Administration for Children and Families Youth Programs –Youth Participant Entry and Exit Survey Pretest

INSTRUMENT 5

PREP PARTICIPANT ENTRY SURVEY

HIGH SCHOOL AND OLDER

June 2025

Form approved

OMB Control No: 0970-0497

Expiration Date: XX/XX/XXXX

PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP)

PARTICIPANT ENTRY SURVEY

HIGH SCHOOL AND OLDER

Thank you for your help with this important study. This survey includes questions about your family, friends, school, and also your attitudes and behaviors. Your name will not be on the survey 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. We hope that you will answer all of the questions, but you may skip any questions you do not wish to answer.

   THE PAPERWORK REDUCTION ACT OF 1995

   Public reporting burden for this collection of information is estimated to average 7 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 collected will help policy makers, program providers and other stakeholders understand the experiences of youth today and identify ways to reduce risky behaviors. This information will also inform programs on how best to serve their participants. The collection of this information is voluntary and responses will be kept private to the extent allowed by law. The OMB number for this information collection is 0970-0497 and the expiration date is XX/XX/XXXX.

3. The answers you give will be kept private to the extent permitted by law.

General Instructions

PLEASE READ EACH QUESTION CAREFULLY: There are different ways to answer the questions in this survey. It is important that you follow the instructions when answering each kind of question. Here are some examples.

• PLEASE SELECT ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED.

• USE A PEN OR PENCIL.

If the color of your eyes is brown, you would select (X) the first box as shown.

1. EXAMPLE 1: SELECT ONLY ONE ANSWER

What is the color of your eyes?

SELECT ONLY ONE ANSWER

Brown

Blue

Green

Another color

If you plan to watch a movie and go to a baseball game next week, you would select (X) both boxes.

2. EXAMPLE 2: SELECT ALL THAT APPLY

Do you plan to do any of the following next week?

SELECT ALL THAT APPLY

Watch a movie

Go to a baseball game

Study at a friend’s house

Please answer the following questions as best you can. This first set of questions are about you.

1. What age are you today?

SELECT ONLY ONE ANSWER

□ 10 years

□ 11 years

□ 12 years

□ 13 years

□ 14 years

□ 15 years

□ 16 years

□ 17 years

□ 18 years

□ 19 years

□ 20 years

□ 21 years

2. When you are at home or with your family, what language or languages do you usually speak?

Select all that apply

□ English

□ Spanish

□ Other (specify)

3. What is your race?

SELECT ALL THAT APPLY

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Hispanic or Latino

□ Middle Eastern or North African

□ Native Hawaiian or Other Pacific Islander

□ White

4. What is your sex?

SELECT ONLY ONE ANSWER

□ Male

□ Female

5. Are you currently …?

SELECT ALL THAT APPLY

□ In foster care

□ Unstably housed (moving from place to place), living outside (in a tent or in a car), in a hotel, or in an emergency shelter

□ In a juvenile detention center, juvenile group home, and/or under the supervision of a probation officer

□ None of the above

6. In the past 30 days, did you drink alcohol or use drugs that you didn’t get from a doctor?

SELECT ONLY ONE ANSWER

□ Yes

□ No

The next question is about your goals and talking to your parent or caregiver.

7. For each item below, please mark how true each statement is of you.

SELECT ONLY ONE ANSWER PER ROW
	Not true at all	Somewhat true of me	Very true of me
I feel I have the support I need to reach my goals…..................
I feel I can talk to my parent, guardian or caregiver about things going on in my life………………………………….............
I feel I can talk with my parent, guardian, or caregiver about sex ................

The next questions ask about sexual intercourse and your risk of pregnancy and sexually transmitted infections. Remember, your responses will be kept private.

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

SELECT ONLY ONE ANSWER

□ I have never had sexual intercourse

□ 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

□ 19 years old or older

9. Did you drink alcohol or use drugs before the last time you had sexual intercourse?

SELECT ONLY ONE ANSWER

□ I have never had sexual intercourse

□ Yes

□ No

10. The last time you had sexual intercourse, did you or a partner use a condom?

SELECT ONLY ONE ANSWER

□ I have never had sexual intercourse

□ Yes

□ No

11. The last time you had sexual intercourse with an opposite-sex partner, what one method did you or your partner use to prevent pregnancy?

SELECT ONLY ONE ANSWER

□ I have never had sexual intercourse with an opposite-sex partner

□ No method was used to prevent pregnancy

□ Birth control pills (Do not count emergency contraception such as Plan B or the “morning after” pill.)

□ Condoms

□ An IUD (such as Mirena or ParaGard) or implant (such as Implanon or Nexplanon)

□ A Shot (such as Depo-Provera), patch (such as Ortho Evra), or birth control ring (such as NuvaRing)

□ Withdrawal or some other method

□ Not sure

12. To the best of your knowledge, have you ever been pregnant or gotten someone else pregnant?

SELECT ONLY ONE ANSWER

□ I have never had sexual intercourse

□ Yes

□ No

□ Not sure

13. Have you ever been told by a doctor or other medical provider that you had a sexually transmitted infection (STI) or sexually transmitted disease (STD)?

SELECT ONLY ONE ANSWER

□ Yes

□ No

Thank you for participating in this survey!