Table of Contents
Background:
The questionnaire included a large number of questions about sexuality, including questions on the following topics: existence of a boyfriend/girlfriend and age difference of that boy/girlfriend, knowledge about sexual topics, self-efficacy to avoid various sexual behaviors, norms about various sexual behaviors, perceptions of peer behaviors, opportunity to have sex, pressures to have sex, pre-coital sexual behaviors, various measures of sexual behavior, attempts to pressure someone else to have sex, and reasons to have and not to have sex.
Author of Tool:
Centre for AIDS Prevention Studies (CAPS)
Key references:
Marín BV, Coyle K, Gómez C, Carvajal S, Kirby D (2000). Older Boyfriends and Girlfriends Increase Risk of Sexual Initiation in Young Adolescents. Journal of Adolescent Health, 27, 409–418.
Primary use / Purpose:
Questionnaire evaluating the impact of middle school HIV/pregnancySTD Prevention Programs
Psychometrics:
For psychometric properties see article:
Marín, B.V., Coyle, K., Gomez, C., Carvajal, S. , Kirby, D. (2000) Older Boyfriends and Girlfriends Increase Risk of Sexual Initiation in Young Adolescents. Journal of Adolescent Health, 27: 409-418.
STUDENT HEALTH QUESTIONNAIRE
The University of California at San Francisco Center for AIDS Prevention Studies
and ETR Associates
TEAR OFF THIS PAGE WHEN TOLD TO DO SO
Funded by the National Institutes of Health (Grant Number MH51515).
Instructions for Students
We are asking you to complete this survey so we can learn whether programs that teach students about AIDS and pregnancy are working.
The survey asks questions about preventing AIDS and pregnancy. There are also questions about sexual behavior.
You do not have to answer any questions that make you feel uncomfortable. Your participation is voluntary. It is YOUR CHOICE to answer the questions on this survey. Your grades in school will not be affected by answering this survey.
Your answers will be private. No one at your school will know your answers. It is very important that you answer every question truthfully.
Thank you for your help.
MARKING INSTRUCTIONS
Mark your answers with a #2 pencil.
Make dark marks that fill the circle.
Erase cleanly any mark you change.
Make no stray marks.
EXAMPLES:
Use this mark Do not use these marks
0 0 0 0 0 0 0 0
Please turn page and begin ➔
QUESTIONS ABOUT YOU AND YOUR FAMILY
Instructions: Read each question carefully. Mark your answers in the square next to the questions. Mark one answer for each question, unless the instructions say to mark more than one answer.
1. How old are you today?
□ 10 years old or younger
□ 11 years old
□ 12 years old
□ 13 years old
□ 14 years old
□ 15 years old
□ 16 years old or older
2. What grade are you in this year?
□ 5th grade
□ 6th grade
□ 7th grade
□ 8th grade
□ 9th grade
3. Which are you?
□ Boy/Man
□ Girl/Woman
4. Mark the group(s) that best describes YOU. (Mark All That Apply.)
□ Hispanic/Latino/Mexican
□ Black/African American
□ Asian or Pacific Islander
□ Native American/Alaskan Native
□ White
□ Other
5. What kind of grades do you usually get in school? (Mark All That Apply.)
□ A’s
□ B’s
□ C’s
□ D’s
□ F’s
6. What languages do you usually speak with your friends?
□ Only English
□ Mostly English
□ About half English and half my other language
□ Mostly my other language
□ Only my other language
7. What languages are spoken the most at home?
□ Only English
□ Mostly English
□ About half English and half my other language
□ Mostly my other language
□ Only my other language
8. How long have you lived in the United States?
□ All my life
□ Less than one year
□ 1 to 3 years
□ 4 to 6 years
□ More than 6 years
9. How far do you think you will go in school?
□ Won’t finish high school
□ Will graduate from high school
□ Will attend college, but probably won’t complete four years
□ Will graduate from a four year college
10. What is the highest level your mother (or stepmother) completed in school?
□ She completed 8th grade or less than 8th grade
□ She completed some high school
□ She graduated from high school
□ She had some college after high school
□ She graduated from a four year college
COULD YOU DO IT ?
□ Don’t know
Some of the questions in the rest of the survey use the words “having sex.” This means a man’s penis in a woman’s vagina. When it says “private parts” it means penis or vagina.
IMAGINE YOU ARE ALONE WITH SOMEONE YOU LIKE VERY MUCH.
11. Could you stop them if they wanted to kiss you
I I I I
Definitely Probably Probably Definitely Could Could Could Not Could Not
on the lips? □ □ □ □
12. Could you stop them if they wanted to tongue
kiss or French kiss you? □ □ □ □
13. Could you stop them if they wanted to touch
your chest or breasts? □ □ □ □
14. Could you stop them if they wanted to touch
your private parts below the waist? □ □ □ □
15. Could you stop them if they wanted to have
sex with you? □ □ □ □
16. Could you stop yourself from having sex if the person said they would break up with you unless
I I I I
Definitely Probably Probably Definitely Could Could Could Not Could Not
you had sex with them? □ □ □ □
17. Could you stop yourself from having sex if
you had been drinking alcohol? □ □ □ □
18. Could you stop yourself from having sex if
you had strong sexual feelings for someone? □ □ □ □
19. If you needed a condom, could you go to
the store and buy one? □ □ □ □
20. If you decided to have sex, could you tell the
IS IT OK ?
other person you wanted to use a condom?□ □ □ □
|
Definitely |
Probably |
Not |
Probably |
Definitely |
|
Not OK |
Not OK |
Sure |
OK |
OK |
|
□ |
□ |
□ |
□ |
□ |
21. Is it OK for a boy to pressure a girl for a kiss if they have kissed before?
22. Is it OK for a girl to pressure a boy for a kiss if they have
kissed before? □ □ □ □ □
23. Is it OK for a boy to pressure a girl to have sex if they have
had sex before? □ □ □ □ □
24. Is it OK for a girl to pressure a boy to have sex if they have
had sex before? □ □ □ □ □
The following questions ask you about your FRIENDS and what they think and do. If you are not sure, mark the answer that you think best describes what they think and do.
WHAT PEOPLE YOUR AGE THINK AND DO
|
Less Than |
More Than |
|||
|
None |
Half |
Half |
Half |
All |
|
□ |
□ |
□ |
□ |
□ |
|
□ |
□ |
□ |
□ |
□ |
25. How many of your friends have a boyfriend or girlfriend?
26. How many of your friends have kissed a boy or girl?
27. How many of your friends have touched someone else’s private parts below the
waist? □ □ □ □ □
28. How many of your friends have had sex? □ □ □ □ □
29. How many of your friends think people your age should wait until they are older
to have sex? □ □ □ □ □
30. How many of your friends think it is OK for people your age to have sex with a
serious boyfriend or girlfriend? □ □ □ □ □
YOUR ACTIVITIES
31. In the PAST 3 MONTHS, how often have you been alone with someone you are very attracted to?
□ Never
□ 1 or 2 times
□ 3 to 5 times
□ 6 or more times
32. In the PAST 3 MONTHS, how often have you been alone kissing and touching someone you really like?
□ Never
□ 1 or 2 times
□ 3 to 5 times
□ 6 or more times
33. In the PAST 3 MONTHS, how often have you laid down on a couch or bed alone with someone you really like?
□ Never
□ 1 or 2 times
□ 3 to 5 times
□ 6 or more times
34. In the PAST 3 MONTHS, how often have you been at a party where there were no adults in the house?
□ Never
□ 1 or 2 times
□ 3 to 5 times
□ 6 or more times
35. Have you ever had a serious boyfriend or girlfriend?
□ Yes
□ No
36. How old was your oldest serious boyfriend or girlfriend?
□ I’ve never had a serious boyfriend or girlfriend
□ 10 years old or younger
□ 11 years old
□ 12 years old
□ 13 years old
□ 14 years old
□ 15 years old
□ 16 years old
□ 17 years old
□ 18 years old or older
37. In the PAST 12 MONTHS, has someone tried to kiss you on the lips when you didn’t want to?
□ No
□ Yes, someone tried, but they didn’t kiss me
□ Yes, someone tried, and they kissed me
38. In the PAST 12 MONTHS, has someone tried to tongue kiss or French kiss you when you didn’t want to?
□ No
□ Yes, someone tried, but they didn’t tongue kiss me
□ Yes, someone tried, and they tongue kissed me
39. In the PAST 12 MONTHS, has someone tried to touch your private parts below your waist when you didn’t want to?
□ No
□ Yes, someone tried, but they didn’t touch me
□ Yes, someone tried, and they touched me
40. In the PAST 12 MONTHS, has someone tried to get you to have sex when you didn’t want to?
□ No
□ Yes, someone tried, but we didn’t have sex
□ Yes, someone tried, and we had sex
41a. Has someone ever forced you to do sexual things you didn’t want to?
□ Yes
□ No
41b. Has someone ever forced you to have sex (penis in vagina)?
□ Yes
□ No
42. In the PAST 12 MONTHS, have you kissed someone on the lips (other than your parents or another relative)?
□ Yes
□ No
43. In the PAST 12 MONTHS, have you tongue kissed or French kissed?
□ Yes
□ No
44. If you are a boy, in the PAST 12 MONTHS, have you touched a girl’s breasts?
□ Yes
□ No
□ I’m a girl
45. If you are a girl, in the PAST 12 MONTHS, has someone touched your chest or breasts?
□ Yes
□ No
□ I’m a boy
46. In the PAST 12 MONTHS, have you touched someone else’s private parts below the waist?
□ Yes
□ No
47. In the PAST 12 MONTHS, has someone touched your private parts below the waist?
□ Yes
□ No
48. Have you ever had sex?
□ Yes
□ No
49. How old were you the first time you had sex?
□ I have never had sex
□ 10 years old or younger
□ 11 years old
□ 12 years old
□ 13 years old
□ 14 years old
□ 15 years old
□ 16 years old
50. The first time you had sex, when did you decide you were going to have sex with that person?
□ I have never had sex
□ I never really decided, it just happened
□ I decided to have sex a few minutes before we had sex
□ I decided a few hours before we had sex
□ I decided a day or more before we had sex
51. The first time you had sex, when did you talk to the other person about having sex?
□ I have never had sex
□ We never really talked about sex, it just happened
□ We talked a few minutes before we had sex
□ We talked a few hours before we had sex
□ We talked a day or more before we had sex
52. How many people have you had sex with in your life?
□ I have never had sex
□ 1 person
□ 2 people
□ 3 people
□ 4 people
□ 5 people
□ 6 or 7 people
□ 8 or 9 people
□ 10 or more people
53. Have you had sex in the PAST 12 MONTHS?
□ I have never had sex
□ Yes, I have had sex in the PAST 12 MONTHS
□ No, I have not had sex in the PAST 12 MONTHS
54. How many times have you had sex in the PAST 12 MONTHS?
□ I have never had sex
□ I have not had sex in the past 12 months
□ 1 time
□ 2 times
□ 3 times
□ 4 times
□ 5 times
□ 6 times
□ 7 times
□ 8 times
□ 9 times
□ 10 or more times
55. How many people have you had sex with in the PAST 12 MONTHS?
□ I have never had sex
□ I have not had sex in the past 12 months
□ 1 person
□ 2 people
□ 3 people
□ 4 people
□ 5 people
□ 6 people
□ 7 people
□ 8 people
□ 9 people
□ 10 or more people
56. Have you had sex in the PAST 3 MONTHS?
□ I have never had sex
□ Yes, I have had sex in the PAST 3 MONTHS
□ No, I have not had sex in the PAST 3 MONTHS
57. Of all the times you have had sex, how often did you use condoms?
□ I have never had sex
□ We always used condoms
□ We used condoms more than half the time
□ We used condoms half the time
□ We used condoms less than half the time
□ We never used condoms
58. The LAST TIME you had sex, did you use a condom?
□ I have never had sex
□ Yes, we used condoms
□ No, we did not use condoms
59. The LAST TIME you had sex, did you drink alcohol or use drugs before you had sex?
□ I have never had sex
□ Yes
□ No
60. If you are a girl, have you had your first menstrual period?
□ Yes
□ No
□ Not sure
□ I’m a boy
In the PAST 12 MONTHS, have YOU tried to do these things, even though the other person did not want to?
But It Yes,
61. Have you tried to kiss someone on the lips,
Did Not And It
No Happen Happened
but they didn’t want you to? □ □ □
62. Have you tried to tongue kiss or French kiss someone, but they didn’t
want you to? □ □ □
63. Have you tried to touch someone’s
private parts below the waist, but they didn’t
want you to? □ □ □
64. Have you tried to have sex with someone,
but they didn’t want you to? □ □ □
WOULD YOU DO IT ?
IMAGINE YOU ARE ALONE WITH SOMEONE YOU LIKE VERY MUCH.
Definitely Probably Probably Definitely Not Not Yes Yes
65. Would you let them kiss you on
the lips? □ □ □ □
66. Would you let them tongue kiss or
French kiss you? □ □ □ □
67. Would you let them touch your
private parts below your waist? □ □ □ □
68. Would you let them have sex
WHAT ARE YOUR REASONS ?
with you? □ □ □ □
Here are some reasons for NOT having sex. Which of these are reasons YOU would choose for NOT having sex at your age?
69. I would not have sex because I’m too young to have sex.
□ True for me
□ Not true for me
□ I’m not sure
70. I would not have sex at my age because it is against my beliefs.
□ True for me
□ Not true for me
□ I’m not sure
71. I would not have sex because I do not want to have a baby right now.
□ True for me
□ Not true for me
□ I’m not sure
72. I would not have sex because I don’t want to get AIDS or other diseases you can get from sex.
□ True for me
□ Not true for me
□ I’m not sure
73. I would not have sex at my age because I don’t want to have a bad reputation.
□ True for me
□ Not true for me
□ I’m not sure
74. I would not have sex at my age because I would lose respect for myself.
□ True for me
□ Not true for me
□ I’m not sure
75. I would not have sex at my age because I could feel guilty afterwards.
□ True for me
□ Not true for me
□ I’m not sure
76. I would not have sex at my age because my parents would be angry.
□ True for me
□ Not true for me
□ I’m not sure
77. I would not have sex at my age because I think it is gross.
□ True for me
□ Not true for me
□ I’m not sure
Here are some reasons FOR HAVING sex. Which are reasons why YOU would have sex now?
78. I would have sex now so my boyfriend or girlfriend would not break up with me.
□ True for me
□ Not true for me
□ I’m not sure
79. I would have sex now if I had a boyfriend or girlfriend I loved.
□ True for me
□ Not true for me
□ I’m not sure
80. I would have sex now to feel more accepted and loved.
□ True for me
□ Not true for me
□ I’m not sure
81. I would have sex now to be more popular.
□ True for me
□ Not true for me
□ I’m not sure
82. I would have sex now to satisfy my sexual desires.
□ True for me
□ Not true for me
□ I’m not sure
83. I would have sex now because I’m curious to know what it is like.
□ True for me
□ Not true for me
□ I’m not sure
84. I would have sex now because my friends are having sex.
□ True for me
□ Not true for me
WHAT DO YOU THINK ABOUT CONDOMS ?
□ I’m not sure
85. Would you be embarrassed to buy
Definitely Probably Not Probably Definitely Not Not Sure Yes Yes
condoms? □ □ □ □ □
86. Would you be embarrassed to talk with a boyfriend or girlfriend
about using condoms? □ □ □ □ □
87. Would you be embarrassed to carry a condom with you in a wallet,
YOUR BELIEFS
purse or backpack? □ □ □ □ □
Definitely Probably Probably Definitely
88. Are girls more popular if they have
Not Not Maybe Yes Yes
sex? □ □ □ □ □
89. Are boys more popular if they have
sex? □ □ □ □ □
90. If you have sex now, would your
father or stepfather think it was OK? □ □ □ □ □
91. If you have sex now, would your
WHAT DO YOU KNOW ?
mother or stepmother think it was OK? □ □ □ □ □
92. Is it against the law for buy condoms?
□ Yes
□ No
□ Not sure
people under 16 years old to
93. Do condoms help protect against HIV, the virus that causes AIDS?
□ Yes
□ No
□ Not sure
94. Do condoms help protect people from getting pregnant?
□ Yes
□ No
□ Not sure
95. Can you tell if a person has HIV or AIDS just by looking at them?
□ Yes
□ No
□ Not sure
96. Can you get AIDS from kissing someone who has AIDS?
□ Yes
□ No
□ Not sure
97. Can you get HIV/AIDS if you only have sex once or twice without a condom?
□ Yes
□ No
□ Not sure
98. Do most teens who have had sex wish they had waited until they were older?
□ Yes
□ No
□ Not sure
99. Are most teens your age having sex?
□ Yes
□ No
□ Not sure
100. Do you think that not having sex is the safest way to keep from getting pregnant or getting a disease like AIDS?
□ Yes
□ No
□ Not sure
101. Since school started this year, how many times have you talked with a teacher or other adult at school about relationships, sex, or other personal things?
□ 0 times
□ 1 – 2 times
□ 3 – 5 times
□ 6 – 10 times
□ More than 10 times
Thank you for completing this questionnaire.