07 EYT Survey A (Ages 10-13) IntroductionYou are being asked to fill out this survey because you are part of the [Empowering Youth Today (EYT) Program]. This survey asks you what you think about your relationships with other people, your future goals and beliefs. You can choose to fill out the survey or not fill out the survey. If you choose not to fill out the survey, it will not affect you in any way. If you fill out the survey, you can skip any question you do not want to answer. You can change your mind about filling out the survey at any time. Your answers will help us to make [EYT] better. No one will know your answers, including parents and teachers. Please do not write your name anywhere on this survey. There are no right or wrong answers. Please read each question carefully. Clearly mark your answer to each question. Mark only one answer for each question or each row in a table unless the question says to select more than one response.1. How old are you?9101112131415161718 or older2. Are you of Hispanic, Latino/a, or Spanish origin? No Yes 3. What is your race? One or more categories my be selected. American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 4. What is your biological sex? Male Female Prefer not to say 5. These questions are about your future. Please circle the response that best describes your feelings.MARK () ONE ANSWER FOR EACH ITEMHow important is it to your family that you continue your education after high school?Not important at allSomewhat importantVery importantExtremely importantHow important is it to you to stay in school?Not important at allSomewhat importantVery importantExtremely importantHow important is it to you to do well in school?Not important at allSomewhat importantVery importantExtremely important6. What is the highest level of schooling you think you’ll finish? Please circle one.Drop out before finishing high schoolGraduate from high schoolFinish a trade/vocational schoolGraduate from a junior collegeGraduate from collegeGraduate from a professional (doctor, lawyer), Masters, or PhD program7. These statements describe a person who may or may not be like you. Please circle the response that tells how well the statement describes you.MARK () ONE ANSWER FOR EACH ITEMIf something matters to me, I commit myself fully and completely to it.Not at all like meA little like meMostly like meVery much like meI keep trying until I achieve my goal.Not at all like meA little like meMostly like meVery much like meWhen something is important to me, I don’t let obstacles discourage me.Not at all like meA little like meMostly like meVery much like me8. How important are each of the following to you in your life?MARK () ONE ANSWER FOR EACH ITEMDoing what I believe is right, even if my friends make fun of me.Not importantSomewhat importantQuite importantExtremely importantStanding up for what I believe, even when it's unpopular to do.Not importantSomewhat importantQuite importantExtremely importantTelling the truth, even when it's not easy.Not importantSomewhat importantQuite importantExtremely importantAccepting responsibility for my actions when I make a mistake or get in trouble.Not importantSomewhat importantQuite importantExtremely importantDoing my best, even when I have a job I don't like.Not importantSomewhat importantQuite importantExtremely important9. Please circle the response that shows how much you agree or disagree with the following statements.MARK () ONE ANSWER FOR EACH ITEMI'm given lots of chances to make my town or city a better place in which to live.Strongly DisagreeDisagreeAgreeStrongly AgreeIn my neighborhood, there are lots of people who care about me.Strongly DisagreeDisagreeAgreeStrongly AgreeIn my town or city, I feel like I matter to people.Strongly DisagreeDisagreeAgreeStrongly Agree10. Think about your relationship with others in this program. Next to each statement below, please circle the response that best applies to your relationship with or involvement with this group.MARK () ONE ANSWER FOR EACH ITEMI feel like I belong in this group.NeverRarelyAbout half the timeMost of the timeAlwaysBeing a part of this group makes me feel good about myself.NeverRarelyAbout half the timeMost of the timeAlwaysPeople in this group support and believe in me.NeverRarelyAbout half the timeMost of the timeAlways11. Please circle the response that shows how strongly do you agree or disagree with the following statements.MARK () ONE ANSWER FOR EACH ITEMHaving a child would make it harder for teens to pay for things like food, clothing, and rent.Strongly DisagreeDisagreeAgreeStrongly AgreeHaving a child would make it harder for teens to continue their education after high school.Strongly DisagreeDisagreeAgreeStrongly Agree12. Please circle the response that shows how much you agree or disagree with the following statements.MARK () ONE ANSWER FOR EACH ITEMI know how to avoid situations that could lead to bad outcomes.Strongly DisagreeDisagreeAgreeStrongly AgreeI am more likely to achieve my goals if I avoid alcohol and drugs.Strongly DisagreeDisagreeAgreeStrongly AgreeI can identify risky behaviors that would make it harder to achieve my goals.Strongly DisagreeDisagreeAgreeStrongly AgreeI am prepared to make good choices to achieve my goals, even when it may be hard.Strongly DisagreeDisagreeAgreeStrongly AgreeI have the skills needed to avoid risky behaviors, like drugs and sexual activity.Strongly DisagreeDisagreeAgreeStrongly Agree13. Please circle the response that shows how much you agree or disagree with the following statements. In a healthy relationship, I have the right:MARK () ONE ANSWER FOR EACH ITEMTo say what I think.Strongly DisagreeDisagreeAgreeStrongly AgreeTo have my own feelings and express them freely.Strongly DisagreeDisagreeAgreeStrongly AgreeTo have my limits and values respected.Strongly DisagreeDisagreeAgreeStrongly AgreeTo refuse affection.Strongly DisagreeDisagreeAgreeStrongly AgreeTo be heard.Strongly DisagreeDisagreeAgreeStrongly AgreeTo have as many friends as I want.Strongly DisagreeDisagreeAgreeStrongly AgreeTo have time by myself.Strongly DisagreeDisagreeAgreeStrongly Agree14. Please circle the response that shows how much you agree or disagree with the following statements. In a healthy relationship, I have the responsibility:MARK () ONE ANSWER FOR EACH ITEMTo communicate clearly and honestlyStrongly DisagreeDisagreeAgreeStrongly AgreeTo determine my limitsStrongly DisagreeDisagreeAgreeStrongly AgreeTo ask for help when I need itStrongly DisagreeDisagreeAgreeStrongly AgreeTo be considerateStrongly DisagreeDisagreeAgreeStrongly AgreeTo set high expectations for myselfStrongly DisagreeDisagreeAgreeStrongly AgreeTo not put myself in situations that would lead to something I might regretStrongly DisagreeDisagreeAgreeStrongly AgreeTo respect other people’s limits and valuesStrongly DisagreeDisagreeAgreeStrongly Agree15. Please circle the response that shows how much you agree or disagree with the following statements.MARK () ONE ANSWER FOR EACH ITEMAfter the program, I am more confident I can make decisions that will make me healthy.Strongly DisagreeDisagreeAgreeStrongly AgreeAfter the program, I am more confident I can identify what is healthy in a relationshipStrongly DisagreeDisagreeAgreeStrongly AgreeThis program helped me develop skills needed to set goals.Strongly DisagreeDisagreeAgreeStrongly AgreeThis program helped me develop skills needed to achieve my goals.Strongly DisagreeDisagreeAgreeStrongly AgreeI was satisfied with the program overall.Strongly DisagreeDisagreeAgreeStrongly Agree
