1. What is the name of your school?
______
2. What is your school identification number (ID#) and grade level? ID#______Grade Level______
3. Please enter the following information. (MM/DD/YY)
Today’s Date:______
Your Birthday:______
4. In what country were you born?
United States Other ______
5. How many years have you lived in the United States? ______Years
6. Who do you currently live with (check all that apply)?
Mother Father Both Grandparents Other: ______
7. How many brother and sisters do you have?
Sisters______Brothers______
8. Most of the time, what languages do ADULTS in your family speak at home?
English Spanish Both Other: ______
9. Which of these best categorizes your race/ethnic background (you may choose more than one)?
Hispanic or Latino White Asian African American or Black
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
10. Do you plan to go to college? Yes No I don’t know.
11. I can tell my mother if I have a problem.
Strongly Agree Agree Unsure Disagree Strongly Disagree
12. My mother and I are able to discuss different beliefs and feelings without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
13. If I ask my mother questions about body changes, she answers me without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
14. My mother and I are able to discuss breast development and care without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
15. My mother and I are able to discuss beliefs related to sexual behavior without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
16. If I ask my mother questions about sexual behavior, she answers me without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
17. What has prevented you from talking to your mother about sexuality? (You may check more than one reason.)
My father doesn’t approve.
It is against our religious beliefs.
She thinks that I am too young.
I feel embarrassed.
She is too uncomfortable or embarrassed.
She might get mad.
She may not know the answers/have the wrong answers.
I do not understand what she means (sexuality words in Spanish).
There is no time/place to talk alone.
I would rather talk to a counselor/teacher at school or another female.
She might think that I want to have sex.
There is no problem; we always talk.
18. My mother and I have discussed (You may check more than one option.):
Rules about going out with my friends
What to do if I like a boy
What to do if I do not like a boy that likes me
At what age I can start having a boyfriend
How a girl can get pregnant
19. Please list all of the ways that you take care of your body.
______
20. If a girl has her period, how often should she change her pad (sanitary napkin)?
I don’t know. Every 2 hours Every 4 hours Every 6 hours Every 12 hrs
21. If a girl has her period, how often should she change her tampon?
I don’t know. Every 2 hours Every 4 hours Every 6 hours Every 12 hrs
22. If you have to change your pad or tampon, when should you wash your hands?
I don’t know. Before After Before and After Never
23. There is a thin piece of tissue (hymen) that covers the vagina. A girl is still a virgin even if it tears accidentally.
I don’t know. True False
24. A girl can get pregnant even if she has sex standing up. I don’t know. True False
25. A guy can tell whether or not a girl is a virgin by the way she walks. I don’t know. True False
26. A girl can get pregnant if she has sex in the water. I don’t know. True False
27. A girl will never get pregnant the first time she has sex. I don’t know. True False
28. Girls should not swim when they are on their period. I don’t know. True False
29. A girl can get pregnant during her period. I don’t know. True False
30. If a girl misses her period, she is definitely pregnant. I don’t know. True False
31. HIV (Human Immunodeficiency Virus) is a virus that can be cured with treatment. I don’t know. True False
32. You can get HIV/STDs (Sexually Transmitted Diseases) through vaginal intercourse (i.e. sex, sexual intercourse, relaciones sexuales). I don’t know. True False
33. Abstinence (not having sex) is the only way to protect you from HIV/STDs. I don’t know. True False
34. Condoms will protect you 100% of the time from getting HIV/STDs. I don’t know. True False
35. There is a risk of getting HIV if you get a tattoo. I don’t know. True False
36. There is a risk of getting HIV if you have a cut and come in contact with infected blood. I don’t know. True False
37. What would you like to learn during this workshop?
______
Thank you for completing ALL questions on the survey!
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