Sexual Risk Avoidance Program (SRAE)
Participant Entry Survey
High School and Older

Question Title

Please answer the following questions as best you can. This first set of questions are about you.

Question Title

* 1. How old are you?

Question Title

* 2. What grade are you in?

(Note: If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)

9th

10th

11th

12th

My school does not assign grade levels

I dropped out of school, and I am not working on getting a high school diploma or GED

I am working toward a GED

I have a high school diploma or GED but I am not currently enrolled in college or technical school

I have a high school diploma or GED and I am currently enrolled in college or technical school

Question Title

* 3. When you are at home or with your family, what language or languages do you usually speak? (Mark all that apply.)

English

Spanish

Other (please specify)

Question Title

* 4. Are you Hispanic or Latino? (Mark only one answer.)

Yes

Question Title

* 5. What is your race? (Mark all that apply.)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Other (please specify)

Question Title

* 6. What is your sex? (Mark only one answer.)

Male

Female

Question Title

* 7. Are you currently...? (Mark all that apply.)

Living with family [parent(s), guardian, grandparents, or other relatives]

In foster care, living with a family

In foster care, living in a group home

Couch surfing or moving from home to home

Living outside, in a tent city or homeless camp, in a car, in an abandoned vehicle or in an abandoned building

Staying in an emergency shelter or transitional living program

Staying in a hotel or motel

In juvenile detention or another correctional facility, or under the supervision of a probation officer

None of the above

The next questions ask about alcohol, tobacco, and other substance use. Remember, all of your responses will be kept private.

Question Title

* 8. In the past three months, have you...

	Yes	No
drunk alcohol (more than a few sips, including beer, wine, and liquor)?	drunk alcohol (more than a few sips, including beer, wine, and liquor)? Yes	drunk alcohol (more than a few sips, including beer, wine, and liquor)? No
smoked cigarettes or cigar products (cigars, cigarillos, or little cigars)?	smoked cigarettes or cigar products (cigars, cigarillos, or little cigars)? Yes	smoked cigarettes or cigar products (cigars, cigarillos, or little cigars)? No
used other tobacco products (such as chewing tobacco, snuff, dip, or snus)?	used other tobacco products (such as chewing tobacco, snuff, dip, or snus)? Yes	used other tobacco products (such as chewing tobacco, snuff, dip, or snus)? No
used electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? (electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, hookahs, hookah pens, and mods)	used electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? (electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, hookahs, hookah pens, and mods) Yes	used electronic vapor products (such as JUUL, Vuse, MarkTen, and blu)? (electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, hookahs, hookah pens, and mods) No
used marijuana (also called pot, weed, or cannabis)?	used marijuana (also called pot, weed, or cannabis)? Yes	used marijuana (also called pot, weed, or cannabis)? No
taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it?	taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it? Yes	taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it? No

Question Title

* 9. In the past three months, how often would you say you...

	All of the time	Most of the time	Some of the time	None of the time
resisted or said no to peer pressure?	resisted or said no to peer pressure? All of the time	resisted or said no to peer pressure? Most of the time	resisted or said no to peer pressure? Some of the time	resisted or said no to peer pressure? None of the time
managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)?	managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)? All of the time	managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)? Most of the time	managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)? Some of the time	managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)? None of the time
thought about the consequences before making a decision?	thought about the consequences before making a decision? All of the time	thought about the consequences before making a decision? Most of the time	thought about the consequences before making a decision? Some of the time	thought about the consequences before making a decision? None of the time
talked with my parent, guardian, or caregiver about sex?	talked with my parent, guardian, or caregiver about sex? All of the time	talked with my parent, guardian, or caregiver about sex? Most of the time	talked with my parent, guardian, or caregiver about sex? Some of the time	talked with my parent, guardian, or caregiver about sex? None of the time

Question Title

* 10. For each of the items below, please mark how true each statement is of you.

	Not true at all	Somewhat true of me	Very true of me
I make plans to reach my goals	I make plans to reach my goals Not true at all	I make plans to reach my goals Somewhat true of me	I make plans to reach my goals Very true of me
I care about doing well in school	I care about doing well in school Not true at all	I care about doing well in school Somewhat true of me	I care about doing well in school Very true of me
I save money to get things I want	I save money to get things I want Not true at all	I save money to get things I want Somewhat true of me	I save money to get things I want Very true of me
I would speak up or ask for help if I am being bullied in person or online, via text, while gaming, or through other social media	I would speak up or ask for help if I am being bullied in person or online, via text, while gaming, or through other social media Not true at all	I would speak up or ask for help if I am being bullied in person or online, via text, while gaming, or through other social media Somewhat true of me	I would speak up or ask for help if I am being bullied in person or online, via text, while gaming, or through other social media Very true of me
I would speak up or ask for help if others are being bullied in person or online, via text, while gaming, or through other social media	I would speak up or ask for help if others are being bullied in person or online, via text, while gaming, or through other social media Not true at all	I would speak up or ask for help if others are being bullied in person or online, via text, while gaming, or through other social media Somewhat true of me	I would speak up or ask for help if others are being bullied in person or online, via text, while gaming, or through other social media Very true of me

Question Title

* 11. The next few questions are about relationships and dating. Please answer the questions below even if you are not currently dating or going out with someone.

For each of the items below, please mark how true each statement is of you.

	Not true at all	Somewhat true of me	Very true of me
I understand what makes a relationship healthy	I understand what makes a relationship healthy Not true at all	I understand what makes a relationship healthy Somewhat true of me	I understand what makes a relationship healthy Very true of me
I would be able to resist or say no to someone I am dating if they pressured me to participate in sexual acts, such as kissing, touching private parts, or sex.	I would be able to resist or say no to someone I am dating if they pressured me to participate in sexual acts, such as kissing, touching private parts, or sex. Not true at all	I would be able to resist or say no to someone I am dating if they pressured me to participate in sexual acts, such as kissing, touching private parts, or sex. Somewhat true of me	I would be able to resist or say no to someone I am dating if they pressured me to participate in sexual acts, such as kissing, touching private parts, or sex. Very true of me
I would talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes me uncomfortable, hurts me, or pressures me to do things I want to do.	I would talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes me uncomfortable, hurts me, or pressures me to do things I want to do. Not true at all	I would talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes me uncomfortable, hurts me, or pressures me to do things I want to do. Somewhat true of me	I would talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes me uncomfortable, hurts me, or pressures me to do things I want to do. Very true of me

Question Title

* 12. For each of the items below, please mark how true each statement is of you.

	Not true at all	Somewhat true of me	Very true of me
I plan to delay having sexual intercourse until I graduate high school or receive my GED.	I plan to delay having sexual intercourse until I graduate high school or receive my GED. Not true at all	I plan to delay having sexual intercourse until I graduate high school or receive my GED. Somewhat true of me	I plan to delay having sexual intercourse until I graduate high school or receive my GED. Very true of me
I plan to delay having sexual intercourse until I graduate college or complete another education or training program.	I plan to delay having sexual intercourse until I graduate college or complete another education or training program. Not true at all	I plan to delay having sexual intercourse until I graduate college or complete another education or training program. Somewhat true of me	I plan to delay having sexual intercourse until I graduate college or complete another education or training program. Very true of me
I plan to delay having sexual intercourse until I am married.	I plan to delay having sexual intercourse until I am married. Not true at all	I plan to delay having sexual intercourse until I am married. Somewhat true of me	I plan to delay having sexual intercourse until I am married. Very true of me
I plan to be married before I have a child.	I plan to be married before I have a child. Not true at all	I plan to be married before I have a child. Somewhat true of me	I plan to be married before I have a child. Very true of me
I plan to have a steady full-time job before I get married.	I plan to have a steady full-time job before I get married. Not true at all	I plan to have a steady full-time job before I get married. Somewhat true of me	I plan to have a steady full-time job before I get married. Very true of me
I plan to have a steady full-time job before I have a child.	I plan to have a steady full-time job before I have a child. Not true at all	I plan to have a steady full-time job before I have a child. Somewhat true of me	I plan to have a steady full-time job before I have a child. Very true of me

The next questions ask about some personal behaviors, including sexual intercourse and pregnancy. Remember, all of your responses will be kept private.

Question Title

* 13. Have you ever had sexual intercourse? (Mark only one answer.)

Yes

Question Title

* 14. To the best of your knowledge, have you ever been pregnant or gotten someone else pregnant? (Mark only one answer.)

Yes

Not sure

Question Title

* 15. Have you ever been told by a doctor or other medical provider that you had a sexually transmitted infection? (Mark only one answer.)

Yes

Question Title

* 16. Please select your school:

Thank you for participating in this survey!

Sexual Risk Avoidance Program (SRAE)Participant Entry SurveyHigh School and Older

Question Title

Question Title

* 1. How old are you?

Question Title

* 2. What grade are you in?(Note: If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)

Question Title

* 3. When you are at home or with your family, what language or languages do you usually speak? (Mark all that apply.)

Question Title

* 4. Are you Hispanic or Latino? (Mark only one answer.)

Question Title

* 5. What is your race? (Mark all that apply.)

Question Title

* 6. What is your sex? (Mark only one answer.)

Question Title

* 7. Are you currently...? (Mark all that apply.)

Question Title

* 8. In the past three months, have you...

Question Title

* 9. In the past three months, how often would you say you...

Question Title

* 10. For each of the items below, please mark how true each statement is of you.

Question Title

* 11. The next few questions are about relationships and dating. Please answer the questions below even if you are not currently dating or going out with someone.For each of the items below, please mark how true each statement is of you.

Question Title

* 12. For each of the items below, please mark how true each statement is of you.

Question Title

* 13. Have you ever had sexual intercourse? (Mark only one answer.)

Question Title

* 14. To the best of your knowledge, have you ever been pregnant or gotten someone else pregnant? (Mark only one answer.)

Question Title

* 15. Have you ever been told by a doctor or other medical provider that you had a sexually transmitted infection? (Mark only one answer.)

Question Title

* 16. Please select your school:

Sexual Risk Avoidance Program (SRAE)
Participant Entry Survey
High School and Older

* 2. What grade are you in?

(Note: If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)

* 11. The next few questions are about relationships and dating. Please answer the questions below even if you are not currently dating or going out with someone.

For each of the items below, please mark how true each statement is of you.