CHILD MAIN INTERVIEW QUESTIONNAIRE Table of Contents INTRODUCTION (AGES 0-4) AND PHYSICAL MEASUREMENTS (CM) . . . . . . . . Child 1 INTRODUCTION (AGES 10-14) AND PHYSICAL MEASUREMENTS (KA) . . . . . . . Child 3 AGES AND STAGES (XA-XC, XY, XD, XZ, XE-XI) . . . . . . . . . . . . . . . . . . . . . . . . . Child 5 WOODCOCK-JOHNSON (LW, AP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 6 SCHOOLING (SC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 7 CHILD-MOTHER RELATIONSHIP SCALE (ACASI) (MR) . . . . . . . . . . . . . . . . . . . Child 14 MOTHER-CHILD ACTIVITIES (ACASI) (YM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 18 PARENTAL MONITORING (ACASI) (MO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 21 FATHER INVOLVEMENT (ACASI) (FA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 24 FATHER-CHILD RELATIONSHIP (ACASI) (FR) . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 26 DELINQUENCY SCALE (ACASI) (DS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 30 SEX AND PREGNANCY (ACASI) (SX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 34 BRIEF SYMPTOM INVENTORY (ACASI) (YS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child 39
INTRODUCTION (AGES 0-4) AND PHYSICAL MEASUREMENTS >Y_CM_BEG
Y_CM1< [IF PRIMARY CAREGIVER INTERVIEW COMPLETED] Before we start this next section, I need to ask a few more questions about [CHILD]. [IF PRIMARY CAREGIVER INTERVIEW NOT COMPLETED] Before we start this first section, I need to ask a few questions about [CHILD]. What is [CHILD]'s date of birth? MONTH _____ DAY _____ YEAR _____ >Y_CM2< Was [CHILD] born within a week of [his/her] expected due date? 1=YES –> go to CM5 2=NO >Y_CM3< Was [CHILD] born early or late? 1=EARLY 2=LATE >Y_CM4< How many weeks [early/late] was [he/she]? WEEKS _____
Child 1
>Y_CM5< [IF CHILD’S AGE IS LESS THAN OR EQUAL TO 1] As part of this study, we'd like to find out how tall [CHILD] is, how much [he/she] weighs, and the size around [his/her] head. Let's start with height. [IF CHILD’S AGE IS GREATER THAN 1] As part of this study, we'd like to find out how tall [CHILD] is and how much [he/she] weighs. Let's start with height. MEASURE AND RECORD HEIGHT: FEET _____ INCHES _____ >Y_CM6< MEASURE AND RECORD WEIGHT: POUNDS _____ >Y_CM7
Y_KA_BEG
Y_KA1< INTERVIEWER: OBTAIN CHILD'S ASSENT USING THE FOLLOWING SCRIPT: You are being asked to complete this interview for a project which is trying to find out how children and their parents are doing and what kind of help they need. We are interviewing both mothers and children. In order for this project to be helpful, just answer the questions based on what you really believe, know, and do. Don't pick an answer because you think that's what someone wants you to say. The answers you give will be kept totally private. This means that your answers will NOT be connected with your name or with anything else that identifies you. No one, including your parent(s), will ever know your answers. >Y_KA2a< The interview will take about an hour to complete. For taking the time to do this we will pay you $10. For most of the questions, I will ask you the question and then enter your answer into the computer. For some questions, however, I will ask you to listen to the question over a pair of headphones, and you will enter your answer into the computer yourself. I will explain how to do this when we get to that part. >Y_KA2b< Completing this interview is up to you and you will not be affected in any way, good or bad. Some of the questions may seem personal or embarrassing, for example, some questions will ask about sexual experiences and other types of behaviors; but you will be using the computer yourself to answer these questions. You don't have to answer any question you don't want to and, if at anytime you do not want to finish the interview, just let me know. Your parent or guardian has signed a consent form saying that you can decide for yourself whether or not you want to do this interview. If you do not want to do this interview, or if you have any questions, please let me know now; otherwise, please sign your name at the bottom of this form.
Child 3
>Y_KA2c< HAVE CHILD SIGN CONSENT FORM READ, IF NECESSARY: If you have questions, you may call RTI at 1-800-647-9670. If you have questions related to your rights as a participant, you may call Steve Garfinkel, the chair of the RTI Human Subjects Committee, at 1-800-334-8571. >Y_KA3< First, as part of this study, we'd like to find out how tall you are and how much you weigh. Let's start with height. MEASURE AND RECORD HEIGHT: FEET _____ INCHES _____ >Y_KA4< MEASURE AND RECORD WEIGHT: POUNDS _____
End of the Introduction (Ages 10-14)
Child 4
AGES AND STAGES AGES AND STAGES QUESTIONNAIRES: A PARENT-COMPLETED, CHILD-MONITORING SYSTEM. JANE SQUIRES, LAWANDA POTTER, DIANE BRICKER. SECOND EDITION, COPYRIGHT 1999, BROOKES PUBLISHING CO., P.O. BOX 10624, BALTIMORE, MD 21285. THIS PARENT-REPORT MEASURE COVERS FIVE AREAS OF EARLY CHILD DEVELOPMENTAL SKILLS: COMMUNICATION, GROSS MOTOR, FINE MOTOR, PROBLEM SOLVING, AND PERSONAL-SOCIAL. THE MEASURE IS GIVEN TO PARENTS OF CHILDREN AGE 3 MONTHS TO 2 YEARS. Section XA for children ages 3 to 5 months Section XB for children ages 5 to 7 months Section XC for children ages 7 to 9 months Section XY for children ages 9 to 11 months Section XD for children ages 11 to 13 months Section XZ for children ages 13 to 15 months Section XE for children ages 15 to 17 months Section XF for children ages 17 to 19 months Section XG for children ages 19 to 21 months Section XH for children ages 21 to 23 months Section XI for children ages 23 to 24 months
( 91 - 154 days) (155 - 210 days) (211 - 273 days) (274 - 336 days) (337 - 392 days) (393 - 455 days) (456 - 518 days) (519 - 574 days) (575 - 637 days) (638 - 700 days) (701 days but less than 2 years old)
Child 5
WOODCOCK-JOHNSON WOODCOCK-JOHNSON PSYCHO-EDUCATIONAL BATTERY, REVISED. COPYRIGHTED 1989 BY THE RIVERSIDE PUBLISHING COMPANY, ITASCA, IL. TWO SUBSETS OF THE STANDARD BATTERY OF THE TESTS OF ACHIEVEMENT, THE LETTER-WORD IDENTIFICATION AND APPLIED PROBLEMS, ARE ADMINISTERED TO CHILDREN AGES 2 AND ABOVE. Section LW – Letter-Word Identification Section AP – Applied Problems
Child 6
SCHOOLING >Y_SC_BEG
Y_SC1< These next questions are about your school and after school activities. Are you currently enrolled in school? 1 = YES –> go to SC3 2 = NO >Y_SC2< Why are you not attending school? 1= 2= 3= 4= 5= 6= 7= 8= 9=
ON SUMMER BREAK DROPPED OUT - DISLIKED SCHOOL — — DROPPED OUT - PREGNANT/HAD BABY DROPPED OUT TO GET A JOB DROPPED OUT TO JOIN THE MILITARY EXPELLED OR SUSPENDED HEALTH PROBLEMS MOVED AROUND TOO MUCH OTHER (SPECIFY) — — — — — — — — —
| | | | - go to | SC5 | | |
>Y_SC2a< Will you be attending school in September? 1 = YES 2 = NO
Child 7
>Y_SC3< [IF CHILD ON SUMMER BREAK (SC2 = 1)] During the school year, did you attend an elementary school, middle school, junior high, high school or some other type of school? [IF CURRENTLY ATTENDING SCHOOL (SC1=1)] Do you attend an elementary school, middle school, junior high, high school or some other type of school? 1= 2= 3= 4= 5=
ELEMENTARY SCHOOL MIDDLE SCHOOL JUNIOR HIGH HIGH SCHOOL SOME OTHER TYPE OF SCHOOL (SPECIFY)
>Y_SC4< [IF CHILD ON SUMMER BREAK (SC2 = 1)] During the past school year, what grade were you in? [IF CURRENTLY ATTENDING SCHOOL (SC1=1)] What grade or year are you currently in? 1= 2= 3= 4= 5= 6=
FIRST SECOND THIRD FOURTH FIFTH SIXTH
7= 8= 9= 10 = 11 =
SEVENTH EIGHTH NINTH TENTH ELEVENTH 12 = TWELFTH
>Y_SC5< The last time you got a report card, what were your grades? 1= 2= 3= 4= 5= 6= 7= 8= 9=
MOSTLY A's — — — — | MOSTLY A's AND B's | MOSTLY B's | MOSTLY B's AND C's | - go to MOSTLY C's | SC6 MOSTLY C's AND D's | MOSTLY D's | MOSTLY FAILING — — | R'S SCHOOL DOES NOT GIVE LETTER GRADES
Child 8
>Y_SC5A< Overall, how would you say you are doing in school? Would you say... 1= 2= 3= 4= 5=
Very well, well, average, below average, or not well at all?
>Y_SC6< Were you ever held back a year or made to repeat a grade? 1 = YES 2 = NO –> go to SC7 >Y_SC6B< Which grades? CODE ALL THAT APPLY 55= KINDERGARTEN 1 = FIRST 2 = SECOND 3 = THIRD 4 = FOURTH 5 = FIFTH 6 = SIXTH 7 = SEVENTH 8 = EIGHTH 9 = NINTH 10 = TENTH 11 = ELEVENTH 12 = TWELFTH F3 = DON'T KNOW F4 = REFUSED >Y_SC6_CK< CHECKPOINT - REPEATED GRADES HIGHER THAN CURRENT GRADE The computer has recorded that you were held back or made to repeat [SC6B] grade(s), but that you are currently in [SC4] grade. Which information needs to be corrected? 1 = BOTH ARE CORRECT 2 = GRADE HELD BACK IS INCORRECT –> go back to SC6B 3 = GRADE CURRENTLY IN IS INCORRECT –> go back to SC4
Child 9
>Y_SC7< In the past 12 months, have you been elected officer of a school class or of a school club? 1 = YES 2 = NO >Y_SC8< In the past 12 months, have you received an award or recognition for your school grades or performance? 1 = YES 2 = NO >Y_SC9< In the past 12 months, have you received an award or letter for sports, music or art? 1 = YES 2 = NO >Y_SC10< In the past 12 months, have you played on any sports teams through school or through a community group? 1 = YES 2 = NO >Y_SC11< In the past 12 months, have you taken art or music lessons outside of school? 1 = YES 2 = NO >Y_SC12< In the past 12 months, have you participated in after-school or summertime clubs or programs either at school or in your community? 1 = YES 2 = NO
Child 10
>Y_SC13< In the past 12 months, have you attended a YMCA or Boys/Girls Club or other community place for kids? 1 = YES 2 = NO >Y_SC14< Now I'd like you to think about your future. How far do you expect to get in school? Do you think you will... 1= 2= 3= 4= 5= 6= 7=
not finish high school, get a GED, graduate from high school, get training after high school, get a 2-year college degree, get a 4-year college degree, go to a professional school after college such as law school or medical school?
>Y_SC15< Do you have a regular job or work that you get paid for? This could include a formal job, such as at a restaurant, or informal work like babysitting, doing hair, or yard work. 1 = YES 2 = NO –> go to SC20A >Y_SC16A< What type of work do you do? 1 = CLEANING/MAINTENANCE/YARD WORK 2 = BABYSITTING 3 = DOING HAIR/NAILS 4 = DELIVERING PAPERS 5 = SERVICE WORK IN RESTAURANT 6 = OTHER (SPECIFY)
Child 11
>Y_SC16B< Where do you work? 1= 2= 3= 4= 5= 6=
OWN HOME RELATIVE'S HOME NEIGHBOR’S HOME RESTAURANT OFFICE OTHER (SPECIFY)
>Y_SC17< How many hours per week do you usually work? HOURS _____ >Y_SC18< How much do you get paid? DOLLARS _____ per: 1 = HOUR 2 = WEEK >Y_SC19< Do you give any of your earnings to your household? 1 = YES 2 = NO –> go to SC20a >Y_SC20< How much do you usually give? DOLLARS _____ per: 1 = DAY 2 = WEEK 3 = MONTH
Child 12
>Y_SC20a
go to SC21 >Y_SC20b< How many hours per week did you usually work during the school year? HOURS _____ >Y_SC21< In the past 12 months, how often have you gone to church or attended religious services? Would you say... 1= 2= 3= 4= 5= 6=
never in the past 12 months, several times in the past 12 months, once a month, several times a month, once a week, or more than once a week?
>Y_SC22< How important is religion or God in your life? Would you say it is... 1= 2= 3= 4=
not important, a little important, pretty important, or very important?
End of Schooling Section
Child 13
CHILD-MOTHER RELATIONSHIP SCALE (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_MR_BEG
Y_MR8< I tell my [RELATIVE] about my problems and troubles. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_MR9< I feel angry with my [RELATIVE]. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_MR10< I get a lot of attention from my [RELATIVE]. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
Child 16
>Y_MR11< I trust my [RELATIVE]. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_MR12< My [RELATIVE] doesn't understand what I'm going through these days. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
End of the Child-Mother Relationship Scale
Child 17
MOTHER-CHILD ACTIVITIES (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_YM_BEG
Y_YM2< During the past school year, how often has your [RELATIVE] talked to you about what you were learning in school or how you did on a test? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
Child 18
>Y_YM3< During the past school year, how often has your [RELATIVE] helped you with your homework or with studying? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
>Y_YM4< During the past 12 months, how often has your [RELATIVE] scolded or yelled at you? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
>Y_YM5< During the past 12 months, how often has your [RELATIVE] spanked or hit you? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
>Y_YM6< During the past 12 months, how often has your [RELATIVE] threatened to spank or hit you? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
Child 19
>Y_YM9< During the past 12 months, how often has your [RELATIVE] told you she would punish you if you didn't behave? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
>Y_YM10< During the past 12 months, how often has your [RELATIVE] threatened to put you out of the house? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
End of the Mother-Child Activities Section
Child 20
PARENTAL MONITORING (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_MO_BEG
Y_MO4< How much does your [RELATIVE] know about where you are most afternoons after school? 1 = doesn't know 2 = knows a little 3 = knows a lot
Child 22
>Y_MO5< How much does your [RELATIVE] know about where you go at night? 1 = doesn't know 2 = knows a little 3 = knows a lot >Y_MO6< How much does your [RELATIVE] know about what you do with your free time? 1 = doesn't know 2 = knows a little 3 = knows a lot >Y_MO7< How much does your [RELATIVE] know about how you spend your money? 1 = doesn't know 2 = knows a little 3 = knows a lot
End of the Parental Monitoring Section
Child 23
FATHER INVOLVEMENT (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_FA_BEG
Y_FA1< Now I'd like to talk about your father, that is, your natural or biological father. >Y_FA2< Is your biological father still alive? 1 = Yes 2 = No –> go to the end of the Father Involvement Section >Y_FA2a< Does your biological father live in your household with you? 1 = Yes –> go to FA15 2 = No >Y_FA3< In the past 12 months, how often have you seen your father? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
>Y_FA4< In the past 12 months, how often have you talked to your father on the phone or communicated in other ways when you weren't with him? 1= 2= 3= 4= 5=
never in the past 12 months a few times once a month or more once a week or more almost every day
Child 24
>FA5_FC
Y_FA15< How often can you count on your father if you need him for something? 1= 2= 3= 4= 5=
never rarely sometimes usually always
>Y_FA16< How often can you find your father pretty quickly if you want to talk to him? 1= 2= 3= 4= 5=
never rarely sometimes usually always
End of the Father Involvement Section
Child 25
FATHER-CHILD RELATIONSHIP (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_FR_BEG
Y_FR1< The following statements are about your feelings about your father. For each item, please tell me how true that statement is for you. My father accepts me as I am. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR2< I like to get my father's point of view on things I'm concerned about. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR3< Talking over my problems with my father makes me feel ashamed or foolish. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
Child 26
>Y_FR4< My father expects too much of me. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR5< I get upset a lot more than my father knows about. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR6< When we discuss things, my father cares about my point of view. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR7< My father has his own problems, so I don't bother him with mine. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
Child 27
>Y_FR8< I tell my father about my problems and troubles. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR9< I feel angry with my father. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR10< I get a lot of attention from my father. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
>Y_FR11< I trust my father. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
Child 28
>Y_FR12< My father doesn't understand what I'm going through these days. 1= 2= 3= 4= 5=
never true rarely true sometimes true often true always true
End of the Father-Child Relationship Section
Child 29
DELINQUENCY SCALE (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_DS0_FC
Y_DS1< These next questions are about things you may or may not have done in the past 12 months. In the past 12 months, how often have you copied homework or a class assignment from somebody else? 1= 2= 3= 4=
never once or twice several times often
>Y_DS2< In the past 12 months, how often have you been given detention or made to stay after school? 1= 2= 3= 4=
never once or twice several times often
>Y_DS3< In the past 12 months, how often have you cheated on a class test? 1= 2= 3= 4=
never once or twice several times often
>Y_DS4< In the past 12 months, how often have you been suspended or expelled from school? 1= 2= 3= 4=
never once or twice several times often
Child 30
>Y_DS5< In the past 12 months, how often have you smoked cigarettes or used chewing tobacco? 1= 2= 3= 4=
never once or twice several times often
(No item DS6) >Y_DS7< In the past 12 months, how often have you stolen something from a store or another person? 1= 2= 3= 4=
never once or twice several times often
>Y_DS8< In the past 12 months, how often have you gotten in trouble with the police? 1= 2= 3= 4=
never once or twice several times often
>Y_DS9< In the past 12 months, how often have you carried a weapon? 1= 2= 3= 4=
never once or twice several times often
>Y_DS10< In the past 12 months, how often have you used a phony ID? 1= 2= 3= 4=
never once or twice several times often
Child 31
>Y_DS11< In the past 12 months, how often have you gotten drunk? 1= 2= 3= 4=
never once or twice several times often
>Y_DS12< In the past 12 months, how often have you run away from home? 1= 2= 3= 4=
never once or twice several times often
>Y_DS13< In the past 12 months, how often have you skipped a full day of school or work without an excuse? 1= 2= 3= 4=
never once or twice several times often
>Y_DS14< In the past 12 months, how often have you purposely damaged or destroyed property that did not belong to you? 1= 2= 3= 4=
never once or twice several times often
>Y_DS15< In the past 12 months, how often have you gotten into a physical fight? 1= 2= 3= 4=
never once or twice several times often
Child 32
>Y_DS16< In the past 12 months, how often have you attacked someone with the idea of seriously hurting or killing them? 1= 2= 3= 4=
never once or twice several times often
>Y_DS17< In the past 12 months, how often have you smoked marijuana or hashish (pot, grass, hash)? 1= 2= 3= 4=
never once or twice several times often
>Y_DS18< In the past 12 months, how often have you used hard drugs such as heroin, cocaine, or LSD? 1= 2= 3= 4=
never once or twice several times often
End of the Delinquency Section
Child 33
SEX AND PREGNANCY (ACASI) NOTE:
THIS SECTION IS ADMINISTERED IN AUDIO-CASI.
>Y_SX_BEG
Y_SXIN< These next questions are about sexual intercourse. Sometimes this is called "having sex", "making love" or "going all the way". Remember there are no right or wrong answers, and no one else will be able to see the answers you give. >Y_SX1< Have you ever had sexual intercourse? 1 = Yes 2 = No –> go to SX14 >Y_SX2< How old were you the first time you had sexual intercourse? YEARS _____ >Y_SX3< When you had sexual intercourse for the first time, how old was your partner? YEARS _____ >Y_SX4< The last time you had sexual intercourse, how old was your partner? YEARS _____ >Y_SX5< How long ago was the last time you had sexual intercourse? 1= 2= 3= 4=
within the past 30 days 1-6 months ago 7-12 months ago more than a year ago –> go to SX10
Child 34
>Y_SX6< About how many times have you had sexual intercourse in the past 12 months? 1 = Once –> go to SX9A 2 = Twice 3 = 3-10 times 4 = 11-25 times 5 = 26-100 times 6 = More than 100 times >Y_SX7< How many different partners have you had sexual intercourse with within the past 12 months? 1 = One 2 = Two 3 = 3-5 4 = 6-10 5 = 11-20 6 = More than 20 >Y_SX8A< When you had sexual intercourse in the past 12 months, how often did you or your partner use withdrawal or "pulling out" as a birth control method? 1= 2= 3= 4= 5=
Never in the past 12 months Less than half the time About half of the time More than half the time Always
>Y_SX8B< When you had sexual intercourse in the past 12 months, how often did you or your partner use the rhythm or "safe period" method for birth control? 1= 2= 3= 4= 5=
Never in the past 12 months Less than half the time About half of the time More than half the time Always
Child 35
>Y_SX8C< When you had sexual intercourse in the past 12 months, how often did you or your partner use a condom? 1= 2= 3= 4= 5=
Never in the past 12 months Less than half the time About half of the time More than half the time Always
>Y_SX8D< When you had sexual intercourse in the past 12 months, how often did you or your partner use some other type of birth control device or medicine, such as the pill, a diaphragm, an IUD, or NORPLANT? 1= 2= 3= 4= 5=
Never in the past 12 months Less than half the time About half of the time More than half the time Always
>Y_SX8E< When you had sexual intercourse in the past 12 months, how often did you or your partner have unprotected sex without using any type or method of birth control? 1= 2= 3= 4= 5=
Never in the past 12 months –| Less than half the time | About half of the time | – go to SX10 More than half the time | Always — ———–|
>Y_SX9A< Did you or your partner use withdrawal or "pulling out" as a method of birth control? 1 = Yes 2 = No >Y_SX9B< Did you or your partner use the rhythm or "safe period" method for birth control? 1 = Yes 2 = No Child 36
>Y_SX9C< Did you or your partner use a condom? 1 = Yes 2 = No >Y_SX9D< Did you or your partner use any other type of birth control device or medicine, such as the pill, a diaphragm, an IUD, or NORPLANT? 1 = Yes 2 = No >Y_SX10< [FOR MALES] Have you ever gotten a girl pregnant? [FOR FEMALES] Have you ever been pregnant? 1 = Yes 2 = No –> go to SX14 >Y_SX11< [FOR MALES] How many times have you gotten a girl pregnant? [FOR FEMALES] How many times have you been pregnant? NUMBER _____ >Y_SX12< [FOR MALES] What happened with the first pregnancy you were responsible for? [FOR FEMALES] What happened with your first pregnancy? 1= 2= 3= 4= 5=
Live birth —| Still birth | - go to Miscarriage | SX12FC Abortion — –| Still pregnant
>Y_SX12A< [FOR MALES] In what month is the girl due? [FOR FEMALES] In what month are you due? MONTH _____ Child 37
>Y_SX12FC
Y_SX13< [FOR MALES] What happened with the next pregnancy you were responsible for? [FOR FEMALES] What happened with your next pregnancy? 1= 2= 3= 4= 5=
Live birth —| Still birth | - ask SX13 for next Miscarriage | pregnancy or go to SX14 Abortion — –| Still pregnant
>Y_SX13a< [FOR MALES] In what month is the girl due? [FOR FEMALES] In what month are you due? MONTH _____ >Y_SX14< Has anyone - a stranger, friend, acquaintance, date, or relative - ever tried or succeeded in doing something sexual to you or making you do something sexual to them against your wishes? 1 = Yes 2 = No –> go to the end of the Sex and Pregnancy Section >Y_SX15< About how many times has this happened? 1= 2= 3= 4=
Once Twice Three times Four or more times
>Y_SX16< How old were you the first time this happened? YEARS _____ End of the Sex and Pregnancy Section Child 38
BRIEF SYMPTOM INVENTORY (ACASI) THIS SECTION IS ADMINISTERED IN AUDIO-CASI. THE 18-ITEM VERSION OF THE BRIEF SYMPTOM INVENTORY (ORIGINAL COPYRIGHT 1982, ADAPTED VERSION 1988) BY LEONARD R. DEROGATIS, PHD. ALL RIGHTS RESERVED, BY NATIONAL COMPUTER SYSTEMS, INC. LICENSED THROUGH NATIONAL COMPUTER SYSTEMS, INC. THE 18-ITEM VERSION (ITEMS YS1 - YS18) OF THE BRIEF SYMPTOM INVENTORY INCLUDES SUBSCALES OF DEPRESSION, ANXIETY, AND SOMATIZATION. CHILDREN AGE 10 AND ABOVE ARE GIVEN THIS SECTION. A:\child.wpd June 3, 1999
Child 39
