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CHILD MAIN INTERVIEW QUESTIONNAIRETable of Contents

INTRODUCTION (AGES 0-4) AND PHYSICAL MEASUREMENTS (CM)..................Child 2

INTRODUCTION (AGES 10-14) AND PHYSICAL MEASUREMENTS (KA)...............Child 4

AGES AND STAGES (XA-XC, XY, XD, XZ, XE-XI).....................................................Child 6

WOODCOCK-JOHNSON (LW, AP).................................................................................Child 7

SCHOOLING (SC)............................................................................................................ Child 8

CHILD-MOTHER RELATIONSHIP SCALE (ACASI) (MR)........................................Child 15

MOTHER-CHILD ACTIVITIES (ACASI) (YM)............................................................Child 19

PARENTAL MONITORING (ACASI) (MO)..................................................................Child 22

FATHER INVOLVEMENT (ACASI) (FA).....................................................................Child 25

FATHER-CHILD RELATIONSHIP (ACASI) (FR)........................................................Child 27

DELINQUENCY SCALE (ACASI) (DS)........................................................................Child 31

SEX AND PREGNANCY (ACASI) (SX)........................................................................Child 35

BRIEF SYMPTOM INVENTORY (ACASI) (YS)..........................................................Child 40

INTRODUCTION (AGES 0-4) AND PHYSICAL MEASUREMENTS

>Y_CM_BEG< THIS SECTION IS FOR CHILDREN AGE 5 OR YOUNGER

>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 B> 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 2

>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< IF CHILD=S AGE IS LESS THAN OR EQUAL TO 1

MEASURE HEAD CIRCUMFERENCE: INCHES _____

End of the Introduction (Age 0-4) and Physical Measurements

Child 3

INTRODUCTION (AGES 10-14) AND PHYSICAL MEASUREMENTS

>Y_KA_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

>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.

>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)

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 ( 91 - 154 days)Section XB for children ages 5 to 7 months (155 - 210 days)Section XC for children ages 7 to 9 months (211 - 273 days)Section XY for children ages 9 to 11 months (274 - 336 days)Section XD for children ages 11 to 13 months (337 - 392 days)Section XZ for children ages 13 to 15 months (393 - 455 days)Section XE for children ages 15 to 17 months (456 - 518 days)Section XF for children ages 17 to 19 months (519 - 574 days)Section XG for children ages 19 to 21 months (575 - 637 days)Section XH for children ages 21 to 23 months (638 - 700 days)Section XI for children ages 23 to 24 months (701 days but less than 2 years old)

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 B Letter-Word IdentificationSection AP B Applied Problems

SCHOOLING

>Y_SC_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

>Y_SC1<

These next questions are about your school and after school activities.

Are you currently enrolled in school?

1 = YES B> go to SC3 2 = NO

>Y_SC2<

Why are you not attending school?

1 = ON SUMMER BREAK 2 = DROPPED OUT - DISLIKED SCHOOL C C | 3 = DROPPED OUT - PREGNANT/HAD BABY | 4 = DROPPED OUT TO GET A JOB | 5 = DROPPED OUT TO JOIN THE MILITARY | - go to 6 = EXPELLED OR SUSPENDED | SC5 7 = HEALTH PROBLEMS | 8 = MOVED AROUND TOO MUCH | 9 = OTHER (SPECIFY) C C C C C C C C C |

>Y_SC2a<

Will you be attending school in September?

1 = YES 2 = NO

>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 = ELEMENTARY SCHOOL 2 = MIDDLE SCHOOL 3 = JUNIOR HIGH 4 = HIGH SCHOOL 5 = 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 = FIRST 7 = SEVENTH 2 = SECOND 8 = EIGHTH 3 = THIRD 9 = NINTH 4 = FOURTH 10 = TENTH 5 = FIFTH 11 = ELEVENTH 6 = SIXTH 12 = TWELFTH

>Y_SC5<

The last time you got a report card, what were your grades?

1 = MOSTLY A's C C C C | 2 = MOSTLY A's AND B's | 3 = MOSTLY B's | 4 = MOSTLY B's AND C's | - go to 5 = MOSTLY C's | SC6 6 = MOSTLY C's AND D's | 7 = MOSTLY D's | 8 = MOSTLY FAILING C C | 9 = R'S SCHOOL DOES NOT GIVE LETTER GRADES

>Y_SC5A<

Overall, how would you say you are doing in school? Would you say...

1 = Very well, 2 = well, 3 = average, 4 = below average, or 5 = not well at all?

>Y_SC6<

Were you ever held back a year or made to repeat a grade?

1 = YES 2 = NO B> 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 B> go back to SC6B 3 = GRADE CURRENTLY IN IS INCORRECT B> go back to SC4

>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

>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 = not finish high school, 2 = get a GED, 3 = graduate from high school, 4 = get training after high school, 5 = get a 2-year college degree, 6 = get a 4-year college degree, 7 = 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 B> 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)

>Y_SC16B<

Where do you work?

1 = OWN HOME 2 = RELATIVE'S HOME 3 = NEIGHBOR=S HOME 4 = RESTAURANT 5 = OFFICE 6 = 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 B> go to SC20a

>Y_SC20<

How much do you usually give?

DOLLARS _____

per: 1 = DAY 2 = WEEK 3 = MONTH

>Y_SC20a< ASK THIS ITEM IF CHILD ON SUMMER BREAK (SC2 = 1); ALL OTHERS GO TO SC21

During the past school year, did you work at any type of paying job?

1 = YES 2 = NO B> 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 = never in the past 12 months, 2 = several times in the past 12 months, 3 = once a month, 4 = several times a month, 5 = once a week, or 6 = more than once a week?

>Y_SC22<

How important is religion or God in your life? Would you say it is...

1 = not important, 2 = a little important, 3 = pretty important, or 4 = very important?

End of Schooling Section

CHILD-MOTHER RELATIONSHIP SCALE (ACASI)

NOTE: THIS SECTION IS ADMINISTERED IN AUDIO-CASI.

>Y_MR_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

NOTE: WHERE THE QUESTIONS SAY [RELATIVE], THE FILL WILL BE BASED ON THE ADULT=S REPORT OF HER RELATIONSHIP TO THE FOCAL CHILD (FROM THE DEMOGRAPHICS SECTION). IF THE CHILD=S INTERVIEW IS CONDUCTED BEFORE THE ADULT=S, THE FILL WILL BE BASED ON THE ADOLESCENT=S REPORT OF THE ADULT RESPONDENT=S RELATIONSHIP TO HIM/HER. [THIS IS COLLECTED IN SECTION AK, WHICH IS NOT SHOWN IN THE DOCUMENTATION BECAUSE IT CONTAINS ONLY THE INSTRUCTIONS FOR THE AUDIO-CASI PART OF THE INTERVIEW. THE WORDING FOR ITEM AKIN0 IS: AThe rest of this interview you will be completing on your own. But before you start, I just need to enter [ADULT]'s relationship to you. Please tell me what that relationship is.@ ANSWER CHOICES: mother, step-mother, foster mother, sister, grandmother, aunt, niece, cousin, or caretaker.]

>Y_MRIN<

The following statements ask about your feelings about your [RELATIVE] or the person who is most like a mother to you. For each item, please tell me how true that statement is for you.

>Y_MR1<

My [RELATIVE] accepts me as I am.

1 = never true 2 = rarely true 3 = sometimes true 4 = often true 5 = always true

>Y_MR2<

I like to get my [RELATIVE]'s point of view on things I'm concerned about.

>Y_MR3<

Talking over my problems with my [RELATIVE] makes me feel ashamed or foolish.


>Y_MR4<

My [RELATIVE] expects too much from me.


>Y_MR5Y_MR6<

When we discuss things, my [RELATIVE] cares about my point of view. 1 = never true 2 = rarely true 3 = sometimes true 4 = often true 5 = always true

>Y_MR7<

My [RELATIVE] has her own problems, so I don't bother her with mine. 1 = never true 2 = rarely true 3 = sometimes true 4 = often true 5 = always true

>Y_MR8Y_MR9Y_MR10<

I get a lot of attention from my [RELATIVE].

>Y_MR11Y_MR12<

My [RELATIVE] doesn't understand what I'm going through these days.


End of the Child-Mother Relationship Scale

MOTHER-CHILD ACTIVITIES (ACASI)


>Y_YM_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

NOTE: WHERE THE QUESTIONS SAY [RELATIVE], THE FILL WILL BE BASED ON THE ADULT=S REPORT OF HER RELATIONSHIP TO THE FOCAL CHILD (FROM THE DEMOGRAPHICS SECTION). IF THE CHILD=S INTERVIEW IS CONDUCTED BEFORE THE ADULT=S, THE FILL WILL BE BASED ON THE ADOLESCENT=S REPORT OF THE ADULT RESPONDENT=S RELATIONSHIP TO HIM/HER (ITEM AKIN0 IN A SECTION WHICH INTRODUCES THE ACASI: AThe rest of this interview you will be completing on your own. But before you start, I just need to enter [ADULT]'s relationship to you. Please tell me what that relationship is.@ ANSWER CHOICES: mother, step-mother, foster mother, sister, grandmother, aunt, niece, cousin, or caretaker.)

>Y_YM1<

Now I'd like to ask how often your [RELATIVE] does various things with you.

During the past school year, how often has your [RELATIVE] checked your homework or asked to make sure you had done it?

1 = never in the past 12 months 2 = a few times 3 = once a month or more 4 = once a week or more 5 = almost every day

>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?

>Y_YM3<

During the past school year, how often has your [RELATIVE] helped you with your homework or with studying?


>Y_YM4<

During the past 12 months, how often has your [RELATIVE] scolded or yelled at you?


>Y_YM5<

During the past 12 months, how often has your [RELATIVE] spanked or hit you?


>Y_YM6<

During the past 12 months, how often has your [RELATIVE] threatened to spank or hit you?

>Y_YM9<

During the past 12 months, how often has your [RELATIVE] told you she would punish you if you didn't behave?


>Y_YM10<

During the past 12 months, how often has your [RELATIVE] threatened to put you out of the house?


End of the Mother-Child Activities Section

PARENTAL MONITORING (ACASI)


>Y_MO_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

NOTE: WHERE THE QUESTIONS SAY [RELATIVE], THE FILL WILL BE BASED ON THE ADULT=S REPORT OF HER RELATIONSHIP TO THE FOCAL CHILD (FROM THE DEMOGRAPHICS SECTION). IF THE CHILD=S INTERVIEW IS CONDUCTED BEFORE THE ADULT=S, THE FILL WILL BE BASED ON THE ADOLESCENT=S REPORT OF THE ADULT RESPONDENT=S RELATIONSHIP TO HIM/HER (ITEM AKIN0 IN A SECTION WHICH INTRODUCES THE ACASI: AThe rest of this interview you will be completing on your own. But before you start, I just need to enter [ADULT]'s relationship to you. Please tell me what that relationship is.@ ANSWER CHOICES: mother, step-mother, foster mother, sister, grandmother, aunt, niece, cousin, or caretaker.)

>Y_MO1<

The following questions ask about the rules your [RELATIVE] sets and the decisions she makes with you. [FOR Rs NOT CURRENTLY ENROLLED IN SCHOOL (SC1=2)] In a typical week, what is the latest you can stay out on week nights Sunday through Thursday? [FOR Rs CURRENTLY ENROLLED IN SCHOOL (SC12)] In a typical week, what is the latest you can stay out on school nights, Sunday through Thursday? 1 = As late as I want 2 = Before 8:00 3 = 8:00 to 8:59 4 = 9:00 to 9:59 5 = 10:00 to 10:59 6 = 11:00 or later 7 = I am not allowed out Sunday through Thursday nights

>Y_MO1a< FOR Rs CURRENTLY ON SUMMER BREAK FROM SCHOOL (SC2=1)

During the past school year, how late could you stay out on school nights, Sunday through Thursday?

1 = As late as I want 2 = Before 8:00 3 = 8:00 to 8:59 4 = 9:00 to 9:59 5 = 10:00 to 10:59 6 = 11:00 or later 7 = I am not allowed out Sunday through Thursday nights

>Y_MO2<

In a typical week, what is the latest you can stay out on Friday or Saturday night? 1 = As late as I want 2 = Before 8:00 3 = 8:00 to 8:59 4 = 9:00 to 9:59 5 = 10:00 to 10:59 6 = 11:00 or later 7 = I am not allowed out Friday or Saturday nights

>Y_MO3<

How much does your [RELATIVE] know about who your friends are?

1 = doesn't know 2 = knows a little 3 = knows a lot

>Y_MO4<

How much does your [RELATIVE] know about where you are most afternoons after school?

>Y_MO5<

How much does your [RELATIVE] know about where you go at night?


>Y_MO6<

How much does your [RELATIVE] know about what you do with your free time?


>Y_MO7<

How much does your [RELATIVE] know about how you spend your money?


End of the Parental Monitoring Section

FATHER INVOLVEMENT (ACASI)


>Y_FA_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

>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 B> go to the end of the Father Involvement Section

>Y_FA2a<

Does your biological father live in your household with you?

1 = Yes B> go to FA15 2 = No

>Y_FA3<

In the past 12 months, how often have you seen your father?


>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 = never in the past 12 months 2 = a few times 3 = once a month or more 4 = once a week or more 5 = almost every day

>FA5_FC< IF CHILD HAS NEITHER SEEN (FA3) NOR SPOKEN WITH

(FA4) FATHER IN THE PAST 12 MONTHS, GO TO THE END OF THE FATHER INVOLVEMENT SECTION

(No items FA6 through FA14)

>Y_FA15<

How often can you count on your father if you need him for something? 1 = never 2 = rarely 3 = sometimes 4 = usually 5 = always

>Y_FA16<

How often can you find your father pretty quickly if you want to talk to him?

1 = never 2 = rarely 3 = sometimes 4 = usually 5 = always

End of the Father Involvement Section

FATHER-CHILD RELATIONSHIP (ACASI)


>Y_FR_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE OR OLDER.IF CHILD=S BIOLOGICAL FATHER IS DEAD, SKIP THIS SECTION.

>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.


>Y_FR2Y_FR3<

Talking over my problems with my father makes me feel ashamed or foolish.

>Y_FR4<

My father expects too much of me.


>Y_FR5Y_FR6<

When we discuss things, my father cares about my point of view.


>Y_FR7<

My father has his own problems, so I don't bother him with mine.

>Y_FR8Y_FR9Y_FR10Y_FR11<

I trust my father.

>Y_FR12<

My father doesn't understand what I'm going through these days.


End of the Father-Child Relationship Section

DELINQUENCY SCALE (ACASI)


>Y_DS0_FC< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

>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 = never 2 = once or twice 3 = several times 4 = often

>Y_DS2<

In the past 12 months, how often have you been given detention or made to stay after school?


>Y_DS3<

In the past 12 months, how often have you cheated on a class test? 1 = never 2 = once or twice 3 = several times 4 = often

>Y_DS4<

In the past 12 months, how often have you been suspended or expelled from school?

>Y_DS5<

In the past 12 months, how often have you smoked cigarettes or used chewing tobacco?


(No item DS6)

>Y_DS7<

In the past 12 months, how often have you stolen something from a store or another person?


>Y_DS8<

In the past 12 months, how often have you gotten in trouble with the police?


>Y_DS9<

In the past 12 months, how often have you carried a weapon?


>Y_DS10<

In the past 12 months, how often have you used a phony ID?

>Y_DS11<

In the past 12 months, how often have you gotten drunk?


>Y_DS12<

In the past 12 months, how often have you run away from home?


>Y_DS13<

In the past 12 months, how often have you skipped a full day of school or work without an excuse?


>Y_DS14<

In the past 12 months, how often have you purposely damaged or destroyed property that did not belong to you?


>Y_DS15<

In the past 12 months, how often have you gotten into a physical fight?


>Y_DS16<

In the past 12 months, how often have you attacked someone with the idea of seriously hurting or killing them?


>Y_DS17<

In the past 12 months, how often have you smoked marijuana or hashish (pot, grass, hash)?


>Y_DS18<

In the past 12 months, how often have you used hard drugs such as heroin, cocaine, or LSD?


End of the Delinquency Section

SEX AND PREGNANCY (ACASI)


>Y_SX_BEG< THIS SECTION IS FOR CHILDREN 10 YEARS OF AGE AND OLDER

>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 B> 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 = within the past 30 days 2 = 1-6 months ago 3 = 7-12 months ago 4 = more than a year ago B> go to SX10

>Y_SX6<

About how many times have you had sexual intercourse in the past 12 months?

1 = Once B> 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 = Never in the past 12 months 2 = Less than half the time 3 = About half of the time 4 = More than half the time 5 = 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?

>Y_SX8C<

When you had sexual intercourse in the past 12 months, how often did you or your partner use a condom?


>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?


>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 = Never in the past 12 months B| 2 = Less than half the time | 3 = About half of the time | B go to SX10 4 = More than half the time | 5 = Always C C C C B |

>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

>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 B> 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 = Live birth C| 2 = Still birth | - go to 3 = Miscarriage | SX12FC 4 = Abortion C B| 5 = Still pregnant

>Y_SX12A<

[FOR MALES] In what month is the girl due? [FOR FEMALES] In what month are you due?

MONTH _____

>Y_SX12FC< IF R HAS GOTTEN A GIRL PREGNANT/BEEN PREGNANT ONCE (SX11=1), GO TO SX14. OTHERWISE, ASK SX13 AND SX13a FOR EACH SUBSEQUENT PREGNANCY.

>Y_SX13<

[FOR MALES] What happened with the next pregnancy you were responsible for? [FOR FEMALES] What happened with your next pregnancy?

1 = Live birth C| 2 = Still birth | - ask SX13 for next 3 = Miscarriage | pregnancy or go to SX14 4 = Abortion C B| 5 = 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 B> go to the end of the Sex and Pregnancy Section

>Y_SX15<

About how many times has this happened?

1 = Once 2 = Twice 3 = Three times 4 = Four or more times

>Y_SX16<

How old were you the first time this happened?

YEARS _____

End of the Sex and Pregnancy Section

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.

/tt/file_convert/5f7c29640013cb21260abee9/document.docJune 3, 1999

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