Baseline survey for youth

INSTRUMENT 8

youth baseline survey

This page intentionally left blank for double sided copying

OMB #: XXX-XXXX

EXP. DATE: XX/XX/XXXX

Strengthening Relationship Education and Marriage Services (STREAMS) Youth Baseline Survey ACASI Version

GENERAL INSTRUCTIONS Thank you for your help with this important study. This survey includes questions about your background, your attitudes about marriage and relationships, and your relationship experiences. Your name will not be on the questionnaire and your responses will remain private to the extent permitted by law. We want you to know that: 1. Your participation in this survey is voluntary. 2. The survey will take about 30 minutes to complete. 3. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer. 4. The answers you give will be kept private to the extent permitted by law.

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. The information requested in this survey will be used to document how programs receiving HMRF grant funding operate and describe participant outcomes. The data gathered will allow ACF to better monitor grantee progress and performance. In accordance with the requirements of the Privacy Act of 1974, as amended (5 U.S.C. 552a), ACF/OPRE established system of records titled: 09-80-0361 OPRE Research and Evaluation Project Records, HHS/ACF/OPRE. A Federal Register Notice (80 FR 17893) announced the system.

SECTION A: YOUR BACKGROUND

ALL

A1. Are you male or female?

Select one only

 Male 1

 Female 2

NO RESPONSE M

ALL

A2. What is your date of birth?

PROGRAMMER: INSERT DROPDOWNS WITH FOLLOWING RANGES

Month Day Year

▼

▼

▼

(1-12) (1-31) (1980 - 2010)

NO RESPONSE M

ALL

A3. What is your ethnicity?

Select one only

 Hispanic or Latino 1

 Not Hispanic or Latino 2

NO RESPONSE M

ALL

A4. Where were you born?

Select one only

 In the United States 1

 Outside the United States 99

Specify

NO RESPONSE M

ALL

A5. Where was your mother born?

Select one only

 In the United States 1

 Outside the United States 99

Specify

NO RESPONSE M

ALL

A6. Where was your father born?

Select one only

 In the United States 1

 Outside the United States 99

Specify

NO RESPONSE M

ALL

A7. Which one best describes your race?

Select one or more

 American Indian or Alaska Native 1

 Asian 2

 Black or African-American 3

 Native Hawaiian or other Pacific Islander 4

 White 5

 Other 99

Specify

NO RESPONSE M

ALL

A8. Which language is spoken in your home most of the time?

Select one only

 English 1 A10

 Spanish 2 A9

 Other 99 A9

Specify

NO RESPONSE M

A8 NE 01

A9. How well do you speak English?

Select one only

 Very well 1

 Well 2

 Not well 3

 Not at all 4

NO RESPONSE M

ALL

A10. What is your current grade?

Select one only

 Less than 9th grade 1

 9th grade 2

 10th grade 3

 11th grade 4

 12th grade 5

 College 6

NO RESPONSE M

All

A11. What kind of grades do you usually get in school?

Select one only

 My courses are not graded 1

 Mostly As 2

 About half As and half Bs 3

 Mostly Bs 4

 About half Bs and half Cs 5

 Mostly Cs 6

 About half Cs and half Ds 7

 Mostly Ds 8

 Mostly below Ds 9

NO RESPONSE M

all

A12. How many times have you ever been suspended or expelled from school?

Select one only

 None 1

 One time 2

 More than one time 3

NO RESPONSE M

all

A13. On a scale of 1-5, where 1 is low and 5 is high, how much do you want to go to college?

Not at all 1  2  3  4  5  Very much

NO RESPONSE M

all

A14. On a scale of 1-5, where 1 is low and 5 is high, how likely is it that you will go to college?

Not at all likely 1  2  3  4  5  Very likely

NO RESPONSE M

all

A15. What is your current employment status?

Select all that apply

 Full time employment (usually work more than 35 hours a week) 1

 Part-time employment (usually work 1-34 hours a week) 2

 Employed, but number of hours changes from week to week 3

 Temporary, occasional, or seasonal employment, or odd jobs for pay 4

 Not currently employed 5

NO RESPONSE M

ALL

A16. How much do you agree or disagree with the following statement?

I have specific goals for my future career.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

ALL

A17. How much do you agree or disagree with the following statement?

I have a plan for reaching my future career goals.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

ALL

A18. How much do you agree or disagree with the following statement?

Planning a career is not worth the effort.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

ALL

A19. How much do you agree or disagree with the following statement?

I haven’t thought much about my future career.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

ALL

A20. How much do you agree or disagree with the following statement?

If I have a career, I won’t be able to enjoy other things in life.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

ALL

A21. How much do you agree or disagree with the following statement?

Going to college is important for getting a good job.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

A22. In the past 12 months, how often did you attend religious services or activities?

Select one only

 Never 1

 Less than once a month 2

 1-3 times per month 3

 Once a week 4

 More than once a week 5

NO RESPONSE M

all

A23. In general, how would you describe your health?

Select one only

 Excellent 1

 Very Good 2

 Good 3

 Fair 4

 Poor 5

NO RESPONSE M

SECTION B: FAMILY AND FRIENDS

ALL

B1. The next few questions ask about your biological parents.

Do you live with your biological mother?

Select one only

 Yes, all of the time 1

 Yes, most of the time 2

 Yes, some of the time 3

 No, none of the time 4

NO RESPONSE M

ALL

B2. Do you live with your biological father?

Select one only

 Yes, all of the time 1

 Yes, most of the time 2

 Yes, some of the time 3

 No, none of the time 4

NO RESPONSE M

all

B3. Which of the following best describes the relationship between your biological mother and biological father?

Select one only

 They are married to each other 1

 They were married to each other but are now separated or divorced 2

 They were never married to each other 3

 One or both of my biological parents has died 4

 Don’t know 5

NO RESPONSE M

all

B4. What is your current living situation?

Select one only

 Live with a parent, relative, or someone else who rents/owns the home 3

 Live in a shelter, halfway house, or treatment center 4

 Live on streets, car, abandoned building, or other place not meant for sleeping 5

 Other 99

Specify

NO RESPONSE M

CALCULATE AGE USING DATE IN A2, IF 20 YEARS OR LESS ASK B5, else skip to b6

B5. Have you ever been in foster care?

 Yes 1

 No 0 B6

NO RESPONSE M B6

B5=1

B5a. Are you currently in foster care?

 Yes 1 B6

 No 0

NO RESPONSE M B6

B5a=0

B5b. Did you leave foster care in the past 6 months?

 Yes 1

 No 0

NO RESPONSE M

all

B6. In the past month, how often did you feel like you could count on at least one of your parent(s) to be there when you needed them?

Select one only

 None of the time 1

 Some of the time 2

 Most of the time 3

 All of the time 4

NO RESPONSE M

all

B7. In the past month, how often did you feel like you could talk with your parent(s) about things that really matter?

Select one only

 None of the time 1

 Some of the time 2

 Most of the time 3

 All of the time 4

NO RESPONSE M

all

B8. In the past month, how often did you feel like you could share your thoughts and feelings with your parent(s)?

Select one only

 None of the time 1

 Some of the time 2

 Most of the time 3

 All of the time 4

NO RESPONSE M

all

B9. In the past month, how often did you feel like you could count on your friends to be there when you needed them?

Select one only

 None of the time 1

 Some of the time 2

 Most of the time 3

 All of the time 4

NO RESPONSE M

all

B10. In the past month, how often did you feel like you could talk with your friends about things that really matter?

Select one only

 None of the time 1

 Some of the time 2

 Most of the time 3

 All of the time 4

NO RESPONSE M

all

B11. In the past month, how often did you feel like you could share your thoughts and feelings with your friends?

Select one only

 None of the time 1

 Some of the time 2

 Most of the time 3

 All of the time 4

NO RESPONSE M

SECTION C: Information and Opinions

All

C1. The next few questions are about things you may have learned in school.

In the past 12 months, did you have any classes on romantic relationships or dating?

 Yes 1

 No 0

NO RESPONSE M

All

C2. In the past 12 months, did you have any classes on dating violence?

 Yes 1

 No 0

NO RESPONSE M

All

C3. In the past 12 months, did you have any classes on teen pregnancy or sexually transmitted infections?

 Yes 1

 No 0

NO RESPONSE M

All

C4. In the past 12 months, did you have any classes on marriage?

 Yes 1

 No 0

NO RESPONSE M

All

C5. In the past 12 months, did any of your friends have any classes on romantic relationships or dating?

 Yes 1

 No 0

 I don’t know 2

NO RESPONSE M

All

C6. In the past 12 months, did any of your friends have any classes on dating violence?

 Yes 1

 No 0

 I don’t know 2

NO RESPONSE M

All

C7. In the past 12 months, did any of your friends have any classes on teen pregnancy or sexually transmitted infections?

 Yes 1

 No 0

 I don’t know 2

NO RESPONSE M

All

C8. In the past 12 months, did any of your friends have any classes on marriage?

 Yes 1

 No 0

 I don’t know 2

NO RESPONSE M

all

C9. How much do you agree or disagree with the following statement?

Marriages are happy or unhappy and there is not much you can do to change it.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C10. How much do you agree or disagree with the following statement?

If you are happily married, you don't need to work on your relationship.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C11. How much do you agree or disagree with the following statement?

There is only one true love out there who is right for me to marry.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C12. How much do you agree or disagree with the following statement?

In the end, feelings of love should be enough to sustain a happy marriage.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C13. How much do you agree or disagree with the following statement?

Living together before marriage will improve a couple’s chances of remaining happily married.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C14. How much do you agree or disagree with the following statement?

A boy angry enough to hit his girlfriend must love her very much.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C15. How much do you agree or disagree with the following statement?

Girls sometimes deserve to be hit by the boys they date.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C16. How much do you agree or disagree with the following statement?

A girl who makes her boyfriend jealous on purpose deserves to be hit.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C17. How much do you agree or disagree with the following statement?

Boys sometimes deserve to be hit by the girls they date.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C18. How much do you agree or disagree with the following statement?

A girl angry enough to hit her boyfriend must love him very much.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C19. How much do you agree or disagree with the following statement?

A boy who makes his girlfriend jealous on purpose deserves to be hit.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C20. How much do you agree or disagree with the following statement?

Violence between dating partners can improve the relationship.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C21. How much do you agree or disagree with the following statement?

There are times when violence between dating partners is ok.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C22. How much do you agree or disagree with the following statement?

Sometimes violence is the only way to express your feelings.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C23. How much do you agree or disagree with the following statement?

Some couples must use violence to solve their problems.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

All

C24. How much do you agree or disagree with the following statement?

Violence between dating partners is a personal matter and people should not interfere.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

C25. How much do you agree or disagree with the following statement?

Two people who are in love do not need to use condoms/birth control.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

C26. How much do you agree or disagree with the following statement?

At my age right now, it is okay to have sexual intercourse if I use protection, like a condom, the pill, etc.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

C27. When you think of your future, what do you think are the chances that you will get married?

Select one only

 Almost no chance 1

 Some chance but probably not 2

 A 50-50 chance 3

 A good chance 4

 Almost certain 5

NO RESPONSE M

all

C28. When you think of your future, what do you think are the chances that you will be married to one person for life?

Select one only

 Almost no chance 1

 Some chance but probably not 2

 A 50-50 chance 3

 A good chance 4

 Almost certain 5

NO RESPONSE M

all

C29. When you think of your future, what do you think are the chances that you will live with a partner without being married?

Select one only

 Almost no chance 1

 Some chance but probably not 2

 A 50-50 chance 3

 A good chance 4

 Almost certain 5

NO RESPONSE M

all

C30. When you think of your future, what do you think are the chances that you will have children?

Select one only

 Almost no chance 1

 Some chance but probably not 2

 A 50-50 chance 3

 A good chance 4

 Almost certain 5

 I already have children 6

NO RESPONSE M

all

C31. When you think of your future, what do you think are the chances that you will have a child without being married?

Select one only

 Almost no chance 1

 Some chance but probably not 2

 A 50-50 chance 3

 A good chance 4

 Almost certain 5

 I already have children 6

NO RESPONSE M

SECTION D: Relationship Skills

all

D1. How much do you agree or disagree with the following statement?

I believe I will be able to effectively deal with conflicts that arise in my relationship.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

D2. How much do you agree or disagree with the following statement?

I feel good about my ability to make a romantic relationship last.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

D3. How much do you agree or disagree with the following statement?

I am very confident when I think of having a stable, long term relationship.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

D4. How much do you agree or disagree with the following statement?

I have the skills needed for a lasting stable romantic relationship.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

all

D5. How good are you at admitting that you might be wrong during an argument?

Select one only

 I am extremely good at this 1

 I am good at this 2

 I am ok at this 3

 I am bad at this 4

NO RESPONSE M

all

D6. How good are you at avoiding saying things that could turn an argument into a big fight?

Select one only

 I am extremely good at this 1

 I am good at this 2

 I am ok at this 3

 I am bad at this 4

NO RESPONSE M

all

D7. How good are you at accepting another person's point of view even if you don't agree with it?

Select one only

 I am extremely good at this 1

 I am good at this 2

 I am ok at this 3

 I am bad at this 4

NO RESPONSE M

all

D8. How good are you at listening to another person's opinion during an argument?

Select one only

 I am extremely good at this 1

 I am good at this 2

 I am ok at this 3

 I am bad at this 4

NO RESPONSE M

all

D9. How good are you at working through problems without arguing?

Select one only

 I am extremely good at this 1

 I am good at this 2

 I am ok at this 3

 I am bad at this 4

NO RESPONSE M

All

D10. How often do you show respect for teachers and neighbors?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

All

D11. How often do you get along well with other people your age?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

All

D12. How often do you try to understand other people’s feelings?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

All

D13. How often do you try to see things from another person's point of view?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

All

D14. How often do you work hard to listen to what other people have to say?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

All

D15. How often do you say thank you when someone does something nice?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

All

D16. How often do you apologize when you’re wrong?

Select one only

 All of the time 1

 Most of the time 2

 Some of the time 3

 None of the time 4

NO RESPONSE M

SECTION E: Your Relationships

All

E1. How would you define your current relationship status?

Select one only

 Seriously dating 1 E2

 Casually dating 2 E2

 Not currently in a relationship or dating 3 E12

NO RESPONSE M

e1 ne 3

E2. The following questions are about your current relationship.

On a scale of 0-10, where 0 is not at all happy and 10 is completely happy, how happy would you say your current relationship is?

Not at all happy 0  1  2  3  4  5  6  7  8  9  10  Completely happy

NO RESPONSE M

e1 ne 3

E3. How much do you agree or disagree with the following statement?

I am very satisfied with how my partner and I talk with each other.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

e1 ne 3

E4. How much do you agree or disagree with the following statement?

I am very satisfied with how my partner and I treat each other.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

e1 ne 3

E5. How much do you agree or disagree with the following statement?

I can turn to my partner for advice about problems.

Select one only

 Strongly agree 1

 Agree 2

 Disagree 3

 Strongly disagree 4

NO RESPONSE M

E1 NE 3

E6. How often does your partner criticize your ideas?

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

NO RESPONSE M

E1 NE 3

E7. How often does your partner insult or swear at you?

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

NO RESPONSE M

E1 NE 3

E8. How often does your partner destroy things belonging to you? 

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

NO RESPONSE M

E1 NE 3

E9. When you have a serious disagreement with your partner, how often do you end up throwing things or hitting something? 

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

NO RESPONSE M

E1 NE 3

E10. How often do you insult or swear at your partner?

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

NO RESPONSE M

E1 NE 3

E11. How often do you destroy things belonging to your partner?

Select one only

 None of the time 1

 Some of the time 2

 Half of the time 3

 Most of the time 4

 All of the time 5

NO RESPONSE M

All

E12. Do you consider yourself to be…

Select one only

 Straight 1

 Gay or lesbian 2

 Bisexual 3

 Something else/I am not certain 4

NO RESPONSE M

all

E13. Have you ever had sexual intercourse?

 Yes 1 E14

 No 0 F1

NO RESPONSE M

E13 = 1

E14. In the past 3 months, have you ever had sexual intercourse?

 Yes 1

 No 0

NO RESPONSE M

E13 = 1 and E14=1

E15. In the past 3 months, have you ever had sexual intercourse without using a condom?

 Yes 1

 No 0

NO RESPONSE M

E13 = 1 and E14=1

E16. 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, Paragard, or Skyla), implant (Implanon or Nexplanon). In the past 3 months, have you had sexual intercourse without using any of these methods of birth control?

 Yes 1

 No 0

NO RESPONSE M

a1 = 2 AND E13=1

E17. Are you currently pregnant?

 Yes 1

 No 0

NO RESPONSE M

A1 = 1 AND E13=1

E18. Is anyone currently pregnant with your child?

 Yes 1

 No 0

NO RESPONSE M

E13=1

E19. How many children do you have? (Do not include current pregnancies)

Enter zero if you do not have any children F1

(RANGE 0-10)

NO RESPONSE M

E19 > 0

E20. Do you have children of your own living with you in your home?

Select one only

 I have one or more children, but they do not live with me 2 E21

 I live with at least one of my children 3 E23

NO RESPONSE M

E20 =2

E21. When is the last time you saw your youngest child?

Select one only

 In the past week 1 E22

 In the past month 2 E22

 In the past six months 3 F1

 In the past year 4 F1

 1-2 years ago 5 F1

 More than 2 years ago 6 F1

 Never 7 F1

NO RESPONSE M F1

E21=1 or 2

E22. In the past month, how often did you see or visit your youngest child?

Select one only

 Every day or almost every day 1 F1

 One to three times a week 2 F1

 One to three times a month 3 F1

 I did not see or visit this child in the past month 4 F1

NO RESPONSE M F1

if E20=3

E23. The remaining questions in this section are about your YOUNGEST CHILD that lives with you. Please answer these questions about that child.

Thinking about your youngest child, how often does the following happen in your family?

I am happy being with my child.

Select one only

 Often 1

 Sometimes 2

 Hardly ever 3

 Never 4

NO RESPONSE M

if E20=3

E24. Thinking about your youngest child, how often does the following happen in your family?

My child and I are very close to each other.

Select one only

 Often 1

 Sometimes 2

 Hardly ever 3

 Never 4

NO RESPONSE M

If e20=3

E25. Thinking about your youngest child, how often does the following happen in your family?

I try to comfort my child when he/she is upset.

Select one only

 Often 1

 Sometimes 2

 Hardly ever 3

 Never 4

NO RESPONSE M

if E20=3

E26. Thinking about the times when your youngest child has done something wrong, how often do you hit, spank, grab, or use physical punishment with your child?

Select one only

 Every day or almost every day 1

 A few times a week 2

 A few times a month 3

 Never 4

NO RESPONSE M

if E20=3

E27. Thinking about the times when your youngest child has done something wrong, how often do you yell, shout, or scream at your child because you are mad at him/her?

Select one only

 Every day or almost every day 1

 A few times a week 2

 A few times a month 3

 Never 4

NO RESPONSE M

if E20=3

E28. Thinking about the times when your youngest child has done something wrong, how often do you talk to your child about what he/she did wrong?

Select one only

 Every day or almost every day 1

 A few times a week 2

 A few times a month 3

 Never 4

NO RESPONSE M

SECTION F: Future Contact

ALL

F1. The next questions are about how to contact you in the future for your next survey.

What is your address?

Please only enter your street address here. We will ask for your PO BOX or mailing address later.

Street Address 1

(STRING 200)

Street Address 2 or Apt

(STRING 200)

City

(STRING 200)

State/Territory

Select▼

(INSERT DROPDOWN)

Zip

(STRING 10)

SOFT CHECK: IF STREET ADDRESS 1 IS MISSING; Please enter your street address so we can send your payment. To continue to the next question without providing a response, click the continue button.

SOFT CHECK: IF CITY IS MISSING; Please enter your city. To continue to the next question without providing a response, click the continue button.

ALL

F2 What is your cell phone number?

NO RESPONSE M

F2a. □ Check here if you don’t have a cell phone 1

HARD CHECK: IF F2 HAS DATA ENTERED, BUT IS NOT 10 NUM DIGITS; The phone number should be 10 digits. Please correct the number below.

PROGRAMMER BOX F2a.1

IF COMPLETE CELL PHONE ENTERED (REGARDLESS OF F2a CHECK BOX), CONTINUE TO F3;

IF F2 = M, SKIP TO F4.

F2 HAS COMPLETE PHONE NUMBER ENTERED

F3. May we send you text messages? Message and data rates may apply.

 Yes 1

 No 0

NO RESPONSE M

ALL

F4. What is another phone number where you can be reached?

NO RESPONSE M

F4a. □ Check here if you don’t have another phone number 1

HARD CHECK: IF F4 HAS DATA ENTERED, BUT IS NOT 10 NUM DIGITS; The phone number should be 10 digits. Please correct the number below.

PROGRAMMER BOX F4a.1

IF COMPLETE PHONE ENTERED (REGARDLESS OF F4a CHECK BOX), CONTINUE TO F5;

IF F4 = M, SKIP TO F7.

F4 HAS COMPLETE PHONE NUMBER ENTERED

F5. Is this number, [F4], for a cell phone?

 Yes 1

 No 0

NO RESPONSE M

F4 HAS COMPLETE PHONE NUMBER ENTERED

F6. Whose name is that number listed under?

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 20)

NO RESPONSE M

F6a. □ Check here if you don’t know 1

PROGRAMMER BOX F6a.1

IF F5 = 1, CONTINUE TO F6b;ELSE, SKIP TO F7.

F5 = 1

F6b. May we send you text messages at this number: ([FILL F4_phone])? Message and data rates may apply.

 Yes 1

 No 0

NO RESPONSE M

all

F7. What is the best e-mail address to reach you at?

E-Mail

(STRING 50)

NO RESPONSE M

F7a. □ Check here if you don’t have an e-mail address 1

HARD CHECK: IF E-MAIL DOES NOT HAVE A “@” OR “.”; Please enter a valid e-mail address. The e-mail should include an “@” sign and a period.

PROGRAMMER BOX F7a.1

IF A VALID E-MAIL IS ENTERED (REGARDLESS OF F7a CHECKBOX),

CONTINUE TO F8; ELSE, SKIP TO BOX F9.

F7 IS HAS VALID E-MAIL ENTERED

F8. If you have another e-mail address, what is it?

E-Mail

(STRING 50)

NO RESPONSE M

F8a. □ Check here if you don’t have another e-mail address 1

HARD CHECK: IF E-MAIL DOES NOT HAVE A “@” OR “.”; Please enter a valid e-mail address. The e-mail should include an “@” sign and a period.

All

F9. Do you have a Facebook account?

 Yes 1

 No 0 F10

NO RESPONSE M F10

F9 = 1

F9a. What name do you use on Facebook?

(STRING 100)

NO RESPONSE M

All

F10. Do you have an Instagram account?

 Yes 1

 No 0 F11

NO RESPONSE M F11

F10 = 1

F10a. What name do you use on Instagram?

(STRING 100)

NO RESPONSE M

All

F11. Do you have a Twitter account?

 Yes 1

 No 0 F12

NO RESPONSE M F12

F11 = 1

F11a. What user name or handle do you use on Twitter?

(STRING 100)

NO RESPONSE M

ALL

F12. Do you have a social networking account other than Facebook, Instagram, or Twitter?

 Yes 1

 No 0 PROGRAMMER

LOOP BOX F12b

NO RESPONSE M PROGRAMMER

LOOP BOX F12b

F12 = 1

F12a. What other social networking provider do you use?

Name of social network

(STRING 100)

NO RESPONSE M

F12= 1

F12b. What name do you use on this social networking account?

(STRING 100)

NO RESPONSE M

PROGRAMMER LOOP BOX F12b.

BEGIN LOOP

ASK F13 to F16 Two TIMES.

LOOP ENDS EARLY WHEN F13 = M OR F13a = 1.

ALL

FOR F13a BOX: FILL else FOR SECOND LOOP

F13. FIRST PERSON:

As part of the study, we will contact you again in a year. In case you move, we would like the name, address and telephone number of up to two relatives (such as your parents or grandparents) or other adults who would know where you are. We will only contact them if we have trouble getting in touch with you directly.

What is the name of the first person who will know where you are?

SECOND PERSON:

What is the name of another relative or adult who will know how to contact you a year from now?

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 20)

NO RESPONSE M F17

F13a. □ Check here if there is no one [else] will know how to contact you 1 F17

SOFT CHECK: IF F13 (FIRST PERSON) FIRST NAME = M AND F13a = M; It is important you provide at least one person to help us reach you in the future. Please check the box below if there is no one who will know how to contact you.

SOFT CHECK: IF F13 (2nd PERSON) FIRST NAME = M AND F13a = M; Please provide the name of the next person. Please check the box below if there is no one else who will know how to contact you.

F13 = ANSWERED

F14. What is [FILL NAME]’s relationship to you?

 Mother 1

 Father 2

 Sister or Brother 3

 Friend 4

 Grandparent 5

 Aunt or Uncle 6

 Other 7

 Spouse or Partner 8

NO RESPONSE M

F13 = ANSWERED

F15. What is [FILL NAME]’s telephone number?

NO RESPONSE M

F15a. □ Check here if you can’t find the number. 1

HARD CHECK: IF F15 HAS DATA ENTERED, BUT IS NOT 10 NUM DIGITS; The phone number should be 10 digits. Please correct the number below.

F13 = ANSWERED

F16. What is [FILL NAME]’s address?

Please complete as much of the address as you can.

Street Address 1

(STRING 200)

Street Address 2

(STRING 200)

City

(STRING 200)

State/Territory

Select▼

(INSERT DROPDOWN)

Zip

(STRING 10)

NO RESPONSE M

SOFT CHECK: IF CITY AND STATE ARE MISSING; Please enter just the city and state if you can.

To continue to the next question, click the “next” button below.

SOFT CHECK: IF ALL FIELDS ARE MISSING; Please enter any information you can, even if it is just the city and/or state.

To continue to the next question, click the “next” button below.

PROGRAMMER LOOP BOX F16.1.

RETURN TO F13 AND ASK FOR ANOTHER CONTACT.

END LOOP IF THIS IS THE second LOOP.

ALL

F17. The last questions are about the best ways to reach you for future surveys.

How would you like to be contacted in the future about upcoming surveys?

Select all that apply

 Flyer or letter from school 1

 Letter in the mail 2

 E-Mail 3

 Notification via the STREAMS App 4

 Text message 5

 Cell phone 6

 Home phone 7

 Facebook message 8

 Some other way 9

Specify (STRING 200)

NO RESPONSE M

SPECIFY TEXT: Please specify what other way you were contacted:

ALL

END. You’re finished! Thank you for completing the survey!

 Click here and press “Next” to submit your survey. 1

HARD CHECK: IF RADIO BUTTON NOT SELECTED; Please click the button below and press “Next” to submit your survey.

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