Adolescent Family Life Prevention Programs Core Follow-up Questionnaire

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PRIVACY

We want you to know that:

1. Your answers to these questions will help us learn what people your age know, think, and do.
   
2. You may skip any questions you do not wish to answer. But we hope that you will answer as many questions as you can.
   
3. 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!

 

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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

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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

1. 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.
   
2. Use a pencil to complete the survey.
   
3. Completely black out the circle beside your answer choice.
           INCORRECT              CORRECT
                          
   
4. If you make a mistake, erase it cleanly and then mark the circle beside your correct answer choice.
   
5. Do not make any stray marks.
   
6. 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.

 

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.

 

ACTIVITIES

 

The first question asks about activities you may do.

1.       Think about activities that you do after school that are planned or that have adults there. These can be clubs, youth groups, or sports. They can also be lessons or other activities. How often do you do these activities?

Mark ONE

₀  0 times per week

₁  1 time per week

₂  2 times per week

₃  3 or more times per week

 

WHAT YOU THINK

 

2.       What do you think about each of these statements?

Mark ONE ANSWER FOR EACH	Strongly agree	Agree	Disagree	Strongly disagree
a.  I know adults I could talk to about my problems................	1	2	3	4
b.  I know adults who often cheer me on...	1	2	3	4

 

3.       Here are some things that people your age might say when they think of the future.

In general, do you agree or disagree with each statement? 

Mark ONE ANSWER FOR EACH		Agree	Disagree
a.  I don’t know what I want out of life.....		1	0
b.  I have a clear picture of what I’d like to be doing in the future................		1	0
c.  I don’t know what my long-range goals are.....................................		1	0

 

4.       Who do you live with now?

Mark ALL THAT APPLY

₁  Mother (including stepmother, adoptive mother, or foster mother)

₂  Father (including stepfather, adoptive father, or foster father)

₃  Other adult relative(s)

₄  Other adult(s) I am not related to

₅  I do not live with any adults

 

5.       For each of the following, does your family have rules?

Mark ONE ANSWER FOR EACH	Yes	No
a.  The people I hang around with.....	1	0
b.  Dating and going to parties with boys or girls..............................	1	0
c.  Telling my parents where I am.....	1	0
d.  What movies or TV shows I can watch........................................	1	0
e.  Hanging around with boys or girls when no adults are around..........	1	0

 

6.       How much do your parents TRY to know…

Mark ONE ANSWER FOR EACH	Try a lot	Try a little	Don’t try
a.  Who your friends are?........................	3	2	1
b.  Where you go at night?......................	3	2	1
c.  What you do with your free time?........	3	2	1
d.  Where you are most afternoons after school?............................................	3	2	1

 

7.       Please mark which of the following is true for you.

Mark ONE

₀  I do not have a mother or someone who is like a mother to me at all. (SKIP TO #10)

₁  I have a mother or someone who is like a mother to me (even if she
does not live with me).

 

8.       Answer the next question about your mother or someone who is like a mother to you. 

How close do you feel to her?

Mark ONE

₀  Not very close

₁  A little close

₂  Pretty close

₃ Very close

 

9.       What do you think about these statements? They are about your mother or the person who is like a mother to you. For each, mark how true the statement is:

 

Mark ONE ANSWER FOR EACH	Mostly true	Sometimes true	Hardly ever true
a.  It is easy to talk with her about things that happen in school.............	1	2	3
b.  It is easy to talk with her about things that happen in my life.............	1	2	3

 

 

10.   Please mark which of the following is true for you.

Mark ONE

₀  I do not have a father or someone who is like a father to me at all. (SKIP TO #13)

₁  I have a father or someone who is like a father to me (even if he does not
live with me).

 

11.   Answer the next question about your father or someone who is like a father to you. 

How close do you feel to him?

Mark ONE

₀  Not very close

₁  A little close

₂  Pretty close

₃  Very close

 

12.   What do you think about these statements? They are about your father or the person who is like a father to you. For each, mark how true the statement is:

Mark ONE ANSWER FOR EACH	Mostly true	Sometimes true	Hardly ever true
a.  It is easy to talk with him about things that happen in school.............	1	2	3
b.  It is easy to talk with him about things that happen in my life.............	1	2	3

 

These next two questions are about since you last took this survey on ___ ___ ___ ___ ___ ___. MM/DD/YY

 

13.   How often have you talked to one or both of your parents about any of these things?

Mark ONE ANSWER FOR EACH	Not at all	1 time	2–3 times	4 times or more
a.  Dating behavior that is OK.......................................................	0	1	2	3
b.  How your mother feels about teen sex......................................	0	1	2	3
c.  How your father feels about teen sex........................................	0	1	2	3
d.  How your friends feel about teen sex........................................	0	1	2	3
e.  Questions about facts about sex..............................................	0	1	2	3
f.  Reasons for not having sex......................................................	0	1	2	3
g.  Things that happen to teens who have sex................................	0	1	2	3
h.  Why not having sex is important..............................................	0	1	2	3
i.  Diseases people can get when having sex................................	0	1	2	3
j.  How babies are made.............................................................	0	1	2	3
k.  What TV, radio, movies, magazines, and/or the Internet say about sex..............................................................................	0	1	2	3
l. How your body grows and changes..........................................	0	1	2	3
m.  Peer pressure........................................................................	0	1	2	3
n.  Sex in marriage......................................................................	0	1	2	3
o.  What other people will say or think about you or your friends......	0	1	2	3

 

14.   How easy is it for you to talk to your parents about these things?

Mark ONE

₀  Never talk to my parents about these things

₁  Never easy

₂  A little easy

₃  Very easy

 

WHAT YOUNG PEOPLE THINK AND DO

 

The next questions are about things that some young people think about or do.

Please remember that all of your answers will be kept private.

 

15.   How much would you say that the following statement is true about you?

I can say “No” to activities that I think are wrong.

Mark ONE

  ₁   Very much like me

  ₂   Mostly like me

  ₃   Little like me

  ₄   Not at all like me

₉₇   Don’t know

 

16.   How often would you say that the following statement is true about you?

I have learned to stay away from people who might get me in trouble.

Mark ONE

  ₁   Almost always

  ₂   Usually

  ₃   Some of the time

  ₄   Almost never

₉₇   Don’t know

 

MORE QUESTIONS

WHAT YOU THINK AND DO

34.     Have you had sex during the last 6 months?

  ₁   Yes

  ₀   No (SKIP TO #36)

 

35.. During the past 3 months, with how many people did you have sex?

Mark ONE

₀  I have had sex, but not during the last 3 months

₁  1 person

₂  2 people

₃  3 people

₄  4 people

₅  5 people

₆  6 or more people

 

36.. Think about the last time you had sex. Did you or your partner use...

Mark ALL THAT APPLY

  ₁   Birth control pills

  ₂   Condoms

  ₃   Depo-Provera (injectable birth control)

  ₄   Withdrawal, pulling out

  ₅   Some other method (Describe________________________)

  ₀   None of the above

₉₇   Not sure

 

That’s all! 
Thank you very much for your time.

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