Form approved
OMB Control No: 0970-0536
Expiration Date: 01/31/2026
Revised: 01/06/2022
SEXUAL RISK AVOIDANCE EDUCATION PROGRAM(SRAE)
PARTICIPANT ENTRY 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 8 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.
Back
Next
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
If you plan to watch a movie and go to a baseball game next week, you would mark (X) both boxes.
Back
Next
Please answer the following questions as best you can. This first set of questions are about you.
How old are you?
10
11
12
13
14
15
16
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.)
5th
6th
7th
8th
9th
My school does not assign grade levels
I am not currently enrolled in school
When you are at home or with your family, what language or languages do you usually speak?
English
Spanish
Other
Are you Hispanic or Latino?
Yes
No
Back
Next
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
Back
Next
The next questions ask about alcohol, tobacco, and other substance use. Remember, all of your responses will be kept private.
MARK ONLY ONE ANSWER PER ROW
Rows
Yes
No
a. drunk alcohol (more than a few sips, including beer, wine, and liquor)?
b. smoked cigarettes or cigar products (cigars, cigarillos, or little cigars)?
c. used other tobacco products (such as chewing tobacco, snuff, dip, or snus)?
d. 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)
e. used marijuana (also called pot, weed, or cannabis)?
f. taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it?
9. In the past three months, how often would you say you MARK ONLY ONE ANSWER PER ROW
Rows
All of the time
Most of the time
Some of the time
None of the time
a. resisted or said no to peer pressure?
b. managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)?
C. thought about the consequences before making a decision?
d. talked with your parent, guardian, or caregiver about sex?
5
Back
Next
10. For each of the items below, please mark how true each statement is of you.
MARK ONLY ONE ANSWER PER ROW
MARK ONLY ONE ANSWER PER ROW
Rows
Not true at all
Somewhat true of me
Very true of me
a. I make plans to reach my goals
b. I care about doing well in school
C. I save money to get things I want
d. 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
e. 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.
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.
MARK ONLY ONE ANSWER PER ROW
MARK ONLY ONE ANSWER PER ROW
Rows
Not true at all
Somewhat true of me
Very true of me
a. I understand what makes a relationship healthy
b. I would be able to resist or say no to someone if they pressured me to participate in acts, such as kissing, touching private parts, or sex
C. 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 don't want to do
Thank you for participating in this survey!
Preview PDF
Submit
Should be Empty: