Sexual Behavior Questionnaire

Sexual Behavior Questionnaire

1. consent

Informed Consent Protocol Title: The Association between School-Based Sex Education Programs and Adolescents' Contraceptive Use

Please read this consent document carefully before you decide to participate in this study.

Purpose of the research study: To determine the association between school-based sex education programs and the contraceptive use among adolescents.

What you will be asked to do in the study: You will be asked to answer approximately thirty-four questions on a questionnaire.

Time required: 20-45 minutes

Risks and Benefits: You may experience emotions regarding your sexual behavior. There are no potential benefits to participating in this study.

Compensation: There is no financial compensation for participating in this research.

Confidentiality: Your identity will be kept confidential to the extent provided by law. No identifying information will be obtained for you, with the website being a secured site so that your answers may not be traced back to you.

Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. Whom to contact if you have questions about the study: Caroline Payne, Graduate Student, Department of Family, Youth and Community Sciences, 352-353-5105 Rose Barnett, Associate Professor, Department of Family, Youth and Community Sciences, (352) 273-3519 Whom to contact about your rights as a research participant in the study: IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; phone 392-0433.

* 1. Agreement:

I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description.

nmlkj agree

n m l k j disagree

* 2. If you are under the age of 18 parental consent is needed and therefore you may

not participate in this study.

I hereby certify that I am 18 years of age or older.

nmlkj yes nmlkj no

Page 1

Sexual Behavior Questionnaire

2. Demographics

3. Are you:

nmlkj male

4. How old are you?

n m l k j female

5. Please select your ethnicity ( all that apply)

gfedc White gfedc Black or African American gfedc American Indian or Alaska Native gfedc Asian gfedc Native Hawaiian or Other Pacific Islander gfedc Other

6. Current UF GPA:

nmlkj 3.6-4.0 nmlkj 3.0-3.59 nmlkj 2.5-2.9 nmlkj 2.0-2.49 nmlkj below 2.0

7. Who do you live with: (please select all that apply)

gfedc No one I live alone gfedc Roommates (no relatives) gfedc Siblings/ Relatives gfedc My Child(ren) gfedc Parent(s)or guardian(s) gfedc Spouse or significant other

8. Martial Status:

nmlkj Single nmlkj Married nmlkj Divorced nmlkj Widowed

Page 2

Sexual Behavior Questionnaire

9. Mother/mother-figure's marital status:

nmlkj Single nmlkj Married nmlkj Divorced nmlkj Widowed

10. Father/Father figure's marital status:

nmlkj Single nmlkj Married nmlkj Divorced nmlkj Widowed

11. My partner(s) are:

nmlkj Male nmlkj Female nmlkj Both

12. Was your father part of your life during your teenage years?

nmlkj always

nmlkj often

n m l k j some

n m l k j rarely

13. Was your mother part of your life during your teenage years?

nmlkj always

nmlkj often

n m l k j some

n m l k j rarely

n m l k j never n m l k j never

Page 3

Sexual Behavior Questionnaire

3. Sexual Behavior Questions

For the following questions please either select the best answer or fill in the blank.

14. Have you been sexually active in the past year (sexual activity refers to any type of genital contact or sexual stimulation between two persons including, but not limited to sexual intercourse)?

nmlkj Yes

n m l k j No

15. If you are sexually active or have ever been sexually active, how many partners have you had total?

nmlkj 1-2

n m l k j 3-5

n m l k j 6-9

n m l k j more than 10

16. Have you ever had sexual intercourse while under the influence of drugs or alcohol?

nmlkj always

nmlkj often

n m l k j sometimes

n m l k j rarely

n m l k j never

17. Have you ever had oral sex while under the influence of drugs or alcohol?

nmlkj always

nmlkj often

n m l k j sometimes

n m l k j rarely

n m l k j never

18. Have you or one of your sexual partners ever become pregnant?

nmlkj Yes

nmlkj No

n m l k j Not that I am aware of

19. If you answered yes to question 18, how long had you and your partner been sexually active at the time of conception?

nmlkj less than a month nmlkj 2-3 months nmlkj 4-6 months nmlkj 6 months to a year nmlkj longer than a year

20. If you answered yes to question 18, what decision did you and/or your partner make regarding the pregnancy?

nmlkj kept the baby nmlkj abortion nmlkj adoption nmlkj other

Page 4

Sexual Behavior Questionnaire

4. Sexual Behaviors

21. Please indicate on a scale of Never to Daily how often you engage in the

following sexual behaviors.

Never

Few times in life

Few times a year

Few times a Once a week

month

Few times a week

Kissing

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

French Kissing

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

Touching a partner's breast

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

or having your breast

touched by a partner

Stimulating a partner's

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

penis or having your penis

stimulated by a partner

Stimulating a partner's

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

vagina or having your

vagina stimulated by a

partner

Performing oral sex

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

Receiving oral sex

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

Sexual intercourse

nmlkj

n m l k j

n m l k j

n m l k j

n m l k j

n m l k j

Daily

n m l k j n m l k j n m l k j

n m l k j

n m l k j

n m l k j n m l k j n m l k j

Page 5

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download