Instrument 2 - Participant Exit Survey

Form approved

OMB Control No: 0970-0536

Expiration Date: XX/XX/XXXX

SEXUAL RISK AVOIDANCE EDUCATION PROGRAM (SRAE)

PARTICIPANT EXIT 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 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 0970-0536 and the expiration date is XX/XX/XXXX.

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

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

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

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

General Instructions

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

For questions 6 – 9, please think about how the program you just completed has affected you, even if your program did not cover the topic. Remember, your answers will be kept private, and you may skip any questions you do not wish to answer.

6. Has being in the program made you more likely to…

SELECT ONLY ONE ANSWER PER ROW
	Yes	No
a. avoid drinking alcohol (more than a few sips) including beer, wine, or liquor? …………………….……………..........................................
b. avoid smoking cigarettes or using other tobacco products?.............
c. avoid using electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? ………...............................................................
d. avoid using marijuana (also called pot or weed)?.............................
e. avoid using any other drugs that you didn’t get from a doctor?........

7. Has being in the program made you more likely to…

SELECT ONLY ONE ANSWER PER ROW

	Yes	No
a. avoid doing harmful things because your friends want you to? .....................
b. handle your feelings in ways that are not hurtful to yourself or others? ......
c. think about what might happen before making a decision? ........................
d. talk with your parent, guardian, or caregiver about things that are important to you? .....................................................................................
e. talk with your parent, guardian, or caregiver about sex? …………………...

8. Has being in the program made you more likely to…

SELECT ONLY ONE ANSWER PER ROW

	Yes	No
a. make plans to reach your goals?
b. care about doing well in school?

9. Has being in the program made you more likely to…

SELECT ONLY ONE ANSWER PER ROW

	Yes	No	Not sure
a. plan to delay having sexual intercourse until you are married?
b. plan to be married before you have a child?

The next questions ask you about your experiences in the program that you just completed. Think about all of the sessions or classes of the program that you attended.

10. How often in this program…

SELECT ONLY ONE ANSWER PER ROW

	Most of the time	Some of the time	None of the time
a. did you feel the information for the program was clear?
b. did discussions or activities help you to learn program lessons?
c. did you feel respected by the person teaching the program?

11. Did you get enough information about choosing not to have sex?

SELECT ONLY ONE ANSWER

□ Yes

□ No

Thank you for participating in this survey!

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