Measuring Self- and Co-Regulation in Sexual Risk Avoidance Education Programs Phase 1

OMB Control No: 0970-0356

Expiration Date: 02/29/2024

Instrument B: Youth self-regulation survey

DRAFT

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide program development in the area of adolescent pregnancy prevention. Public reporting burden for the collection of information is estimated to average 10 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 OMB number and expiration date for this collection are OMB #: 0970-0356, Exp: 02/29/2024. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Tiffany Waits at twaits@mathematica-mpr.com..

February 2023

Thank you in advance for taking this survey! The purpose of this short survey is to learn about how you think and feel about the things that happen around you and how you act in different situations.

This study is sponsored by the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services and is being conducted by Mathematica.

Your participation in this survey is voluntary. There are no risks or benefits associated with completing the survey, which should take about 10 minutes. We will not collect any personal information (for example, your name, email, or phone number) as part of the survey. Your answers will remain private, except as required by law, and no teachers, staff, or peers from your school will see your individual responses. We hope you answer all survey questions, but you may skip any question you do not want to answer.

If you have any questions or comments about this information collection, contact Tiffany Waits, the survey director, at twaits@mathematica-mpr.com or (202) 264-3498. If you have any questions or concerns about your rights as a study participant, please contact the Health Media Lab Institutional Review Board at (202) 246-8504.

[IF WEB SURVEY]: If you agree to participate in this survey, click NEXT to begin.

[IF PAPER]: By completing this survey, you are agreeing to participate in this research study.

1. You will be asked to take this survey twice, once before the program begins and once after the program ends. In order to protect your privacy, we will not collect any identifying information on this survey. Instead, your answers to the following questions will be used to connect your pre-program survey responses to your post-program survey responses without us needing your name. It is important that these answers stay the same between surveys.

a. What is the first letter of your first name?

A 1 m	F 6 m	K 11 m	P 16 m	U 21 m	Z 26 m
B 2 m	G 7 m	L 12 m	Q 17 m	V 22 m
C 3 m	H 8 m	M 13 m	R 18 m	W 23 m
D 4 m	I 9 m	N 14 m	S 19 m	X 24 m
E 5 m	J 10 m	O 15 m	T 20 m	Y 25 m

b. What is the first letter of your middle name?

No middle name 0 m	E 5 m	J 10 m	O 15 m	T 20 m	Y 25 m
A 1 m	F 6 m	K 11 m	P 16 m	U 21 m	Z 26 m
B 2 m	G 7 m	L 12 m	Q 17 m	V 22 m
C 3 m	H 8 m	M 13 m	R 18 m	W 23 m
D 4 m	I 9 m	N 14 m	S 19 m	X 24 m

c. What is the second letter of your last name? Please select the response that includes the letter.

1 m A-E

2 m F-J

3 m K-O

4 m P-T

5 m U-Z

d. In what month were you born?

January 1 m	July 7 m
February 2 m	August 8 m
March 3 m	September 9 m
April 4 m	October 10 m
May 5 m	November 11 m
June 6 m	December 12 m

e. What color are your eyes? If they are more than one color, pick the color they are closest to.

1 m Green

2 m Brown

3 m Black

4 m Blue

5 m Hazel

6 m Grey

2. Below are questions about ways people may feel or act. There are no right or wrong answers. Please answer each question honestly.

How much do you feel the following are true for you?	MARK ONLY ONE PER ROW
	NEVER	NOT OFTEN	SOMETIMES	OFTEN	ALMOST ALWAYS
a. I set goals for myself1	1 m	2 m	3 m	4 m	5 m
b. I can find a way to stick with my plans and goals, even when it’s tough 2	1 m	2 m	3 m	4 m	5 m
c. I am good at keeping track of lots of things going on around me, even when I’m feeling stressed 2	1 m	2 m	3 m	4 m	5 m
d. I pay attention to how I feel)3	1 m	2 m	3 m	4 m	5 m
e. When I’m upset, I lose control over my behavior 3	1 m	2 m	3 m	4 m	5 m
f. I can calm myself down when I’m excited 2	1 m	2 m	3 m	4 m	5 m
g. It is hard for me to stop myself from acting on my feelings 4	1 m	2 m	3 m	4 m	5 m
h. I can say “no” to a friend who wants to break the rules1	1 m	2 m	3 m	4 m	5 m
i. Before making up my mind, I consider all the positives and negatives of a decision 4	1 m	2 m	3 m	4 m	5 m
j. I can resist doing something when I know I shouldn’t 2	1 m	2 m	3 m	4 m	5 m
k. I can wait for what I want (BR)5	1 m	2 m	3 m	4 m	5 m
l. I think carefully before I make a decision 6	1 m	2 m	3 m	4 m	5 m
m. I get frustrated if I have to wait for something 7	1 m	2 m	3 m	4 m	5 m
n. It’s easy for my feelings to get overwhelming3	1 m	2 m	3 m	4 m	5 m
o My mood affects how I treat others 1	1 m	2 m	3 m	4 m	5 m
p. I find myself getting pulled into other people's drama	1 m	2 m	3 m	4 m	5 m
q. I get involved in things that I later wish I could get out of4	1 m	2 m	3 m	4 m	5 m
r. I post things online or send texts that I later wish I hadn't	1 m	2 m	3 m	4 m	5 m
s. I can stay calm when everyone around me is stressed.8	1 m	2 m	3 m	4 m	5 m
t. When I'm feeling stressed, I know ways I can calm myself down. 1	1 m	2 m	3 m	4 m	5 m

Thank you for sharing your experiences with us today.

1 Adapted from the WCSD Social and Emotional Competency Long-Form Assessment (Washoe County School District, 2018)

2 Adapted from the Adolescent Self-Regulatory Inventory (ASRI; Moilanen 2007)

3 Adapted from the Difficulties in Emotion Regulation Scale (DERS) (Gratz, K. L. & Roemer, L, 2004)

4 Adapted from the Urgency, Premeditation (lack of), Perseverance (lack of), Sensation Seeking, Positive Urgency, Impulsive Behavior Scale (UPPS-P) (Lynam, Smith, Whiteside, & Cyders, 2006)

5 Adapted from the Social Emotional Health Survey-Secondary (SEHS-S) (Furlong, M. J., Dowdy, E., & Nylund-Gibson, K., 2018)

6 Adapted from the Strengths and Difficulties Questionnaire (SDQ(S))-Youth Report Measures for Children and Adolescents (National Health Service, Department of Health and Ageing. Goodman, 2001)

7 Adapted from Anger Expression in Children (Steele, Legerski, Nelson, Phipps, 2008)

8 Adapted from the Panorama Social and Emotional Learning - Student Survey (Panorama Education, 2014)