ADOLESCENT FAMILY LIFE CARE PROGRAMS CORE FOLLOW-UP QUESTIONNAIRE
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We want you to know that:
- Your answers to these questions will help us learn what people your age know, think, and do.
- You may skip any questions you do not wish to answer. But we hope that you will answer as many questions as you can.
- Your answers will be combined with those of other teens. We will keep your answers private.
PLEASE DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY!
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0290. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
U.S. Department of Health & Human Services; OS/OIRM/PRA;
Independence Ave., S.W., Suite 531-H; Washington D.C. 20201;
Attention: PRA Reports Clearance Officer
To be completed by project staff:
1. Client ID: ____ ____ ____ ____ ____ ____
2. Site Number: ____ ____ ____ ____ ____ ____
3. Today's Date: ____ ____ ____ ____ ____ ____ mmddyy
4. Site Name: _______________________________ Write the site name on page 3 for item #24, response options 9, 10, and 11.
5. Baseline Survey Date: ____ ____ ____ ____ ____ ____ mmddyy
6. Most Recent Survey Date (Baseline or Follow Up): ____ ____ ____ ____ ____ ____ mmddyy
If this respondent completed a baseline survey for pregnant teens:
- Write the baseline survey date on page 2 above item #10.
- Cross out the line that states “These next questions refer to the child born MONTH/YEAR” that appears before item 14.
- Write the baseline survey date on page 5, item #33
- Cross out item #34 on page 5.
If this respondent completed a parenting baseline survey:
- Copy the date that the respondent’s child was born from survey item #14 on the parenting baseline survey to the space above item #14 on this follow-up survey on page 2.
- Cross out the line that says, “These next questions are about the child you were pregnant with on MM/DD/YY.”
- Cross out items #10 through #13.
- Write the baseline survey date on page 5, item #34
- Cross out item #33 on page 5.
For all surveys:
- Write the date of this respondent’s most recently completed survey (either baseline or follow up) on page 5 for item #36.
After the survey has been completed and turned in, please complete page 8. You will need to make a copy of the immunization records provided by the adolescent.
Do not complete this section in front of the adolescent.
GENERAL INSTRUCTIONS
- Read all the answers before marking your choice. If none of the printed answers exactly applies to you, black out the circle beside the answer that best fits.
- Use a pencil to complete the survey.
- Completely black out the circle beside your answer choice.
INCORRECT CORRECT
- If you make a mistake, erase it cleanly and then mark the circle beside your correct answer choice.
- Do not make any stray marks.
- PLEASE READ EACH QUESTION CAREFULLY.
Follow the directions for responding to each kind of question. These are:
1. Mark ONE What is the color of your eyes? Mark ONE 1 Brown 2 Blue 3 Green 4 Another color | If the color of your eyes is green, you would mark the third circle as shown.
|
2. Mark ONE What is the color of your hair? Mark ONE 1 Brown 2 Black 3 Blonde 4 Red 5 Some other color (Describe) Purple | If your hair is purple, you would mark “Some other color.” Then you would write “purple” in the blank.
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3. BLANK BOX If a question has only a blank box, write your answer in the space provided. What is the name of the school you are currently attending?  |
4. Mark ALL THAT APPLY Do you plan to do any of the following next week? Mark one or more 1 Rent a video 2 Go to a baseball game 3 Study at a friend’s house | If you plan to rent a video and go to a baseball game, you mark both.
|
5. QUESTION WITH A SKIP 1. Do you ever eat chocolate? Mark ONE 1 Yes 0 No ( SKIP TO #3) 2. Do you always brush your teeth after you eat chocolate? Mark ONE 1 Yes 0 No 3. Did you do any of the following last week? Mark ALL THAT APPLY 1 Saw a play 2 Went to a movie 3 Attended a sporting event | If you answered “Yes” to Question 1, you go to Question 2. After you answer Question 2, you go to Question 3.
If you answered “No” to Question 1, you skip Question 2. Then you go to Question 3. |
ABOUT THE FUTURE
Think about the future and answer these questions:
1. How important is it to you to graduate high school? Or to graduate vocational or trade school?
Mark ONE
1 Not important at all
2 Somewhat important
3 Very important
4 Extremely important
96 Already graduated
Answer the next question using a scale from 1 to 5. 1 is “not at all,” and 5 is “a lot.”
2. How much do you want to get more education or training? This could be college, vocational or technical school, or a nursing certification.
Mark ONE
Not at all | | | | A lot | Don’t know |
1 | 2 | 3 | 4 | 5 | 97 |
3. How important is it for you to get training to get the kind of job you want?
Mark ONE
Not important | | | | Very important | Don’t know |
1 | 2 | 3 | 4 | 5 | 97 |
WHAT YOU THINK
4. Please mark how much you agree or disagree with this statement:
It is better for a person to get married than to go through life being single.
Mark ONE
1 Strongly agree
2 Agree
3 Neither agree nor disagree
4 Disagree
5 Strongly disagree
97 Don’t know
5. How much do you stay away from people who might get you into trouble?
Mark ONE
1 Almost never
2 Some of the time
3 Usually
4 Almost always
Please mark how much the following statements sound like you.
6. I think I should work to get something, if I really want it.
Mark ONE
1 Not at all like me
2 A little like me
3 Mostly like me
4 Very much like me
97 Don’t know
7. I make decisions to help me reach my goals.
Mark ONE
1 Not at all like me
2 A little like me
3 Mostly like me
4 Very much like me
97 Don’t know
8. Some young women feel they are not ready to be a parent. For these women, I think adoption is a good choice.
Mark ONE
1 Not at all like me
2 A little like me
3 Mostly like me
4 Very much like me
97 Don’t know
The next question is about your mother or father. Or a person like a mother or father to you.
9. How often do you talk to your mother or father about your problems?
Mark ONE
1 Almost never
2 Some of the time
3 Usually
4 Almost always
96 There is no person who is like a mother or father to me
ABOUT YOUR CHILD
These next questions are about the child you were pregnant with on __ __ __ __ __ __. MM/DD/YY
10. Did this pregnancy end in a live birth?
1 Yes
0 No (IF YOUR ANSWER IS “NO,” SKIP TO #30 ON PAGE 4.)
11. When was this child born? ___ ___ / ___ ___
MONTH / YEAR
12. An early birth is one that occurs at 36 weeks or earlier in pregnancy. As far as you know, did you have an early birth?
Mark ONE
1 Yes
0 No
97 Don’t know
13. How much did this child weigh at birth?
Mark ONE
1 5½ pounds or more
2 Less than 5½ pounds
97 Don’t know
These next questions refer to the child born
___ ___ / ___ ___
MONTH / YEAR
14. Did you breastfeed this child at all?
1 Yes
0 No (SKIP TO #16)
15. How old was this child when you completely stopped breastfeeding him or her?
Mark ONE
1 I am still breastfeeding
2 Less than 1 month old
3 1 month old to 2 months old
4 3 months old or more
16. Is this child alive now?
1 Yes
0 No (IF YOUR ANSWER IS “NO,” SKIP TO #30 ON PAGE 4.)
17. This next question is about after the birth of this child. About how many times has this child had a regular check up or “well-baby” visit? This is a visit to a doctor or nurse when your child is not sick, but to get checked out or to get shots. Would you say . . .
MARK ONE
1 Never (SKIP TO #19 ON PAGE 3)
2 1-3 times
3 4 or more times
97 Don’t know
18. When was this child’s last “well baby” visit?
Mark THE MOST RECENT
1 Within the past 3 months
2 Within the past 6 months
3 Within the past 12 months
4 More than a year ago
97 Don’t know
19. Does this child live with you?
Mark ONE
2 Yes
1 Sometimes
0 No
20. Where does this child live now?
Mark ONE
1 With the child’s father
2 With other relatives
3 With adoptive family
4 Other (Describe______________________)
97 Don’t know
21. Is this child 3 months old or older?
1 Yes
0 No (SKIP TO # 23)
22. Has this child had any of the following vaccinations/shots?
MARK ONE ANSWER FOR EACH | Yes | No | Don’t Know |
a. | Diptheria, Tetanus, Pertussis (DTaP) | 1 | 0 | 97 |
b. | Inactivated Poliovirus (IPV) | 1 | 0 | 97 |
c. | Haemophilus influenzae type b (Hib) | 1 | 0 | 97 |
d. | Hepatitis B (HepB) | 1 | 0 | 97 |
e. | Pneumococcal (PCV) | 1 | 0 | 97 |
f. | Rotavirus (Rota) | 1 | 0 | 97 |
IF YOUR CHILD DOES NOT LIVE WITH YOU, PLEASE SKIP TO #26 ON PAGE 4.
23. This next question is about the past four weeks. Has this child received any regular child care? This could be a day care, nursery school, play group, babysitter, after school care, relative, or some other child care plan. (“Regular” means at least once a week for a month or more.)
1 Yes
0 No (SKIP TO #26)
24. Which of these has been your main child care provider in the past four weeks?
Mark ONE
1 Child’s father/stepfather
2 My brother/sister aged 13 years or older
3 My brother/sister younger than 13 years old
4 Child’s grandparent
5 Other relative
6 Non-relative or babysitter
7 Nursery/preschool
8 Family day care
9 _______________________________________
10 Day care center referred by ________________
__________________________________________
11 Day care center not referred by_____________
__________________________________________
12 Other (Describe _________________________)
13 Child has not received regular child care in past four weeks
25. How many hours a week is this child in child care? This includes all the different plans that you use.
Hours
97 MARK HERE IF YOU DON’T KNOW
26. Which of these statements best describes your relationship with your child’s father?
Mark ONE
1 We do not see or talk to each other
2 We hardly ever see or talk to each other
3 We are just friends
4 We are involved in an on-again, off-again relationship
5 We are romantically involved on a steady basis but are not married
6 We are married (SKIP TO # 31)
7 Don’t know
IF YOU ARE MARRIED TO THE FATHER OF YOUR CHILD, SKIP TO #31.
27. Do you and your child’s father have a legal agreement for child support, alimony, custody, visitation, or where the child will live?
1 Yes
0 No
28. Does your child’s father give you money or buy clothes for the child? Or pay for doctor visits or provide other kinds of support?
1 Yes
0 No
29. Does your child’s father help you in other ways, such as watching the child or helping with chores?
1 Yes
0 No
30. What is your marital status?
Mark ONE
1 Single, never married (including living with someone or engaged)
2 Married
3 Separated or divorced
4 Widowed
5 Other (Describe ______________________)
31. Who do you live with now?
Mark ALL THAT APPLY |
| a. I live alone |
| b. With husband |
| c. With my mother (include stepmother) |
| d. With my father (include stepfather) |
| e. With this child’s father |
| f. With this child’s father’s mother |
| g. With this child’s father’s father |
| h. With partner |
| i. With other relatives |
| j. With friends |
| k. In a group home/institution |
| l. In a foster home |
| m. Other (Describe ___________________) |
ABOUT YOUR HEALTH
These next questions are about your health and healthcare.
32. These are some ways people try to avoid sexually transmitted diseases. What way(s) did you try this month?
Mark ALL THAT APPLY |
| a. No method used this month |
| b. Abstinence (did not have sex this month) |
| c. Condom |
| d. Female condom, vaginal pouch |
| e. Other (Describe ___________________) |
33. Our records show that you were pregnant on
___ ___ ___ ___ ___ ___. MM/DD/YY
Have you been pregnant since that pregnancy ended?
1 Yes
0 No
34. Have you been pregnant since _____________? MM/DD/YY
1 Yes
0 No
35. These are some ways people try to avoid pregnancy. What way(s) did you try this month?
Mark ALL THAT APPLY |
| a. DOES NOT APPLY- I am pregnant now |
| b. No method used this month |
| c. Abstinence (did not have sex this month) |
| d. Birth control pills |
| e. Condom |
| f. Withdrawal, pulling out |
| g. Depo-Provera, injectables (the shot) |
| h. Natural family planning (rhythm or safe period by calendar, temperature or cervical mucus test) |
| i. Diaphragm |
| j. Female condom, vaginal pouch |
| k. Foam |
| l. Jelly or cream |
| m. Cervical cap |
| n. Suppository |
| o. Sponge |
| p. IUD |
| q. “Morning after” pills or emergency contraception |
| r. Contraceptive patch |
| s. NuvaRing (vaginal ring) |
| t. Implanon |
| u. Other method (Describe ______________) |
36. Since _________________ (MM/DD/YY), have you received . . .
Mark ALL THAT APPLY |
| a.. a pregnancy test? |
| b. an abortion? |
| c.. prenatal care? |
| d.. post pregnancy care? |
ABOUT YOU
These questions ask about you.
37. What is your current school status?
Mark ONE
1 In school or GED program
2 Graduated from high school or completed GED (SKIP TO #39)
3 Dropped out of school
4 Other (Describe ____________________)
38. IF YOU HAVE NOT FINISHED HIGH SCHOOL OR COMPLETED YOUR GED:
Do you want to have another baby before you finish high school?
1 Yes
0 No
97 Don’t know
39. What is the highest grade you have completed?
Mark ONE
1 8th grade or below
2 9th grade
3 10th grade
4 11th grade
5 12th grade
6 Some college
7 College degree or more
97 Don’t know
40. Have you ever been in a job training program?
1 Yes
0 No (SKIP TO #42)
41. Did you ever complete a job training program?
Mark ONE
1 Yes
2 No and not now in a job training program
3 No and now in a job training program
42. How many hours do you work per week?
WRITE 00 IF YOU DO NOT WORK
Hours per week
43. Do you receive money or aid from any of the following sources?
Mark ALL THAT APPLY |
| a. Medicaid |
| b. Food stamps |
| c. WIC (Women, Infants, and Children) Program |
| d. TANF (Temporary Aid to Needy Families) |
| e. Social Security |
| f. Unemployment or Workers’ Compensation |
| g. Other public aid |
| h. Child support |
| i. My job |
| j. Husband or partner |
| k. Parent(s) |
| l. Other (Describe_____________________) |
44. What is your main source of financial support?
Mark ONE
1 My job
2 Husband or partner
3 Parents
4 Public aid
5 Other relatives
6 Other (Describe _______________________)
That's all!
Thank you so very much for your time.
TO BE COMPLETED BY SURVEY ADMINISTRATION STAFF
After the survey has been completed and turned in, please complete this page. You will need to make a copy of the immunization records provided by the adolescent. Do not complete this section in front of the adolescent.
1. Child’s birth date (can be copied from item #11):
___ ___ / ___ ___
MONTH / YEAR
2. Do you have access to this child’s immunization record?
1 Yes
2 No (SKIP TO PAGE 9)
3. Using the child’s immunization records, mark whether or not the child has received at least one dose of each of the immunizations listed below.
Mark one for each | Yes | No | Unknown/
not mentioned |
a. | Diptheria, Tetanus, Pertussis (DTaP) | 1 | 0 | 97 |
b. | Inactivated Poliovirus (IPV) | 1 | 0 | 97 |
c. | Haemophilus influenzae type b (Hib) | 1 | 0 | 97 |
d. | Hepatitis B (HepB) | 1 | 0 | 97 |
e. | Pneumococcal (PCV) | 1 | 0 | 97 |
f. | Rotavirus (Rota) | 1 | 0 | 97 |
SURVEY ADMINISTRATOR:
YOU HAVE COMPLETED THIS RECORD ABSTRACTION.
THANK YOU FOR YOUR TIME!
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