Baseline Survey of impact study participants

OMB Control No: XXXX-XXXX

Expiration Date:

Attitudes, Behaviors, and Choices Study

BASELINE SURVEY

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.

SECTION 1: BACKGROUND INFORMATION

1.1. In what month and year were you born?

/ MONTH / YEAR

1.2. Are you Hispanic or Latino?

MARK (X) ONE

Yes

No

1.3. 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

1.4. What grade are you currently in?

MARK (X) ONE

5th grade or below

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade

1.5. How often would you say you skip school?

MARK (X) ONE

Never or almost never

Sometimes, but less than once a week

Not every day, but at least once a week

Daily or almost every day

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

MARK (X) ONE

Never

Once

More than once

1.7. How likely is it that you will graduate from high school?

MARK (X) ONE

Not at all likely

A little bit likely

Somewhat likely

Very likely

SECTION 2: FAMILY AND RELATIONSHIPS

2.1. Do you have someone in your life right now who cares for you as a mother figure? This could be your biological mother, stepmother, adoptive mother, or some other adult you think of as a mother.

MARK (X) ONE

Yes

No GO TO QUESTION 2.5

2.2. How much of the time do you live with her?

MARK (X) ONE

None of the time

Some of the time

All of the time

2.3. What is the highest level of education she has achieved?

MARK (X) ONE

Less than high school

High school graduate or GED

Some college but no degree

2-year or 4-year college graduate (Associate’s or Bachelor’s degree)

Graduate or professional school

Don’t know

2.4. How close do you feel to her?

MARK (X) ONE

Not at all close

Not very close

Somewhat close

Very close

2.5. Do you have someone in your life right now who cares for you as a father figure? This could be your biological father, stepfather, adoptive father, or some other adult you think of as a father.

MARK (X) ONE

Yes

No GO TO 2.9

2.6. How much of the time do you live with him?

MARK (X) ONE

None of the time

Some of the time

All of the time

2.7. What is the highest level of education he has achieved?

MARK (X) ONE

Less than high school

High school graduate or GED

Some college but no degree

2-year or 4-year college graduate (Associate’s or Bachelor’s degree)

Graduate or professional school

Don’t know

2.8. How close do you feel to him?

MARK (X) ONE

Not at all close

Not very close

Somewhat close

Very close

2.9. In the past 12 months, how many times have you changed where you live?

MARK (X) ONE

Never

Once

Twice

Three times

Four times or more

SECTION 3: INFORMATION, THOUGHTS, AND OPINIONS

3.1. In the past 12 months, did you attend any classes or sessions where the following were discussed? These classes or sessions could have been in health class at school, through a program at a community center such as the Boys Club or Girls Club, or at the YMCA. MARK (X) ONE FOR EACH QUESTION
		YES	NO
	a. Relationships, dating, or marriage
	b. Abstinence from sex
	c. Methods of birth control, such as condoms, pills, the patch, the shot, the ring, IUD, or an implant
	d. Where to get birth control
	e. Sexually transmitted diseases, also known as STDs or STIs

3.2. How strongly do you agree or disagree with each of the following statements? MARK (X) ONE FOR EACH QUESTION
	STRONGLY AGREE	AGREE	NEITHER AGREE NOR DISAGREE	DISAGREE	STRONGLY DISAGREE
a. Having sex is a good thing for you to do at your age
b. At your age right now, having sex would create problems
c. At your age right now, not having sex is important for you to be safe and healthy
d. At your age right now, it is okay for you to have sex if you use birth control, such as condoms, pills, the patch, the shot, the ring, IUD, or an implant
e. It is against your beliefs to have sex before marriage
f. It is against your beliefs to use any form of birth control, such as condoms, pills, the patch, the shot, the ring, IUD, or an implant

3.3. In the past 3 months, about how many times have you asked one or both of your parents/guardians questions about sex?

TIMES

3.4. How comfortable are you talking to your parents/guardians about sex? Please answer for the parent/guardian whom you feel most comfortable talking to.

MARK (X) ONE

I don’t feel comfortable talking to a parent/guardian about sex

Somewhat comfortable

Comfortable

Very comfortable

3.5a. Sometimes people don’t want to have sex but have difficulty saying “no.” If you were with someone you have known for a few days or less, how likely is it you would be able to say “no” to having sex?

MARK (X) ONE

Not at all likely

A little bit likely

Somewhat likely

Very likely

3.5b. If you were with someone you have dated for a long time, how likely is it you would be able to say “no” to having sex?

MARK (X) ONE

Not at all likely

A little bit likely

Somewhat likely

Very likely

3.5c. If you were with someone with whom you have already had sex, how likely is it you would be able to say “no” to having sex?

MARK (X) ONE

Not at all likely

A little bit likely

Somewhat likely

Very likely

3.5d. If you were with someone who is pushing you to have sex, how likely is it you would be able to say “no” to having sex?

MARK (X) ONE

Not at all likely

A little bit likely

Somewhat likely

Very likely

3.5e. If you were with someone who does not want to use a condom, how likely is it you would be able to say “no” to having sex?

MARK (X) ONE

Not at all likely

A little bit likely

Somewhat likely

Very likely

3.6. The next series of statements is about condom use. How strongly do you agree or disagree with each of these statements? 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 sex
b. Condoms decrease sexual pleasure
c. Condoms are important to make sex safer
d. Using condoms means you don’t trust your partner
e. Using condoms is morally wrong
f. Condoms are a hassle to use
g. Condoms are pretty easy to get

3.7. If condoms are used correctly and consistently, how much can they decrease the risk of pregnancy?

MARK (X) ONE

Not at all

A little

A lot

Completely

Don’t know

3.8. If condoms are used correctly and consistently, 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

Completely

Don’t know

3.9. If birth control pills are used correctly and consistently, how much can they decrease the risk of pregnancy?

MARK (X) ONE

Not at all

A little

A lot

Completely

Don’t know

3.10. If birth control pills are used correctly and consistently, 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

Completely

Don’t know

3.11. Can you get a sexually transmitted disease, also known as an STD or STI, from having 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 own penis or vagina.

MARK (X) ONE

Yes

No

Don’t know

3.12. Can you get a sexually transmitted disease, also known as an STD or STI, from having anal sex? 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 own anus or butt.

MARK (X) ONE

Yes

No

Don’t know

3.13. The next statements are about condoms. Please select whether you think each statement is true, false, or you don’t know. MARK (X) ONE FOR EACH QUESTION
	TRUE	FALSE	DON’T KNOW
a. It is okay to use the same condom more than once
b. Condoms have an expiration date
c. When putting on a condom, it is important to leave a space at the tip
d. It is okay to use petroleum jelly or Vaseline as a lubricant when using latex condoms
e. When using a condom, it is important for the man to pull out right after ejaculation
f. Wearing two latex condoms will provide extra protection

3.14. The next statements are about birth control pills. Please select whether you think each statement is true, false, or you don’t know. MARK (X) ONE FOR EACH QUESTION
	TRUE	FALSE	DON’T KNOW
a. Birth control pills are effective, even if a woman misses taking them for two or three days in a row
b. Women should “take a break” from the pills every couple of years
c. After a woman stops taking birth control pills, she is unable to get pregnant for at least two months
d. In order to get the birth control pill, a woman must have a pelvic exam
e. Birth control pills can reduce risk of getting a sexually transmitted disease (STD)

3.15. The next statements are about about IUDs (such as Mirena, ParaGard, or Skyla). Please select whether you think each statement is true, false, or you don’t know. MARK (X) ONE FOR EACH QUESTION
	TRUE	FALSE	DON’T KNOW
a. All IUDs are banned from use in the United States
b. A woman can use an IUD, even if she has never had a child
c. Women who use IUDs cannot use tampons
d. A woman can get an IUD without going to a doctor’s office, clinic or medical professional.
e. An IUD cannot be felt by a woman’s partner during sex
f. IUDs can move around in a woman’s body
g. An IUD is effective (prevents pregnancy) for at least 3 years

3.16. The next statements are about other forms of birth control. Please select whether you think each statement is true, false, or you don’t know. MARK (X) ONE FOR EACH QUESTION
	TRUE	FALSE	DON’T KNOW
a. Women using the birth control shot, Depo-Provera, must get an injection every 3 months
b. Even if a woman is late getting her birth control shot, she is still protected from pregnancy for at least 3 more months
c. Women using the vaginal ring, NuvaRing, must have it inserted by a doctor or health care provider every month
d. Long acting methods like the implant (Implanon or Nexplanon) or an IUD (Mirena, ParaGard, or Skyla) cannot be removed early, even if a woman changes her mind about wanting to get pregnant
e. Long-acting methods like the implant or an IUD can make it more difficult to become pregnant in the future when a woman is no longer using them.
f. Long-acting methods like the implant, an IUD, or the shot can reduce the risk of getting a sexually transmitted disease (STD).

3.17. The next statements are about pregnancy. Please select whether you think each statement is true, false, or you don’t know. MARK (X) ONE FOR EACH QUESTION
	TRUE	FALSE	DON’T KNOW
a. The very first time you have sex, you cannot get pregnant
b. Douching (washing the vagina) after sex can prevent pregnancy
c. Pregnancy is much less likely to occur if a couple has sex standing up
d. The only way to completely prevent pregnancy is by not having sex
e. During a woman’s monthly cycle, there are certain days when she is more likely to become pregnant if she has sex

SECTION 4: HEALTH AND SEXUAL BEHAVIOR

4.1. How do you describe your gender?

MARK (X) ONE

Male

Female

Transgender

Unsure

Other (specify)

4.2. The next questions are about your sexual behaviors and experiences. Please be as honest as possible. Your answers will be kept private and will not be shared with anyone.

People are different in their sexual attraction to other people. Which best describes your feelings? Are you…?

MARK (X) ONE

Only attracted to females

Mostly attracted to females

Equally attracted to females and males

Mostly attracted to males

Only attracted to males

Questioning/not sure

Other (specify)

4.3. Have you ever sent nude or nearly nude pictures or videos of yourself to others?

MARK (X) ONE

Yes

No

4.4. Have you ever received nude or nearly nude pictures or videos of someone else?

MARK (X) ONE

Yes

No

4.5. Have you ever touched someone’s private parts? Private parts are the parts of the body covered by underwear or a bra.

MARK (X) ONE

Yes

No

4.6. Other than a doctor or a nurse, have you ever let someone touch your private parts?

MARK (X) ONE

Yes

No

4.7. The next questions are about vaginal sex. By vaginal sex, we mean a male putting his penis into a female's vagina. Have you ever had vaginal sex?

MARK (X) ONE

Yes

No GO TO 4.15

4.8. The very first time you had vaginal sex, how old were you?

MARK (X) ONE

11 years old or younger

12 years old

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old or older

4.9. The first time you had vaginal sex, did you or your partner use any of these methods of birth control? MARK (X) ONE FOR EACH QUESTION
	YES	NO	DON’T KNOW
a. Condoms
b. Birth control pills
c. The patch, such as Ortho-Evra
d. The shot, such as Depo-Provera or other injectable birth control
e. The ring, such as NuvaRing
f. An IUD, such as Mirena, ParaGard, or Skyla
g. An implant, such as Implanon or Nexplanon
h. Withdrawal or pulling out
i. Emergency contraceptive pills, such as Plan B
j. Another method PRINT OTHER METHOD USED

4.10. How many DIFFERENT PEOPLE have you ever had vaginal sex with, even if only one time?

NUMBER OF PEOPLE – Your best estimate is fine.

4.11. Now please think about the past 3 months. In the past 3 months, have you had vaginal sex, even once?

MARK (X) ONE

Yes

No SKIP TO 4.15

4.12. In the past 3 months, how many TIMES have you had vaginal sex?

NUMBER OF TIMES – Your best estimate is fine.

4.13. The next question is about your use of the following methods of birth control:

• Condoms

• Birth control pills

• The shot (Depo-Provera)

• The patch (Ortho-Evra)

• The ring (NuvaRing)

• IUD (Mirena, ParaGard, or Skyla)

• Implant (Implanon or Nexplanon)

In the past 3 months, how many TIMES have you had vaginal sex without using any of these methods of birth control?

NUMBER OF TIMES – Your best estimate is fine.

4.14. In the past 3 months, how many TIMES have you had vaginal sex without using a condom?

NUMBER OF TIMES – Your best estimate is fine.

ALL

4.15. Do you intend to have vaginal sex in the next year, if you have the chance?

MARK (X) ONE

Yes, definitely

Yes, probably

No, probably not

No, definitely not

4.16. 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 own penis or vagina. Have you ever had oral sex?

MARK (X) ONE

Yes

No SKIP TO 4.21

4.17. The very first time you had oral sex, how old were you?

MARK (X) ONE

11 years old or younger

12 years old

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old or older

4.18. Now please think about the past 3 months. In the past 3 months, have you had oral sex?

MARK (X) ONE

Yes

No SKIP TO 4.21

4.19. In the past 3 months, how many TIMES have you had oral sex?

NUMBER OF TIMES – Your best estimate is fine.

4.20. In the past 3 months, how many TIMES have you had oral sex without using a condom?

NUMBER OF TIMES – Your best estimate is fine.

ALL

4.21. 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 own anus or butt. Have you ever had anal sex?

MARK (X) ONE

Yes

No GO TO PROGRAMMER BOX 1

Programmer box 1:

Not sexually active – skip to 4.26 (hung out alone)

Sexually active – skip to 5.1

4.22. The very first time you had anal sex, how old were you?

MARK (X) ONE

11 years old or younger

12 years old or younger

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old or older

4.23. Now please think about the past 3 months. In the past 3 months, have you had anal sex?

MARK (X) ONE

Yes

No GO TO 5.1

4.24. In the past 3 months, how many TIMES have you had anal sex?

NUMBER OF TIMES – Your best estimate is fine.

4.25. In the past 3 months, how many TIMES have you had anal sex without using a condom?

NUMBER OF TIMES – Your best estimate is fine.-Skip to 5.1

4.26. Have you ever hung out alone with someone you were attracted to?

MARK (X) ONE

Yes

No SKIP TO 4.28

4.27. How old were you the first time you hung out alone with someone you were attracted to?

MARK (X) ONE

Don’t know/Can’t remember

YEARS OLD

4.28. Have you ever kissed someone you were attracted to on the mouth?

MARK (X) ONE

Yes

No GO TO 4.30

4.29. Have you ever tongue kissed or French kissed someone?

MARK (X) ONE

Yes

No

4.30. Have you ever laid down alone with someone you were attracted to?

MARK (X) ONE

Yes

No

4.31. Have you ever had a boyfriend or girlfriend?

MARK (X) ONE

Yes

No GO TO 4.33

4.32. How many boyfriends or girlfriends have you had?

4.33. In general, how much pressure, if any, do you feel from your friends to have sex?

MARK (X) ONE

A lot of pressure

Some pressure

A little pressure

No pressure

4.34. How many of your friends who are your age think the following things? Your best guess is fine. MARK (X) ONE FOR EACH
	NONE	SOME	HALF	MOST	ALL	DON’T KNOW
a. Having sex is a good thing for them to do at their age
b. It would be okay for them to have sex as long as they used birth control, like a condom
c. It would be okay for them to have sex if they were dating the same person for a long time
d. They should wait until they are older to have sex
e. They should wait until marriage to have sex

4.35. How many of your friends who are your age have had sex? Your best guess is fine.

MARK (X) ONE

None

Some

Half

Most

All

Don’t know

4.36. Here are some reasons people your age might choose NOT to have sex. 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 or an STI
b. I don’t want to disappoint my parents
c. I am too young to have sex
d. I want to wait until I’m married
e. It is against my personal beliefs
f. I haven’t met the right person yet
g. I haven’t had the chance
h. I do not want to get pregnant or get someone pregnant

4.37. How strongly do you agree or disagree that each of the following statements are benefits to you of waiting to have sex? MARK (X) ONE FOR EACH
	STRONGLY AGREE	AGREE	NEITHER AGREE NOR DISAGREE	DISAGREE	STRONGLY DISAGREE
a. Respect for yourself
b. Keeping true to religious beliefs
c. Respect from friends
d. Better chance for a good marriage in the future

SECTION 5: HEALTHCARE AND PREGNANCY

5.1. In the past 12 months, did you receive information from a doctor, nurse, or clinic about any of the following? MARK (X) ONE FOR EACH QUESTION
		YES	NO
	a. Methods of birth control, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant
	b. Where to get birth control
	c. Sexually transmitted diseases, also known as STDs or STIs
	d. The HPV vaccine, also known as Gardasil

5.2. In the past 12 months, did you get any type of birth control from a doctor, nurse, or clinic, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant?

MARK (X) ONE

Yes

No

5.3. Have you ever been told by a doctor, nurse, or some other health professional that you had any of the following sexually transmitted diseases? MARK (X) ONE FOR EACH QUESTION
		YES	NO
	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 disease (STD) PRINT OTHER STD

5.4. Have you ever talked about contraception or sexually transmitted diseases with someone you were attracted to?

MARK (X) ONE

Yes

No

ASK IF 4.7=YES. IF 4.7=NO, SKIP TO 5.6.

5.5. To the best of your knowledge, are you currently or have you ever been pregnant, or have you gotten someone pregnant?

MARK (X) ONE

Yes GO TO 6.1

No

5.6. Do you want to have children in the future?

MARK (X) ONE

Yes

No GO TO 6.1

5.7. If it were just up to you, what age would you like to have your first child?

YEARS OLD

SECTION 6: SMOKING, ALCOHOL, DRUG USE, AND HEALTH

6.1. The next questions are about tobacco, alcohol, drugs, and general health. Please be as honest as possible, and remember that your answers will be kept private and will not be shared with anyone.

During the past 30 days, on how many days did you use an electronic vapor product such as blu, NJOY, Vuse, MarkTen, Logic, Vapin Plus, eGo, and Halo?

Electronic vapor products include e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens?

MARK (X) ONE

0 days

1 or 2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 to 29 days

All 30 days

6.2. Now think about cigarettes. Do not include electronic vapor products. During the past 30 days, on how many days did you smoke one or more cigarettes?

MARK (X) ONE

0 days

1 or 2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 to 29 days

All 30 days

6.3. The next two questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.

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

MARK (X) ONE

0 days GO TO 6.5

1 or 2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 to 29 days

All 30 days

6.4. During the past 30 days, on how many days did you have 5 or more drinks in a row, that is, within a couple hours?

MARK (X) ONE

0 days

1 day

2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 or more days

6.5. During the past 30 days, on how many days did you use marijuana, also called weed or pot?

MARK (X) ONE

0 days

1 or 2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 to 29 days

All 30 days

6.6. During the past 30 days, on how many days did you use any other type of illegal drug, inhalant, or a prescription drug in a way that was not prescribed?

MARK (X) ONE

0 days

1 or 2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 to 29 days

All 30 days

6.7. Now thinking about experiences throughout your life, how many times have you experienced the following things? MARK (X) ONE FOR EACH QUESTION
	NEVER	ONCE	TWO OR THREE TIMES	FOUR OR MORE TIMES
a. Heard gunshots in your neighborhood
b. Witnessed a shooting
c. Been robbed or mugged
d. Been fearful that someone you are dating might physically hurt you

SECTION 7: YOUR RELATIONSHIPS

7.1. The next questions are about your experiences and attitudes toward relationships and dating. How would you define your current relationship status?

MARK (X) ONE

Not currently in a relationship or dating

Casually dating

Seriously dating

Engaged

Married

7.2. Have you ever been contacted online or through social media by a complete stranger who wanted to meet in-person?

MARK (X) ONE

Yes

No

7.3. Have you ever contacted a complete stranger online or through social media who you wanted to meet in-person?

MARK (X) ONE

Yes

No

7.4. How much do you agree or disagree with each of the following statements? MARK (X) ONE FOR EACH QUESTION
	STRONGLY AGREE	AGREE	NEITHER AGREE NOR DISAGREE	DISAGREE	STRONGLY DISAGREE
a. In a good dating relationship, you don’t always get your own way
b. There are times when hitting or pushing between people who are dating is okay
c. A good dating relationship is based on mutual respect, not just sex
d. People who make their dating partner jealous deserve to be hit or pushed
e. It would be easy to trust someone you are dating, even when you’re apart
f. Avoiding a disagreement with someone you are dating is always better than talking about your problems

Thank you for

completing this survey!

ABC Study Baseline Survey 1