Instrument 3. Youth Self-Assessment Survey

OMB No.: 0970-0355

Expiration Date: 08/31/2024

Instrument 3. SRAENE Co-Regulation Measures Pilot Study: Youth Self-Assessment Survey

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 the development of a survey of self- and co-regulation in the area of adolescent pregnancy prevention. Public reporting burden for this 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 #: 0970-0355, Exp: 08/31/2024. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Heather Zaveri at hzaveri@mathematica-mpr.com.

Summer 2024

How I Feel and What I Do

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. The information collected will help us better understand the ways that teens and young adults regulate their emotions and behaviors. The study team will be the only ones who use the data.

It’s your choice to take this survey. There are no risks or benefits associated with the survey, which should take about 10 minutes. We hope you answer all questions, but you may skip any question you do not want to answer. We do not ask for any personal information, such as your name, email, or phone number, and your answers will be kept private; we have created procedures to prevent parents, teachers, staff, or peers from seeing your responses. As required by law, we will only share information if there is a risk of harm to yourself or others.

By completing this survey, you are agreeing to participate in this research study.

[NOTE: Q1 ONLY ADMINISTERED IN PHASE 3 OF TESTING]

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 5 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 the answers to these 5 questions 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. On what day of the month were you born?

1 1 m	6 6 m	11 11 m	16 16 m	21 21 m	26 26 m	31 31 m
2 2 m	7 7 m	12 12 m	17 17 m	22 22 m	27 27 m
3 3 m	8 8 m	13 13 m	18 18 m	23 23 m	28 28 m
4 4 m	9 9 m	14 14 m	19 19 m	24 24 m	29 29 m
5 5 m	10 10 m	15 15 m	20 20 m	25 25 m	30 30 m

c. 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

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

1 m Green 4 m Blue

2 m Brown 5 m Hazel

3 m Black 6 m Grey

e. 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

2. Below are questions about ways people may feel or act. There are no right or wrong answers. Please do your best to answer honestly.

	SELECT ONE ONLY
How easy or hard is it to…	Very hard	Hard	A little hard, a little easy	Easy	Very easy
a. Set goals for myself.	1 	2 	3 	4 	5 
b. Find a way to stick with my goals, even when it’s tough.	1 	2 	3 	4 	5 
c. Keep track of lots of things going on around me, even when I’m feeling stressed.	1 	2 	3 	4 	5 
d. Resist getting pulled into other people’s drama.	1 	2 	3 	4 	5 
e. Calm myself down when I’m too excited to focus.	1 	2 	3 	4 	5 
f. Stop myself from acting on my feelings without thinking first.	1 	2 	3 	4 	5 
g. Consider all the positives and negatives before making a decision.	1 	2 	3 	4 	5 
h. Resist doing something when I know I shouldn’t.	1 	2 	3 	4 	5 
i. Wait for what I want.	1 	2 	3 	4 	5 
j. Remain calm when things go wrong for me.	1 	2 	3 	4 	5 
k. Resist saying something that I know I will later regret.	1 	2 	3 	4 	5 
l. Think carefully before making a decision.	1 	2 	3 	4 	5 
m. Stay away from situations that could bring trouble.	1 	2 	3 	4 	5 
n. Calm myself down when I’m stressed.	1 	2 	3 	4 	5 
o. Know what I’m feeling.	1 	2 	3 	4 	5 
p. Find ways to make myself study even when my friends want to go out.	1 	2 	3 	4 	5 
q. Talk calmly with someone I disagree with.	1 	2 	3 	4 	5 
r. Know when I start to feel frustrated.	1 	2 	3 	4 	5 
s. Keep my reactions in check when I’m upset.	1 	2 	3 	4 	5 
t. To be a good friend, even when I’m in a bad mood.	1 	2 	3 	4 	5 

3. Please rate how often you do the following:

	SELECT ONE ONLY
	Almost never	Sometimes	Often	Almost always
a. When I’m having a hard time paying attention, I take a few deep breaths to refocus.	1 	2 	3 	4 
b. When I am feeling stressed, I listen to my body’s signals.	1 	2 	3 	4 
c. When I’m in the middle of an argument with my parent or caregiver, I take a break to calm myself down.	1 	2 	3 	4 
d. When I’m feeling overwhelmed, I can calm myself down.	1 	2 	3 	4 
e. I can name the emotions I’m feeling.	1 	2 	3 	4 
f. Naming my emotions helps me figure out what matters to me.	1 	2 	3 	4 

4. How much do you agree or disagree with these statements?

	Select one only
	Strongly disagree	Disagree	Agree	Strong agree
a. There are adults at this school I could talk with if I had a personal problem.	1 	2 	3 	4 
b. If I tell a teacher that someone is bullying me, the teacher will do something to help.	1 	2 	3 	4 
c. I am comfortable asking my teachers for help with my schoolwork.	1 	2 	3 	4 
d. There is at least one teacher or other adult at this school who really wants me to do well.	1 	2 	3 	4 

5. POST SURVEY ONLY: The next questions are about your experiences with the person teaching you the [FILL] class. We refer to this person as the facilitator. How much do you agree with the following statements about the facilitator?

	Select one only
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. The facilitator knows my name..	1 	2 	3 	4 	5 
b. The facilitator and I connected	1 	2 	3 	4 	5 
c. The facilitator and I formed a good relationship	1 	2 	3 	4 	5 
d. The facilitator genuinely cares about me	1 	2 	3 	4 	5 
e. The facilitator was enthusiastic about teaching the class	1 	2 	3 	4 	5 
f. The facilitator knows a lot about what they are teaching	1 	2 	3 	4 	5 
g. The facilitator welcomed all student input and feedback	1 	2 	3 	4 	5 
h. The facilitator treated students fairly	1 	2 	3 	4 	5 
i. The facilitator responded to questions without judgement..	1 	2 	3 	4 	5 
j. I wanted to learn about the topics that the facilitator discussed for this course	1 	2 	3 	4 	5 

6. How confident are you that you could…

	Select one only
	Not at all confident	A little confident	Somewhat confident	Confident	Very confident
a. Consider all the positives and negatives before making a decision about sex.	1 	2 	3 	4 	5 
b. Think carefully before making a decision about sex	1 	2 	3 	4 	5 
c. Stop yourself from acting on your feelings without thinking first before making a decision about sex	1 	2 	3 	4 	5 
d. Tell your partner your feelings about what you do and do not want to do sexually	1 	2 	3 	4 	5 
e. Know what you are feeling when faced with a decision about sex.	1 	2 	3 	4 	5 

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

	Select one only
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. At your age right now, having sex could create problems.	1 	2 	3 	4 	5 
b. At your age right now, it is okay for you to have sex if you use birth control, like a condom, the pill, etc.	1 	2 	3 	4 	5 
c. A person should only have sex if they are married.	1 	2 	3 	4 	5 
d. At your age right now, it is okay to have sex if you are dating the same person for a long time	1 	2 	3 	4 	5 
e. Teens should wait to have sex until they are out of high school.	1 	2 	3 	4 	5 

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

m None of the time 1

m Some of the time 2

m Most of the time 3

m All of the time 4

9. How important is it to you to talk with your parents/guardians about your decisions related to having sex? Please answer for the parent/guardian whom you feel most comfortable talking to. (MPC Eval)

 Not at all important 1

 Somewhat important 2

 Important 3

 Very important 4

10. How comfortable are you talking with your parents/guardians about your decisions related to having sex? Please answer for the parent/guardian whom you feel most comfortable talking to.

 Not at all comfortable 1

 Somewhat comfortable 2

 Comfortable 3

 Very comfortable 4

11. In general, how much pressure, if any, do you feel from your friends to have sex? (MPC, PREP)

m A lot of pressure 1

m Some pressure 2

m A little pressure 3

m No pressure 4

12. If your dating partner wanted to have sex, but you didn’t, you would find it hard to say “no.”

m Strongly agree 1

m Agree 2

m Disagree 3

m Strongly disagree 4

13. How confident are you that you could say no to drinking or using drugs when you don’t want to? (STREAMS)

m Completely confident 1

m Very confident 2

m Confident 3

m A little confident 4

m Not at all confident 5