AFL Prevention Programs - Core Baseline Questionnaire
back to Evaluation Instruments main page 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 0990-0291. 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
OMB NO.: 0990-0291
EXPIRATION DATE: 09/30/2008
1. Client ID: ____ ____ ____ ____ ____ ____
2. Site Number: ____ ____ ____ ____ ____ ____
3. Entry Date: ____ ____ ____ ____ ____ ____
CORE BASELINE QUESTIONNAIRE
AFL Pregnancy Prevention Programs
Section 1
These first questions ask about you and your family. 1.1 How old are you (in years only): _________
1.2 Are you a girl or boy?
Boy
Girl
1.3 Who do you live with now? CHECK ALL THAT APPLY.
PARENTS (Includes step parents, adoptive parents and foster parents):
Mother
Father
ADULT GUARDIANS
Other adult relatives
Other adults I am not related to
1.4 Answer the next few questions about your mother or female guardian. How close do you feel to her?
Not very close
A little close
Pretty close
Very close
1.5 Does she spend enough time with you?
Not enough time, but I don’t want more
Not enough time, I wish she spent more time with me
She spends enough time with me
1.6 Here are some statements about you and your mother or female guardian. For each one, check how true the statement is:
| | Mostly True | Some-times True | Hardly Ever True | Does Not Apply |
a. | I am comfortable talking with her about things that happen in school |
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b. | I am comfortable talking with her about things that happen in my life |
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1.7 Answer the next few questions about your father or male guardian. How close do you feel to him?
Not very close
A little close
Pretty close
Very close
1.8 Does he spend enough time with you?
Not enough time, but I don’t want more
Not enough time, I wish she spent more time with me
She spends enough time with me
1.9 Here are some statements about you and your father or male guardian. For each one, check how true the statement is:
| | Mostly True | Some-times True | Hardly Ever True | Does Not Apply |
a. | I am comfortable talking with him about things that happen in school |
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b. | I am comfortable talking with him about things that happen in my life |
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1.10 What is your ethnic background?
Hispanic or Latino
Not Hispanic or Latino
1.10 a. Check the box or boxes that describes your race. CHECK ALL THAT APPLY.
American Indian
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
These next few questions are about your family rules and family communication.
1.11 For each of the following, tell us if your family has strict rules, some rules, or no rules about…
| | Strict Rules | Some Rules | No Rules |
a. | The people I hang out with |
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b. | Dating and going to parties with boys or girls |
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c. | Telling my parents or guardian where I am |
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1.12 Which of the following would your parent(s) or guardian(s) do if they found out that you had broken an important rule? CHECK ALL THAT APPLY.
Discuss it calmly with you
Ignore it, pretend that it didn’t happen, or let you get away with it
Sulk, pout, or give you the silent treatment
Take away a privilege, ground you, or give you a chore
Make threats that won’t be kept
Yell, shout, or scream at you
Use physical punishment
None of the above
1.13 Have you ever talked to one or both of your parents or guardians about any of these things?
| | | Yes | No |
a. | Puberty – that is, the physical changes in your body and your emotions that happen when young people develop |
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b. | How someone gets pregnant |
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c. | Why people your age should not drink or do drugs |
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d. | Why people your age should not have sex |
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e. | How to say “no” to alcohol, drugs, or sex |
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1.14 How often during the past year have you asked one or both of your parents or guardians questions about the changes in your body, dating, or alcohol and drugs?
Never
1 or 2 times
A few times
Many times
Section 2
These next questions are about activities you may do.
2.1 Please mark yes or no for each activity that you do in school or after school.
| | | Yes | No |
a. | Band, orchestra, chorus, choir or other music group |
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b. | School play or musical |
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c. | Student government or student council |
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d. | Hobby club like photography or chess |
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e. | Sports team |
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f. | Dance or gymnastics |
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g. | Girl Scouts, Boy Scouts, Girls Clubs, Boys Clubs, or 4-H |
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h. | After school tutoring program |
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i. | Community service or volunteer activity |
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j. | Church or religious youth group |
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k. | Mostly watch TV or hang out |
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l. | Some other club |
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Section 3
In this section, there are questions about things people your age have to make decisions about.
3.1 At what age do you think it is appropriate for someone to go on a “alone” date, that is, not in a group?
Less than 14 years old
14-15 years old
16 years old
Don't Know
3.2 How much do you agree with the following statement?
It’s okay for teens to date someone three or more years older or younger than they are.
Agree strongly
Agree
Disagree
Disagree strongly
Don't know
The next few questions are about some things that adolescents think about or do.
3.3 People your age often feel pressure from a lot of different places and for different reasons. Thinking about yourself, how much pressure have you personally felt to do things you might get in trouble for?
A lot
Some
Not much
None
Don't Know
3.4 How much would you say that the following statement is true about you?
You can say no to activities that you think are wrong.
Not at all like you
Little like you
Mostly like you
Very much like you
Don't Know
3.5 How much would you say that the following statement is true about you?
You have learned to stay away from people who might get you in trouble.
Almost never
Some of the time
Usually
Almost always
Don't Know
3.6 During the past month, how often have you smoked cigarettes?
I have never smoked cigarettes
Not at all
Only a few times
1 or 2 times a week
Several times a week or more
3.7 How often do you drink alcohol, like beer, wine, or liquor?
I have never had a drink
I have had alcohol in the past, but do not drink alcohol anymore
1 or 2 times a month
Several times a month or more
3.8 How many of your friends drink alcohol like beer, wine, or liquor?
None
A few
Some
Most
3.9 How often do you use marijuana or other drugs?
I have never used marijuana or other drugs
I have used marijuana in the past, but do not use marijuana anymore
1 or 2 times a month
Several times a month or more
3.10 How many of your friends have tried marijuana or other drugs?
None
A few
Some
Most
Section 4
These next questions ask about a variety of things that people your age might think about themselves.
4.1 Here are some opinions that adolescents sometimes have about themselves. Please tell us how much you agree or disagree with each one.
| | Agree A Lot | Agree A Little | Disagree A Little | Disagree A Lot |
a. | I don’t have enough control over the way my life is going. |
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b. | For me, good luck is more important than hard work for success. |
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c. | I can't do things as well as most other people. |
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d. | My plans hardly ever work out. |
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e. | When I make plans, I know I can make them work. |
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f. | Chance and luck are important for what happens in my life. |
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g. | I can do just about anything I really set my mind to. |
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4.2 Please tell us how much you agree or disagree with each of these statements.
| | Strongly Disagree | Disagree | Agree | Strongly Agree |
a. | You know at least one adult you could talk to about personal problems. |
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a. | You know adults who encourage you often. |
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4.3 Comparing yourself with your other friends in the group you hang out with, would you say you have more self-confidence, less, or about the same amount?
More confidence
Less confidence
About the same
Don't Know
Section 5
These next questions ask about your future.
5.1 As you look to the future, how important is it for you to get a good education?
Not important at all
Not too important
Somewhat important
Quite important
Very important
5.2 As you look to the future, how important is it for you to get a good job or to be successful in a career?
Not important at all
Not too important
Somewhat important
Quite important
Very important
5.3 As you look to the future, how important is it for you to remain abstinent (not to have sex) until marriage?
Not important at all
Not too important
Somewhat important
Quite important
Very important
5.4 As you look to the future, how important is it to you for the person who becomes your spouse to remain abstinent (not to have sex) until marriage?
Not important at all
Not too important
Somewhat important
Quite important
Very important
5.5 As you look to the future, how important is it for you to have a good marriage and family life?
Not important at all
Not too important
Somewhat important
Quite important
Very important
5.6 Here are some things that people your age might say when they think of their lives in the future. In general, do you agree or disagree with each statement?
| | | Agree | Disagree |
a. | I don’t know what I want out of life. |
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b. | I have a clear picture of what I'd like to be doing in the future. |
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c. | I don’t know what my long-range goals are. |
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Section 6
Section 6: Because these questions, and the definition of sexual activity given in the section, may be considered sensitive, particularly for the youngest clients served in AFL Prevention demonstration projects, the OPA will consider granting a waiver to its use on a case basis and with adequate written justification by the grantee. |
The next few questions ask for your opinions on topics about having sex. “Having sex” means oral, anal, and vaginal sex.
6.1 Does having sex as a teenager make it harder for someone to study and stay in school in the future?
No, not harder at all
Yes, somewhat harder
Yes, much harder
Haven't thought about it yet
6.2 Does having sex before marriage make it harder for someone to have a good marriage and a good family life in the future?
No, not harder at all
Yes, somewhat harder
Yes, much harder
Haven't thought about it yet
6.3 Does having sex as a teenager make it harder for a teen to grow and develop emotionally and morally?
No, not harder at all
Yes, somewhat harder
Yes, much harder
Haven't thought about it yet
6.4 Is there a problem with unmarried teens having sex if no pregnancy results from it?
No problem at all
Some problem
A big problem
Haven't thought about it yet
6.5 For each of the following questions please tell us how much you agree or disagree with each one.
| | Agree A Lot | Agree A Little | Disagree A Little | Disagree A Lot |
a. | Only married people should have sex. |
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b. | It would be OK for teens who have been dating for a long time to have sex. |
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c. | Having a good marriage does not seem realistic for me. |
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d. | I admire teens who remain abstinent (do not have sex) until marriage. |
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e. | My friends admire teens who remain abstinent until marriage. |
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f. | Remaining abstinent is the only certain way to avoid pregnancy, STDs, and other related health problems. |
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6.6 How many of your 5 closest friends think someone should wait until marriage before having sex?
None of them
One or two of them
Three or four of them
All of them
Thank you for participating in the questionnaire!
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