Young Adult Confidential Survey

Young Adult Confidential Survey

Author(s) of Instrument:

Heather Taussig, Ph.D.

Edward Garrido, Ph.D.

Key References: Publications related to this instrument

Taussig, H. & Garrido, E. (2017). Long-term impact of a positive youth development program on

dating violence outcomes during the transition to adulthood: Draft final summary overview. NCJ

251206. Washington, DC: Office of Justice Programs’ National Criminal Justice Reference

Service. https://www.ncjrs.gov/pdffiles1/nij/grants/251206.pdf

Primary Use/Purpose: This section describes what this instrument was designed to measure.

The Fostering Health Families (FHF) program is a positive development program for at risk youth,

including those with a history of child maltreatment and foster care placement. Previous data

were collected at three time points as a part of this study and was used to determine risk at

baseline. Participation in the FHF program was evaluated as a potential protective factor against

the negative outcome typically associated with a history of maltreatment and involvement in the

foster care system. The Young Adult Survey was developed to evaluate Fostering Healthy Futures

program’s effect on perpetration or victimization of teen dating violence (TDV) or intimate

partner violence (IPV).

Background and Development: How and why this instrument was developed.

At the time of the Young Adult Survey, the sample included youth ages 18 to 22. Four domains

were measured in the survey: risk factors prior to participation, current risk and protective

factors, possible mediating factors, and TDV. Measures were created using a variety of existing

instruments previously found to be affective measures of these concepts.

https://www.ncjrs.gov/pdffiles1/nij/grants/251206.pdf

Psychometrics (if applicable): Any testing of this instrument.

Information on the development and testing of this instrument and its components can be found

in the report cited above.

Link to Instrument: Link to the instrument if available.

https://www.icpsr.umich.edu/icpsrweb/NACJD/studies/36880/datadocumentation or see

attached.

Submitted by: Heather Taussig certified permission to publicly share this instrument.

https://www.icpsr.umich.edu/icpsrweb/NACJD/studies/36880/datadocumentation

Demographics

DEM Y5DEM1. Birth date: __ __/__ ___/___ ___ ___ ___ Mo. Day Year Y5DEM2 Age: ___________ Y5DEM 3. How do you describe your race or ethnicity? ______________________________________

__________________________________________________________________________

Y5DEM 4. Are you Hispanic/ Latino/a? Yes No 1 0

Y5DEM 5. Are you . . . ? Yes No

a American Indian/Alaska Native (Tribe_______________________) 1 0

b Asian 1 0

c Native Hawaiian/Other Pacific Islander 1 0

d African American (Black) 1 0

e Caucasian (White) 1 0

f Other___________________________ 1 0

Y5DEM6 What is your sexual orientation? 1 Heterosexual/straight

2 Gay/lesbian 3 Bisexual 4 Other: __________________ code ____ 88 Don’t know

HOUSEHOLD: Y5FAM1. What is your marital status?

1 Never married 4 Divorced 2 Married /Civil union 5 Widowed 3 Separated 6 Other _______________________ code______

Y5YDEM11. What is your current living situation? Are you. . .

11 Living in your own place (with or without roommates or significant other) 3a Living in your biological mother’s home (with or without a step parent) 3b Living in your biological father’s home (with or without a step parent) 3c Living in your biological mother and father’s home 1 Living in a foster family’s home 2 Living in a relative’s home 15 Living in a stepparent’s home 14 Living in a family friend’s home 12 Living in your adoptive parents’ home 18 Living in the home of a friend’s or significant other’s parents 19 Living in the home of another adult – not a relative 20 Living in a school dormitory 21 Living in transitional or subsidized housing 24 Living in a substance use treatment facility/rehab facility 4 Living in a residential treatment center (RTC/TRCCF) 5 Living in a group home or halfway house 6 Living in a psychiatric hospital 9 Living in a juvenile detention center/jail/prison 22 Couch surfing, living in a motel, or moving from house to house (because you don’t

have a place to stay) 8 Living in a homeless shelter 23 Homeless 7 Other ____________________________code____

Y5DEM12. How long have you been living __________________ (months) [LIVING SITUATION CHOSEN ABOVE]? Y5DEMs3 Do you feel that your housing situation is stable (for example, can you stay as long as you OPPS would like to, do you have control over whether you stay)?

Yes No 1 0

Y5DEMs4 Do you feel safe inside your home? OPPS Yes No

1 0

Y5DEMs5 Do you feel safe in the neighborhood where you live? OPPS Yes No

1 0

Y5DEM 13. How many people are living with you currently ____________ (not including self) on more days than not? (Default to 20 if living in a group setting)

Y5DEM 14. Who are they? (Enter #s in spaces)

1. ____Biological mother

2. ____Biological mother’s partner/spouse/ex

3. ____Biological father

4. ____Biological father’s partner/spouse/ex

5. ____Siblings (full, half, step) over the age of 18

6. ____Siblings (full, half, step) under the age of 18

a. ____ # you are primarily caring for

7. ____Other biological relatives over the age of 18

a. ____ # that helped raise you

b.____ # that help care for you now

8. ____Other biological relatives under the age of 18

a.____ # you are primarily caring for

9. ____ Adoptive family members (parents, sibs, relatives of adoptive

family)

a.____ # under the age of 18

b.____ # over the age of 18

10. ____ Foster family members (parents, sibs, relatives of foster

family)

a.____ # under the age of 18

b.____ # over the age of 18

11.____ A female partner/spouse/girlfriend

12.____ A male partner/spouse/boyfriend

13.____ Your own children

a.____# of biological children

b.____# of step children

14.____ Female roommate(s)

15.____ Male roommates(s)

16.____Other unrelated adult females

17.____Other unrelated adult males

18.____Other unrelated children

a.____ # you are primarily caring for

19.____Multiple others in a group setting (n = 20)

20.____Other

Describe: ________________________________________________________

Significant Other (SO) Y5S01. How many dating partners have you had? _____________ Y5SO2. What was/is the length of your longest relationship? ______________ (months) Y5SO3. Do you currently have a:

1 Husband 2 Wife 3 Boyfriend 4 Girlfriend 6 Fiancé (male) 7 Fiancée (female) 5 None of the above ⇒ Skip to YGS1

Y5SO4. How long have you been in this relationship? ______________ (months) Y5SO5. What is his/her year of birth: __________ Y5SO6. What is his/her age? _________________ Y5SO7. Is he/she Hispanic or Latino/a? Yes No 1 0 Y5SO8. Is he/she. . . ? Yes No

1 American Indian or Alaska Native 1 0 2 Asian 1 0 3 Native Hawaiian or Other Pacific Islander 1 0 4 African American (Black) 1 0 5 Caucasian (White) 1 0 6 Other___________________________________ 1 0

Y5SO9a. OPPS

Is s/he currently enrolled in school? Yes 1

No ⇒ Skip to SO11 0

9b. What type of school is s/he currently enrolled in?

(i) High School? (ii) Vocational School? (iii) Community College? (iv) 4-year College? (v) GED Class? (vi) Other?

Yes

1 1 1 1 1 1

No

0 0 0 0 0 0

Y5SO10. OPPS

Is s/he in school full time or part time?

Full Time 2

Part Time 1

Y5SO11. What is the highest level of school that s/he has COMPLETED? (Census2000,P4,9-M)

3……8th grade or less

4……9th grade

5……10th grade

6……11th grade

7……12th grade

7a…..Trade school or technical school

8……1 year of college

9……2 years of college

10…..3 years of college


12…..Graduate school

Y5SO12. NYTD

What is the highest degree or certification that s/he has received?

1 Currently attending high school

2 GED or other high school equivalent diploma

3 High school diploma

4 Vocational certificate

5 Vocational license

6 Associate’s degree

7 Bachelor’s degree

8 Higher degree

0 None of the above

Y5SO13. Has s/he been employed any time in the last year? LONG 1 Yes 0 No

Y5SO14. Which one of the following best describes his/her current employment status? LONG

1 Regularly works full-time (35 or more hours per week)

2 Regularly works part-time (less than 35 hours per week)

3 Works sometimes when work is available

4 Unemployed, looking for work

5 Doesn’t work because of family responsibilities, illness or disability, or doesn’t want to work

6 Doesn’t work because is currently a student

EDUCATION

Y5EDUC1 OPPS

a. Are you currently enrolled in school?

Yes 1

No 0

⇒

Skip

to EDUC2

b. What type of school are

enrolled in?

you currently 1 High School? 2 Vocational/Trade School? 3 Community College?

4 4-year College? 5 GED Class? 6 Other?

Describe:____________________

___________________code:_____

c Are you in school full time or part time? Part Time

1 Full Time

2

d Do you take any of your classes on-line? 0 No, none of them

1 Yes, some of them

2 Yes, all of them

e What kind of grades do you get? 1 Mostly As (90-100)

2 Mostly Bs (80-89)

3 Mostly Cs (70-79)

4 Mostly Ds (60-69)

5 Mostly Fs (less than 60)

f What is your GPA?

______.___________

Y5EDUC2. What is the highest level of school you have COMPLETED (not currently enrolled in)?

3……8th grade or less

4……9th grade

5……10th grade

6……11th grade

7……12th grade

7.5…..Trade school or technical school

8……1 year of college

9……2 years of college



12…..Graduate school

Y5EDUC3 NYTD

What is the highest degree or certification that you have received?

1 Currently still in high school

2 GED or other high school equivalent diploma

3 High school diploma

4 Vocational certificate

5 Vocational license

6 Associate’s degree

7 Bachelor’s degree

8 Graduate degree

0 None of the above

Y5EDUC4

a. Did you ever receive any academic honors or awards? b. What academic honors or awards did you receive?

1 2 3

Yes No ⇒ Skip 1 0 to Educ5

Was this a monetary award?

YES NO

1 0

1 0

1 0

Y5EDUC5

Have you ever taken the SAT, ACT, or another college Yes No entrance exam? 1 0

Y5EDUC6

Yes No ⇒ Skip a. Have you ever applied to any trade school or vocational 1 0 to EDUC7

school?

b. Did you attend a trade school or vocational school?

1

0

c. For how long?

_____________semesters

Y5EDUC7

a1. Have you ever applied to any two-year or community college?

Yes 1

No ⇒ Skip 0 to EDUC8

a2. Did you get accepted? b. Did you attend a two-year or community college?

1

1

0

0

c. For how long? _____________semesters

Y5EDUC8

a1. Have you ever applied to any four-year college or university?

Yes 1

No ⇒ Skip 0 to next section

a2. Did you get accepted? b. Did you attend a four-year or college or university?

1

1

0

0

c. For how long?

______________semesters

EMPLOYMENT Y5EMPL3 OPPSr

Do you currently have one or more paying jobs? Yes 1

No ⇒ Skip to EMPL9 0

Y5EMPL4. How many jobs do you have now? _________________ Y5EMPL5. Tell us about the jobs you have now.

a. What is your job?

b. Who is your employer?

c. How many hours per week do you work?

d. How much do you get paid per hour?

e. How many months have you worked there (round up)?

1

$_____.____

2

$_____.____

3

$_____.____

4

$_____.____

5

$_____.____

Y5EMPL6. LONG

In a typical week, how many hours do you spend working for pay?

1 1-9 hours 2 10-14 hours 3 15-20 hours 4 21-34 hours 5 35-40 hours 6 More than 40 hours

Y5EMPL7. LONG

All things considered, how satisfied are you with your current job or jobs?

1 Not at all satisfied 2 Somewhat dissatisfied 3 Neither satisfied nor dissatisfied 4 Somewhat satisfied 5 Completely satisfied

Y5EMPL8. LONG

How much does your current job(s) cause you stress and tension?

1 Not at all 2 A little 3 Some 4 A considerable amount 5 A lot

Y5EMPL9 Are you looking for work, or a new or additional job Yes No ⇒ Skip to at

the present time? EMPL12 1 0

Y5EMPL10 Westat

How many job applications have you completed since looking for a job this time?

____________________

Y5EMPL11 Westat

What problems have you faced in finding employment?

YES

NO

a Lack of job skills. 1 0

b Lack of experience. 1 0

c Too young. 1 0

d Lack of education. 1 0

e Couldn’t find a job you liked. 1 0

f Lack of transportation. 1 0

g Did not know how to find a job. 1 0

h Lack of child care. 1 0

i Disability or health problem? 1 0

j Criminal history 1 0

k Other? 1 0

_____________________________________________________________________

________________________________________________________ code _____

5EMPL9 Tell us about the paying jobs you have held in the PAST (NOT CURRENT) since you turned 16. Please start with the earliest job.

a. What was your job?

c. Who was your employer?

d. How many hours per week did you work?

e. How much did you get paid per hour?

f. How many months did you work there?

g. What is the main reason you left this job?

1

$_____.____

2

$_____.____

3

$_____.____

4

$_____.____

5

$_____.____

6

$_____.____

7

$_____.____

8

$_____.____

9

$_____.____

10

$_____.____

CODES FOR “WHAT IS THE MAIN REASON YOU LEFT THIS JOB?” 1 Got a better job or promotion 7 Child care problems 2 Wanted to try a different job 8 Returned to school/Joined the military 3 Just a temporary job (incl. baby-sitting) 9 Illness/Disability 4 Laid off 10 Job interfered w/ other responsibilities (i.e., school) 5 Didn’t like the job/people 11 Fired 6 Transportation problems 12 Other (Please describe in box above)

FINANCES: Y5FIN1a. Do you currently have an open checking account? NYTD Yes No ⇒ Skip to FIN2a 1 0

1b. How much do you currently have in your checking account? $______.00

Y5FIN2a. Do you currently have an open savings account?

NYTD

Yes No ⇒ Skip to FIN3 1 0

2b. How much do you currently have in your savings account? $______.00

Y5FIN3

How often do you have enough money to: [FLIPBOOK]

Not very often

Sometimes

Most of the time

Not Applicable

3a Pay for housing? 0 1 2 99

3b Buy clothing? 0 1 2 99

3c Pay for the gas, electricity, and water? 0 1 2 99

3d Pay for phone? 0 1 2 99

3e Buy food? 0 1 2 99

3f Pay for medical care? 0 1 2 99

3g Pay for a car, gas, or other transportation? 0 1 2 99

3h Necessities (e.g., soap, toilet paper) 0 1 2 99

Ever? Are you currently? Y5FIN5 OPPSr

Have you personally ever received any of the following forms of public assistance or support?

Yes

No

Yes

No

a Social Security (SSI/SSDI)

1

0

1

0

b TANF (Temporary Assistance for Needy Families)

1 0 1 0

c Unemployment

1 0 1 0

d Workers’ Compensation

1 0 1 0

e Food Stamps

1 0 1 0

f WIC

1 0 1 0

g Housing Assistance, such as Section 8, FUP voucher (Family Unification Program), Rocky Mountain Housing, Bannock Street, etc.

h Chafee Funds i1. For what: ______________________

______________________code____

1

1

0

0

1

1

0

0

Y5FIN6. Now – I’m going to ask you about the different sources of your current income. Just give your best guess when answering the following questions. How much do you personally receive on a monthly basis from the following sources?

Income Source Monthly amount (round to nearest dollar)

6a. Employment $___________.00

6b. TANF (Public Assistance) $___________.00

6c. Social Security (SSI/SSDI) $___________.00 SSI for what:___________

6d. Unemployment compensation $___________.00 ______________________

6e. Food Stamps $___________.00 ______________________

6f. WIC $___________.00 _____________code_____

6g. Section 8 (utility check in pocket, not through voucher) $___________.00

6h. Child Support $___________.00

6i. Alimony $___________.00

6j. Illegal activities (i.e., selling drugs or stolen items, prostituting, pimping) $___________.00

6k. Parents or other relatives $___________.00

6l. Other $___________.00

___________________________________________________________code_____

Y5FIN8. How much money do you pay each month for? MIDr

8a. rent & utilities (out of pocket, not through voucher) $_________.00

8b. a car loan(s) or lease? $_________.00

8c. transportation (e.g., bus pass) $_________.00

8d. a student loan(s)? $_________.00

8e. alimony? $_________.00

8f. child support? $_________.00

Y5FIN10 OPPSr

a. Are you responsible for providing for yourself financially?

Yes 1

Partially No ⇒ 2 0

Skip to TRAN1

b. At what age did you become financially _____________ responsible for yourself?

Yes No Y5FIN13 MID

Since you have been providing for yourself financially, has your gas, electricity, or water ever been shut off because you were unable to pay your bills on time?

1

0

Y5FIN14 MID

Since you have been providing for yourself financially, has your phone service ever been cut off because you were unable to pay your bills on time?

1 0

Y5FIN15 MID

Since you have been providing for yourself financially, have you ever been evicted because you were unable to pay rent/mortgage on time?

1 0

Y5FIN16 MIDr

Since you have been providing for yourself financially, have you ever missed two or more meals in one day because there was not enough money to buy food?

1 0

Y5FIN17 Since you have been providing for yourself financially, did you 1 0 LONG ever cut the size of your meals or skip meals because there was

not enough money for food?

Y5FIN18 How much do you worry about not having enough money to LONG make ends meet?

0 Never 1 Rarely 2 Sometimes 3 A lot 4 Almost all of the time

TRANS Y5TRAN1. Do you have access to the transportation you need to get to school or work or other places OPPS you need to go? YES NO 1 0 Y5TRAN2. Do you own your own motor vehicle? OPPS YES NO 1 0

CADRI No matter how well dating partners get along, there are times when they disagree, get annoyed, want different things, or just have arguments or fights because they are in a bad mood, are tired, or for some other reason. Dating partners also have many different ways of trying to settle their differences. This is a list of things that might have happened when you had a difference with a boyfriend, girlfriend, dating partner, spouse, or ex. These include things you might have done and things your dating partners may have done. Please indicate how many times each of the following things happened. Again, we appreciate your honesty in answering these confidential questions. [FLIPBOOK]

EVA

a. In the last year, how often did a dating partner…

b. How many times before the last year?

c. How many dating partners did this to you?

d. Were the partners…

f. Did this take place…

YES

N

O

i. Did your dating partner do this in play, just kidding around?

j. When this happened to you, did you feel . . .

YES

NO

1 Do something to try to make you jealous? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year

4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None

_______

1 Mostly male 2 Mostly female 3 Both

1 In person 2 By text/phone 3 By email 4 On the Internet (e.g. Facebook)

1 1 1 1

0 0 0 0

1 Never 2 Sometimes 3 Most times 4 Always

1 Afraid 2 Ashamed 3 Angry 4 Weak 5 Responsible 6 Stressed 7 Embarrassed

1 1 1 1 1 1 1

0 0 0 0 0 0 0

e. Were they…

1 Mostly younger (by several years)

2 Mostly older (by several years)

3 Mostly the same age






YES

N

O



YES

NO

2 Bring up something bad you had done in the past? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0

e. Were they…



3 Mostly the same age 3 Say things to make

you angry? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0

1 Mostly male 2 Mostly female 3 Both e. Were they…









YES

N

O



YES

NO

4 Insult you with put downs? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0

e. Were they…




5 Ridicule you or make fun of you in front of others? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0










YES

N

O



YES

NO

6 Keep track of who you were with and where you were going? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0


1 Afraid 2 Ashamed 3 Angry 4 Weak 5 Responsible 6 Stressed 7 Embarrassed 8 Excited 9 Safe

1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0

e. Were they…




7 Blame you for the problem? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0









YES

N

O



YES

NO

8 Accuse you of flirting with someone else? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0


1 Afraid 2 Ashamed 3 Angry 4 Weak 5 Responsible 6 Stressed 7 Embarrassed 8 Excited

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0

e. Were they…




9 Threaten to end your relationship 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0









YES

N

O



YES

NO

10 Speak to you in a hostile or mean tone of voice 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_______



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0

e. Were they…




a. In the last year, how often have you…




YES

N

O

g. When you did this, were you under the influence of drugs or alcohol?

i. Did you do this in play, just kidding around?

j. When you did this, were you feeling . . .

YES

NO

11 Done something to make a dating partner jealous? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0



1 Afraid 2 Ashamed 3 Angry 5 Strong 6 Jealous 7 Excited 8 Responsible 9 Stressed 10 Weak 11 Powerful

1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0

c. With how many dating partners?

e. Were they…

________



3 Mostly the same age 12 Brought up

something bad that your dating partner had done in the past? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0




e. Were they…

________








YES

N

O




YES

NO

13 Said things to make your dating partner angry? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0


e. Were they…

________



3 Mostly the same age 14 Insulted your dating

partner with put downs? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0




e. Were they…

________




a. In the last year, how often have you….




YES

N

O




YES

NO

15 Ridiculed or made fun of your dating partner in front of others? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0


e. Were they…

________



3 Mostly the same age 16 Kept track of who

your dating partner was with and where they were? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time




1 1 1 1

0 0 0 0



1 Afraid 2 Ashamed 3 Angry 5 Strong 6 Jealous 7 Excited 8 Responsible

1 1 1 1 1 1 1

0 0 0 0 0 0 0



0 None in past year 9 Stressed 10 Weak 11 Powerful

1 1 1

0 0 0


e. Were they…

________








YES

N

O




YES

NO

17 Blamed your dating partner for the problem? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0


e. Were they…

________



3 Mostly the same age 18 Accused your dating

partner of flirting with someone else?



1 In person 2 By text/phone 3 By email

1 1 1

0 0 0

1 Never 2 Sometimes 3 Most times

1 Never 2 Sometimes 3 Most times

1 Afraid 2 Ashamed 3 Angry

1 1 1

0 0 0

4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year



4 On the Internet (e.g. Facebook)

1

0

4 Always 4 Always 5 Strong 6 Jealous 7 Excited 8 Responsible 9 Stressed 10 Weak 11 Powerful

1 1 1 1 1 1 1

0 0 0 0 0 0 0


e. Were they…

________








YES

N

O




YES

NO

19 Threatened to end a relationship 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0



1 Afraid 2 Ashamed 3 Angry 4 Playful 5 Strong 6 Jealous 7 Excited 8 Responsible 9 Stressed 10 Weak 11 Powerful

1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they…

________




20 Spoken to your partner in a hostile or mean tone of voice 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0




e. Were they…

________




RATB






YES

N

O



YES

NO

1 Say things to try to turn your friends against you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_________



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0

e. Were they…



3 Mostly the same age 2 Spread rumors about

you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_________



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0










YES

N

O



YES

NO

3 Destroy or threaten to destroy something that you valued? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_________



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0

e. Were they…



3 Mostly the same age 4 Deliberately try to

frighten you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_________



1 1 1 1

0 0 0 0



1 1 1 1 1 1 1

0 0 0 0 0 0 0










YES

N

O



YES

NO

5 Threaten to hurt you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


_________



1 1 1 1

0 0 0 0


1 Afraid 2 Ashamed 3 Angry 4 Excited 5 Weak 6 Responsible 7 Stressed 8 Embarrassed

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0

e. Were they…








YES

N

O




YES

NO

6 Said things to try to turn a dating partner’s friends against them? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they…

________



3 Mostly the same age 7 Spread rumors about

a dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0




e. Were they…

________








YES

N

O




YES

NO

8 Destroyed or threatened to destroy something a dating partner valued? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they…

________



3 Mostly the same age 9 Deliberately tried to

frighten a dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0



1 Afraid 2 Ashamed 3 Angry 4 Playful 5 Strong 6 Jealous 7 Excited 8 Responsible 9 Stressed 10 Weak

1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0




e. Were they…

________




11 Powerful 1 0





YES

N

O




YES

NO

10 Threatened to hurt a dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




1 1 1 1

0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they…

________




Please indicate how many times each of the following things happened, even if they only happened in self-defense. Again, we appreciate your honesty in answering these confidential questions. PA

a. In the last year, how often has a dating partner…



f. Which of the following describes how badly you were hurt when your dating partner(s) [did this to you]? Y

ES

NO

g. When your dating partner did this, were you under the influence of drugs or alcohol?

i. Did your partner do this in play, just kidding around?


YES

NO

1 Thrown something at you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year



1 Knocked down 2 Bruise/Cut/Mark 3 Bleeding 4 Head injury 6 Broken bones 7 Treated by Doctor 8 Hospitalized 9 Other:

_____________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0


e. Were they… h. Did your dating

partner do this in self defense?

________




1 Never

2 Sometimes

3 Most times

4 Always





ES

NO




YES

NO

2 Kicked, hit, or punched you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year



1 Knocked down

2 Bruise/Cut/Mark

3 Bleeding

4 Head injury

6 Broken bones

7 Treated by Doctor

8 Hospitalized

9 Other:

______________

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0



1 Afraid

2 Ashamed

3 Angry

4 Excited

5 Weak

6 Responsible

7 Stressed

8 Embarrassed

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0


e. Were they…

h. Did your dating partner do this in self defense?

________





3 Slapped you or pulled your hair? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year



1 Knocked down

2 Bruise/Cut/Mark

3 Bleeding

4 Head injury

6 Broken bones

7 Treated by Doctor

8 Hospitalized

9 Other:

______________

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0



1 Afraid

2 Ashamed

3 Angry

4 Excited

5 Weak

6 Responsible

7 Stressed

8 Embarrassed

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0





e. Were they…


________









ES

NO




YES

NO

4 Pushed, shoved, or shaken you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year


1 Mostly male

2 Mostly female

3 Both

1 Knocked down

2 Bruise/Cut/Mark

3 Bleeding

4 Head injury

6 Broken bones

7 Treated by Doctor

8 Hospitalized

9 Other:

_______________

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0



1 Afraid

2 Ashamed

3 Angry

4 Excited

5 Weak

6 Responsible

7 Stressed

8 Embarrassed

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0


e. Were they…


________





5 CTS

Grabbed you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year




_______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0


1 Mostly male

2 Mostly female

3 Both



e. Were they…


________









ES

NO




YES

NO

6 CTS

Assaulted you with a knife or gun? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year




_______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0


e. Were they…


________





a. In the last

year, how often have you…



f. Which of the following describes what happened to your dating partner(s) when you [did this]? Y

ES

NO



j. When you did this, were you feeling . . . Y

ES

NO

7 Thrown something at a dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year




______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they… h. Did you do this in self defense?

________





8 Kicked, hit, or punched a dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year

b. How many times

before the last year?



______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0



1 Afraid 2 Ashamed 3 Angry 4 Playful 5 Strong 6 Jealous 7 Excited 8 Responsible 9 Stressed 10 Weak

1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0





e. Were they…

h. Did you do this in self defense?

________





11 Powerful 1 0





ES

NO




YES

NO

9 Slapped or pulled a dating partner’s hair? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year




______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they…


________





10 Pushed, shoved, or shaken a dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year



1 Knocked down 2 Bruise/Cut/Mark 3 Bleeding 4 Head injury 6 Broken bones 7 Treated by Doctor 8 Hospitalized

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0



1 Afraid 2 Ashamed 3 Angry 4 Playful 5 Strong 6 Jealous 7 Excited 8 Responsible

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0





e. Were they…

9 Other: ______________


9 Stressed 10 Weak 11 Powerful

1 1 1

0 0 0

________









ES

NO




YES

NO

11 CTS

Grabbed your dating partner? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year




_______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0


e. Were they…


________





12 CTS

Assaulted a dating partner with a knife or gun? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past

year




_______________

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0




1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0





e. Were they…


________





SA




d. Were the

partners…

e. Were they…

g. When this happened to you, were you under the influence of drugs or alcohol?

i. . Did your dating partner do this in play, just kidding around?


YES

NO

1 Kiss you when you didn’t want them to? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0

2 Touch you sexually when you didn’t want them to? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0





e. Were they…

g. When this happened to you, were you under the influence of drugs or alcohol?

i. . Did your dating partner do this in play, just kidding around?


YES

NO

3 Threaten you in an attempt to have sex with you? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0

4 Force you to have sex when you didn’t want to? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0



c. How many dating partners did you do this with?

d. Were the

partners…

e. Were they…


i. . Did you do this in play, or were you just kidding around?


YES

NO

5 Kissed a dating partner when they didn’t want you to? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0

6 Touched a dating partner sexually when they didn’t want you to? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0



c. How many dating partners did you do this with?

d. Were the

partners…

e. Were they…


i. . Did you do this in play, or were you just kidding around?


YES

NO

7 Threatened a dating partner in an attempt to have sex with them? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0

8 Forced a dating partner to have sex when they didn’t want to? 4 > 10 times 3 6-10 times 2 2-5 times 1 1 time 0 None in past year


________








1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0

Version 6/20/2018

K6 The next questions are about how you have been feeling during the past 30 days. [FLIPBOOK] During the past 30 days…

0 None

of the time

1 A little

of the time

2 Some

of the time

3 Most

of the time

4 All

of the time Y5K6 1a About how often did you feel nervous?

0 1 2 3 4

Y5K6 1b About how often did you feel hopeless?

0 1 2 3 4

Y5K6 1c About how often did you feel restless or fidgety?

0 1 2 3 4

During the past 30 days… Y5K6 1d About how often did you feel so depressed that nothing

could cheer you up?

0 1 2 3 4

Y5K6 1e About how often did you feel that everything was an effort?

0 1 2 3 4

Y5K6 1f About how often did you feel worthless?

0 1 2 3 4

SUBSTANCE USE yARBS-SU

a. In the past year how many times have you…

1

Had a full drink of beer, wine, or other alcohol?

0=None; 1=1 time; 2=2 to 5 times; 3=6 to 10 times; 4=11 to 20 times; 5=more than 20 times

2

Smoked a cigarette or cigar?


3

Used any prescription stimulants when they were not prescribed for you (e.g. Amphetamines, Diet Pills, Ritalin)?


4

Used any prescription sedatives when they were not prescribed for you (e.g., Barbiturates, Seconal, Sleeping Pills, Tranquilizers, Valium, Xanax)?


5

Used any prescription opiods when they were not prescribed for you (e.g., Codeine, Darvon, Demerol, Dilaudid, Methadone, Morphine, Percodan, Talwin)?


6

Used Marijuana, Grass, Pot, or Hashish?


7

Used stimulants that are not prescribed (Ice, Khat, Methamphetamine, Speed, Uppers)?


yARBS-SU

a. Have you ever . . .

8

Used Club Drugs (Ecstasy or MDMA, GHB, Ketamine, Rohypnol)?


9

Used Cocaine or Crack?


10

Used Heroin?


11

Used opioids that are not prescribed (Opium, T’s, Blues)?


12

Used PCP?


13 Used Hallucinogens (DMT, LSD, Acid, Mescaline, Mushrooms, Peyote, Psilocybin)


14

Used Inhalants (Glue, Toluene, Gasoline, Paint, Paint thinner)?


15

Used any other drugs (Amyl nitrite or Poppers, Anabolic steroids, Nitrous oxide, or anything else?


Please specify:

SS The following questions ask about the help and support you receive from family, friends, and

others. Y5SS1 OPPS

When you need someone to give you good advice about a crisis, are there

1 Enough people you can count on? 2 Too few people you can count on? 3 No one you can count on?

Y5SS2 OPPS

When you need someone to loan you money in an emergency, are there

1 Enough people you can count on? 2 Too few people you can count on? 3 No one you can count on?

Y5SS3a OPPS

Is there an adult in your family (not a spouse or significant other) that you will always be able to turn to for support (for example, to help you with a problem, to listen when you’re upset)?

1 Yes

0 No ⇒ Skip to SS4a

3b If yes, which one adult family Opps member do you turn to most often? (Please pick only one)

1 Birth parent 2 Adoptive family member 3 Foster family member 4 Adult sibling 5 Extended family member (i.e., grandparent) 6 Legal guardian 7 Other:____________________ code _____

3c How often do you see or

Long communicate with this family member?

6 Live with him/her 5 Almost every day 4 Two to five times a week 3 About once a month to once a week 2 About once a year to every few months 1 Less than once a year

3d How much can you count on

this family member to provide you with the support you need?

1 Always 2 Most of the time 3 Sometimes 4 Not very often

Y5SS4a

Do you have good friends other than a boyfriend, girlfriend or spouse that you will always be able to turn to for support?

1 Yes

0 No ⇒ Skip to SS5a

4b If yes, how many friends do you have that you can count on for support?

______________________

4d How much can you count

on these friends to provide you with the support you need?


Y5SS5a OPPS

Is there an adult other than a friend, significant other, or family member that you will always be able to turn to for support?

1 Yes

0 No ⇒ Skip to SS-B

5b If yes, which one adult other than a family member do you turn to most often? (Please pick only one)

1 Caseworker 2 Teacher/coach 3 Non-relative mentor (mentor from a program) 4 Adult from your church/faith-based

community 5 Your lawyer/GAL 6 A family friend/neighbor 7 Someone from work 8 Staff person from a RTC/TRCCF/group home 9 Other Please specify: _______________ code_____

5c How often do you see or

Long communicate with this person?

5 Almost every day 4 Two to five times a week 3 About once a month to once a week 2 About once a year to every few months 1 Less than once a year

5d How much can you count

on this person to provide you with the support you need?


Social Support-B (with MOS scale)

Y5SocialSupport-B How often do you have someone not a member of your family who:

None of the Time

1 A little of the time

2 Some of the time

3 Most of the time

4 All of the time

5

1 Would suggest doing something with you just to take your mind off of your problems?

1 2 3 4 5

2 Visits with you or invites you over.

1 2 3 4 5

3 Has a good time with you.

1 2 3 4 5

4 Calls you just to see how you are doing.

1 2 3 4 5

5 Comforts you when you are upset.

1 2 3 4 5

6 Listens when you need to talk about your feelings.

1 2 3 4 5

7 Gives you encouragement to do something difficult.

1 2 3 4 5

8 Does not pass judgment on you.

1 2 3 4 5

9 Gives you a hug or shows affection for you.

1 2 3 4 5

10 Would give you a ride if you needed one.

1 2 3 4 5

11 Would show you how to do something you didn’t know how to do?

1 2 3 4 5

12 Would offer you a place to stay if you needed one.

1 2 3 4 5

13 Would help you out with a meal or a necessary purchase if you were broke.

1 2 3 4 5

14 Would loan you money.

1 2 3 4 5

15 Would give you good advice.

1 2 3 4 5

16 Would help you think about a problem or make a decision.

1 2 3 4 5

17 Would help you solve a difficult problem.

1 2 3 4 5

SAFE DATES EVALUATION QUESTIONNAIRE

Y5Gender-Stereotypes

How strongly do you agree or disagree with the following statements:

0 Strongly Disagree

1 Disagree Somewhat

2 Agree Somewhat

3 Strongly Agree

1 Most women can’t be trusted.

0 1 2 3

2 In a dating relationship, the boy should be smarter than the girl.

0 1 2 3

3 Girls are always trying to manipulate boys.

0 1 2 3

4 In a dating relationship, the boy and girl should have about equal power.

0 1 2 3

5 Swearing is worse for a girl than for a boy.

0 1 2 3

6 On a date, the boy should be expected to pay all expenses.

0 1 2 3

7 In general, the father should have greater authority than the mother in making family decisions.

0 1 2 3

8 It’s all right for a girl to ask a boy out on a date.

0 1 2 3

9 It is more important for boys than girls to do well in school.

0 1 2 3

10 If both husband and wife have jobs, the husband should do a share of the housework, such as washing dishes and doing the laundry.

0 1 2 3

11 Girls should have the same freedom as boys.

0 1 2 3

Y5Communication During the last six months, when you had a disagreement with someone, how much of the time did you do the following things?

0 Never

1 Not much of the Time

2 Some of the Time

3 Most of the Time

1 Told the person how I felt.

0 1 2 3

2 Hung up the phone on them.

0 1 2 3

3 Tried to calm down before I talked to them.

0 1 2 3

4 Refused to talk to them about the problem.

0 1 2 3

5 Asked lots of questions so that I could get the whole story.

0 1 2 3

6 Gave them the silent treatment by refusing to talk, text, or email with them.

0 1 2 3

7 Asked them what they were feeling.

0 1 2 3

8 Let them know what was important to me.

0 1 2 3

9 Tried to find a solution that suited both of us.

0 1 2 3

10 Stomped off during arguments.

0 1 2 3

11 Listened to their side of the story.

12 Acted like nothing was wrong.

Version 6/20/2018

Attitudes The next questions are about opinions that teens may or may not have. How strongly do you agree with the following statements.

0 Strongly Disagree

1 Disagree Somewhat

2 Agree Somewhat

3 Strongly Agree

Y5ATT 1 It is OK to hit your dating partner if they did something to

make you mad.

0 1 2 3

Y5ATT 2 It is OK to hit your dating partner if they insulted you.

0 1 2 3

Y5ATT 3 Girls sometimes deserve to be hit by the people they date.

0 1 2 3

Y5ATT 4 A person who makes their dating partner jealous on purpose deserves to be hit.

0 1 2 3

Y5ATT 5 Boys sometimes deserve to be hit by the people they date.

0 1 2 3

Y5ATT 6 Sometimes boys have to hit their dating partners to get them back under control.

0 1 2 3

Y5ATT 7 Sometimes girls have to hit their dating partners to get them back under control.

0 1 2 3

Y5ATT 8 It is OK for a boy to hit his dating partner if the dating partner hit him first.

0 1 2 3

Y5ATT 9 It is OK for a girl to hit her dating partner if the dating partner hit her first.

0 1 2 3

How strongly do you agree or disagree with the following statements.

0 Strongly Disagree

1 Disagree Somewhat

2 Agree Somewhat

3 Strongly Agree

Y5ATT 10 If I hit a dating partner, they would break up with me.

0 1 2 3

Y5ATT 11 Bad things happen to people who are violent to their dating partners.

0 1 2 3

Y5ATT 12 If I hit a dating partner, I would be arrested.

0 1 2 3

Y5ATT 13 If I hit a dating partner, my friends would think I was cool.

0 1 2 3

Y5ATT 14 Hitting a dating partner is not that big of a deal.

0 1 2 3

Y5ATT 15 Violence between dating partners improves the relationship.

0 1 2 3

Attitudes About Aggression In Dating Situations Scale

Below is a list of situations in which someone gets angry at their dating partner. How much do you agree or disagree with the reactions described below?

0 Strongly Disagree

1 Disagree Somewhat

2 Agree Somewhat

3 Strongly Agree

Y5ATT 16 Lisa won’t stop making fun of Charlie in front of their

friends. Charlie loses his temper and pushes Lisa. How much do you agree with Charlie’s reaction?

0 1 2 3

Y5ATT 17 Keisha sees Rick flirting with Angie. Keisha gets mad. She hits Rick and tells him to keep his hands off Angie. How much do you agree with Keisha’s reaction?

0 1 2 3

Y5ATT 18 Alex finds out that Chris is seeing somebody else. Alex gets really mad and slaps Chris. How much do you agree with Alex’s reaction?

0 1 2 3

Y5ATT 19 Tony is harassing Gina about her new haircut, saying that she looks like a poodle. Gina gets really angry at Tony and pushes him. How much do you agree with Gina’s reaction?

0 1 2 3

Y5ATT 20 John catches Maria flirting with Tyrone. John gets really mad and hits Janet. How much do you agree with John’s reaction?

0 1 2 3

Trauma Symptom Checklist

Please tell me how often you experienced each of the following in the last two months, using a scale from 0 to 3, with 0 meaning “never” and 3 meaning “often.” [FLIPBOOK]

0 Never

1 Occasionally

2 Fairly Often

3 Often

Y5TSC 1 Headaches

0 1 2 3

Y5TSC 2 Insomnia (trouble getting to sleep)

0 1 2 3

Y5TSC 3 Weight loss (without dieting)

0 1 2 3

Y5TSC 4 Stomach problems

0 1 2 3

Y5TSC 5 Sexual problems

0 1 2 3

Y5TSC 6 Feeling isolated from others

0 1 2 3

Y5TSC 7 “Flashbacks” (sudden, vivid, distracting memories)

0 1 2 3

Y5TSC 8 Restless sleep

0 1 2 3

Y5TSC 9 Low sex drive (low interest in sex)

0 1 2 3

Y5TSC 10 Anxiety attacks

0 1 2 3

Y5TSC 11 Sexual overactivity

0 1 2 3

Y5TSC 12 Loneliness

0 1 2 3

Y5TSC 13 Nightmares

0 1 2 3

Y5TSC 14 “Spacing out” (going away in your mind)

0 1 2 3

Y5TSC 15 Sadness

0 1 2 3

Y5TSC 16 Dizziness

0 1 2 3

Y5TSC 17 Not feeling satisfied with your sex life

0 1 2 3

Y5TSC 18 Trouble controlling your temper

0 1 2 3

Y5TSC 19 Waking up early in the morning and can’t get back to sleep

0 1 2 3

Y5TSC 20 Uncontrollable crying

0 1 2 3

Y5TSC 21 Fear of men 0 1 2 3

0 Never

1 Occasionally

2 Fairly Often

3 Often

Y5TSC 22 Not feeling rested in the morning

0 1 2 3

Y5TSC 23 Having sex that you didn’t enjoy

0 1 2 3

Y5TSC 24 Trouble getting along with others

0 1 2 3

Y5TSC 25 Memory problems

0 1 2 3

Y5TSC 26 Desire to physically hurt yourself

0 1 2 3

Y5TSC 27 Fear of women

0 1 2 3

Y5TSC 28 Waking up in the middle of the night

0 1 2 3

Y5TSC 29 Bad thoughts or feelings during sex

0 1 2 3

Y5TSC 30 Passing out

0 1 2 3

Y5TSC 31 Feeling that things are “unreal”

0 1 2 3

Y5TSC 32 Unnecessary or over-frequent washing

0 1 2 3

Y5TSC 33 Feelings of inferiority (feeling that you are not as good as others)

0 1 2 3

Y5TSC 34 Feeling tense all the time

0 1 2 3

Y5TSC 35 Being confused about your sexual feelings

0 1 2 3

Y5TSC 36 Desire to physically hurt others

0 1 2 3

Y5TSC 37 Feelings of guilt

0 1 2 3

Y5TSC 38 Feeling that you are not always in your body

0 1 2 3

Y5TSC 39 Having trouble breathing

0 1 2 3

Y5TSC 40 Sexual feelings when you shouldn’t have them

0 1 2 3

Trauma History Questionnaire (Y5THQ) The following is a series of questions about serious or traumatic life events.

Yes

No

How old were you the first time?

How many times in your life?

How many times in the past year?

THQ

1

Has anyone ever tried to take something directly from you by using force or the threat of force, such as a stick-up or mugging?

1

0

THQ 2 Has anyone ever attempted to rob you or actually robbed you (i.e. stolen your personal belongings)?

1 0

THQ 3 Has anyone ever attempted to or succeeded in breaking into your home when you weren’t there?

1 0

THQ 4 Has anyone ever attempted to or succeeded in breaking into your home while you were there?

1 0

THQ jvq

5 Has anyone ever broken or ruined any of your things on purpose?

1 0

THQ fhf

6 Has anyone ever stolen your identity by using your social security number and/or IDs, or in any other way?

1 0

THQ 7 Have you ever had a serious accident at work, in a car or somewhere else?

1 0

THQ 8 Have you ever experienced a natural disaster such as a tornado, hurricane, flood, major earthquake, etc. where you felt you or your loved ones were in danger of death or injury?

1 0

THQ 9 Have you ever experienced a “man-made disaster such as a train crash, building collapse, bank robbery, fire, etc., where you felt you or your loved ones were in danger of death or injury?

1 0

Yes

No




THQ

10

Have you ever been exposed to dangerous chemicals or radioactivity that might threaten your health?

1

0

THQ 11 Have you ever been in any other situation in which you were seriously injured?

1 0

THQ 12 Have you ever been in any other situation in which you feared you might be killed or seriously injured?

1 0

THQ 13 Have you ever seen someone seriously injured or killed?

1 0

THQ 14 Have you ever seen dead bodies (other than at a funeral)?

1 0

THQ bbts

15 Have you ever witnessed someone you were very close to committing suicide, being killed, or being injured by another person so severely as to result in marks, bruises, burns, blood, or broken bones? This might include a close friend in combat.

1 0

THQ 16 Have you ever experienced the death of a boyfriend/girlfriend/spouse?

1 0

THQ alces

17 Have you ever experienced the death of a caregiver other than a biological parent?

1 0

THQ alces

18 Have you ever experienced the death of a close friend?

1 0

THQ

19

Have you ever had a serious or life-threatening illness?

1

0

THQ 20 Have you ever received news of a serious injury, or life-threatening illness in someone close to you?

1 0

THQ 21 Have you ever had to engage in combat while in military service in an official or unofficial war?

1 0

Yes

No




THQ

24

Has anyone ever attacked you with a gun, knife or some other weapon?

1

0

THQ 25 Has anyone ever attacked you without a weapon and seriously injured you?

1 0

Yes

No

How many times since you turned 18?


THQ

22

Since you’ve turned 18, has anyone (excluding dating partners) ever made you have sex against your will?

1

0

THQ 23 Since you’ve turned 18, has anyone (excluding dating partners) ever forced you to have any other unwanted sexual contact?

1 0

Version 6/20/2018

Source of Dating Violence Information Y5DVI Did you ever receive information about dating violence… b. How/where did you receive the information?

Did you… c. Did you seek this out or just given?

d. Was it:

e. What happened as a result? (*Read from key at bottom)

Yes No Did you…

Yes No

1a. At school?

1 Yes

0 No

b1. Have a one-time presentation/discussion?

1 0 1 Seek

2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info

1. Feel more informed 1 0

2. Feel worried 1 0

b2. Have an ongoing presentation/discussion (like a class unit, series of assemblies)?

1 0 3. Ask for more info 1 0

4. Change behavior 1 0

5. Encourage/help others 1 0

b3. Get the info from a poster or pamphlet?

1 0 6. Other: __________

__________________

1 0

2a. From parents or adult relatives?

1 Yes

0 No

99 N/A

b1. Have a one-time discussion? 1 0 1 Seek

2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0

3. Ask for more info 1 0



6. Other: __________

__________________

1 0

b2. Have ongoing discussions? 1 0

*1-9e RESULT: 1. Feel more informed 2. Feel worried or concerned 3. Ask for more information or a referral for treatment 4. Change your dating behavior, such as end a

relationship or be more careful choosing partners

5. Encourage a friend or relative to change their dating behavior or help others who were experiencing dating violence

6. Other

Version 6/20/2018

Y5DVI Did you ever receive information about dating violence… b. How/where did you receive the information?


d. Was it:


Yes No Did you…

Yes No

3a. From friends or siblings?

1 Yes

0 No


2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0

3. Ask for more info 1 0



b2. Have ongoing discussions? 1 0 6. Other: __________

__________________

1 0

4a. In individual, group, or family therapy?

1 Yes

0 No


2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0

b2. Have ongoing discussions? 1 0 3. Ask for more info 1 0




1 0 6. Other: __________

__________________

1 0

*1-9e RESULT:

1. Feel more informed 2. Feel worried or concerned 3. Ask for more information or a referral for treatment 4. Change your dating behavior, such as end a



6. Other

Version 6/20/2018



d. Was it:


Yes No Did you…

Yes No

5a. Through media—TV, Internet, Social Networking, or billboards?

1 Yes

0 No

b1. See a one-time presentation? 1 0 1 Seek

2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0

b2. See a series of (more than one) presentations?




b3. See info presented online, on TV, on a billboard, or see a public service announcement?

1 0 6. Other: __________

__________________

1

0

6a. In a residential treatment center?

1 Yes

0 No

b1. Have a one-time presentation or discussion?

1 0 1 Seek

2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0

b2. Have ongoing presentations or discussions?





1 0 6. Other: __________

__________________

1 0

*1-9e RESULT:




6. Other

Version 6/20/2018



d. Was it:


Yes No Did you…

Yes No

7a. In a doctor’s office?

1 Yes

0 No


2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0





1 0 6. Other: __________

__________________

1 0

8a. In a detention facility /jail/ prison/police office?

1 Yes

0 No


2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0





1 0 6. Other: __________

__________________

1 0

*1-9e RESULT:




6. Other

Version 6/20/2018



d. Was it:


Yes No Did you…

Yes No

9a. Anywhere else? _______ ____________________________________ code ________

1 Yes

0 No


2 Given

3 Both

1 Not enough info

2 Right amount

3 Too much info


2. Feel worried 1 0





1 0 6. Other: __________

__________________

1 0

*1-9e RESULT:



5. Encourage a friend or relative to change their dating

behavior or help others who were experiencing dating violence

6. Other

Version 6/20/2018

Y5RBQ (Risk Behavior Questionnaire)

Using this scale, tell me how much you agree or disagree with the following statements. [FLIPBOOK]

Strongly disagree

Disagree

Neutral

Agree

Strongly

Agree RBQ 2 You would feel uncomfortable talking

to a sex partner about using condoms (barriers).

1

2

3

4

5

RBQ 3 If you had sex with someone new, there are things you would not do because of the risk of getting HIV or AIDS.

1

2

3

4

5

RBQ 4 If someone new tells you they know they don’t have HIV or AIDS, you would feel all right having unprotected sex.

1

2

3

4

5

RBQ 5 If someone new objected to condoms (barriers), you would not have sex with that person.

1

2

3

4

5

RBQ 6 Have you ever had sex by your own choice?

Yes

1 No ⇒ Skip to RBQ42 0

RBQ

7

How many times have you had sex in the past year?

0 None 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times

RBQ

8

How many times in the past month?


RBQ

9

Approximately how many sexual partners have you had in your life?

___________ or >20

RBQ

10

How many sexual partners in the past year?

___________ or >20

RBQ

11 How many sexual partners in the past month? ___________ or >20

RBQ

5 PD

12 How many of your sexual partners have been

female?

___ ⇒

______ orSkip to RBQ25

if 0

>20

21 In the last have sex?

year, with how many females did you __________ or >20

RBQ 13 How old were you the

with a female? first time you had sex _______ years old

RBQ

14 How many of your female partners have been injection drug users?

___________ or >20

RBQ

16 How many of your female partners are/were having sex with someone other than you?

___________ or >20

RBQ

17 How many of your female partners are/were women who have HIV?

___________ or >20

RBQ

18 How many of your female partners are/were women you just met or didn’t know?

___________ or >20

RBQ 19 How many times did you have sex with female

partners while high from drugs or right after using drugs?

___________ or >20

RBQ 20 FOR MALES ONLY: In the past year, how _____

many women did you have sex with? ______ or >20

RBQ Longs

21

a. FOR MALES ONLY: In the last year, how

often did you and your female partner use protection for the purpose of birth control?

0 1 2

Never ⇒ Skip to RBQ22 Less than half the time About half the time

3 More than half the time 4 88

Always Don’t know

b. FOR MALES ONLY: What types of birth Yes No

control protection did you and your partner(s) use? 1. Condom

2. Pill

1 1

0 0

3. Withdrawal 1 0 4. Diaphragm 1 0 5. IUD 1 0

6. Depo-Provera/implant 1 0 7. Other ____________ 1 0

___________________

RBQ 22 FOR MALES ONLY: In the last year, how often did you use condoms when you had sex with your female partner(s)?

0 1 2 3

Never Less than half the time About half the time More than half the time

4 88

Always Don’t know

RBQ 25 FOR MALES AND FEMALES: How many __of your sexual partners have been male?

_______ ⇒

if

orSkip to 0

>20 RBQ38

RBQ

26

How old were you the with a male?

first time you had sex _______ years old

RBQ

27

How many of your male injection drug users?

partners have been ___________ or >20

RBQ

29

How many of your male partners are/were having sex with someone other than you?

___________ or >20

RBQ

30

How many of your who have HIV?

male partners are/were men ___________ or >20

RBQ

31

How many of your you just met or did

male partners are/were men n’t know?

___________ or >20

RBQ

32

How many times did you have sex with male partners while high from drugs or right after using drugs?

___________ or >20

RBQ

33

In the past year, with how have sex?

many men did you _________

If

_0

_ ⇒

or Skip

>20 RBQ38

RBQ 34 In the last year, how often did you use condoms 0 Never when you had sex with your male partner(s)? 1 Less than half the time

2 About half the time

3 More than half the time

4 Always

88 Don’t know

Version 6/20/2018

RBQ

36

a. FOR FEMALES ONLY: In the last year,

how often did you and your male partner(s) use protection for the purpose of birth control?

0 Never ⇒ Skip to RBQ37

1 Less than half the time



4 Always

88 Don’t know

b.

FOR FEMALES ONLY: What types of birth control protection did you and your partner(s) use?

1. Condom

Yes

1

No

0

2. Pill 1 0

3. Withdrawal 1 0

4. Diaphragm

5. IUD

1

1

0

0

6. Depo-Provera/implant

7. Other ____________

1

1

0

0 ___________________

RBQ 37 FOR FEMALES ONLY: In the last year, how often did your partner use condoms when you had sex?

0 Never

1 Less than half the time



4 Always

88 Don’t know

Version 6/20/2018

Have you ever . . .

Yes

No




RBQ

38

Given sex to get drugs?

1

0

RBQ 39 Given sex to get money?

1 0

RBQ 39b Given sex to get anything else, such as shelter, food, etc.

1 0

RBQ 40 Given someone drugs to have sex with you?

1 0

RBQ 41 Given someone money to have sex with you?

1 0

RBQ 41b Given someone anything else, such as shelter, food, etc., to have sex with you?

1 0

Have you ever . . .

Yes

No

How old were you when this was first diagnosed?

RBQ

42

Been told by a doctor or a nurse that you had Hepatitis B?

1

0

RBQ 43 Been told by a doctor or a nurse that you had Hepatitis C?

1 0

RBQ 44 Been told by a doctor or a nurse that you had Gonorrhea?

1 0

RBQ 45 Been told by a doctor or a nurse that you had Syphilis?

1 0

RBQ 46 Been told by a doctor or a nurse that you had Genital Warts (HPV)?

1 0

RBQ 47 Been told by a doctor or a nurse that you had Chlamydia (NGU)?

1 0

RBQ 48 Been told by a doctor or a nurse that you had Genital Herpes?

1 0

RBQ 49 Been told by a doctor or a nurse that you had Tuberculosis?

1 0

RBQ 50 Had an HIV test?

1 0

RBQ 51 Been told by a doctor or a nurse that you have HIV?

1 0

RBQ 52 Been told by a doctor or a nurse that you have AIDS?

1 0

RBQ 53 Has anyone EVER given you information about AIDS or risk reduction supplies like bleach or condoms?

1 0

RBQ 54 Given your present sexual and substance use behaviors, what do you think your chance of getting HIV is?

0 1 2 3 4 5

No chance Slight chance Some chance Half chance High chance Sure chance

RBQ 55 a.

How many people do you know who have been infected with HIV (including those who now have HIV, AIDS, or have died of AIDS)?

__________ ⇒ Skip

to RBQ56 if 0

b. Of these

or family

people, how many are close friends members?

__________

RBQ Longsc

56 How likely is it that you next 6 months?

will have sex during the 1 2 3 4

Definitely won’t Probably won’t Probably will Definitely will

RBQ 57 If you did NOT WANT TO have sex, how sure 1 Very sure Longsc are you that you could keep from having sex? 2 Sort of sure

3 Not too sure 4 I probably couldn’t

RBQ 58 What do most of your friends think about people 1 Not OK to have sex Longsc your age having sex? 2 OK, if you have a steady

boyfriend or girlfriend 3 OK, even if you don’t have a

steady boyfriend or girlfriend

RBQ 59 Do you think your friends believe that it is 1 Definitely no Longsc important to use condoms? 2 Mostly no

3 Mostly yes 4 Definitely yes

RBQ 60 How many of your friends who are having sex 1 None of them Longsc use condoms? 2

3 4

Some of them Most of them None of my friends are having sex

88 Don’t know

Y5PEERd (Peer Deviance) Y5PEERd. Now I’m going to ask you some more questions about your friends, those people you hang out with on a regular basis. [FLIPBOOK]

0 No Friends

1 A few friends

2 About half of your

friends

3 Most of your

friends

4 All of your friends

IN THE PAST YEAR: 1 How many of your friends are going to school? 0 1 2 3 4

2 How many of your friends have a job? 0 1 2 3 4

3 How many of your friends are involved in criminal activities? 0 1 2 3 4

4 How many of your friends have been or are homeless? 0 1 2 3 4

5 How many of your friends own their own home? 0 1 2 3 4

6 How many of your friends have children? 0 1 2 3 4

7 How many of your friends have graduated from high school? 0 1 2 3 4

8 How many of your friends use drugs? 0 1 2 3 4

9 How many of your friends have spent time in jail/prison? 0 1 2 3 4

Y5ARBS (Risk Taking)

Y5ARBS 14

How many times in the past year, have you willingly

(Provide #s)

14a

Gone places you knew were dangerous?

_____

14b

Talked to strangers who tried to keep you from going your way?

_____

14c

Let people see how much money you were carrying?

_____

14d

Gone on a blind date with someone you didn’t know?

_____

14f

Hitchhiked?

_____

14g

Walked alone through unsafe neighborhoods?

_____

14j

Let somebody use your ID, social security card or social security number?

_____

14k

Gotten drunk or high with someone or a group of people you didn’t know very well?

_____

14l

Gotten drunk or high while you were on a date with someone you didn’t know very well?

_____

14PD1

Engaged in extremely risky behaviors (like jumping off of a cliff or bridge or driving really fast and erratically) that put your life in danger? (Not a suicide attempt)

_____

Y5ARBS (Adolescent Risk Behavior Survey) For the next set of questions, please tell me only about those things you did voluntarily – that is, things you chose to do. [FLIPBOOK]

Y5ARBS

a. Have you ever. . .

Yes

No

b. How old were you the first time?

c. How many times in your life? (use codes below)

d. How many times in the past year? (use codes below)

e. Were you under the influence of drugs or alcohol?

S24

Begged for money or things from strangers?

1

0

1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times


0 Never 1 Sometimes 2 Most of the time 3 Always

S25 Used someone else’s social security card or number?

1 0 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times



S5 Avoided paying for things you were supposed to pay for (like the movies or a bus)?




S17 Used fake money to pay for something?




S18 Used or tried to use checks, credit cards, or bankcards without the owner’s permission?




S19 Tried to cheat someone by selling them something that was worthless or not what you said it was?

1 0 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times

0 None 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times

0 Never 1 Sometimes 2 Most of the time

5 >20 times 5 >20 times 3 Always

5ARBS


Yes

No





S20 Embezzled money, that is, stolen money that was entrusted to your care (e.g., stolen money from work)?




S16 Knowingly bought, sold, or held stolen goods or tried to do any of these things?




S11 Stolen or tried to steal money or things worth $5 or less?




S12 Stolen or tried to steal money or things worth between $5 and $50?




S13 Stolen or tried to steal money or things worth more than $50 but less that $100?




S14 Stolen or tried to steal money or things worth more than $100?




Version 6/20/2018

5ARBS


Yes

No





5 Stolen or tried to steal a motor vehicle?




S15 Snatched someone’s purse or wallet or picked someone’s pocket?




S22 Used force to get money or things from people?

1

0

1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times



4 Burglarized a house or building?




9 Purposely set fire or tried to set fire to any building or structure?




8 Purposely damaged any building/structure (e.g., thrown rocks through windows; tagged something)?




S29 Danced or stripped for pay or money?




Version 6/20/2018

5ARBS


Yes

No





S10 Been drunk in a public place?



S26 Used someone else’s ID or a fake ID to buy cigarettes or alcohol?




S8 Driven while under the influence of drugs or alcohol?



6 Sold drugs? 1 0 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times



S21 Had or tried to have sex with someone against their will?




10 Started a fist fight or shoving match?




S28 Been involved with gang activities?




Version 6/20/2018

5ARBS


Yes

No





S23 Been involved in gang fights?




S4 Hit or tried to hit one of your parents, caregivers, supervisors, or teachers?




7 Carried a hidden weapon, like a knife or a gun?




11 Used a weapon to attack someone?




12 Hurt or tortured animals?




S3 Hit or beaten someone up so badly that they probably needed to see a doctor?




Version 6/20/2018

5ARBS


Yes

No





S1 Attacked someone with the idea of seriously hurting or killing them?




Version 6/20/2018

Community Violence Y5ARBS44 Now I am going to ask you about things you may have seen or heard in the neighborhoods

where you have lived or in the communities where you have spent time in the past year.

[FLIPBOOK]

How many times in the past year . . .

44

a2

have you heard guns being shot?

0 Never 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times

44 b2 have you seen somebody arrested?


44 c2 have you seen somebody being beaten up?


44 d2 have you seen drug deals?


44 e2 have you seen gangs in your neighborhood?


44 f2 have you seen somebody steal something from another person’s house or store?


How many times in the past year . . .

44 g2 has your house been broken into?


44 h2 have you seen somebody pull a knife on another person?


44 i2 have you seen somebody get stabbed?


44 j2 have you seen somebody pull a gun on another person?


44 k2 have you seen somebody get shot?


44 l2 have you seen a dead body (not at a funeral)? 0 Never 1 1 time 2 2 to 5 times 3 6 to 10 times 4 11 to 20 times 5 >20 times

The Internet Questionnaire (INT) These next questions are about cell phones and access. Y5INT1

a Do you have your own cell phone? Yes 1

No ⇒ If NO, Skip 0 to INT2a

b

c

For how long have you had your own phone? How often do you change your phone number?

____________________ years 0 Never 1 Once per year 2 Twice per year 3 3-5 times per year 4 6-11 times per year 5 Every month

d Does your phone ever get cut off?

Yes 1

No ⇒ If NO, Skip to f 0

e If so, how often? 1 Once per year 2 Twice per year 3 3-5 times per year 4 6-11 times per year 5 Every month

f Do you have unlimited minutes?

Yes 1

No 0 ⇒ If YES,

Skip to h

g If no, how many minutes do you have each month?

___________ minutes

h Do you have unlimited texting?

Yes 1

No 0 ⇒ If YES,

Skip to j

i

If no, how many texts do you have each month?

____________ texts

Version 6/20/2018

j

Can you access the internet with your phone? k Do you have unlimited data?

Yes 1 Yes 1

No 0 ⇒ If NO, Skip

to INT2a No 0

5INT2 a Do you have access to the internet (besides on

your phone)? Yes 1

No ⇒ Skip 0 to INT3a

b

Where do you access the internet on a computer/tablet? (Circle all that apply) 1. Home 2. School 4. Work 3. Other? (Specify ____________________code____)

1 Yes 1 Yes 1 Yes 1 Yes

0 No 0 No 0 No 0 No

c Can you access the internet whenever you want?

Yes

1 No 0

d How often do you use the internet? 0 Never 1 One time per month 2 One time per week 3 2-3 times per week 4 4-6 times per week 5 Daily

e When you use the internet, how long do you typically spend on the internet per day?

1 15 minutes or less 2 Between 16 and 30 minutes 3 Between 31 and 60 minutes 4 1-2 hours 5 2-3 hours 6 More than 3 hours

f What do you typically use the internet for: a. Homework b. To get information other than homework (i.e., news) c. Social networking (i.e., Facebook, Twitter, etc.); video chat

(i.e., Skype, Facetime); chat rooms; instant messaging; discussion boards; blogging

d. Email e. Shopping/purchasing h. Online games i. General browsing/watching videos/reading articles j. Other? (Specify__________________________________code____)

1 Yes 1 Yes 1 Yes

1 Yes 1 Yes 1 Yes 1 Yes 1 Yes

0 No 0 No 0 No 0 No 0 No 0 No 0 No 0 No

Version 6/20/2018

5INT3 a Do you have a social networking account like Facebook, Instagram or Twitter?

Yes 1

No ⇒ Skip 0 to WWW

b Which do you use? (Write down all)

1. _________________________________________________ code _____ 2. _________________________________________________ code _____ 3. _________________________________________________ code _____

WWW [FLIPBOOK]

WWW4 a In the last year, have you received rude, nasty or threatening comments from someone through texting, or online, including through email, chat, or social networking sites?

Yes 1

No ⇒ Skip 0 to 5a

b How often in the past year?

1 Once 2 A few times 3 Once or twice a month 4 Once or twice a week 5 Every day/almost every day

c Who did this? Please list all people (relationships):

1. ___________________________________________________code_______ 2. ___________________________________________________code_______ 3. ___________________________________________________code_______

WWW5 a In the last year, have you been the target of rumors spread through texting or online, whether they were true or not?

Yes 1

No ⇒ Skip 0 to PD19a



c Who did this? Please list all people (relationships):

1. ___________________________________________________code_______ 2. ___________________________________________________code_______ 3. ___________________________________________________code_______

WWW6 a In the last year, have you made rude, nasty or

threatening comments to someone through texting or online?

Yes 1

No ⇒ Skip 0 to 10a



c To whom? Please list all people (relationships):

1. ___________________________________________________code_______ 2. ___________________________________________________code_______ 3. ___________________________________________________code_______

WWW10 a In the last year, have you spread rumors through texting or online, whether they were true or not?

Yes 1

No ⇒ Skip 0 to PD20a



c To whom? Please list all people (relationships):

1. ___________________________________________________code_______ 2. ___________________________________________________code_______ 3. ___________________________________________________code_______

ACTIVITIES

Y5ACT Have you participated in the following activities in the last year? YES NO Y5ACT

1

Have you participated on an athletic team or league (as a participant, not as a fan or spectator)?

1

0

Y5ACT

2

Have you been involved in a music or dance group or other arts related group?

1

0

Y5ACT

3

Have you attended an apartment, neighborhood, or other community meeting?

1

0

Y5ACT

4

Have you been an active member of a political or advocacy group?

1

0

Y5ACT

5

Have you attended a political rally or march?

1

0

Y5ACT

6

Have you been part of a volunteer group, or participated in volunteer/community service that was not mandatory?

1

0

Y5ACT

7a

Do you consider yourself to be part of a particular religion?

1

0

7b

What religion? 1 Catholic 2 Other Christian denomination/Protestant (like Baptist,

Methodist, Lutheran) 3 Jewish 4 Islamic (Moslem) 5 Other_________________________________________

Y5ACT

Y5ACT

Y5ACT

9

8

10a

10b

In the past year, have you been involved in religious or church group activities such as committees, choir, study groups, etc.? In the past year, have you been a member of a religious or church group?

In the past year, have you participated in any other club, committee, or group activities (something that you have not already told us about)? What was it? _______________________________________

Yes

1

1

Yes

1

No 0

0

No 0

___________________________________________________

_______________________________________________

Y5ACT

Y5ACT

Y5ACT

12

13

14

Have you ever filed a tax return?

Are you registered to vote?

How often do you vote in local, state, or national elections?

Yes

1

Yes No

1 0

0 Never, don’t want to

1 Never, haven’t had the opportunity

2 Almost never

No 0

⇒ Skip to

ACT15

3 4

Occasionally

Most of the time

5 All of the time

Y5ACT

15

How often do you read or watch the national, or international news?

local, 0 1 2 3 4 5

Never

Once in a while

Once or twice per month

Once or twice per week

Most days

Every day

Y5ACT

17

How much of your free time do you spend reading books?

0 1 2 3

None of my free time

Some of my free time

Most of my free time

All of my free time

Y5ACT

19

Which of the following documents do you have access currently?

to

Yes

No

a

Social Security Card or (Green Card)

Proof of Citizenship/Residency 1

0

b

Birth Certificate 1

0

c Immunization Record

1

0

d1

Driver’s License

1

0

d2

If no, have you ever had a valid driver’s license?

1

0

e

Other State Identification 1

0

Young Adult Confidential Survey

Documents

Transcript of Young Adult Confidential Survey