Form approved
OMB Control No: 0970-0536
Expiration Date: 01/31/2026
Revised: 01/06/2022
SEXUAL RISK AVOIDANCE EDUCATION PROGRAM(SRAE)
PARTICIPANT EXIT SURVEY MIDDLE SCHOOL
Thank you for your help with this important study. This survey includes questions
about your family, friends, school, and also your attitudes and behaviors. Your
name will not be on the survey and your responses will remain private to the extent
permitted by law. We want you to know that:
1. Your participation in this survey is voluntary.
2. We hope that you will answer all of the questions, but you may skip any
questions you do not wish to answer.
3. The answers you give will be kept private to the extent permitted by law.
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The information collected will help policy makers, program providers and other stakeholders understand the
experiences of youth today and identify ways to reduce risky behaviors. This information will also inform programs on how best to
serve their participants. The collection of this information is voluntary and responses will be kept private to the extent allowed by
law. The OMB number for this information collection is 0970-0536 and the expiration date is 01/31/2026.
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General Instructions
PLEASE READ EACH QUESTION CAREFULLY: There are different ways to answer the questions in this survey. It is important that you follow the instructions when answering each kind of question. Here are some examples.
PLEASE MARK ALL ANSWERS WITHIN THE WHITE BOXES PROVIDED.
1. EXAMPLE 1: MARK ONLY ONE ANSWER
What is the color of your eyes?
Brown
Blue
Green
Another color
2. EXAMPLE 2: MARK ALL THAT APPLY
Do you plan to do any of the following next week?
Watch a movie
Go to a baseball game
Study at a friend's house
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Please answer the following questions as best you can. This first set of questions are
about you.
1. How old are you?
MARK ONLY ONE ANSWER
How old are you?
10
11
12
13
14
15
16
2. What grade are you in? (If you are currently on vacation or in summer school, indicate the grade you will be in when you go back to school.)
MARK ONLY ONE ANSWER
What grade are you in?
5th
6th
7th
8th
9th
My school does not assign grade levels
I am not currently enrolled in school
3. When you are at home or with your family, what language or languages do you usually speak?
MARK ALL THAT APPLY
When you are at home or with your family, what language or languages do you usually speak?
English
Spanish
Other
4. Are you Hispanic or Latino?
MARK ONLY ONE ANSWER
Are you Hispanic or Latino?
Yes
No
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5. What is your race?
MARK ALL THAT APPLY
What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
6. What is your sex?
MARK ONLY ONE ANSWER
What is your sex?
Male
Female
7. Are you currently ...?
MARK ALL THAT APPLY
Are you currently ...?
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 center, juvenile group home, and/or under the supervision of a probation officer
None of the above
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For questions 8–12, please think about how the program you just completed has affected you, even if your program did not cover the topic.
8. Has being in the program made you more likely, about the same, or less likely to...
(Note: If the program has not affected your likelihood to do any of the following, choose "About the same.")
MARK ONLY ONE ANSWER PER ROW
Rows
Much more likely
Somewhat more likely
About the same
Somewhat less likely
Much less likely
a. make decisions to not drink alcohol?
b. make decisions to not smoke cigarettes or cigar products (cigars, cigarillos, or little cigars)?
C. make decisions to not use other tobacco products (such as chewing tobacco, snuff, dip, or snus)?
d. make decisions to not use 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)
e. make decisions to not use marijuana (also called pot, weed, or cannabis)?
f. make decisions to not take prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it?
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9. Has being in the program made you more likely, about the same, or less likely to... (Note: If the program has not affected your likelihood to do the following, choose "About the same.")
MARK ONLY ONE ANSWER PER ROW
Rows
Much more likely
Somewhat more likely
About the same
Somewhat less likely
Much less likely
a. resist or say no to peer pressure?
b. manage your emotions in healthy ways (for example, ways that are not hurtful to you or others)?
C. think about the consequences before making a decision?
d. talk with your parent, guardian, or caregiver about sex?
10. Has being in the program made you more likely, about the same, or less likely to... (Note: If the program has not affected your likelihood to do the following, choose "About the same".)
MARK ONLY ONE ANSWER PER ROW
Rows
Much more likely
Somewhat more likely
About the same
Somewhat less likely
Much less likely
a. make plans to reach your goals?
b. care about doing well in school?
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11. Has being in the program made you more likely, about the same, or less likely to... (Note: If the program has not affected your likelihood to do the following, choose "About the same.")
MARK ONLY ONE ANSWER PER ROW
MARK ONLY ONE ANSWER PER ROW
Rows
Much more likely
Somewhat more likely
About the same
Somewhat less likely
Much less likely
a. better understand what makes a relationship healthy?
b. resist or say no to someone if they pressure you to participate in acts, such as kissing, touching private parts, or sex?
c. talk to a trusted person/adult (for example, a family member, teacher, counselor, coach, etc.) if someone makes you uncomfortable, hurts you, or pressures you to do things you don't want to do?
12. Has being in the program made you more likely, about the same, or less likely to...
MARK ONLY ONE ANSWER PER ROW
MARK ONLY ONE ANSWER PER ROW
Rows
Much more likely
Somewhat more likely
About the same
Somewhat less likely
Much less likely
a. plan to delay having sexual intercourse until you graduate high school or receive your GED
b. plan to delay having sexual intercourse until you graduate college or complete another education or training program
c. plan to delay having sexual intercourse until you are married
d. plan to be married before you have a child
e. plan to have a steady full-time job before you get married
f. plan to have a steady full-time job before you have a child
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The next questions ask you about your experiences in the program that you just
completed. Think about all of the sessions or classes of the program that you attended.
13. Even if you didn't attend all of the sessions or classes in this program, how often in this program...
MARK ONLY ONE ANSWER PER ROW
Rows
All of the time
Most of the time
Some of the time
None of the time
a. did you feel interested in program sessions and classes?
b. did you feel the material presented was clear?
C. did discussions or activities help you to learn program lessons?
d. did you have a chance to ask questions about topics or issues that came up in the program?
e. did you feel respected as a person?
Thank you for participating in this survey!
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