“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”
Attachment 1d. ACASI Survey-Parents
Form Approved
OMB No. 0920-0840
Expiration Date 01/31/2013
“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”
ACASI Survey-Parents
Public reporting burden of this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)
MOTHER ASSESSMENT
[ALL NOTES FOR THE ACASI PROGRAMMER ARE IN BRACKETS]
[PLEASE ADD “NOT APPLICABLE,” “REFUSE TO ANSWER,” AND “I DON’T KNOW/DO NOT REMEMBER OPTIONS FOR ALL QUESTIONS]
[PLEASE ADD PROMPTS ON A SEPARATE SCREEN FROM THE QUESTIONS]
***FIRST SET OF BACKGROUND QUESTIONS.
1. Age: ____ years
3. Your Ethnicity (cultural background): Check all that apply (If your ethnicity is mixed, indicate approximate percentages or fractions)
__Latino-a/Hispanic (Cuban? YES___;NO___)
__Asian
__African-American
__European/Anglo-American
__Other (specify):_____ [[PLEASE ADD 30 SPACES FOR RESPONSE]
4. Your country of birth:________ [PLEASE ADD 15 SPACES FOR RESPONSE]
5. Mother's country of birth:________ [PLEASE ADD 15 SPACES FOR RESPONSE]
6. Father's country of birth:________ [PLEASE ADD 15 SPACES FOR RESPONSE]
-. My father’s ethnicity is __________________________ [PLEASE ADD 15 SPACES FOR RESPONSE]
-. My mother’s ethnicity is __________________________ [PLEASE ADD 15 SPACES FOR RESPONSE]
7. Answer this section only if you were born in the US (check one):
___I am 1st generation (parents not born in the US)
___2nd generation American (parents born in the US)
___3rd generation American (grandparents born in the US)
___Other (please specify): ________________
8. Approximate total amount of time (indicate months or years) you have lived in: USA
9. Other Country?______(which one-s and for how long). [PLEASE ADD 30 SPACES FOR RESPONSE]
PROMPT: The next few questions are about your relationship with [Name]
16) What is your relationship to {NAME}?
Biological mother (SKIP TO 20)
Biological father (SKIPT TO 17)
Other Relative __________________________________
Foster Parent___________________________________
Friend of Biological Parent _________________________
Other_________________________________________
17) Does {NAME}’s biological mother live in this household?
NO
YES
18) Did {NAME} ever live with (his/her) biological mother?
NO
YES
19) In what year did {NAME} most recently live with (his/her) biological mother?
_______________
20) Does {NAME}’s biological father live in this household?
NO
YES
21) Did {NAME} ever live with (his/her) biological father?
NO
YES
22) In what year did {NAME} most recently live with (his/her) biological father?
______________
Benet-Martinez Acculturation Scale
(Benet-Martinez, 2006)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND INDICATE ANSWER OPTIONS WHERE 1=“LITTLE KNOWLEDGE” TO 6=“PERFECTLY FLUENT”]
[SKIP OUT FOR AFRICAN AMERICAN PARTICIANTS, SECTION A]
PROMPT:
The following questions are about your language use. Please rank your answers from 1 to 6 where 1=little knowledge to 6=perfectly fluent.
A. LANGUAGE USE little knowledge perfectly fluent
1. Rate your overall English language ability (1-6)
2. Rate your overall Spanish language ability (1-6)
3. How much do you use/have you used English to speak with your mother? (1-6)
4. How much do you use/have you used Spanish to speak with your mother? (1-6)
5. How much do you use/have used English to speak with your father? (1-6)
6. How much do you use/have used Spanish to speak with your father? (1-6)
7. How much did you use English in general during childhood and adolescence? (1-6)
8. How much did you use Spanish in general during childhood and adolescence? (1-6)
9. How much have you used English in general as an adult? (1-6)
10 How much have you used Spanish in general as an adult? (1-6)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND INDICATE ANSWER OPTIONS WHERE 1= “NOT AT ALL” TO 6= “ALL THE TIME”]
PROMPT:
The following questions are about your media preferences. Please rank your answers from 1 to 6 where 1=not at all to 6=all the time.
B. MEDIA PREFERENCE
1. How often do you read Anglo (i.e. in English) newspapers/magazines?(1-6)
2. How often do you read Latino newspapers/magazines?(1-6)
3. How often do you watch Anglo (i.e. in English) shows on TV?(1-6)
4. How often do you watch Latino shows on TV?(1-6)
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND INDICATE ANSWER OPTIONS WHERE 1= “STRONGLY AGREE” TO 6= “STRONGLY DISAGREE”]
PROMPT:
We would like to ask you about your cultural identity, that is, the culture(s) you feel you belong to, the culture(s) you share your beliefs and values with. Please tell us how much you agree or disagree with the statements below by circling the appropriate number. Please rate BOTH statements where 1=strongly agree to 6=strongly disagree.
C. CULTURAL IDENTITY
I feel North-American (US):(1-6)
I feel Latino-a:(1-6)
[INCLUDE ALL QUESTIONS FROM THIS SCALE]
PROMPT LATINOS:
As a Latino-a living in the United States, you have been exposed to two cultures: Latino and North American cultures. Thus you could be described as a bi-cultural individual. Please think how much the Latino and North-American cultures feel as SEPARATE or COMBINED cultures for you. Next, read the statements below, think about their meaning carefully, and choose the one that best describes your particular experience. Very important: Choose ONE statement and only one (if both are more or less true, choose the one that is most true to you).
PROMPT AFRICAN AMERICAN:
As an African American/Black person living in the United States, you have been exposed to two cultures: African American and North American or White cultures. Thus you could be described as a bi-cultural individual. Please think how much the African American and North-American cultures feel as SEPARATE or COMBINED cultures for you. Next, read the statements below, think about their meaning carefully, and choose the one that best describes your particular experience. Very important: Choose ONE statement and only one (if both are more or less true, choose the one that is most true to you).
D. WAYS OF BALANCING CULTURES
1. I combine both cultures (e.g., I feel a mixture of North-American and Latino-a most of the time)
2. I keep both cultures separate (e.g., Most of the time I feel North-American in some places and Latino in others)
3. I don't feel caught between the two cultures
4. I feel caught (i.e., conflicted) between two cultures (e.g., I usually feel like I must choose between being North-American OR Latino-a)
5. I feel Latino-a-North American" (i.e., a mixture of all of these)
6. I feel Latino-a in North America
7. I feel as part of a combined culture
8. I feel as someone moving between the two cultures
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY AGREE,” “SOMEWHAT AGREE,” “STRONGLY DISAGREE” AND “SOMEWHAT DISAGREE” AS ANSWERS OPTIONS]
PROMPT:
The following statements are about different ethnic groups, including your own. Please indicate how much you agree or disagree.
Ethnic Identity
***The Multigroup Ethnic Identity Measure
[PROGRAM 30 SPACES FOR RESPONSE]
1. I have spent time trying to find out more about my own ethnic group, such as its history, traditions and customs.
2. I am active in organizations or social groups that include mostly members of my own ethnic group.
3. I have a clear sense of my ethnic background and what it means for me.
4. I like meeting and getting to know people from ethnic groups other than my own.
5. I think a lot about how my life will be affected by my ethnic group membership.
6. I am happy that I am a member of the group I belong to.
7. I sometimes feel it would be better if different ethnic groups didn’t try to mix together.
8. I am not very clear about the role of my ethnicity in my life.
9. I often spend time with people from ethnic groups other than my own.
10. I really have not spent much time trying to learn more about the culture and history of my ethnic group.
11. I have a strong sense of belonging to my own ethnic group.
12. I understand pretty well what my ethnic group membership means to me, in terms of how to relate to my own group and other groups.
13. In order to learn more about my ethnic background, I have often talked to other people about my ethnic group.
14. I have a lot of pride in my ethnic group and its accomplishments.
15. I don’t try to become friends with people from other ethnic groups.
16. I participate in cultural practices of my own group, such as special food, music and customs.
17. I am involved in activities with people from other ethnic groups.
18. I feel a strong attachment towards my own ethnic group.
19. I enjoy being around people from ethnic groups other than my own.
20. I feel good about my cultural or ethnic background.
1. How old was your child when you first talked to her/him about sexual intercourse?
Age____
2. When was the last time you talked to your child about sexual intercourse?
Enter age of child_____or check “I have not talked to my child about sex”.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY AGREE,” “SOMEWHAT AGREE,” “STRONGLY DISAGREE” AND “SOMEWHAT DISAGREE” AS ANSWERS OPTIONS]
***Parent-Adolescent Communication About Sex
PROMPT:
Parents have different ways and reasons for talking to their children about sex. Please tell us if you agree or disagree with the following statements.
[PROGRAM THIS SCALE FOR GENDER BASED ON STRATA CRITERIA. THAT IS, PARITICIPANTS WILL EITHER ANSWER THIS SCALE FOR A MALE OR FEMALE CHILD].
1. I really don’t know enough about sex and birth control to talk about it with my son.
2. It would embarrass me to talk about sex and birth control with my son.
3. It would embarrass my son to talk with me about sex and birth control.
4. My son would not take me seriously if I tried to talk with him about sex and birth control.
5. It would be difficult for me to explain things if I talked with my son about sex and birth control.
6. My son will get the information somewhere else, so I don’t really need to talk with him about sex and birth control.
7. It wouldn’t do much good if I talked with my son about sex and birth control.
8. I don’t need to talk with my son about sex and birth control; he knows what he needs to know.
9. My son would not be honest with me if I talked with him about sex and birth control.
10. My son will think that I do not trust him if I try to talk to him about sex and birth control.
11. It would be difficult to find a convenient time and place to talk to my son about sex and birth control.
12. My son is just too busy to talk to me about sex and birth control.
13. My son would ask me too many personal questions if I tried to talk with him about sex and birth control.
14. My son does not want to hear what I have to say when it comes to talking about sex and birth control.
15. My son and I would only argue if we were to try and talk about sex and birth control.
16. I would have a difficult time being honest about my behavior with my son if we were to talk about sex and birth control.
17. My son would think that I was nosy if I tried to talk to him about sex and birth control.
18. If I talked about sex and birth control with my son, he might ask me something I don’t know the answer to.
19. If I talk to my son about birth control, he would think I approve of him having sex.
20. Talking about birth control with my son will only encourage him to have sex.
21. My son would just make fun of me if I tried to talk with him about sex and birth control.
Additional Caregiver Questions:
1. It wouldn’t do much good if I talked with my daughter about sex and birth control.
2. My daughter will think I do not trust her if I try to talk to her about sex and birth control.
3. My daughter is just too busy to talk to me about sex and birth control.
4. My daughter doesn’t want to hear what I have to say about sex and birth control.
5. My daughter would think I was nosy if I tried to talk to her about sex and birth control.
6. If I talk with my daughter about birth control, she would think I approve of her having sex.
7. Talking about birth control with my daughter will only encourage her to have sex.
8. My daughter would just make fun of me if I tried to talk with her about sex and birth control.
[INCLUDE ALL QUESTIONS FROM THIS SCALE]
PROMPT: Below is a list of topics related to sex. For each topic, please indicate whether you have ever had a conversation with your child about the topic. If not, please tell us whether the topic is something that you intend to discuss with your child while he/she is an adolescent.
A. How girls’ bodies change physically as they grow up
B. How boys’ bodies change physically as they grow up
C. Menstruation (having menstrual periods)
D. Wet dreams
E. How people get pregnant and have babies
F. Masturbation
G. What qualities are important in choosing close friends
H. How to ask someone out on a date
I. When it would be OK for your child to start having sex
J. How your child will know when he/she is ready to have sex
K. What it feels like to have sex
L. Homosexuality
M. Pros and cons of getting pregnant/getting someone pregnant
N. How birth control prevents pregnancy
O. How condoms prevent sexually transmitted diseases
P. Choosing a method of birth control
Q. How to use a condom
R. How people get sexually transmitted diseases
S. How people can prevent getting sexually transmitted diseases
T. Symptoms of sexually transmitted diseases
U. What to do if a partner doesn’t want to use a condom
V. Not to pressure other people to have sex
W. Positive aspects of having sex
X. Reasons why your child should not have sex
Y. How your child will know if he/she is in love
Z. How your child can say no if someone wants to have sex and your child doesn’t want to
7. How to protect yourself from sexually transmitted diseases (STDs) such as Acquired Immune Deficiency Syndrome (AIDS)?
9. About not having sex until s/he is older?
10. How to handle pressure from friends to have sex?
11. How to handle pressure from boyfriends/girlfriends to have sex
14. About abstaining from sex/not having sex?
8) Which of the following topics have come up when you talk to your child about sex?
S/he was informed that S/he shouldn’t engage in any sexual behavior.
S/he was informed that S/he should only go so far sexually for right now.
S/he was told that S/he should wait to have sex until s/he was married.
S/he was told that S/he should wait to have sex until s/he was older.
S/he was told that it is better to wait to have sex until married but I did not tell him/her not to have sex.
I asked if s/he was having sex.
We talked about heavy petting (touching a boy or girl on his/her private parts).
We talked about oral sex.
We talked about French kissing or kissing with the tongue.
We talked about dating and/or relationships.
We talked about his/her orientation (whether s/he was attracted to boys or girls).
Are there any other topics that have come up when you talk to your child about sex, relationships, or dating.
________________________________________________________________
________________________________________________________________
________________________________________________________________
HAVE YOU EVER TALKED TO YOUR CHILD ABOUT INTIMATE PARTNER VIOLENCE (BEING HIT, PUNCHED, KICKED, YELLED AT, ETC) BY A BOYFRIEND OR GIRLFRIEND?
HAVE YOU EVER TALKED TO YOUR CHILD ABOUT RAPE/DATE RAPE?
[INCLUDE ALL QUESTIONS FROM THIS SCALE USE “ALWAYS/ALMOST ALWAYS” “OFTEN” “HALF THE TIME” “OCCASIONALLY” AND NEVER/ALMOST NEVER” AS ANSWER OPTIONS]
[PROGRAM: CHILD’S NAME SHOULD AUTOMATICALLY PROGRAM TO THESE QUESTIONS]
***Parent Involvement & Supervision
PROMPT:
The following questions are about how your family currently interacts with each other on a day to day basis. Please indicate how often this applies to you.
1. How well do you get along with (Insert Child Name)
2. How often do/did you get in an argument or conflict with your son/daughter?
3. How often do you talk with (Insert Child Name) about what he/she does in class/school?
4. How often do you talk with (Insert Child Name) about things he/she does with friends?
5. How often does (Insert Child Name) get to do things without telling you exactly where he/she is?
6. When (Insert Child Name) is at a friend’s house, how often do you think that an adult is there?
7. How often does (Insert Child Name) attend parties with friends?
8. When (Insert Child Name) attends a party, how often are there adults supervising?
9. How often do you think (Insert Child Name) goes to places you have asked him/her not to go?
10. How difficult is it for you to know where (Insert Child Name) is and what he/she is doing now that he/she is older?
11. How often do you feel you can trust (Insert Child Name) to do activities away from home and with friends without getting into trouble?
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “YES” AND “NO” AS ANSWER OPTIONS]
12. Is there a particular time (Insert Child Name) has to be home at night on weekdays?
13. Is there a particular time (Insert Child Name) has to be home at night on weekends?
14. How many times a month on average does (Insert Child Name) spend the night away from home at friends’ houses? ___ ___ # times
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “AGREE” “NO OPINION” AND “DISAGREE” AS ANSWER OPTIONS]
***Health Locus of Control - Parent/Child (HLCP)
PROMPT:
The following statements are about your child’s health. Please indicate how much you agree or disagree.
1. My child's good health comes from being lucky.
2. There is nothing that I can do to keep my child from getting sick.
3. Bad luck makes my child get sick.
4. I can only do what the doctor tells me to do for my child.
5. Getting sick just happens to children.
6. Children who never get sick are just plain lucky.
7. It is my job as a mother to keep my child from getting sick.
8. Only a doctor or a nurse keeps children from getting sick.
9. I can make very few choices about my child's health.
10. Accidents just happen to children.
11. I can do many things to fight illness in my child.
12. Only the dentist can take care of my child's teeth.
13. The only way I can make my child stay healthy is to do what other people tell me to do.
14. I take my child to the doctor right away if my child gets hurt.
15. It will be my child's teachers' job to keep my child from having accidents at school.
16. I can make many choices about my child's health.
17. If my child feels sick, I have to wait for other people to tell me what to do.
18. Whenever my child feels sick, I take my child to the doctor right away.
19. There is nothing I can do to make sure my child has healthy teeth.
20. I can do many things to prevent my child from having accidents.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “TRUE’ AND “FALSE” AS ANSWER OPTIONS]
***Neighborhood Environment
PROMPT:
The following statements are about your neighborhood. Please indicate how much each applies to you.
1. Within walking distance of my house there is a park or playground where I like to walk and enjoy myself, playing sports or games.
2. There are plenty of safe places to walk or play outdoors in my neighborhood.
3. Every few weeks, some kid in my neighborhood gets beat-up or mugged.
4. Every few weeks, some adult gets beat-up or mugged in my neighborhood.
5. In my neighborhood, I see signs of racism and prejudice at least once a week.
6. In my neighborhood, many yards and alleys have broken bottles and trash lying around.
7. I have seen people using or selling drugs in my neighborhood.
8. In the morning or later in the day, I often see drunk people on the street in my neighborhood.
9. Most adults in my neighborhood respect the law.
10. There are abandoned or boarded-up buildings in my neighborhood.
11. I feel safe when I walk around my neighborhood by myself.
12. The people who live in my neighborhood often damage or steal each other’s property.
13. The people who live in my neighborhood always take care of each other and protect each other from crime.
14. Almost everyday I see homeless people walking or sitting around in my neighborhood.
15. In my neighborhood, the people with the most money are the drug dealers.
16. In my neighborhood, there are a lot of poor people who don’t have enough money for food and basic needs.
17. For many people in my neighborhood, going to church on Sunday or religious days is a very important activity.
18. The people who live in my neighborhood are the best people in the world.
[INCLUDE ALL QUESTIONS FROM THIS SCALE]
***Teaming African American Parents with Survival Skills (T.A.A.P.S.S.)
PROMPT:
The following questions ask about family rules. Please answer all questions only in reference to your child who is participating in this program.
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “ALWAYS TRUE” “USUALLY TRUE” “SOMETIMES TRUE/SOMETIMES FALSE” “USUALLY FALSE” AND “ALWAYS FALSE” AS ANSWER OPTIONS]
1. I know where my child is after school.
2. If my child is going to be home late, s/he is expected to call me to let them know.
3. My child tells me who s/he is going to be with before s/he goes out.
4. When my child goes out at night, I know where s/he is.
5. My child talks with me about the plans s/he has with her/his friends.
6. When my child goes out, I ask where s/he is going.
1. After school, my child is expected to be at a certain place by a certain time (home, school activities, etc.).
2. When school is out my child goes some place where he/she is watched by an adult.
3. My child is allowed to have friends over to my house while I am not at home.
4. I know most of my child’s friends.
5. I have a set of time that my child has to be in bed during the week and on weekends.
6. My child can go out (leave the neighborhood) after school without asking me (or another adult in charge).
7. I know in advance whether an adult will be there when my child goes somewhere with his or her friends (parties, movies, etc.)
8. I talk to the parents of my child’s friend before I allow my child to spend the night at their house.
9. I know the parents of my child’s friends.
10. My child can do things or go places without telling me exactly where he/she will be.
11. I let my child hang out with kids who are known to get into trouble.
12. It is hard for me to keep track of where my child is when I am away from home.
13. When your child goes out of the house for more than an hour, do you check on him/her?
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “STRONGLY AGREE” “AGREE” “NEITHER AGREE/NOR DISAGREE” “DISAGREE” AND “STRONGLY DISAGREE” AS ANSWER OPTIONS]
[INCLUDE ALL QUESTIONS FROM THIS SCALE AND USE “YES” AND “NO” AS ANSWER OPTIONS]
CUES TO ACTION – SEX COMMUNICATION
16. Did you talk to your child about sex in the past 3 months?
[ADD “YES” AND “NO” AS ANSWER OPTIONS AND SKIP TO QUESTION 19 IF PARTICIPANT ANSWERS NO]
17. What prompted you to talk to him or her? Please check all that apply.
a. I learned that my child was involved in inappropriate conversation, play or touching.
b. My child admitted to being sexually active.
c. My child’s friend(s) is going to be a mother or father.
d. A young member of our family is going to be a mother or father.
e. My child’s friend(s) is known to be sexually active.
f. I overheard my child talking about being in a sexually related act (i.e., kissing, hugging, hand holding).
g. I believe my child might be sexually active.
h. My child is getting older and I felt the time was right to talk about sex and sexuality.
i. My child is going through physical sexual development (i.e., boys: wet dreams, j. changing voice, or girls: menstruation, developing breast).
j. My child initiated the conversation, or asked me a question about sex, or sexuality.
k. We were watching television, looking at a movie or music video or listening to a song that raised thought related to sex and sexuality.
l. I found a condom or birth control pills in my child’s possession.
m. None of the above.
n. I have not talked to my child about sex in the last 3 months.
ATTITUDES TOWARD THE BEHAVIOR (SEX COMMUNICATION)
18. When you spoke to your child about sex how were you feeling? If more than one feeling applies select the feeling that best represents how you felt.
a. Angry
b. Afraid (about their health and safety)
c. Concerned
d. Frustrated
e. Protective (Of their safety or future)
f. Supportive (Wanted child to know I’m here to help)
g. Other. Specify: _______________________________________________
CUES TO ACTION: COMMUNICATION ABOUT DRUGS
19. Did you talk to your child about drugs (not including alcohol) in the past 3 months?
[ADD “YES” AND “NO” AS ANSWER OPTIONS AND SKIP TO QUESTION 22 IF PARTICIPANT ANSWERS NO]
20. What prompted you to talk to your child about drugs. Please check all that apply.
a. I learned that my child was involved in activity related to drugs.
b. .My child’s friend(s) was suspended from school or arrested for activity related to drugs.
c. I believe my child’s friend(s) was involved with the use of drugs.
d. I believe my child’s friend(s) was involved with selling drugs.
e. I believe my child was involved with the use of drugs.
f. I believe my child was involved with selling drugs.
g. I believed a family member was involved with the use of drugs.
h. I believe a family member was involved with selling drugs.
i. My child is getting older and I felt the time was right to talk about drugs.
j. Drug activity is present in our neighborhood.
k. My child initiated the conversation, or asked me a question about drugs.
l. My child is friends with someone suspected of selling or using drugs.
m. We were watching a television, looking at a movie or music video, or listening to a song that raised thoughts related to drug use and drug selling.
n. I found drug paraphernalia (rolling paper, marijuana, a joint, small plastic bags used to store drugs) in my child’s possession.
o. My child was behaving in a manner that led me to believe he/she was using drugs (i.e., altered mood – more quiet or more loud than usual. Inability to concentrate, avoiding others).
p. My child appeared as though he/she was using drugs (i.e., red eyes, constricting pupils, enlarged pupils, a blank stare).
q. I smelled traces of drug use on my child’s clothing (i.e., clothes had the odor of smoke or marijuana.
r. None of the above
s. I have not talked to my child about drugs in the last 3 months. If you check this box, please skip the next question and go to question 56.
21. When you spoke to your child about drugs how were you feeling? If more than one feeling applies select the feeling that best represents how you felt.
a. Angry
b. Afraid (About their health and safety)
c. Concerned
d. Frustrated
e. Protective (Of their safety or future)
f. Supportive (Wanted child to know I’m here to help)
g. Other. Specify: _______________________________________________
22. Did you talk to your child about alcohol in the past 3 months?
[ADD “YES” AND “NO” AS ANSWER OPTIONS AND SKIP TO QUESTION 25 IF PARTICIPANT ANSWERS NO]
23. What prompted you to talk to him or her? Please check all that apply.
a. I learned that my child was involved in activity related to alcohol use.
b. My child’s friend(s) was suspended from school or arrested for alcohol use.
c. I believe my child’s friend(s) was involved with the use of alcohol.
d. I believed my child was involved with the use of alcohol.
e. My child is getting older and I felt the time was right to talk about alcohol.
f. There are state stores (liquor stores) and other signs of alcohol use present in our neighborhood.
g. My child initiated the conversation, or asked me a question about alcohol.
h. My child is a friend of someone suspected of alcohol use.
i. A family member has an alcohol problem.
j. We were watching television, looking at a movie or music video, or listening to a song that raised thought related to alcohol use.
k. I found alcohol or a flask in my child’s possession.
l. My child was behaving in a manner that led me to believe he/she was using alcohol (i.e., active or louder than usual, unusual inability to concentrate).
m. My child appeared as though he/she was intoxicated (i.e., slurred speech, unsteady walk or stumbling, vomiting without other reason or cause).
n. I smelled traces of alcohol use on my child (i.e., breath smelled of alcohol)
o. Other Specify: ________________________________________
p. I have not talked to my child about alcohol in the past 3 months. If you check this box, please skip the next question and go to question 58.
24. When you spoke to your child about alcohol how were you feeling? If more than one feeling applies select the feeling that best represents how you felt.
a. Angry
b. Afraid (About their health and safety)
c. Concerned
d. Frustrated
e. Protective
f. Supportive
g. Nervous
h. Unsure (Of what to say)
i. Overwhelming
j. Other Specify: ________________________________________
25. At what age do you think it would be okay for your son or daughter to have a sexual relationship? ____________Years
PROMPT:
The following questions are about [NAME OF CHILD PARTICIPATING IN STUDY FROM QUESTION ??]
37) Was there ever a period of at least 6 months when {NAME} did not live with you?
NO
YES
38)
During which years of (his/her) life has {NAME} been away from you
for at least 6
months?
_________________________________________________________________
39) Does (he/she) have a specific learning disability, such as difficulties with attention, dyslexia, or some other reading, spelling, writing, or math disability?
NO
YES
40) During the past 12 months did (he/she) receive any type of special education service?
NO
YES
41) Does (he/she) use tobacco regularly, that is, once a week or more?
NO
YES
42) Does (he/she) drink alcohol at least once a month?
NO
YES
43) Do you think that (he/she) has ever gone out on a date?
NO
YES
44) Do you think that (he/she) has ever kissed and necked?
NO
YES
45) Do you think that (he/she) has ever had sexual intercourse? [IF NO, SKIP TO ??]
NO
YES
46) How old do you think (he/she) was when (he/she) first had sexual intercourse?
[USE “STRONGLY AGREE” “AGREE” “NEITHER AGREE/NOR DISAGREE” “DISAGREE” AND “STRONGLY DISAGREE” AS ANSWER OPTIONS FOR QUESTIONS 26-28]
26. I would be less concerned if I learned that my child had sexual intercourse and used condoms.
27. My child is too young to have sex.
28. Sex outside of marriage is wrong and sinful.
1) What is your date of Birth? __ __ / __ __ / __ __
month day year
2) How old are you? (Write age).
______________
3) What is the last grade or year that you completed in school?
NONE, NO FORMAL SCHOOLING
PRIMARY/ELEMENTARY
JUNIOR HIGH
HIGH
SCHOOL/GED
COLLEGE/TECHNICAL SCHOOL YEARS
GRADUATE/PROFESSIONAL
4) Are you currently married, separated, divorced, widowed, or have you never been married?
MARRIED
SEPARATED
DIVORCED
WIDOWED
NEVER MARRIED
5) Are you currently living together with [your use/boyfriend/girlfriend/partner]?
NO
YES
6) What is your religion?
Christian
(eg., Protestant, Baptist, Methodist)
Catholic
Jewish
Muslim
Other
None
7) How often do you attend religious services? (Check one).
About once a week, sometimes more
Once or twice a month
Less than once a month
A few times a year
Once a year or less
8) How important is God in your life? (Check one).
Not important
A little important
Pretty important
Very important
9) Are there any cigarette smokers in your household?
NO
YES
10) Do you smoke?
NO
YES
11) Including yourself, what is the highest level of education of any of the adults in the house or apartment where you live?
Did not finish high school.
Finished high school or GED.
Some college education
College degree (BA or BS).
Some graduate education
Graduate degree (MA, JD, Ph.D., Doctorate, Medical Doctor)
12) What is your total annual household income? That is, the total amount of money that people in your home make per year.
Less than $10,000
$10,000 to $15,000
$15,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
Greater than $50,000
I DON’T WANT TO SAY
DON’T KNOW
13) How many people, children and adults, including yourself, are dependent upon this income?
(number of people)
14) Do you have enough money to pay your bills each month?
NO
YES
This ends the questionnaire. Thank you very much for your time and cooperation. Your answers are very important to us and will remain confidential.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lnw8 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |