
Funding
for data collection supported by the
Center for Substance Abuse
Prevention (CSAP)
Substance Abuse and Mental Health Services
Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep young people from using drugs and getting infected with HIV.
Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.
We would like you to work fairly quickly, so that you can finish. Please work quietly by yourself. If you have any questions or don’t understand something, let the data collector know.
We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort!
Public Burden Statement: 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 control number for this project is 0930-0298. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857. |
INSTRUCTIONS
1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles.
3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth. ___________________________________________________________________________________
MARKING YOUR ANSWERS
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Record Management Section: To be Completed by Designated Staff
Grant ID
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Study Design Group (Select one)
Intervention Comparison
Participant ID
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Date of Survey Administration
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Month |
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Year |
Interview Type (Select one)
Baseline Exit Follow-up
Intervention Duration (Select one)
Single Session Intervention
Multiple Session Brief Intervention (less than 30 day duration)
Multiple Session Long Intervention (30 days or longer duration)
Intervention Name(s) (If the participant is receiving direct services from more than one intervention, please list each intervention below)
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Section One: Facts About You
First, we’d like to ask some questions about you. We are not going to use this information to identify you, but instead to talk about what different groups of people have to say. For example, what boys have to say, and how that may be different from what girls have to say. Or how 12-year-olds feel about different things, and how that might be different from what 17-year-olds feel. |
1. How would you describe yourself? (Gender)
Male
Female
2. In what year were you born? (Enter all four digits of the year in the boxes below, and fill in corresponding circles)
-
1
2
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
3. In what month were you born?
January July
February August
March September
April October
May November
June December
4. Are you Hispanic or Latino?
Yes
No
5. What is your race? (Select one or more)
White
Black or African American
American Indian
Native Hawaiian or Other Pacific Islander
Asian
Alaskan Native
Other
6. How would you describe yourself? (Sexual orientation)
Straight or heterosexual
Bisexual
Gay or lesbian
Unsure
7. What is your primary spoken language?
English
Spanish
Asian (Chinese, Japanese, or other)
American Indian (Apache, Blackfoot, Navajo, or other)
Other
8. How long have you lived in the United States?
Less than a year
1 to 2 years
3 to 4 years
5 or more years
All my life
9. With whom do you live? (Mark all that apply)
Alone
With my mother
With my father
With my brother(s) and/or sister(s)
With my grandparent(s)
With other relatives or guardian(s)
With my spouse or significant other
With my child or my children
With roommates
Other
10. Describe where you live.
In my own home or apartment
In a relative’s home
In a group home
In a foster home
Homeless or in a shelter
Other
11. What is the highest level of education you have finished, whether or not you received a degree? (Mark the highest grade you have completed.)
1st grade College freshman
2nd grade College sophomore
3rd grade College junior
4th grade College completion
5th grade Some graduate school, but
6th grade no degree received
7th grade Master’s degree
8th grade Some professional school,
9th grade (such as medical or law
10th grade school) but no degree
11th grade received, or doctoral
12th grade program
Doctorate or professional degree
12. During the past 12 months, have you driven
a vehicle while you were under the influence of alcohol?
Yes
No
Don’t know or can’t say
13. Have you ever been suspended from school for drug or alcohol use?
Yes
No
14. Have you ever been in juvenile/adult detention, jail, or prison for more than 3 days?
Yes
No
15. If YES to question 14, how long has it been
since you last got out of juvenile/adult detention, jail, or prison?
Never in juvenile/adult detention, jail, or prison for more than 3 days
Less than 30 days
Between 30 days and 1 year
Between 1 and 2 years
Between 2 and 3 years
Between 3 and 4 years
Between 4 and 5 years
More than 5 years
16. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?
No, (Skip to #18)
Yes, 1 person
Yes, 2 people
Yes, 3 people
Yes, 4 people
Yes, 5 people
Yes, 6 or more people
17. If yes, answer the following questions for each person you marked in question 16 (up to six people).
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Service Member #1 |
Service Member #2 |
Service Member #3 |
Service Member #4 |
Service Member #5 |
Service Member #6 |
Service Member’s relationship to you: |
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Mother |
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Father |
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Brother/Sister |
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Aunt/Uncle |
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Grandparent |
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Other |
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(specify) |
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Has the Service Member experienced any of the following (select all that apply)? |
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17a.
Deployed in support of combat operations |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
17b. Was physically injured during combat operations? |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
17c. Developed combat stress symptoms/ difficulties adjusting following deployment, including PTSD, depression, or suicidal thoughts? |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
17d. Died or was killed? |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
End of Section 1
Section Two: Attitudes & Knowledge
In this section, we are going to ask how you feel about certain things, such as school, substance use, and sexual behavior. We are also going to ask what you know about HIV/AIDS. Remember, your answers are private and will not be used to identify you. |
The next few questions ask about how you feel about school. First, we need some background information.
18. Are you enrolled in school?
Yes
No
19. Are you on summer break or vacation?
Yes
No
20. What were your most recent grades in school?
I am not in school
Mostly As
Mostly Bs
Mostly Cs
Mostly Ds
Mostly Fs
21. How often do you feel that the school work you are assigned is meaningful and important?
I am not in school
Almost always
Often
Sometimes
Seldom
Never
22. How interesting are most of your classes to you?
I am not in school
Very interesting
Quite interesting
Fairly interesting
Slightly dull
Very dull
23. How important do you think things you are learning in school are going to be for you later in life?
I am not in school
Very important
Quite important
Fairly important
Slightly important
Not at all important
Now think back over the last year in school...
24. How often did you enjoy being in school?
I was not in school during the last year
Almost always
Often
Sometimes
Seldom
Never
25. How often did you hate being in school?
I was not in school during the last year
Almost always
Often
Sometimes
Seldom
Never
26. How often did you try to do your best in school?
I was not in school during the last year
Almost always
Often
Sometimes
Seldom
Never
The next few questions ask about your ETHNIC GROUP. An ethnic group is a cultural group that has a shared history, similar customs, traditions, and sometimes shared values.
27. I have spent time trying to find out more about my ethnic group, such as its history, traditions, and customs.
Strongly agree
Agree
Disagree
Strongly disagree
28. I am active in organizations or social groups that include mostly members of my own ethnic group.
Strongly agree
Agree
Disagree
Strongly disagree
29. I think a lot about how my life is affected by my ethnic group membership.
Strongly agree
Agree
Disagree
Strongly disagree
30. I have often talked to other people about my ethnic background.
Strongly agree
Agree
Disagree
Strongly disagree
31. I am interested in learning more about my ethnic background.
Strongly agree
Agree
Disagree
Strongly disagree
32. I participate in cultural practices of my own ethnic group, such as special food, music, or customs.
Strongly agree
Agree
Disagree
Strongly disagree
The next few questions ask about your religious or spiritual beliefs and their role in your daily life.
33. In general, how important are religious or spiritual beliefs in your day-to-day life?
Very important
Fairly important
Not too important
Not at all important
34. When you have problems or difficulties with your school (education), work, family, friends, or personal life, how often do you seek spiritual guidance and support?
Almost always
Often
Sometimes
Rarely
Never
35. How spiritual or religious would you say you are?
Very spiritual or religious
Fairly spiritual or religious
Not too spiritual or religious
Not spiritual or religious at all
The next section begins with a question about your thoughts on how your friends feel about you using cigarettes, followed by a set of questions asking how you feel about someone your age using alcohol, tobacco, and drugs. Please tell us if you approve or disapprove of their actions.
36. How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
37. How do you feel about someone your age smoking one or more packs of cigarettes a day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
38. How do you feel about someone your age trying marijuana or hashish once or twice?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
39. How do you feel about someone your age using marijuana once a month or more?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
40. How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs. |
41. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
42. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
43. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
The next set of questions is about SEX.
By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth.
One question asks about sexual partners. A sexual partner is someone with whom you have sex, that is, engage in sexual activity.
When we ask about safe sex, we mean sex that is protected by using condom.
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In the next 3 months, how likely are you to...
44. Be sexually active?
Not at all likely
A little likely
Somewhat likely
Very likely
45. Have more than one sexual partner?
Not at all likely
A little likely
Somewhat likely
Very likely
46. To practice safe sex?
Not intending to have any sex during the next 3 months
Not at all likely
A little likely
Somewhat likely
Very likely
47. I can get my boyfriend or girlfriend to use a condom, even if he or she does not want to. (If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)
Strongly agree
Agree
Disagree
Strongly disagree
48. I would be able to say to my boyfriend or girlfriend that we should use a condom. (If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)
Strongly agree
Agree
Disagree
Strongly disagree
49. I could refuse if someone wanted to have sex without a condom.
Strongly agree
Agree
Disagree
Strongly disagree
50. I could say no if someone pressured me to have sex when I did not want to.
Strongly agree
Agree
Disagree
Strongly disagree
51. I would be able to say no if a friend offered me a drink of alcohol.
Strongly agree
Agree
Disagree
Strongly disagree
52. I would be able to refuse if a friend offered me drugs, including marijuana.
Strongly agree
Agree
Disagree
Strongly disagree
HIV/AIDS – What You Know
The next set of questions is about HIV/AIDS. Please indicate whether you think each of the following statements is true or false, or if you don’t know.
53. Only people who look sick can spread the HIV/AIDS virus.
True
False
Don’t know
54. Only people who have sex with gay (homosexual) people get HIV/AIDS.
True
False
Don’t know
55. Birth control pills protect women from getting the HIV/AIDS virus.
True
False
Don’t know
56. There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.
True
False
Don’t know
57. There is no cure for AIDS.
True
False
Don’t know
58. Young people under age 18 need their parents’ permission to get an HIV test.
True
False
Don’t know
59. Having another sexually transmitted disease like gonorrhea or herpes increases a person’s risk of becoming infected with HIV.
True
False
Don’t know
60. Sharing intravenous needles increases a person’s risk of becoming infected with HIV.
True
False
Don’t know
61. You
can become infected with HIV by
having unprotected
oral sex.
True
False
Don’t know
The next few questions ask about HIV testing.
62. Have you ever been tested for the HIV virus that causes AIDS?
Yes
No
63. If YES to question 62, did you receive or go back to get your results?
I have never been tested
Yes
No
64. If you had the opportunity to be tested for HIV, would you?
Yes
No
Don’t know
End of Section Two
Section Three: Behavior & Relationships
The
next two questions are about CIGARETTES
and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products.
65. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
66. During the past 30 days, on how many days did you use other tobacco products? (Includes any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next two questions are about ALCOHOL.
By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you drank alcohol.
67. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
68. During the past 30 days, on how many days did you have 4 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
69. During the past 30 days, on how many days did you have 5 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
70. During the past 30 days, on how many days have you been drunk or very high from drinking alcoholic beverages?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
T
Now we would like to ask about your use of several specific drugs.
Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.
71. During the past 30 days, on how many days did you use marijuana or hashish?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.
These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or to get high), heroin, crack or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and report on how many days, if any, you used other illegal drugs. |
72. During the past 30 days, on how many days did you use any other illegal drug?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
73. During the past 30 days, on how many days have you sniffed glue or breathed the contents of aerosol spray cans, or inhaled (huffed) any other gases or sprays in order to get high?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
74. During the past 30 days, on how many days did you use cocaine or crack?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
75. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
76. During the past 30 days, on how many days did you inject any drugs? (Count only injections without a doctor’s orders, those you had just to feel good or to get high.)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
77. During the past 30 days, how stressful have things been for you because of your use of alcohol or drugs?
I have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
78. During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?
I have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
79. Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Mark one)
More likely
Less likely
Would make no difference
Don’t know or can’t say
The next few questions ask about the FIRST TIME you used a substance.
Think back whether you have EVER used any substances. If so, tell us your age the FIRST TIME you used the following substances. |
80. How old were you the first time you smoked part or all of a cigarette? (Include menthol and regular cigarettes and loose tobacco rolled into cigarettes)
I have never smoked part or all of a cigarette
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
81. How old were you the first time you used any other tobacco product? (Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
I have never used any other tobacco products
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
82. How old were you the first time you had a
drink of an alcoholic beverage? (Includes beer, wine, wine coolers, malt beverages, and liquor) DO NOT include any time when you only had a sip or two from a drink.
I have never had a drink of an alcoholic beverage
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
83. How old were you the first time you used marijuana or hashish? (Also known as grass, pot, hash, or hash oil)
I have never used marijuana or hashish
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
84. How old were you the first time you used any other illegal drug?
I have never used any other illegal drugs
5 years old or younger 14 years old
6 years old 15 years old
7 years old 16 years old
8 years old 17 years old
9 years old 18 years old
10 years old 19 years
11 years old or older
12 years old Don’t know
13 years old or can’t say
Sexual Behavior
These questions ask about your personal experience with sex.
By sex, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth.
When a male inserts his penis into his female partner’s vagina, the partners are considered to be having vaginal sex.
When one partner’s mouth touches the other partner’s genitals (penis or vagina) or anus during sex, the partners are considered to be having oral sex.
When a male’s penis is inserted into his male or female partner’s anus, the partners are considered to be having anal sex.
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85. Have you ever had sex (either vaginal, oral, or anal)?
Yes
No
86. How old were you when you had sex for the first time (include vaginal, oral, or anal sex)?
I have never had sex
Under 5 years old
Between 5 and 10 years old
Between 11 and 14 years old
Between 15 and 18 years old
Over 18 years old
87. During the last 30 days, have you had sex?
Yes
No
88. If YES to question 87, did you or your partner use a condom?
I did not have sex during the last 30 days
Yes
No
89. In the last 30 days, did you and your boyfriend or girlfriend talk about using condoms?
I do not have a boyfriend or girlfriend
Yes
No
90. During your life, with how many people have you had sex?
0 people
1 person
2 people
3 people
4 people
5 people
6 or more people
91. During the last 3 months, with how many people did you have sex?
0 people
1 person
2 people
3 people
4 people
5 people
6 or more people
92. Think about the last time you had sex. Did you drink alcohol or use drugs before you had sex the last time?
I have never had sex
Yes
No
93. In the last 3 months, have you had sex after getting drunk or high?
Yes
No
94. Have you ever had sex for money, drugs, or other things?
Yes
No
Your Family and Friends
The next few questions ask about your family.
95. Do you have any children?
Yes
No
Don’t know or can’t say
96. If YES to question 95, how many children do you have?
I don’t have any children
1
2
3
4
5 or more children
97. Now, think about the past 12 months through today. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? (By PARENTS, we mean your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.)
Yes
No
Don’t know or can’t say
These questions ask about your relationship with your family.
98. I’m available when others in my family want to talk to me.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
99. I listen to what other family members have to say, even when I disagree.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
100. Members of my family ask each other for help.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
101. Members of my family like to spend free time with each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
102. Members of my family feel very close to each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
103. We can easily think of things to do together as a family.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
The next set of questions asks about things your friends may do or think.
How many of your friends do the following:
104. Drink beer, wine, wine coolers, or hard liquor (besides a few sips)?
None
A few
Some
Most
All
105. Get good grades?
None
A few
Some
Most
All
106. Smoke cigarettes?
None
A few
Some
Most
All
107. Get suspended from school or dropped out?
None
A few
Some
Most
All
108. Smoke marijuana or weed?
None
A few
Some
Most
All
109. Sniff glue, gases, or sprays to get high?
None
A few
Some
Most
All
110. Volunteer for community work?
None
A few
Some
Most
All
111. Get arrested?
None
A few
Some
Most
All
112. Get involved in religious activities?
None
A few
Some
Most
All
113. Exercise or play sports?
None
A few
Some
Most
All
114. Are sexually active?
None
A few
Some
Most
All
115. Been
pregnant or got someone
pregnant?
None
A few
Some
Most
All
Prevention Education
You may get information about substance abuse, HIV/AIDS, or other health issues from many different sources. The next few questions ask about some of these sources.
116. During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention of substance abuse?
Yes
No
Don’t know or can’t say
Please tell us how much you have learned about prevention of substance abuse, HIV, or other health problems from the following sources:
117. Your friends, brothers, or sisters?
A lot
Some
Only a little
Nothing at all
118. Your parents or guardians?
A lot
Some
Only a little
Nothing at all
119. Teachers, school nurses, or classes at school?
A lot
Some
Only a little
Nothing at all
120. A doctor or other health care provider?
A lot
Some
Only a little
Nothing at all
121. Television shows or movies?
A lot
Some
Only a little
Nothing at all
122. Books or pamphlets?
A lot
Some
Only a little
Nothing at all
123. Popular magazines such as Essence, Seventeen, Audrey, Latina Style, Hombre, Cosmopolitan?
A lot
Some
Only a little
Nothing at all
124. The Internet?
A lot
Some
Only a little
Nothing at all
125. In the past 30 days, have you been in any classes or programs where they talked about preventing HIV or AIDS?
Yes
No
126. In the past 30 days, have you been in any classes or programs where they talked about prevention of drug and alcohol abuse?
Yes
No
The last two questions are about your experience with this survey.
127. How comfortable was it for you to answer the questions in this survey?
Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
128. How truthful were you when answering the questions?
Very truthful
Somewhat truthful
Somewhat untruthful
Very untruthful
YOU ARE DONE!
Thank you for your help!
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | HIV Cohort 6 Youth Baseline Questionnaire |
| Author | Calverton |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
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