Form 4 Follow-up student survey

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

CORE FOLLOW-UP QUESTIONNAIRE FOR STUDENTS

INTRODUCTION

Thank you for helping us understand what young people your age are thinking and doing. Your answers will help us develop programs to help young people live healthy and happy lives.

Please remember that your name will never be identified with your answers. Your answers will be combined with the answers of other people your age.

Please try to answer all questions as honestly and completely as you can. Honest and complete answers will help us understand how well this program is working for young people your age. Although we hope you will answer all questions, you may skip any questions you do not wish to answer.

GENERAL INSTRUCTIONS

• Only use the #2 pencil provided to complete the survey. Do NOT use ink or ballpoint pens.

• Fill in the choice(s) that describes your best answer.

• Make heavy black marks that fill out the box completely.

• If you are not sure which answer to choose, select the answer that comes closest to how you feel.

• If you make a mistake, please erase cleanly any wrong answer and completely black out the circle beside your correct answer choice.

• Do not make any stray marks of any kind anywhere in this booklet.

• DO NOT write your name anywhere on this booklet.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

PLEASE READ EACH QUESTION CAREFULLY. There are different ways to answer the questions in this survey. Here are some examples.

EXAMPLE 1: What is the color of your hair?

If the color of your hair is black, you would FILL IN the first circle as shown.

SELECT ONE ANSWER

Black

Brown

Blond

Another color

EXAMPLE 2: In the last 7 days, how often have you eaten any of the following?
SELECT ONE ANSWER FOR EACH ROW	0 days	1-2 days	3-4 days	5-6 days	7 days
An apple?
Corn?
Fish?
Chicken?
Beans?

Some questions are just for girls and some questions are just for boys. These questions are marked with FOR GIRLS or FOR BOYS. If a question is not marked FOR GIRLS or FOR BOYS, then it is a question for everyone to answer.

In the example, if you are a girl, you would answer Question 1a, skip 1b, and then answer 2. If you are a boy, you would skip Question 1a, answer 1b, and answer 2.

EXAMPLE 3:

1a. FOR GIRLS: Do you want to be a mother someday?

(BOYS: skip this question)

SELECT ONE ANSWER

Yes

No

1b. FOR BOYS: Do you want to be a father someday?

(GIRLS: skip this question)

SELECT ONE ANSWER

Yes

No

2. Do you have any brothers or sisters?

SELECT ONE ANSWER

Yes

No

If you answered “Yes” to Question 1, you go to 2. After you answer Question 2, you go to 3.

If you answered “No” to Question 1, you skip 2. Then you go to Question 3.

EXAMPLE 4:

1. Do you ever eat chocolate?

SELECT ONE ANSWER

Yes

No  SKIP TO 3

2. Do you always brush your teeth after you eat chocolate?

SELECT ONE ANSWER

Yes

No

3. In the last 7 days, did you go to a movie?

SELECT ONE ANSWER

Yes

No

THIS IS THE END OF THE EXAMPLES.

PLEASE START ANSWERING THE SURVEY ON THE NEXT PAGE.

YOU AND YOUR FAMILY

The next questions ask what your parent(s) or guardian(s) know about your free time activities. Please answer about the parent(s) or guardian(s) you live with most of the time.

1. In the past week, how many times have you talked with a parent or guardian about…?

a. How to have healthy romantic relationships

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

b. Being careful about what you post to social media

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

Not applicable – I don’t use social media

c. Avoiding alcohol and/or drugs

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

d. Setting clear limits on what you will or won’t do in a relationship (how “far” you will or will not go)

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

e. Respecting other people’s limits on what they will or won’t do in a relationship (how “far” they will or will not go)

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

f. What movies, TV, music, or the Internet say about sex

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

g. Pressure you might feel to have sex from friends your age

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

h. What your parent(s) or guardian(s) feel about teens your age having sex

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

i. Reasons for not having sex at your age

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

j. Using contraception to reduce the risk of pregnancy and sexually transmitted diseases (STDs) / sexually transmitted infections (STIs)

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

k. Waiting until marriage to have sex

SELECT ONE ANSWER

0 times

1-2 times

3-4 times

5 times or more

2. How strongly do you agree or disagree with the following statement?

My parent(s) or guardian(s) think it is okay for me to have sex at my age.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

YOUR VIEWS AND OPINIONS

3. How strongly do you agree or disagree with each of the statements below?

a. I have goals I want to accomplish as an adult.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

b. It is important to me to finish my high school education (get my diploma).

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

c. It is important to me to get a college education or attend vocational or trade school.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

d. It is important to me to have good career opportunities as an adult.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

e. It is important to me to get married in the future.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

f. It is important to me to have at least one child in the future.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

g. It is important to me to be married before I have a child.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

4. In your opinion, would having sex as a teen make it easier or harder to…?

a. Focus on other things in a romantic relationship besides sex

SELECT ONE ANSWER

Easier

No impact

Harder

b. Have a romantic relationship in the future that does not involve sex

SELECT ONE ANSWER

Easier

No impact

Harder

c. Finish my high school education

SELECT ONE ANSWER

Easier

No impact

Harder

d. Get a college education or attend vocational or trade school

SELECT ONE ANSWER

Easier

No impact

Harder

e. Have good career opportunities as an adult

SELECT ONE ANSWER

Easier

No impact

Harder

f. Have a healthy marriage

SELECT ONE ANSWER

Easier

No impact

Harder

g. Reach your other goals for the future

SELECT ONE ANSWER

Easier

No impact

Harder

5. Romantic relationships are called different things by different people—going out, dating, or having a boyfriend or girlfriend.

In a romantic relationship, how important is it that partners…?

a. Listen to their romantic partner when they are expressing their feelings and opinions

SELECT ONE ANSWER

Not at all important

Slightly important

Moderately important

Very important

Extremely important

b. Be able to count on their romantic partner to be there for them in tough times

SELECT ONE ANSWER

Not at all important

Slightly important

Moderately important

Very important

Extremely important

c. Discuss disagreements without yelling at or insulting their romantic partner

SELECT ONE ANSWER

Not at all important

Slightly important

Moderately important

Very important

Extremely important

d. Do not try to control who their romantic partner sees or spends time with

SELECT ONE ANSWER

Not at all important

Slightly important

Moderately important

Very important

Extremely important

e. Do not try to make their romantic partner feel jealous

SELECT ONE ANSWER

Not at all important

Slightly important

Moderately important

Very important

Extremely important

6. In a romantic relationship, how likely or unlikely is it that you would…?

a. Go against your personal values to please your romantic partner

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

b. Feel bad or guilty when you say “no” to something your romantic partner wants you to do

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

c. Stand up for yourself with your romantic partner if they treat you poorly

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

7. How strongly do you agree or disagree with each of the statements below?

a. It is okay for teens my age to have sex if both partners think they are ready.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

b. It is okay for teens my age to have sex if they have been dating each other for a long time.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

c. It is okay for teens my age to have sex if they love each other.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

d. It is best to wait until marriage to have sex.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

e. It is okay for teens to have sex if they use contraception to reduce the risk of STDs/STIs.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

f. It is okay for teens to have sex if they use contraception to reduce the risk of pregnancy.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

g. It is realistic to think that teens who have had sex can stop and wait until marriage to have sex again.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

h. It is realistic to think that people can wait until marriage to have sex.

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

i. It is okay for teens my age to have casual sex. (Casual sex is sex with someone who is not your romantic partner. Casual sex is also known as “hooking up.”)

SELECT ONE ANSWER

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

8. Please indicate whether each of the following statements is true or false.

a. The brain is completely developed by age 15.

SELECT ONE ANSWER

True

False

Don’t know

b. The pre-frontal cortex is responsible for planning, strategizing, and organizing.

SELECT ONE ANSWER

True

False

Don’t know

c. Dopamine is a reward or pleasure chemical in the brain that can encourage risky behaviors.

SELECT ONE ANSWER

True

False

Don’t know

d. Birth control pills can decrease the risk of STDs or STIs.

SELECT ONE ANSWER

True

False

Don’t know

e. Condoms can decrease the risk of STDs or STIs.

SELECT ONE ANSWER

True

False

Don’t know

f. The most effective way to prevent pregnancy is not to have vaginal sex.

SELECT ONE ANSWER

True

False

Don’t know

9. Now think about what you would do if you wanted to avoid having sex. How likely or unlikely is it that you could…?

a. Avoid situations that might lead to having sex, like going to a party that does not have adult supervision

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

b. Have a conversation with your romantic partner to tell them what behaviors you will or will not do (how “far” you will or will not go)

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

c. Avoid getting into a romantic relationship with someone much older than you

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

d. Go out with friends instead of one-on-one dates with a romantic partner

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

e. Ask a trusted adult or friend for help if you are feeling a lot of pressure from someone to have sex

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

10. Imagine you are alone with someone you like very much and you do not want to have sex. How likely or unlikely is it that you could…?

a. Talk to them about your decision not to have sex

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

b. Say “No” to having sex, even if the other person says they will stop seeing you if you don’t have sex

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

c. Suggest another activity you can do together instead of sex

SELECT ONE ANSWER

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

Please remember that all your answers will be kept private.

11. How likely or unlikely is it that you will have sex in the next 12 months?

SELECT ONE ANSWER

Definitely not

Probably not

50-50 chance

Probably will

Definitely will

12. How likely or unlikely is it that you will have sex before you finish high school?

SELECT ONE ANSWER

Definitely not

Probably not

50-50 chance

Probably will

Definitely will

13. How likely or unlikely is it that you will have sex before you are married?

SELECT ONE ANSWER

Definitely not

Probably not

50-50 chance

Probably will

Definitely will

14. Have you made a public or private written promise to wait to have sex until you are married?

SELECT ONE ANSWER

Yes

No

15 a. FOR GIRLS: If you got pregnant now, how would you feel? (BOYS: skip this question)

SELECT ONE ANSWER

Very unhappy

Somewhat unhappy

Neither happy nor unhappy

Somewhat happy

Very happy

15 b. FOR BOYS: If you got someone pregnant now, how would you feel? (GIRLS: skip this question)

SELECT ONE ANSWER

Very unhappy

Somewhat unhappy

Neither happy nor unhappy

Somewhat happy

Very happy

FRIENDS YOUR AGE

16. How many of your friends your age would agree with the following things? (A best guess is fine.)

SELECT ONE ANSWER FOR EACH ROW	None	Some	Half	Most	All
a. Having sex with a romantic partner is okay to do at your age.
b. Having sex with someone who is not your romantic partner (for example, hooking up) is okay to do at your age.
c. It is best to wait until marriage to have sex.

17. How many of your friends your age have had sex? (A best guess is fine.)

SELECT ONE ANSWER

None

Some

Half

Most

All

18. How much pressure, if any, do you feel from friends your age to have sex?

SELECT ONE ANSWER

None at all

Very little

Some

Quite a bit

A lot

19. How much does the media (for example, movies, TV, music, the Internet) make you feel like you should be having sex?

SELECT ONE ANSWER

Not at all

Very little

Somewhat

Quite a bit

A lot

20. How many of your friends your age do the following things? (A best guess is fine.)

SELECT ONE ANSWER FOR EACH ROW	None	Some	Half	Most	All
a. Vape tobacco or smoke.
b. Drink alcohol, like beer, wine, or liquor.
cc. Use marijuana or other cannabis products recreationally (not medicinally). Marijuana is also called weed or pot. Please do not include CBD oil.

YOUR ACTIVITIES AND EXPERIENCES

21. Have you ever had a romantic relationship such as a boyfriend or girlfriend?

SELECT ONE ANSWER

Yes  GO TO 22

No  SKIP TO 25

22. Have you ever spent time alone with someone you were in a romantic relationship with, such as a boyfriend or girlfriend? (Include one-on-one dates and other alone time.)

SELECT ONE ANSWER

Yes  GO TO 23

No  SKIP TO 25

23. In the last 3 months, how many different boyfriends or girlfriends did you spend time alone with?

SELECT ONE ANSWER

No one in last 3 months

1 person

2 people

3 people

4 people

5 people

6 or more people

24. In the last 3 months, how many times have you spent time alone with a boyfriend or girlfriend?

SELECT ONE ANSWER

None in last 3 months

1 time

2 times

3 times

4 times

5 times

6 or more times

Please remember that all of your answers will be kept private.

25. How often, if at all, do you do the following things?

SELECT ONE ANSWER FOR EACH ROW	Never	A few times a year	A few times a month	A few times a week	Every day
a. Vape tobacco or smoke part or all of a cigarette? Please do not include times when you had a puff or two from a cigarette or vaper.
b. Drink alcohol, like beer, wine, or liquor? Please do not include times when you had a sip or two from a drink.
c. Use marijuana or any cannabis product recreationally (not medicinally)? Marijuana is also called weed or pot. Please do not include CBD oil.
d. Use heroin, cocaine, or prescription pain killers to get high (like OxyContin, Vicodin, Fentanyl)?
e. Drink alcohol or use drugs before having sex? (If you have never had sex, you may leave this item blank.)
f. Send messages with nude, sexually suggestive, or explicit photos or videos of yourself to someone?

26. Have you ever had sexual intercourse?

SELECT ONE ANSWER

Yes  GO TO 27

No  SKIP TO 32

27. How old were you when you had sexual intercourse for the first time?

SELECT ONE ANSWER

11 years old or younger

12 years old

13 years old

14 years old

15 years old

16 years old

17 years old or older

28. During your life, with how many people have you had sexual intercourse?

SELECT ONE ANSWER

1 person

2 people

3 people

4 people

5 people

6 or more people

29. During your life, with whom have you had sexual intercourse?

SELECT ONE ANSWER

Females

Males

Females and males

30. When you consider everything, overall, do you wish you had waited longer before having sex?

SELECT ONE ANSWER

Yes  GO TO 31

 No SKIP to 33

31. Please think about the reasons why you wish you had waited longer to have sex. To what extent does each of the following reasons apply to you?

SELECT ONE ANSWER FOR EACH ROW	Not at all	Very little	Some­what	Quite a bit	A lot
I got pregnant or got someone else pregnant, or I worried about pregnancy.
I got an STD/STI, or worried about STDs/STIs.
c. Having sex went against my values, beliefs, or promises I had made to myself or others.
d. Sex was not like what I had expected.
e. I received negative reactions from family or friends.
f. Sex changed my relationship with my romantic partner in ways I didn’t like.
g. I was not ready for the emotions involved with having sex.
h. Sex got in the way of achieving the goals I had for myself.

SKIP TO 33

32. Please think about the reasons why you have not had sex. To what extent does each of the following reasons apply to you?

SELECT ONE ANSWER FOR EACH ROW	Not at all	Very little	Some­what	Quite a bit	A lot
a. Having sex just isn’t something I’m thinking about.
b Having sex at this point in my life would go against my values, beliefs, or promises I had made to myself or others.
c. I want to have sex but haven’t had the chance yet.
d. I’ve decided to wait until I’m married before I have sex.
e. I’m afraid of getting pregnant or getting someone pregnant.
f. I’m afraid of getting an STD/STI.
g. I am not ready for the emotions involved with having sex.
h. I feel that sex gets in the way of achieving the goals I have for myself.
i. I’m afraid I will receive negative reactions from family or friends

YOUR SURVEY RESPONSES

We are interested in learning more about how you responded to this survey. Please answer the following questions honestly. There will not be any negative consequences for you no matter what your responses are.

33. Were there any questions on the survey you did not feel comfortable answering honestly or accurately?

SELECT ONE ANSWER

Yes  GO TO 34

No  THANK YOU FOR COMPLETING THE SURVEY!

34. What made you feel uncomfortable about responding honestly or accurately to some questions on the survey?

MARK ALL THAT APPLY

I felt like the question was too private to answer honestly or accurately

I felt like some people would not approve of my answer

I did not understand the question well enough to know how to answer

I was worried that teachers or other adults in the room during the survey could see my answers

I was worried that other students in the room during the survey could see my answers

I was worried that someone else besides the researchers would find out my answers

Other

35. How did you respond to the questions you were not comfortable answering honestly or accurately?

MARK ALL THAT APPLY

I left those questions blank (did not answer)

I gave an answer that I thought was more socially acceptable than my real answer

I gave an answer that I thought was less socially acceptable than my real answer

I just picked a random answer

I answered honestly / accurately anyway, even though I felt uncomfortable

THANK YOU FOR COMPLETING THIS SURVEY!

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