Sexual Risk Avoidance Program (SRAE)
Participant Entry Survey
Middle School
Please answer the following questions as best you can. This first set of questions are about you.
1.
How old are you?
10
11
12
13
14
15
16
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.)
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.)
English
Spanish
Other (please specify)
4.
Are you Hispanic or Latino? (Mark only one answer.)
Yes
No
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)
6.
What is your sex? (Mark only one answer.)
Male
Female
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, or 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 b
e kept
private.
8.
In the past three months, have you...
Yes
No
drunk alcohol (more than a few sips, including beer, wine, and liquor)?
Yes
No
smoked cigarettes or cigar products (cigars, cigarillos, or little cigars)?
Yes
No
used other tobacco products (such as chewing tobacco, snuff, dip, or snus)?
Yes
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)
Yes
No
used marijuana (also called pot, weed, or cannabis)?
Yes
No
taken prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it?
Yes
No
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?
All of the time
Most of the time
Some of the time
None of the time
managed your emotions in healthy ways (for example, ways that are not hurtful to you or others)?
All of the time
Most of the time
Some of the time
None of the time
thought about the consequences before making a decision?
All of the time
Most of the time
Some of the time
None of the time
talked with my parent, guardian, or caregiver about sex?
All of the time
Most of the time
Some of the time
None of the time
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
Not true at all
Somewhat true of me
Very true of me
I care about doing well in school
Not true at all
Somewhat true of me
Very true of me
I save money to get things I want
Not true at all
Somewhat true of me
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
Not true at all
Somewhat true of me
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
Not true at all
Somewhat true of me
Very true of me
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
Not true at all
Somewhat true of me
Very true of me
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
Not true at all
Somewhat true of me
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 don't want to do
Not true at all
Somewhat true of me
Very true of me
12.
Please select your school:
Athens City Middle School
Calhoun Elementary School
Chilhowee Middle School
Christ's Legacy Academy
Copper Basin Elementary School
E. K. Baker Elementary School
Englewood Elementary School
Etowah City School
Mountain View Elementary School
Meigs Middle School
Niota Elementary School
Riceville Elementary School
Rogers Creek Elementary School
Valley Christian Academy
Thank you for participating in this survey!
Current Progress,
0 of 12 answered