Instrument 1 - Participant Entry Survey

Form approved

OMB Control No: 0970-0536

Expiration Date: XX/XX/XXXX

SEXUAL RISK AVOIDANCE EDUCATION PROGRAM (SRAE)

PARTICIPANT ENTRY SURVEY

MIDDLE SCHOOL

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 answers 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 5 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 0970-0536 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.

1. EXAMPLE 1: SELECT ONLY ONE ANSWER

What is the color of your eyes?

SELECT ONLY ONE ANSWER

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

Brown

Blue

Green

Another color

2. EXAMPLE 2: SELECT ALL THAT APPLY

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

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

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. Remember, your answers will be kept private, and you may skip any questions you do not wish to answer.

1. What age are you today?

SELECT ONLY ONE ANSWER

□ 10 years

□ 11 years

□ 12 years

□ 13 years

□ 14 years

□ 15 years

□ 16 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 and/or ethnicity?

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

□ None of the above

The next questions ask about alcohol, tobacco, and other substance use. Remember, your answers will be kept private, and you may skip any questions you do not wish to answer.

6. In the past 30 days, did you ...

SELECT ONLY ONE ANSWER PER ROW

	Yes	No
drink alcohol (more than a few sips), including beer, wine, or liquor?
smoke cigarettes or use other tobacco products)?
c. vape or use electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)?
d. use marijuana (also called pot or weed)?
e. use any other drugs that you didn’t get from a doctor?

The next few questions are about your goals and talking to your parent or caregiver.

7. For each item below, please select 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 supported by my parent, guardian, or caregiver to reach my goals………………………………………………...
I feel I can talk to my parent, guardian or caregiver about things that are important to me ………………………………
I feel I can talk with my parent, guardian, or caregiver about sex……………………………………………………….

Thank you for participating in this survey!

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