Parental Assessment Battery Master English

Parental assessment battery master_ENG.pdf

Preventing HIV Risk Behaviors Among Hispanic Adolescents

Parental Assessment Battery Master English

OMB: 0920-0871

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Master Parent English - HEPI 2

Master Parent English - HEPI 2 (English)

Version DE24884EN

Page 1

09/14/04

Master Parent English - HEPI 2

PRE1.

Enter the Respondent's I.D. Number

PRE2.

Enter the timepoint
(PLEASE ENTER TIMEPOINTS BETWEEN 1 AND 5 ONLY PLEASE)

PRE3.

What is the Site ID?

PRE4.

Please enter your interviewer ID.

PRE5.

Enter the Respondent's Age

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__ __ __ __
__

ID
Time Point

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __
__ __
98

Page 2

Interviewer
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

DEMOGRAPHICS

DEMOGRAPHICS
HEP1.

Are you the primary caregiver (the one who is mostly in charge of taking care of) the child in this program?
1
0
8

HEP1a.

Yes
No
Refuse to Answer

What is your relation to the adolescent in this program? (Choose one)

Skip to HEP2

1
2
3
4
5
6
7
8

Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Other
Refuse to Answer

1
2
3
4
5
6
7
8

Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Other
Refuse to Answer

Skip to HEP3.
HEP2.

Who is the person responsible for him/her? (Choose one)

HEP3.

In what country were you born? (Choose one)

HEP4.

HEP5.

00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
98

United States
Cuba
Nicaragua
Honduras
Puerto Rico
Colombia
Mexico
Venezuela
Dominican Republic
Costa Rica
El Salvador
Panama
Peru
Guatemala
Argentina
Ecuador
Bolivia
Uruguay
Paraguay
Chile
Other Country
Refuse to Answer

How long have you lived in the United States ? (Choose one)

0
1
2
8

Less than 3 Years
3 to 10 Years
More than 10 Years
Refuse to Answer

How long have you lived in South Florida? (Choose one)

0
1
2
8

Less than 3 Years
3 to 10 Years
More than 10 Years
Refuse to Answer

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Page 3

09/14/04

Master Parent English - HEPI 2

DEMOGRAPHICS

HEP6.

What is your current marital status? (Choose one)

HEP7.

What is the highest grade in school you have completed? (Choose one)

1
2
3
4
5
6
8

married
living with someone
separated
divorced
widowed
never married and not living with someone
Refuse to Answer
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
08

HEP8.

none
1 (elementary)
2 (elementary)
3 (elementary)
4 (elementary)
5 (elementary)
6 (elementary)
7 (elementary)
8 (elementary)
9 (high school)
10 (high school)
11 (high school)
12 (high school)
13 (college)
14 (college)
15 (college)
16 (college)
17 + (graduate or professional)
Refuse to Answer

Have you completed any other occupational, vocational or technical training?
1
0
8

Yes
No
Refuse to Answer

Skip to HEP10

HEP9.

Did you get a certificate/degree?

HEP10.

Please tell me which of these statements best describes your present work situation. (Choose one)

1
0
8
1
2
3
4
5
6
7
8
9
98

Version DE24884EN

Page 4

Yes
No
Refuse to Answer

working full time, that is, 35 hours or more per week
working part-time, less than 35 hours per week
working occasionally, in temporary jobs
unemployed or laid off and looking for work
unemployed and not looking for work
in school
retired
homemaker
other
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HEP11.

DEMOGRAPHICS

What is your current occupation? What type of work do you do? (Choose one)
01
02
03
04
05
06
07
08
09
98

HEP12.

Higher executive, major professional, owner of large business
Business manager of medium sized business, lesser professionals, i.e. nurses, teachers
Administrative personnel, manager, minor professionals, owner/proprietor of small business
Clerical and sales, technicians, small businesses (bank teller, secretary)
Skilled manual-usually having had training (barber, electrician, mechanic, plumber)
Semi-skilled (painter, bus driver, cook, waiter, machine operator)
Unskilled (attendant, janitor, unspecified labor, include unemployed)
Homemaker
Student, disabled, no occupation
Refuse to Answer

This next section is about your significant other (such as husband/boyfriend or wife/girlfriend). Is there someone who
is like that for you and lives in the home with you and helps you with living expenses and caring for the child in this
program?
1
0
8

HEP13.

Yes
No
Refuse to Answer

Skip to HEP20

Since you have answered Yes, please specify the person who is living with you. (Choose one)
1
2
3
4
8

Husband
Boyfriend
Wife
Girlfriend
Refuse to Answer

HEP14.

How long have you been living together with this person? (Choose one)

HEP15.

What is the highest grade in school your husband/boyfriend; wife/girlfriend has completed? (Choose one)

0
1
2
8
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
08

HEP16.

Less than 3 Years
3 to 10 Years
More than 10 Years
Refuse to Answer

Has your Husband/boyfriend; wife/girlfriend completed any other occupational, vocational or technical training?
1
0
8

Version DE24884EN

Page 5

Yes
No
Refuse to Answer

Skip to HEP18

09/14/04

Master Parent English - HEPI 2

DEMOGRAPHICS

HEP17.

Did he/she get a certificate/degree?

HEP18.

Please tell me which of these statements best describes your husband/boyfriend; wife/girlfriend's present work
situation. (Choose one)

1
0
8

1
2
3
4
5
6
7
8
9
98

HEP19.

What is your husband/boyfriend's; wife/girlfriend's current occupation? What type of work does he/she do? (Choose
one)
01
02
03
04
05
06
07
08
09
98

HEP20.

For the last year, what was the total household income from all sources? Please tell me the letter that best describes
your total household income before taxes. (Choose one)
01
under $5,000
02
03
04
05
06
07
08
09
10
11
08

HEP21.

$5,000 to 9,999
$10,000 to 14,999
$15,000 to 19,999
$20,000 to 24,999
$25,000 to 29,999
$30,000 to 34,999
$35,000 to 39,999
$40,000 to 44,999
$45,000 to 49,999
$50,000 or more
Refuse to Answer

During the past year, did anyone in your family receive any income from the following (check all that apply): (Check
all that apply)
__
__
__
__
__
__
__

HEP22.

Yes
No
Refuse to Answer

What is your first or usual language? (Choose one)

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Page 6

A job, employment
Social security
Public assistance (AFDC, Welfare)
Housing assistance (renter's assistance)
Food stamps
Unemployment
Refuse to Answer
1
2
8

Spanish
English
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HEP23.

HEP24.

HEP25.

DEMOGRAPHICS

Would you say that in your home you speak mostly English, mostly Spanish, or about the same? (Choose one)
1
2
3
8

Mostly English
Mostly Spanish
About the same
Refuse to Answer

00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
98

United States
Cuban
Nicaraguan
Honduran
Puerto Rican
Colombian
Mexican
Venezuelan
Dominican
Costa Rican
Salvadoran
Panamanian
Peruvian
Guatemalan
Argentinian
Ecuadorian
Bolivian
Uruguayan
Paraguayan
Chilean
Other
Refuse to Answer

How would you describe your nationality, race, or ethnic background? (Choose one)

Is your son/daughter in any special classes for: (Choose one)

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Page 7

1
2
3
4
5
6
8

Learning Disability
Emotional Disability
Gifted
None
Don't know
Other
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

FAMILY LIFE CHANGES

FAMILY LIFE CHANGES
Over their life cycle, all families experience many changes as a result of normal growth and development of members
and due to external circumstances. The following list of family life changes can happen in a family at any time.
Because family members are connected to each other in some way, a life change for any one member affects all the
other persons in the family to some degree. "FAMILY" means a group of two or more persons living together who are
related by blood, marriage or adoption. This includes persons who live with you and to whom you have a long term
commitment. Directions: "Did the change happen in your family?" Please read each family life change and decide
whether it happened to any member of your family - including you - during the past 6 months and check Yes or No.
FLC1.

Increase of husband/father's time away from family

1
0
8

Yes
No
Refuse to Answer

FLC2.

Increase of wife/mother's time away from family

1
0
8

Yes
No
Refuse to Answer

FLC3.

A member appears to have emotional problems

1
0
8

Yes
No
Refuse to Answer

FLC4.

A member appears to depend on alcohol or drugs

1
0
8

Yes
No
Refuse to Answer

FLC5.

Increase in conflict between husband and wife

1
0
8

Yes
No
Refuse to Answer

FLC6.

Increase in arguments between parent(s) and child(ren)

1
0
8

Yes
No
Refuse to Answer

FLC7.

Increase in conflict among children in the family

1
0
8

Yes
No
Refuse to Answer

FLC8.

Increased difficulty in managing teenage child(ren)

1
0
8

Yes
No
Refuse to Answer

FLC9.

Increased difficulty in managing school age child(ren) (6-12 yrs.)

1
0
8

Yes
No
Refuse to Answer

FLC10.

Increased difficulty in managing preschool age child(ren) (2.5-6 yrs.)

1
0
8

Yes
No
Refuse to Answer

FLC11.

Increased difficulty in managing toddler(s) (1-2.5 yrs.)

1
0
8

Yes
No
Refuse to Answer

FLC12.

Increased difficulty in managing infant(s) (0-1 yr.)

1
0
8

Yes
No
Refuse to Answer

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Page 8

09/14/04

Master Parent English - HEPI 2

FLC13.

FAMILY LIFE CHANGES

Increase in the amount of "outside activities" which the child(ren) are involved in
1
0
8

Yes
No
Refuse to Answer

FLC14.

Increased disagreement about a member's friends or activities

1
0
8

Yes
No
Refuse to Answer

FLC15.

Increase in the number of problems or issues which don't get resolved

1
0
8

Yes
No
Refuse to Answer

FLC16.

Increase in the number of tasks or chores which don't get done

1
0
8

Yes
No
Refuse to Answer

FLC17.

Increased conflict with in-laws or relatives

1
0
8

Yes
No
Refuse to Answer

FLC18.

Spouse/parent was separated or divorced

1
0
8

Yes
No
Refuse to Answer

FLC19.

Spouse/parent had an "affair"

1
0
8

Yes
No
Refuse to Answer

FLC20.

Increased difficulty in resolving issues with a "former" or separated spouse

1
0
8

Yes
No
Refuse to Answer

FLC21.

Increased difficulty with sexual relationship between husband and wife

1
0
8

Yes
No
Refuse to Answer

FLC22.

Spouse had unwanted or difficult pregnancy

1
0
8

Yes
No
Refuse to Answer

FLC23.

An unmarried member became pregnant

1
0
8

Yes
No
Refuse to Answer

FLC24.

A member had an abortion

1
0
8

Yes
No
Refuse to Answer

FLC25.

A member gave birth to or adopted a child

1
0
8

Yes
No
Refuse to Answer

FLC26.

Took out a loan or refinanced a loan to cover increased expenses

1
0
8

Yes
No
Refuse to Answer

FLC27.

Went on welfare

1
0
8

Yes
No
Refuse to Answer

Version DE24884EN

Page 9

09/14/04

Master Parent English - HEPI 2

FLC28.

FAMILY LIFE CHANGES

Change in conditions (economic, political, weather) which hurts the family investments
1
0
8

FLC29.

Yes
No
Refuse to Answer

Change in agriculture market, stock market, or land values which hurts family investments and/or income
1
0
8

Yes
No
Refuse to Answer

FLC30.

A member started a new business

1
0
8

Yes
No
Refuse to Answer

FLC31.

Purchased or built a home

1
0
8

Yes
No
Refuse to Answer

FLC32.

A member purchased a car or other major item

1
0
8

Yes
No
Refuse to Answer

FLC33.

Increased financial debts due to over-use of credit cards

1
0
8

Yes
No
Refuse to Answer

FLC34.

Increased strain on family "money" for medical/dental expenses

1
0
8

Yes
No
Refuse to Answer

FLC35.

Increased strain on family "money" for food, clothing, energy, home care

1
0
8

Yes
No
Refuse to Answer

FLC36.

Increased strain on family "money" for child(ren)'s education

1
0
8

Yes
No
Refuse to Answer

FLC37.

Delay in receiving child support or alimony payments

1
0
8

Yes
No
Refuse to Answer

FLC38.

A member changed to a new job/career

1
0
8

Yes
No
Refuse to Answer

FLC39.

A member lost or quit a job

1
0
8

Yes
No
Refuse to Answer

FLC40.

A member retired from work

1
0
8

Yes
No
Refuse to Answer

FLC41.

A member started or returned to work

1
0
8

Yes
No
Refuse to Answer

FLC42.

A member stopped working for extended period (e.g. laid off, leave of absence, strike)
1
0
8

Yes
No
Refuse to Answer

Version DE24884EN

Page 10

09/14/04

Master Parent English - HEPI 2

FAMILY LIFE CHANGES

FLC43.

Decrease in satisfaction with job/career

1
0
8

Yes
No
Refuse to Answer

FLC44.

A member had increased difficulty with people at work

1
0
8

Yes
No
Refuse to Answer

FLC45.

A member was promoted at work or given more responsibilities

1
0
8

Yes
No
Refuse to Answer

FLC46.

Family moved to a new home or apartment

1
0
8

Yes
No
Refuse to Answer

FLC47.

A child/adolescent member changed to a new school

1
0
8

Yes
No
Refuse to Answer

FLC48.

Parent/spouse became seriously ill or injured

1
0
8

Yes
No
Refuse to Answer

FLC49.

Child became seriously ill or injured

1
0
8

Yes
No
Refuse to Answer

FLC50.

Close relative or friend of the family became seriously ill

1
0
8

Yes
No
Refuse to Answer

FLC51.

A member became physically disabled or chronically ill

1
0
8

Yes
No
Refuse to Answer

FLC52.

Increased difficulty managing a chronically ill or disabled member

1
0
8

Yes
No
Refuse to Answer

FLC53.

Member or close relative was committed to an institution or nursing home

1
0
8

Yes
No
Refuse to Answer

FLC54.

Increased responsibility to provide direct care or financial help to husband's and/or wife's parent(s)
1
0
8

Yes
No
Refuse to Answer

FLC55.

Experienced difficulty in arranging for satisfactory child care

1
0
8

Yes
No
Refuse to Answer

FLC56.

A parent/spouse died

1
0
8

Yes
No
Refuse to Answer

FLC57.

A child member died

1
0
8

Yes
No
Refuse to Answer

Version DE24884EN

Page 11

09/14/04

Master Parent English - HEPI 2

FAMILY LIFE CHANGES

FLC58.

Death of husband's or wife's parent or close relative

1
0
8

Yes
No
Refuse to Answer

FLC59.

Close friend of the family died

1
0
8

Yes
No
Refuse to Answer

FLC60.

Married son or daughter was separated or divorced

1
0
8

Yes
No
Refuse to Answer

FLC61.

A member "broke up" a relationship with a close friend

1
0
8

Yes
No
Refuse to Answer

FLC62.

A member was married

1
0
8

Yes
No
Refuse to Answer

FLC63.

Young adult member left home

1
0
8

Yes
No
Refuse to Answer

FLC64.

Young adult member began college (or post high school training)

1
0
8

Yes
No
Refuse to Answer

FLC65.

A member moved back home or a new person moved into the household

1
0
8

Yes
No
Refuse to Answer

FLC66.

A parent/spouse started school (or training program) after being away from school for a long time
1
0
8

Yes
No
Refuse to Answer

FLC67.

A member went to jail or juvenile detention

1
0
8

Yes
No
Refuse to Answer

FLC68.

A member was picked up by police or arrested

1
0
8

Yes
No
Refuse to Answer

FLC69.

Physical or sexual abuse or violence in the home

1
0
8

Yes
No
Refuse to Answer

FLC70.

A member ran away from home

1
0
8

Yes
No
Refuse to Answer

FLC71.

A member dropped out of school or was suspended from school

1
0
8

Yes
No
Refuse to Answer

Version DE24884EN

Page 12

09/14/04

Master Parent English - HEPI 2

BICULTURAL INVOLVEMENT QUESTIONNAIRE

BICULTURAL INVOLVEMENT QUESTIONNAIRE
Next you will be asked some questions regarding aspects of Hispanic culture and American culture. The following
questions measure how comfortable you feel. You will be shown a scale from 1 to 5, and you will have to choose 1, 2,
3, 4 or 5. The higher the number that you choose, the more comfortable you feel. The lower the number that you
choose, the less comfortable you feel. For example, if you don't feel at all comfortable, Not at all Comfortable, choose
number 1. If you feel Very Comfortable, choose number 5. Remember that you can also choose 2, 3 or 4.
BIC1.

How comfortable do you feel speaking SPANISH at home?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC2.

How comfortable do you feel speaking SPANISH in school?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC3.

How comfortable do you feel speaking SPANISH at work?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC4.

How comfortable do you feel speaking SPANISH with friends?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC5.

How comfortable do you feel speaking SPANISH in general?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC6.

How comfortable do you feel speaking ENGLISH at home?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC7.

How comfortable do you feel speaking ENGLISH in school?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

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Page 13

09/14/04

Master Parent English - HEPI 2

BICULTURAL INVOLVEMENT QUESTIONNAIRE

BIC8.

How comfortable do you feel speaking ENGLISH at work?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC9.

How comfortable do you feel speaking ENGLISH with friends?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

BIC10.

How comfortable do you feel speaking ENGLISH in general?

1
2
3
4
5
8

Not at all Comfortable
.
.
.
Very Comfortable
Refuse to Answer

The following questions measure how much you enjoy different things. The higher the number that you choose, the
more you enjoy what the question describes. The lower the number that you choose, the less you enjoy it. For example,
if you don't enjoy it at all, Not at All, choose number 1. If you enjoy it Very Much, choose number 5. Remember that
you can also choose 2, 3 or 4.
BIC11.

How much do you enjoy HISPANIC music?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC12.

How much do you enjoy HISPANIC dances?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC13.

How much do you enjoy HISPANIC-oriented places?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC14.

How much do you enjoy HISPANIC-type recreation?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC15.

How much do you enjoy HISPANIC TV programs?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

Version DE24884EN

Page 14

09/14/04

Master Parent English - HEPI 2

BICULTURAL INVOLVEMENT QUESTIONNAIRE

BIC16.

How much do you enjoy HISPANIC radio stations?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC17.

How much do you enjoy HISPANIC books and magazines?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC18.

How much do you enjoy AMERICAN music?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC19.

How much do you enjoy AMERICAN dances?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC20.

How much do you enjoy AMERICAN-oriented places?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC21.

How much do you enjoy AMERICAN-type recreation?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC22.

How much do you enjoy AMERICAN TV programs?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

BIC23.

How much do you enjoy AMERICAN radio stations?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

Version DE24884EN

Page 15

09/14/04

Master Parent English - HEPI 2

BIC24.

BICULTURAL INVOLVEMENT QUESTIONNAIRE

How much do you enjoy AMERICAN books and magazines?

1
2
3
4
5
8

Not at All
.
.
.
Very Much
Refuse to Answer

The following questions measure how often you would like things to be a certain way. The higher the number that you
choose, the more often you wish things could be as the question describes. The lower the number that you choose, the
less often you wish things could be that way. For example, if you would Never want things to be that way, choose
number 1. If you would Always want things to be that way, choose number 5. If you would Sometimes want things to
be that way, choose number 3. Remember that you can also choose 2 or 4.
BIC25.

I would want food to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC26.

I would want language to be SPANISH.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC27.

I would want music to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC28.

I would want TV programs to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC29.

I would want books and magazines to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC30.

I would want dances to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

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09/14/04

Master Parent English - HEPI 2

BICULTURAL INVOLVEMENT QUESTIONNAIRE

BIC31.

I would want radio programs to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC32.

I would want the way of celebrating birthdays to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC33.

I would want the way of celebrating weddings to be HISPANIC.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC34.

I would want food to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC35.

I would want language to be ENGLISH.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC36.

I would want music to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC37.

I would want TV programs to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC38.

I would want books and magazines to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

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09/14/04

Master Parent English - HEPI 2

BICULTURAL INVOLVEMENT QUESTIONNAIRE

BIC39.

I would want dances to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC40.

I would want radio programs to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC41.

I would want the way of celebrating birthdays to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

BIC42.

I would want the way of celebrating weddings to be AMERICAN.

1
2
3
4
5
8

Never
.
Sometimes
.
Always
Refuse to Answer

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Page 18

09/14/04

Master Parent English - HEPI 2

ACCULTURATION SCALE

ACCULTURATION SCALE
ACC1.

Which language do you prefer to speak? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC2.

What language do you speak at home? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC3.

What language do you speak at school? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC4.

What language do you speak at work? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC5.

What language do you speak with friends? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC6.

In what language are the T.V. programs you watch? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC7.

In what language are the radio stations you listen to? (Choose one)

1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

ACC8.

In what language are the books and magazines you read? (Choose one)
1
2
3
4
5
8

Spanish all the time
Spanish most of the time
Spanish and English equally
English most of the time
English all the time
Refuse to Answer

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Page 19

09/14/04

Master Parent English - HEPI 2

ACCULTURATION SCALE

ACC9.

What sort of music do you listen to? (Choose one)

1
2
3
4
5
8

Hispanic all the time
Hispanic most of the time
Hispanic at times and American other times
American most of the time
American all the time
Refuse to Answer

ACC10.

What sort of dances do you dance? (Choose one)

1
2
3
4
5
8

Hispanic all the time
Hispanic most of the time
Hispanic at times and American other times
American most of the time
American all the time
Refuse to Answer

ACC11.

What sort of places do you go to? (Choose one)

1
2
3
4
5
8

Hispanic all the time
Hispanic most of the time
Hispanic at times and American other times
American most of the time
American all the time
Refuse to Answer

ACC12.

What sort of recreation do you engage in? (Choose one)
1
2
3
4
5
8

Hispanic all the time
Hispanic most of the time
Hispanic at times and American other times
American most of the time
American all the time
Refuse to Answer

ACC13.

My way of celebrating birthdays is: (Choose one)

ACC14.

My way of relating to spouse/boyfriend/girlfriend is: (Choose one)

ACC15.

1
2
3
4
5
8

The gestures I use in talking are: (Choose one)

Completely Hispanic
Mostly Hispanic
Mixed: sometimes Hispanic and others American
Mostly American
Completely American
Refuse to Answer

1
2
3
4
5
8

Completely Hispanic
Mostly Hispanic
Mixed: sometimes Hispanic and others American
Mostly American
Completely American
Refuse to Answer

1
2
3
4
5
8

Completely Hispanic
Mostly Hispanic
Mixed: sometimes Hispanic and others American
Mostly American
Completely American
Refuse to Answer

Sometimes life is not as we really want it. If you could have your way, how would you like the following aspects of
your life to be like? Please indicate the response that BEST applies to you.
ACC16.

Food (Choose one)

Version DE24884EN

1
2
3
4
5
8
Page 20

I would wish this to be completely Hispanic
I would wish this to be mostly Hispanic
I would wish this to be both Hispanic and American
I would wish this to be mostly American
I would wish this to be completely American
Refuse to Answer
09/14/04

Master Parent English - HEPI 2

ACCULTURATION SCALE

ACC17.

Language (Choose one)

1
2
3
4
5
8

ACC18.

Music (Choose one)

1
2
3
4
5
8

ACC19.

T.V. Programs (Choose one)

1
2
3
4
5
8

ACC20.

Books/Magazines (Choose one)

1
2
3
4
5
8

ACC21.

Dances (Choose one)

1
2
3
4
5
8

ACC22.

Radio Programs (Choose one)

1
2
3
4
5
8

ACC23.

Way of celebrating birthdays (Choose one)

1
2
3
4
5
8

ACC24.

Way of celebrating weddings (Choose one)

1
2
3
4
5
8

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09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HISPANIC STRESS INVENTORY
Please indicate whether the following situations have occurred to you during the last 3 months. Then if it did occur to
you, indicate how worried or tense the situation made you feel. If the situation did not happen to you, mark "no" and
skip to the next question. Remember there is no right or wrong answer so try and be as honest as you can.
HSI1.

I have seen my son/daughter behave delinquently. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI3

HSI2.

How worried are you about this? (Choose one)

HSI3.

I have questioned the idea that "marriage is forever." Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI5

HSI4.

How worried are you about this? (Choose one)

HSI5.

I have felt unaccepted by others due to my Latino culture. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI7

HSI6.

How worried are you about this? (Choose one)

HSI7.

Because I do not know enough English, it has been difficult for me to interact with others. Has this occurred to you in
the past 3 months?

1
2
3
4
5
8

1
0
8

HSI8.

How worried are you about this? (Choose one)

Version DE24884EN

Yes
No
Refuse to Answer
1
2
3
4
5
8

Page 22

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI9

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI9.

HISPANIC STRESS INVENTORY

My children have been influenced by bad friends. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI11

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI10.

How worried are you about this? (Choose one)

HSI11.

Others have been too worried about the amount and quality of the work I do. Has this occurred to you in the past 3
months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI13

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI12.

How worried are you about this? (Choose one)

HSI13.

I have not been able to forget the last few months in my home country. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI15

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI14.

How worried are you about this? (Choose one)

HSI15.

My spouse has been drinking too much alcohol. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI17

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI16.

How worried are you about this? (Choose one)

HSI17.

I have thought that my children used illegal drugs. Has this occurred to you in the past 3 months?
1
0
8

Version DE24884EN

Page 23

Yes
No
Refuse to Answer

Skip to HSI19

09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HSI18.

How worried are you about this? (Choose one)

HSI19.

My children have been drinking alcohol. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Skip to HSI21

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI23

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI20.

How worried are you about this? (Choose one)

HSI21.

I have been discriminated against. Has this occurred to you in the past 3 months?
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI22.

How worried are you about this? (Choose one)

HSI23.

My spouse has expected me to be more traditional in our relationship. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI25

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI24.

How worried are you about this? (Choose one)

HSI25.

My spouse and I have disagreed on how to bring up our children. Has this occurred to you in the past 3 months?
1
0
8

HSI26.

How worried are you about this? (Choose one)

Version DE24884EN

Page 24

Yes
No
Refuse to Answer

Skip to HSI27

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI27.

HISPANIC STRESS INVENTORY

My spouse and I have disagreed on the importance of religion within our family. Has this occurred to you in the past 3
months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI29

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI28.

How worried are you about this? (Choose one)

HSI29.

I have been criticized about my work. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI31

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI30.

How worried are you about this? (Choose one)

HSI31.

My spouse and I have had disagreements about who should control the household money. Has this occurred to you in
the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI33

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI32.

How worried are you about this? (Choose one)

HSI33.

I have thought a lot about the fact that my son (daughter) left home to live independently. Has this occurred to you in
the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI35

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI34.

How worried are you about this? (Choose one)

HSI35.

Because of American ideas about children it has been difficult for me to decide how strict to be with my children. Has
this occurred to you in the past 3 months?
1
Yes
0
No
Skip to HSI37
8

Version DE24884EN

Page 25

Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HSI36.

How worried are you about this? (Choose one)

HSI37.

Because of my poor English people have treated me badly. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI39

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI38.

How worried are you about this? (Choose one)

HSI39.

I have felt that being too close to my family interfered with my own goals. Has this occurred to you in the past 3
months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI41

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI40.

How worried are you about this? (Choose one)

HSI41.

I have thought that my children want their independence before they are ready. Has this occurred to you in the past 3
months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI43

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI42.

How worried are you about this? (Choose one)

HSI43.

I have felt that members of my family are losing their religion. Has this occurred to you in the past 3 months?
1
0
8

HSI44.

How worried are you about this? (Choose one)

Version DE24884EN

Page 26

Yes
No
Refuse to Answer

Skip to HSI45

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI45.

HISPANIC STRESS INVENTORY

My children have not respected my authority the way they should. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI47

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI46.

How worried are you about this? (Choose one)

HSI47.

Because we have different customs, I have had arguments with other members of my family. Has this occurred to you
in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI49

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI48.

How worried are you about this? (Choose one)

HSI49.

Members of my family have considered divorce as a solution to their marital problems. Has this occurred to you in the
past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI51

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI50.

How worried are you about this? (Choose one)

HSI51.

Because of the lack of family unity, I have felt lonely and isolated. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI53

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI52.

How worried are you about this? (Choose one)

HSI53.

Because I am Latino I have been expected to work harder. Has this occurred to you in the past 3 months?
1
0
8

Version DE24884EN

Page 27

Yes
No
Refuse to Answer

Skip to HSI55

09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HSI54.

How worried are you about this? (Choose one)

HSI55.

It has been difficult for me to understand why my spouse wishes to be more Americanized. Has this occurred to you in
the past 3 months?

1
2
3
4
5
8

1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI57

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI56.

How worried are you about this? (Choose one)

HSI57.

My spouse and I have disagreed on which language is spoken to our children at home. Has this occurred to you in the
past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI59

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI58.

How worried are you about this? (Choose one)

HSI59.

Due to problems in understanding English, I have had difficulties in school. Has this occurred to you in the past 3
months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI61

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI60.

How worried are you about this? (Choose one)

HSI61.

My spouse has not helped with household chores. Has this occurred to you in the past 3 months?
1
0
8

HSI62.

How worried are you about this? (Choose one)

Version DE24884EN

Page 28

Yes
No
Refuse to Answer

Skip to HSI63

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI63.

HISPANIC STRESS INVENTORY

My income has not been sufficient to support my family or myself. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI65

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI64.

How worried are you about this? (Choose one)

HSI65.

I feared the consequences of deportation. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI67

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI66.

How worried are you about this? (Choose one)

HSI67.

I have thought that my children were not receiving a good education. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI69

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI68.

How worried are you about this? (Choose one)

HSI69.

My legal status has been a problem in getting a good job. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI71

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI70.

How worried are you about this? (Choose one)

HSI71.

There have been cultural conflicts in my marriage. Has this occurred to you in the past 3 months?
1
0
8

HSI72.

How worried are you about this? (Choose one)

Version DE24884EN

Page 29

Yes
No
Refuse to Answer

Skip to HSI73

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI73.

HISPANIC STRESS INVENTORY

I have felt that my children's ideas about sexuality are too liberal. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI75

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI74.

How worried are you about this? (Choose one)

HSI75.

There has been physical violence among members of my family. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI77

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI76.

How worried are you about this? (Choose one)

HSI77.

I did not get the job I wanted because I did not have the proper skills. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI79

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI78.

How worried are you about this? (Choose one)

HSI79.

Because I am Latino I have had difficulty finding the type of work I want. Has this occurred to you in the past 3
months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI81

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI80.

How worried are you about this? (Choose one)

HSI81.

My spouse has expected me to be less traditional in our relationship. Has this occurred to you in the past 3 months?
1
0
8

Version DE24884EN

Page 30

Yes
No
Refuse to Answer

Skip to HSI83

09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HSI82.

How worried are you about this? (Choose one)

HSI83.

The pressures to achieve economic success have made me stop going to church. Has this occurred to you in the past 3
months?

1
2
3
4
5
8

1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI85

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI84.

How worried are you about this? (Choose one)

HSI85.

My children have talked about leaving home. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI87

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI86.

How worried are you about this? (Choose one)

HSI87.

My legal status has limited my contact with family or friends. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI89

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI88.

How worried are you about this? (Choose one)

HSI89.

I have felt that I would never regain the status and respect that I had in my home country. Has this occurred to you in
the past 3 months?
1
0
8

HSI90.

How worried are you about this? (Choose one)

Version DE24884EN

Page 31

Yes
No
Refuse to Answer

Skip to HSI91

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI91.

HISPANIC STRESS INVENTORY

I have felt that family relations are becoming less important for people that I'm close to. Has this occurred to you in the
past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI93

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI92.

How worried are you about this? (Choose one)

HSI93.

My children have received bad school reports (or bad grades). Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI95

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI94.

How worried are you about this? (Choose one)

HSI95.

It has been difficult for my spouse and I to combine Latino and American culture. Has this occurred to you in the past
3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI97

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI96.

How worried are you about this? (Choose one)

HSI97.

My boss has thought of me as being too passive. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI99

1
2
3
4
5
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

HSI98.

How worried are you about this? (Choose one)

HSI99.

I have had to watch the quality of my work so others do not think I am lazy. Has this occurred to you in the past 3
months?
1
0
8

Version DE24884EN

Page 32

Yes
No
Refuse to Answer

Skip to HSI101

09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HSI100.

How worried are you about this? (Choose one)

HSI101.

Because I am Latino it has been hard to get promotions or salary raises. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI103

HSI102.

How worried are you about this? (Choose one)

HSI103.

Because of money problems, I have to work away from my family. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI105

HSI104.

How worried are you about this? (Choose one)

HSI105.

I had serious arguments with family members. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

HSI106.

How worried are you about this? (Choose one)

HSI107.

I have been around too much violence. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

HSI108.

How worried are you about this? (Choose one)

HSI109.

I have avoided immigration officials. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Version DE24884EN

Page 33

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI107
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI109
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI111

09/14/04

Master Parent English - HEPI 2

HISPANIC STRESS INVENTORY

HSI110.

How worried are you about this? (Choose one)

HSI111.

I have thought that if I went to a social or government agency I would be deported. Has this occurred to you in the past
3 months?

1
2
3
4
5
8

1
0
8

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI113

HSI112.

How worried are you about this? (Choose one)

HSI113.

My personal goals have been in conflict with family goals. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

HSI114.

How worried are you about this? (Choose one)

HSI115.

Both my spouse and I have had to work. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI115
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI117

HSI116.

How worried are you about this? (Choose one)

HSI117.

Because I do not know enough English, it has been difficult to deal with day to day situations. Has this occurred to you
in the past 3 months?

1
2
3
4
5
8

1
0
8

HSI118.

How worried are you about this? (Choose one)

Version DE24884EN

Yes
No
Refuse to Answer
1
2
3
4
5
8

Page 34

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI119
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI119.

HISPANIC STRESS INVENTORY

I have not been able to forget about the war related deaths which happened to friends or family members.Has this
occurred to you in the past 3 months?
1
Yes
0
No
Skip to HSI121
8

Refuse to Answer

HSI120.

How worried are you about this? (Choose one)

HSI121.

My spouse and I have had disagreements on the use of contraceptives. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI123

HSI122.

How worried are you about this? (Choose one)

HSI123.

My children have seen too much sex on television or at the movies. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI125

HSI124.

How worried are you about this? (Choose one)

HSI125.

I have noticed that religion is less important to me now than before. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI127

HSI126.

How worried are you about this? (Choose one)

HSI127.

I have felt guilty about leaving family and friends in my home country. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

HSI128.

How worried are you about this? (Choose one)

Version DE24884EN

Yes
No
Refuse to Answer
1
2
3
4
5
8

Page 35

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI129
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI129.

HISPANIC STRESS INVENTORY

My spouse has not been adapting to American life. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

Skip to HSI131

HSI130.

How worried are you about this? (Choose one)

HSI131.

I have been forced to accept low paying jobs. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI133

HSI132.

How worried are you about this? (Choose one)

HSI133.

There have been conflicts among members of my family. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Yes
No
Refuse to Answer

Skip to HSI135

HSI134.

How worried are you about this? (Choose one)

HSI135.

I have been questioned about my legal status. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

HSI136.

How worried are you about this? (Choose one)

HSI137.

I have had difficulty finding legal services. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

HSI138.

How worried are you about this? (Choose one)

Version DE24884EN

Yes
No
Refuse to Answer
1
2
3
4
5
8

Page 36

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI137
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI139
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

HSI139.

HISPANIC STRESS INVENTORY

I have felt that I might lose my job to newly arriving immigrants. Has this occurred to you in the past 3 months?
1
0
8

Yes
No
Refuse to Answer

HSI140.

How worried are you about this? (Choose one)

HSI141.

I have felt pressured to learn English. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Skip to HSI141
Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI143

HSI142.

How worried are you about this? (Choose one)

HSI143.

Some members of my family have become too individualistic. Has this occurred to you in the past 3 months?

1
2
3
4
5
8
1
0
8

Yes
No
Refuse to Answer

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

Skip to HSI145

HSI144.

How worried are you about this? (Choose one)

HSI145.

I have felt that my spouse and I have not been able to communicate. Has this occurred to you in the past 3 months?
1
0
8

HSI146.

1
2
3
4
5
8
Yes
No
Refuse to Answer

How worried are you about this? (Choose one)

Version DE24884EN

Skip to instruction before FAM1
1
2
3
4
5
8

Page 37

Not at all worried/tense
A little worried/tense
Moderately worried/tense
Very worried/tense
Extremely worried/tense
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

FAMILY RELATIONS SCALE

FAMILY RELATIONS SCALE
The following questions have to do with families. We want to know how much each one is true about your family.
Click on the item that indicates how true each one is about your family in your opinion.
FAM1.

Family members feel very close to each other. (Choose one)

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

FAM2.

My family expects too much of me. (Choose one)

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

FAM3.

We can easily think of things to do together as a family. (Choose one)
1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

FAM4.

I have trouble accepting someone else's answer to a family problem. (Choose one)
1
2
3
4
8

FAM5.

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

My family and I have the same views about what is right and wrong. (Choose one)
1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

FAM6.

My family doesn't let me be myself. (Choose one)

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

FAM7.

Family members ask each other for help. (Choose one)

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

FAM8.

I often don't understand what other family members are saying. (Choose one)
1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

Version DE24884EN

Page 38

09/14/04

Master Parent English - HEPI 2

FAMILY RELATIONS SCALE

FAM9.

My family knows what I mean when I say something. (Choose one)

FAM10.

I listen to what other family members have to say, even when I disagree. (Choose one)

FAM11.

I am tired of being blamed for family problems. (Choose one)

FAM13.

My family and I have the same views about being successful. (Choose one)

FAM15.

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

1
2
3
4
8

Not at all true
Hardly ever true
True a lot
Almost always or always true
Refuse to Answer

Family members like to spend free time with each other. (Choose one)

FAM12.

FAM14.

1
2
3
4
8

If someone in the family has upset me, I keep it to myself. (Choose one)

I am available when others in the family want to talk to me. (Choose one)

FAM16.

Family togetherness is important. (Choose one)

FAM17.

Kids should value a close relationship with their family and not have to be asked to spend time at home. (Choose one)

1
2
3
4
8
1
2
3
4
8

Version DE24884EN

Page 39

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer
Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer
09/14/04

Master Parent English - HEPI 2

FAMILY RELATIONS SCALE

FAM18.

No matter what, family members should stick together. (Choose one)

FAM19.

Family members should be able to speak their minds with one another. (Choose one)

FAM20.

Children should always talk to their parents with respect. (Choose one)

FAM22.

Kids should obey their parents even when they don't agree with them. (Choose one)

FAM24.

FAM25.

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

Parents should teach their children what they need to know to make it in the world. (Choose one)

FAM21.

FAM23.

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

Parents should expect kids my child's age to do some work around the house. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

Kids my child's age should call home if they think they might be late. (Choose one)

Kids my child's age should clean up for themselves without having to be told. (Choose one)
1
2
3
4
8

Version DE24884EN

Page 40

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PARENTAL LOCUS OF CONTROL SCALE

PARENTAL LOCUS OF CONTROL SCALE
Indicate your agreement or disagreement with each statement by clicking on the appropriate response.
LOC1.

LOC2.

LOC3.

When I set expectations for my child, I am almost certain that I can help him/her meet them. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

I am often able to predict my child's behavior in situations. (Choose one)

When my child gets angry I can usually deal with him/her if I stay calm. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

LOC4.

What I do has little effect on my child's behavior. (Choose one)

LOC5.

No matter how hard a parent tries, some children will never learn to mind. (Choose one)

LOC6.

LOC7.

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

My child usually ends up getting his/her way, so why try. (Choose one)

When something goes wrong between me and my child, there is little I can do to correct it. (Choose one)
1
2
3
4
5
8

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Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer
09/14/04

Master Parent English - HEPI 2

LOC8.

PARENTAL LOCUS OF CONTROL SCALE

Parents should address problems with their children because ignoring them won't make them go away. (Choose one)
1
2
3
4
5
8

LOC9.

It is not always wise to expect too much from my child because many things turn out to be a matter of good or bad luck
anyway. (Choose one)
1
2
3
4
5
8

LOC10.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

If your child tantrums no matter what you try, you might as well give up. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

LOC11.

I am responsible for my child's behavior. (Choose one)

LOC12.

Capable people who fail to become good parents have not followed through on their opportunities. (Choose one)

LOC13.

LOC14.

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

My child's behavior problems are no one's fault but my own. (Choose one)

Parents whose children make them feel helpless just aren't using the best parenting techniques. (Choose one)
1
2
3
4
5
8

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Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

LOC15.

PARENTAL LOCUS OF CONTROL SCALE

There is no such thing as good or bad children-just good or bad parents. (Choose one)
1
2
3
4
5
8

LOC16.

Parents who can't get their children to listen to them don't understand how to get along with their children. (Choose
one)
1
2
3
4
5
8

LOC17.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

The misfortunes and successes I have had as a parent are the direct result of my own behavior. (Choose one)
1
2
3
4
5
8

LOC21.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

When my child is well-behaved, it is because he/she is responding to my efforts. (Choose one)
1
2
3
4
5
8

LOC20.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

Children's behavior problems are often due to mistakes their parents made. (Choose one)
1
2
3
4
5
8

LOC19.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

Most children's behavior problems would not have developed if their parents had had better parenting skills. (Choose
one)
1
2
3
4
5
8

LOC18.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

I feel like what happens in my life is most likely determined by my child. (Choose one)
1
2
3
4
5
8

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Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PARENTAL LOCUS OF CONTROL SCALE

LOC22.

My child does not control my life. (Choose one)

1
2
3
4
5
8

LOC23.

Even if your child frequently tantrums, a parent should not give up. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

LOC24.

My child influences the number of friends I have. (Choose one)

LOC25.

When I make a mistake with my child I am usually able to correct it. (Choose one)
1
2
3
4
5
8

LOC26.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

It is easy for me to avoid and function independently of my child's attempts to have control over me. (Choose one)

LOC27.

My life is chiefly controlled by my child. (Choose one)

LOC28.

Without the right breaks one cannot be an effective parent. (Choose one)

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1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

LOC29.

LOC30.

LOC31.

PARENTAL LOCUS OF CONTROL SCALE

Heredity plays the major role in determining a child's personality. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

Neither my child nor myself is responsible for his/her behavior. (Choose one)

Success in dealing with children seems to be more a matter of the child's moods and feelings at the time rather than
one's own actions. (Choose one)
1
2
3
4
5
8

LOC32.

In order to have my plans work, I make sure they fit in with the desires of my child. (Choose one)
1
2
3
4
5
8

LOC33.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

Most parents don't realize the extent to which how their children turn out is influenced by accidental happenings.
(Choose one)
1
2
3
4
5
8

LOC35.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

I'm just one of those lucky parents who happened to have a good child. (Choose one)
1
2
3
4
5
8

LOC34.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

Being a good parent often depends on being lucky enough to have a good child. (Choose one)
1
2
3
4
5
8

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Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

LOC36.

PARENTAL LOCUS OF CONTROL SCALE

I have often found that when it comes to my children, what is going to happen will happen. (Choose one)
1
2
3
4
5
8

LOC37.

Fate was kind to me-if I had had a bad child I don't know what I would have done. (Choose one)
1
2
3
4
5
8

LOC38.

LOC39.

LOC40.

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer
Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

It is not too difficult to change my child's mind about something. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

My child's behavior is sometimes more than I can handle. (Choose one)

Sometimes I feel that I do not have enough control over the direction my child's life is taking. (Choose one)

LOC41.

I always feel in control when it comes to my child. (Choose one)

LOC42.

Sometimes I feel that my child's behavior is hopeless. (Choose one)

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1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

LOC43.

PARENTAL LOCUS OF CONTROL SCALE

It is often easier to let my child have his/her way than to put up with a tantrum. (Choose one)
1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

1
2
3
4
5
8

Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

LOC44.

I allow my child to get away with things. (Choose one)

LOC45.

I find that sometimes my child can get me to do things I really did not want to do. (Choose one)
1
2
3
4
5
8

LOC46.

My child often behaves in a manner very different from the way I would want him/her to behave. (Choose one)
1
2
3
4
5
8

LOC47.

Sometimes when I'm tired I let my children do things I normally wouldn't. (Choose one)
1
2
3
4
5
8

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Strongly Disagree
Somewhat Disagree
Neither Agree Nor Disagree
Somewhat Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PARENTING PRACTICES SCALE

PARENTING PRACTICES SCALE
These questions refer specifically to your relationship with the child that is in this program with you. The following
questions have to do with the kinds of things that you and your child may have talked about or have done together in
the past six (6) months.
PPR1.

When was the last time that you discussed with your child his/her plans for the coming day? (Choose one)
1
2
3
4
5
8

PPR2.

In the past six months, about how often have you discussed with your child his/her plans for the coming day? (Choose
one)
1
2
3
4
5
8

PPR3.

More than 1 month ago
Within last month
Within last week
Yesterday/today
Don't Know
Refuse to Answer

In the past six months, about how often have you talked with your child about what he/she had actually done during the
day? (Choose one)
1
2
3
4
5
8

PPR5.

Less than once a month
At least once a month
At least once a week
Almost every day
Don't know
Refuse to Answer

When was the last time you talked with your child about what he/she had actually done during the day? (Choose one)
1
2
3
4
5
8

PPR4.

More than 1 month ago
Within last month
Within last week
Yesterday/today
Don't Know
Refuse to Answer

Less than once a month
At least once a month
At least once a week
Almost every day
Don't know
Refuse to Answer

Does your child have a set time to be home on school nights? (Choose one)
1
2
3
4
5
6
7
8

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He/she is not allowed out
Before 8:00 pm
8:00-8:59 pm
9:00-9:59 pm
10:00-10:59 pm
11:00 pm or later
As late as he/she wants
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PPR6.

PARENTING PRACTICES SCALE

Does your child have a set time to be home on weekend nights? (Choose one)
1
2
3
4
5
6
7
8
9
98

PPR7.

He/she is not allowed out
Before 9:00 pm
9:00-9:59 pm
10:00-10:59 pm
11:00-11:59 pm
12:00-12:59 am
1:00- 1:59 am
After 2:00 am
As late as he/she wants
Refuse to Answer

If your child did not come home by the time that was set, would you know? (Choose one)
0
1
2
8

PPR8.

No
Probably
Certainly
Refuse to Answer

If you or another adult are not at home, does your child leave you a note or call you to let you know where he/she is
going? (Choose one)
1
2
3
8

PPR9.

Almost never
Sometimes
Almost always
Refuse to Answer

Do you know who your child's companions are when he/she is not at home? (Choose one)
1
2
3
8

PPR10.

PPR11.

PPR12.

When you are not home, does your child know how to get in touch with you? (Choose one)
1
2
3
8

Almost never
Sometimes
Almost always
Refuse to Answer

1
2
3
8

Almost never
Sometimes
Almost always
Refuse to Answer

When your child is out, do you know what time he/she will be home? (Choose one)

Is it important to you to know what your child is doing when he/she is outside of the home? (Choose one)
1
2
3
8

PPR13.

Almost never
Sometimes
Almost always
Refuse to Answer

No, not important
Yes, somewhat important
Yes, very important
Refuse to Answer

Where does your child usually go after school? More than one response may be selected. (Check all that apply)
__
__
__
__
__
__
__
__

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Home, supervised (adult or responsible minor present)
Home, unsupervised
Somewhere else, supervised (adult or responsible minor present)
Somewhere else, unsupervised
Somewhere else, don't know if supervised
Other
Don't know
Refuse to Answer
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09/14/04

Master Parent English - HEPI 2

PPR14.

PARENTING PRACTICES SCALE

Where is your child usually in the evening? More than one response may be selected. (Check all that apply)
__
__
__
__
__
__
__
__

PPR15.

Where is your child usually on weekends? More than one response may be selected. (Check all that apply)
__
__
__
__
__
__
__
__

PPR16.

How many of your child's friends do you know? (Choose one)

PPR17.

When you and your child are both at home, do you know what he/she is doing? (Choose one)

0
1
2
3
8

None
Some
Most
All
Refuse to Answer

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR18.

Does your child help to plan family activities? (Choose one)

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR19.

Does your child like to get involved in family activities? (Choose one)

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR20.

Do you find time to listen to your child when he/she wants to talk to you? (Choose one)
1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR21.

Do you and your child do things together at home? (Choose one)

PPR22.

Does your child go with members of the family to movies, sports events or other outings? (Choose one)
1
2
3
8

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Hardly ever
Sometimes
Often
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PPR23.

PARENTING PRACTICES SCALE

Does your child go with members of the family to Church, Synagogue, or Sunday school? (Choose one)
1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR24.

How often do you have a friendly chat with your child? (Choose one)

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR25.

Does your child help you? (Choose one)

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

PPR26.

Does your child prefer to be with his/her friends rather than with the family? (Choose one)

PPR27.

PPR28.

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

1
2
3
8

Hardly ever
Sometimes
Often
Refuse to Answer

Do you talk with your child about how he/she is doing at school? (Choose one)

On the average, how much time each day are you together with your child on weekdays, that is, when you and your
child are both awake? (Choose one)
1
Less than 30 minutes
2
3
4
5
8

30 minutes to 1 hour
More than 1 hour, less than 3 hours
3 to 6 hours
More than 6 hours
Refuse to Answer

1
2
3
4
5
8

Less than 30 minutes
30 minutes to 1 hour
More than 1 hour, less than 3 hours
3 to 6 hours
More than 6 hours
Refuse to Answer

PPR29.

And on weekends? (Choose one)

PPR30.

On weekdays, how much of that time are you doing something together, like making something, playing a game,
talking, or going out together? (Choose one)
1
Less than 30 minutes

PPR31.

And on weekend days? (Choose one)

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2
3
4
5
8

30 minutes to 1 hour
More than 1 hour, less than 3 hours
3 to 6 hours
More than 6 hours
Refuse to Answer

1
2
3
4
5
8

Less than 30 minutes
30 minutes to 1 hour
More than 1 hour, less than 3 hours
3 to 6 hours
More than 6 hours
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PARENTING PRACTICES SCALE

PPR32.

In general, are these activities enjoyable? (Choose one)

PPR33.

When your child has done something that you like or approve of, do you not say anything about it, or ignore it?
(Choose one)

1
2
3
8

Not really enjoyable
Sometimes enjoyable
Almost always enjoyable
Refuse to Answer

1
2
3
8

PPR34.

When your child has done something that you like or approve of, do you give him a wink or a smile? (Choose one)
1
2
3
8

PPR35.

Sometimes
Often
Refuse to Answer

When your child has done something that you like or approve of, do you do something special together such as going
to the movies, to a game, playing a game, or going somewhere? (Choose one)
1
Almost never
2
3
8

PPR40.

Sometimes
Often
Refuse to Answer

When your child has done something that you like or approve of, do you give him a special privilege such as staying
up late, or doing some special activity? (Choose one)
1
Almost never
2
3
8

PPR39.

Almost never
Sometimes
Often
Refuse to Answer

When your child has done something that you like or approve of, do you give him some reward for it, like a present,
extra money, or something special to eat? (Choose one)
1
Almost never
2
3
8

PPR38.

Almost never
Sometimes
Often
Refuse to Answer

When your child has done something that you like or approve of, do you give him a hug, pat on the back, or a kiss for
it? (Choose one)
1
2
3
8

PPR37.

Almost never
Sometimes
Often
Refuse to Answer

When your child has done something that you like or approve of, do you say something nice about it; praise or give
approval? (Choose one)
1
2
3
8

PPR36.

Almost never
Sometimes
Often
Refuse to Answer

Sometimes
Often
Refuse to Answer

When your child has done something that you like or approve of, do you mention it to someone else? (Choose one)
1
2
3
8

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Almost never
Sometimes
Often
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PPR41.

PPR42.

PARENTING PRACTICES SCALE

When your child has done something that you like or approve of, do you ask him why he is not always good like this?
(Choose one)

Is there anything else that you do when he has been good?

1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

1
0
8

Yes
No
Refuse to Answer

1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

Consider the past six (6) months in answering the following questions.
PPR43.

If you punish your child, does his/her behavior get worse? (Choose one)

PPR44.

Are you worried that your way of disciplining your child is making him/her stubborn? (Choose one)
1
2
3
8

PPR45.

Do you hesitate to enforce the rules with your child because you fear he/she might then harm someone in your
household? (Choose one)
1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

PPR46.

Do you feel that you must be careful not to upset your child? (Choose one)

PPR47.

Do you feel that other family members must be careful not to upset your child? (Choose one)
1
2
3
8

PPR48.

Almost never
Sometimes
Often
Refuse to Answer

Do you think that your child will take it out on other children if you try to make him obey you? (Choose one)
1
2
3
8

PPR50.

Almost never
Sometimes
Often
Refuse to Answer

Do you feel that it is more trouble than it is worth to ask your child to help you? (Choose one)
1
2
3
8

PPR49.

Almost never
Sometimes
Often
Refuse to Answer

When you are by yourself, do you have much difficulty controlling your child? (Choose one)
1
2
3
8

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Almost never
Sometimes
Often
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PPR51.

PPR52.

PPR53.

PARENTING PRACTICES SCALE

When other adults are present, do you have much difficulty controlling your child? (Choose one)
1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

Do you leave your child alone because of his/her moodiness? (Choose one)

Do you think that your child will try to get back at you if you try to make him/her obey you? (Choose one)
1
2
3
8

Almost never
Sometimes
Often
Refuse to Answer

The following questions have to do with child rearing. Please indicate how often they apply - Almost Never,
Sometimes or Almost Always. If the question does not apply to your family, choose Not Applicable.
PPR54.

If you ask your child to do something and he/she does not do it, do you give up trying to get him/her to do it? (Choose
one)
1
2
3
8
9

PPR55.

If you warn your child that he/she will be punished if he/she does not stop doing something, do you actually punish
him/her if he/she does not stop? (Choose one)
1
Almost never
2
3
8
9

PPR56.

Almost never
Sometimes
Almost always
Refuse to Answer
Not Applicable

Sometimes
Almost always
Refuse to Answer
Not Applicable

If you have told your child that he/she is grounded for a period of time as a punishment, would he/she be let off
(released, forgiven) before the time is up? (Choose one)
1
Almost never
2
3
8
9

Sometimes
Almost always
Refuse to Answer
Not Applicable

1
2
3
8
9

Almost never
Sometimes
Almost always
Refuse to Answer
Not Applicable

PPR57.

Do you let your child get away with things? (Choose one)

PPR58.

Does your child usually know how you will react or punish him/her when he/she has done something wrong?
(Choose one)
1
2
3
8
9

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Almost never
Sometimes
Almost always
Refuse to Answer
Not Applicable

09/14/04

Master Parent English - HEPI 2

PARENTING PRACTICES SCALE

PPR59.

If your child is punished, does the punishment work? (Choose one)

PPR60.

If a punishment has been decided upon, can your child change it by explanations, arguments or excuses? (Choose
one)

1
2
3
8
9

PPR61.

Almost never
Sometimes
Almost always
Refuse to Answer
Not Applicable

Do you disagree openly with your partner about how to discipline your child when he/she is present? (Choose one)
1
2
3
8
9

PPR63.

Almost never
Sometimes
Almost always
Refuse to Answer
Not Applicable

Do you and your partner agree with one another about how to bring up your child? (Choose one)
1
2
3
8
9

PPR62.

Almost never
Sometimes
Almost always
Refuse to Answer
Not Applicable

Who really has the final say about disciplining your child?
Mark Not Applicable if you don't have a partner. (Choose one)
1
2
3
4
5
6
7
98
99

PPR63a.

Who really has the final say about disciplining your child?
Mark Not Applicable if you have a partner.
(Choose one)

PPR64.

Your partner only
Mostly your partner
Yourself and your partner about equally
Mostly yourself
Yourself only
Yourself, your partner and your child about equally
Mostly your child
Refuse to Answer
Not Applicable

04
07
10
98
99

Mostly yourself
Mostly your child
You and your child about equally
Refuse to Answer
Not Applicable

Does the kind of punishment you give your child depend on if you are in a good or a bad mood? (Choose one)
1
2
3
8

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No difference
Some difference
Big difference
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PARENTING PRACTICES SCALE

PPR65.

Is the discipline you use effective for your child? (Choose one)

PPR66.

Do you feel you have found the right kind of discipline to deal with your child? (Choose one)

1
2
3
8
0
1
2
3
4
8

PPR67.

Almost never
Sometimes
Often
Refuse to Answer

If your child does something that he/she is not allowed to do or that you don't like, do you slap or spank him/her or hit
him/her with something? (Choose one)
1
Almost never
2
3
8

PPR73.

Almost never
Sometimes
Often
Refuse to Answer

If your child does something that he is not allowed to do or that you don't like, do you ignore it or not pay attention to
it? (Choose one)
1
2
3
8

PPR72.

Almost never
Sometimes
Often
Refuse to Answer

If your child does something that he is not allowed to do or that you don't like, do you calmly discuss what happened?
(Choose one)
1
2
3
8

PPR71.

Almost never
Sometimes
Often
Refuse to Answer

If your child does something that he is not allowed to do or that you don't like, do you yell or scold? (Choose one)
1
2
3
8

PPR70.

Almost never
Sometimes
Often
Refuse to Answer

If your child does something that he is not allowed to do or that you don't like, do you send him out of the room?
(Choose one)
1
2
3
8

PPR69.

Never
In some situations
Half of the time
In most situations
In all situations
Refuse to Answer

If your child does something that he/she is not allowed to do or that you don't like, do you take away a privilege or
pocket money? (Choose one)
1
2
3
8

PPR68.

Not really
Half of the time
Usually
Refuse to Answer

Sometimes
Often
Refuse to Answer

If your child does something that he/she is not allowed to do or that you don't like, do you tell him/her to get out or
temporarily lock him/her out of the house? (Choose one)
1
Almost never
2
3
8

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Sometimes
Often
Refuse to Answer

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Master Parent English - HEPI 2

PPR74.

PARENTING PRACTICES SCALE

Is there anything else you do when your child does something you do not like?
1
0
8

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Yes
No
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

BEHAVIORAL PROBLEM CHECKLIST

BEHAVIORAL PROBLEM CHECKLIST
Please indicate which of the following are problems, as far as your child in this program is concerned. If an item does
not constitute a problem, or if you have had no opportunity to observe, or have no knowledge about the item, click on
No Problem. If an item constitutes a Mild Problem or Severe Problem, click on the corresponding response.
BPC1.

Restless; unable to sit still. (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC2.

Seeks attention; "shows off" (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC3.

Stays out late at night (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC4.

Self conscious; easily embarrassed (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC5.

Disruptive; annoys and bothers others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC6.

Feels inferior (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC7.

Steals in company with others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC8.

Preoccupied; "in a world of his own;" stares into space (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC9.

Shy, bashful (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC10.

Withdraws; prefers solitary activities (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC11.

Belongs to a gang (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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BEHAVIORAL PROBLEM CHECKLIST

BPC12.

Repetitive speech; says the same thing over and over (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC13.

Short attention span; poor concentration (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC14.

Lacks self-confidence (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC15.

Inattentive to what others say (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC16.

Incoherent speech, what is said doesn't make sense (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC17.

Fights (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC18.

Loyal to delinquent friends (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC19.

Has temper tantrums (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC20.

Truant from school, usually in company with others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC21.

Hypersensitive; feelings are easily hurt (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC22.

Generally fearful; anxious (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC23.

Irresponsible, undependable (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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Master Parent English - HEPI 2

BPC24.

BEHAVIORAL PROBLEM CHECKLIST

Has "bad" companions, ones who are always in some kind of trouble (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC25.

Tense; unable to relax (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC26.

Disobedient; difficult to control (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC27.

Depressed; always sad (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC28.

Uncooperative in group situations (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC29.

Passive, suggestible; easily led by others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC30.

Hyperactive; "always on the go" (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC31.

Distractible; easily diverted from the task at hand (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC32.

Destructive in regard to own and/or other's property (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC33.

Negative; tends to do the opposite of what is requested (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC34.

Impertinent, talks back (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC35.

Sluggish, slow moving, lethargic (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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BEHAVIORAL PROBLEM CHECKLIST

BPC36.

Drowsy, not "wide awake" (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC37.

Nervous, jittery, jumpy, easily startled (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC38.

Irritable, hot-tempered, easily angered (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC39.

Expresses strange, far-fetched ideas (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC40.

Argues; quarrels (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC41.

Sulks and pouts (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC42.

Persists and nags, can't take "no" for an answer (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC43.

Avoids looking others in the eye (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC44.

Answers without stopping to think (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC45.

Unable to work independently; needs constant help and attention (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC46.

Uses drugs in company with others (Choose one)

BPC47.

Impulsive; starts before understanding what to do; doesn't stop and think (Choose one)
0
1
2
8

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No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

BEHAVIORAL PROBLEM CHECKLIST

BPC48.

Chews on inedible things (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC49.

Tries to dominate others; bullies; threatens (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC50.

Picks at other children as a way of getting their attention; seems to want to relate but doesn't know how (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC51.

Steals from people outside the home (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC52.

Expresses beliefs that are clearly untrue (delusions) (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC53.

Says nobody loves him or her (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC54.

Freely admits disrespect for moral values and laws (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC55.

Brags and boasts (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC56.

Slow and not accurate in doing things (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC57.

Shows little interest in things around him or her (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC58.

Does not finish things; gives up easily; lacks perseverance (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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Master Parent English - HEPI 2

BPC59.

BEHAVIORAL PROBLEM CHECKLIST

Is part of a group that rejects school activities such as team sports, clubs, projects to help others (Choose one)

BPC60.

Cheats (Choose one)

BPC61.

Seeks company of older, "more experienced" companions (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC62.

Knows what's going on but is listless and uninterested (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC63.

Resists leaving mother's (or other caretaker's) side (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC64.

Difficulty in making choices; can't make up mind (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC65.

Teases others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC66.

Absentminded; forgets simple things easily (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC67.

Acts like he or she were much younger; immature, "childish" (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC68.

Has trouble following directions (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC69.

Will lie to protect his/her friends (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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Master Parent English - HEPI 2

BEHAVIORAL PROBLEM CHECKLIST

BPC70.

Afraid to try new things for fear of failure (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC71.

Selfish; won't share; always takes the biggest piece (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC72.

Uses alcohol in company with others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC73.

School work is messy, sloppy (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC74.

Does not respond to praise from adults (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC75.

Not liked by others; is a "loner" because of aggressive behavior (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC76.

Does not use language to communicate (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC77.

Cannot stand to wait; wants everything right now (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC78.

Refuses to take directions, won't do as told (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC79.

Blames others; denies own mistakes (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC80.

Admires and seeks to associate with "rougher" peers (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC81.

Punishment doesn't affect his or her behavior (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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BEHAVIORAL PROBLEM CHECKLIST

BPC82.

Squirms, fidgets (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC83.

Deliberately cruel to others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC84.

Feels he or she can't succeed (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC85.

Tells imaginary things as though true; unable to tell real from imagined (Choose one)

BPC86.

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

Does not hug and kiss members of the family; affectionless (Choose one)

BPC87.

Runs away; is truant from home (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC88.

Openly admires people who operate outside the law (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

BPC89.

Repeats what is said to him or her; "parrots" others' speech (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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Master Parent English - HEPI 2

Parent-Adolescent Communication Scale

Parent-Adolescent Communication Scale
The following questions refer specifically to your relationship with the child that is in this program with you. Please
think of him/her when answering the following questions.
PAC1.

I can discuss my beliefs with my child without feeling restrained or embarrassed. (Choose one)
1
2
3
4
5
8

PAC2.

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

Sometimes I have trouble believing everything my child tells me. (Choose one)
1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC3.

My child is always a good listener. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC4.

I am sometimes afraid to ask my child for what I want. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC5.

My child has a tendency to say things to me which would be better left unsaid. (Choose one)
1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC6.

My child can tell how I'm feeling without asking. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC7.

I am very satisfied with how my child and I talk together. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

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Parent-Adolescent Communication Scale

PAC8.

If I were in trouble, I could tell my child. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC9.

I openly show affection to my child. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC10.

When we are having a problem, I often give my child the silent treatment. (Choose one)
1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC11.

I am careful about what I say to my child. (Choose one)

PAC12.

When talking with my child, I have a tendency to say things that would be better left unsaid. (Choose one)

PAC13.

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

When I ask questions, I get honest answers from my child. (Choose one)

PAC14.

My child tries to understand my point of view. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC15.

There are topics I avoid discussing with my child. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

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Parent-Adolescent Communication Scale

PAC16.

I find it easy to discuss problems with my child. (Choose one)

PAC17.

It is very easy for me to express all my true feelings to my child. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC18.

My child nags/bothers me. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC19.

My child insults me when s/he is angry with me. (Choose one)

1
2
3
4
5
8

Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

PAC20.

I don't think I can tell my child how I really feel about some things. (Choose one)
1
2
3
4
5
8

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Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

SPS Social Provisions Scale

SPS Social Provisions Scale
In answering the following questions, think about your current relationships with friends, family members, co-workers,
community members, and so on. Please indicate to what extent each statement describes your current relationships
with other people.
SPS1.

SPS2.

There are people I can depend on to help me if I really need it. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

I feel that I do not have close personal relationships with other people. (Choose one)

SPS3.

There is no one I can turn to for guidance in times of stress. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS4.

There are people who enjoy the same social activities I do. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS5.

Other people do not view me as competent. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS6.

I feel part of a group of people who share my attitudes and beliefs. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS7.

I do not think other people respect my skills and abilities. (Choose one)

SPS8.

If something went wrong, no one would come to my assistance. (Choose one)

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SPS9.

SPS10.

SPS11.

SPS Social Provisions Scale

I have close relationships that provide me with a sense of emotional security and well-being. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Disagree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

There is someone I could talk to about important decisions in my life. (Choose one)

I have relationships where my competence and skill are recognized. (Choose one)

SPS12.

There is no one who shares my interests and concerns. (Choose one)

SPS13.

There is a trustworthy person I could turn to for advice if I were having problems. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS14.

I feel a strong emotional bond with at least one other person. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS15.

There is no one I can depend on for aid if I really need it. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS16.

There is no one I feel comfortable talking about problems with. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS17.

There are people who admire my talents and abilities. (Choose one)

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SPS Social Provisions Scale

SPS18.

I lack a feeling of intimacy with another person. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS19.

There is no one who likes to do the things I do. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS20.

There are people who I can count on in an emergency. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS21.

I know someone who would loan me $100 to help me. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS22.

There are people I regularly spend time with. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS23.

I know someone who would bring my meals to my room or apartment if I were sick. (Choose one)
1
2
3
4
8

SPS24.

If I decided to go to a movie today or tomorrow, I could easily find someone to go with me. (Choose one)
1
2
3
4
8

SPS25.

SPS26.

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer
Strongly Disagree
Disagree
Agree
Agree Strongly
Refuse to Answer

If I needed it, my family or someone else would help me with financial support on a continuing basis. (Choose one)

There are people who depend on me for help. (Choose one)

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1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

SPS27.

SPS Social Provisions Scale

I feel personally responsible for the well-being of another person. (Choose one)
1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS28.

There is no one who really relies on me for their well-being. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

SPS29.

No one needs me to care for them. (Choose one)

1
2
3
4
8

Strongly Disagree
Disagree
Agree
Strongly Agree
Refuse to Answer

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HIV/AIDS KNOWLEDGE QUESTIONNAIRE

HIV/AIDS KNOWLEDGE QUESTIONNAIRE
The following questions are about HIV and AIDS.
AKN1.

Do people get HIV/AIDS infection from holding hands with someone? (Choose one)
1
2
3
4
8

AKN2.

Do people get HIV/AIDS infection from sharing needles used to inject (shoot up) drugs? (Choose one)
1
2
3
4
8

AKN3.

AKN4.

AKN5.

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do people get HIV/AIDS infection from donating blood? (Choose one)

Do people get HIV/AIDS infection from having a blood test? (Choose one)
Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do people get HIV/AIDS infection from using public toilets? (Choose one)
1
2
3
4
8

AKN7.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do people get HIV/AIDS infection from being bitten by mosquitoes or other insects? (Choose one)

1
2
3
4
8

AKN6.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do people get HIV/AIDS infection from having sexual intercourse (sex, going all the way) with an infected person
without a condom (rubber)? (Choose one)
1
Yes
2
3
4
8

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No
Not Sure
Don't Understand the Question
Refuse to Answer

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Master Parent English - HEPI 2

AKN8.

HIV/AIDS KNOWLEDGE QUESTIONNAIRE

Do people get HIV/AIDS infection from being in the same class with a student who has HIV/AIDS infection ?
(Choose one)
1
2
3
4
8

AKN9.

Can you tell if people are infected with HIV/AIDS just by looking at them ? (Choose one)
1
2
3
4
8

AKN10.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do people lower their chances of becoming infected with HIV/AIDS by using latex condoms (rubbers) during sexual
intercourse (sex, going all the way)? (Choose one)
1
Yes
2
3
4
8

AKN12.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a person who has HIV/AIDS virus infect someone else during sexual intercourse (sex, going all the way)?
(Choose one)
1
2
3
4
8

AKN11.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a pregnant woman who has HIV/AIDS infect her unborn baby with the virus? (Choose one)
1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN13.

Is there a cure for HIV/AIDS infection? (Choose one)

AKN14.

Is it true that only homosexual (gay) men can get HIV/AIDS infection ? (Choose one)
1
2
3
4
8

AKN15.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can people lower their chances of becoming infected with the AIDS virus (HIV) by not having any kind of sexual
intercourse (being abstinent, staying a virgin, waiting until you're older for sex) ? (Choose one)
2
3
4
8

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No
Not Sure
Don't Understand the Question
Refuse to Answer

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Master Parent English - HEPI 2

AKN16.

HIV/AIDS KNOWLEDGE QUESTIONNAIRE

Can you get HIV/AIDS from having sex with an injected drug user (a drug user who uses needles, someone who
shoots drugs)? (Choose one)
1
2
3
4
8

AKN17.

Can people lower their chances of becoming infected with HIV/AIDS by taking birth control pills? (Choose one)
1
2
3
4
8

AKN18.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

When people with HIV get cuts or have nosebleeds, can a person taking care of them lower his or her chances of
getting HIV/AIDS by wearing surgical gloves? (Choose one)
1
Yes
2
3
4
8

AKN23.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a person get HIV/AIDS from an infected person who has a nosebleed or cut? (Choose one)
1
2
3
4
8

AKN22.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a person get tuberculosis (TB) from an HIV/AIDS infected person who has TB? (Choose one)
1
2
3
4
8

AKN21.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a person get gonorrhea (clap, drip) and HIV at the same time? (Choose one)
1
2
3
4
8

AKN20.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a person get HIV/AIDS infection from sharing tatoo needles? (Choose one)
1
2
3
4
8

AKN19.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

No
Not Sure
Don't Understand the Question
Refuse to Answer

Can a person protect themselves from HIV/AIDS by using a lambskin condom? (Choose one)
1
2
3
4
8

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Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

AKN24.

HIV/AIDS KNOWLEDGE QUESTIONNAIRE

Can a person have HIV/AIDS for many years without knowing it? (Choose one)
1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN25.

Do all gay men have HIV/AIDS? (Choose one)

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN26.

Does HIV/AIDS attack the immune system ? (Choose one)

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN27.

Can a person get immunized (get a vaccine) to stop from getting HIV/AIDS ? (Choose one)
1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN27a. Can a person with HIV/AIDS live for ten years or more? (Choose one)
1
2
3
4
8

Yes
No
Not sure
Don't understand the question
Refuse to Answer

AKN28.

Can HIV/AIDS be passed in the air, like a cold? (Choose one)

AKN29.

Can a person get HIV/AIDS infection by becoming Blood Brothers/Blood Sisters, cutting their finger and mixing their
blood? (Choose one)

AKN30.

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do only people in the United States get HIV/AIDS? (Choose one)

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AKN31.

HIV/AIDS KNOWLEDGE QUESTIONNAIRE

Does being married prevent a person from getting HIV/AIDS? (Choose one)
1
2
3
4
8

AKN32.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Should you use oil-based lubricants (like petroleum jelly, Vaseline, shortening) with a latex condom? (Choose one)
1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN33.

Is it safe to pick up a discarded needle or syringe? (Choose one)

AKN34.

Can you get HIV/AIDS from sharing a crack pipe when you and the other person have blistered or cracked lips?
(Choose one)
1
2
3
4
8

AKN35.

Is HIV/AIDS easier to catch than most other sexually transmitted diseases (gonorrhea, clap, syphilis, etc.) (Choose
one)
1
2
3
4
8

AKN36.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Do people lower their chances of becoming infected with the HIV/AIDS virus by having anal intercourse (sex in the
butt)? (Choose one)
1
2
3
4
8

AKN38.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Are teenage girls more at risk of HIV/AIDS infection than adult women? (Choose one)
1
2
3
4
8

AKN37.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Are there any treatments for HIV infected pregnant women which can reduce the chance of them giving HIV to their
babies? (Choose one)
1
2
3
4
8

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Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer
09/14/04

Master Parent English - HEPI 2

AKN39.

HIV/AIDS KNOWLEDGE QUESTIONNAIRE

Do doctors always test for HIV when they give you a blood test? (Choose one)
1
2
3
4
8

AKN40.

Can a mother pass the HIV/AIDS virus to her baby through her breast milk? (Choose one)
1
2
3
4
8

AKN41.

AKN44.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Can you get HIV/AIDS from washing your clothes with the clothes of someone who is HIV positive? (Choose one)
1
2
3
4
8

AKN43.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Are people likely to get HIV/AIDS infection from kissing an infected person? (Choose one)
1
2
3
4
8

AKN42.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Has anyone gotten HIV/AIDS from sharing a razor with someone who is HIV positive? (Choose one)

Can a person get HIV/AIDS from oral sex? (Choose one)

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

AKN44a. Will getting an HIV test one time produce results as precise as getting it twice with at least 3 months apart?
(Choose one)
1
2
3
4
8

Yes
No
Not sure
Don't understand the question
Refuse to Answer

AKN45a. More than 35 million people in the world have HIV (Choose one)
1
2
3
4
8

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Yes
No
Not sure
Don't understand the question
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

AKN46.

HIV/AIDS KNOWLEDGE QUESTIONNAIRE

AIDS stands for Acquired Immune Deficiency Syndrome (Choose one)
1
2
3
4
8

AKN47.

Infection with Human Immunodeficiency Virus (HIV) can lead to AIDS (Choose one)
1
2
3
4
8

AKN48.

AKN49.

AKN50.

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer
Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

The HIV antibody test tells you whether or not you have AIDS (Choose one)
1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

1
2
3
4
8

Yes
No
Not Sure
Don't Understand the Question
Refuse to Answer

Everyone who has HIV will get AIDS within two years (Choose one)

Is it easier for an HIV infected person to catch a cold from you or give a cold to you? (Choose one)
1
2
3
4
8

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Catch from you
Give to you
Not Sure
Don't Understand the Question
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

Communication Confidence

Communication Confidence
Think about the child in this project with you. Please indicate whether and how strongly you agree or disagree with
the following statements:
CC1.

I have enough facts to talk to my child about how to use condoms. (Choose one)
1
2
3
4
5
6
8

CC2.

I know how to tell my child good ways to put off sex until he/she is older. (Choose one)
1
2
3
4
5
6
8

CC3.

CC5.

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

I can tell my child the correct facts about many different forms of birth control. (Choose one)
1
2
3
4
5
6
8

CC4.

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

I don't know enough about my child's friends and the neighborhood; my advice may not be realistic or usable.
(Choose one)
1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

I can speak to my child about sex in language he/she understands. (Choose one)

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CC6.

CC7.

CC8.

Communication Confidence

I can speak to my child about drugs in language he/she understands. (Choose one)
1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

I know what my child needs to know about sex at different ages. (Choose one)

I never can find the time to answer my child's questions about sex. (Choose one)

CC9.

I can find the right words to talk to my child about HIV/AIDS. (Choose one)

CC10.

I know enough about Sexually Transmitted Diseases (STDs) and how they are transmitted to educate my child.
(Choose one)
1
2
3
4
5
6
8

CC11.

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

I haven't prepared my son for wet dreams or my daughter for her menstruation. (Choose one)
1
2
3
4
5
6
8

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Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

CC12.

Communication Confidence

I can't talk to my child about sex, because I think he/she is too young to understand. (Choose one)
1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

CC13.

I can always make time to talk to my child about drugs. (Choose one)

CC14.

I know enough about drugs and their effects on you to educate my child. (Choose one)
1
2
3
4
5
6
8

CC15.

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

I know the common street names for drugs and where they are sold; I can give my child usable facts about drugs and
their dangers. (Choose one)
1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

CC16.

I know how to tell my child good ways to avoid drugs. (Choose one)

CC17.

I know how to tell my child to safely handle needles or other sharp objects. (Choose one)
1
2
3
4
5
6
8

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Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

CC18.

Communication Confidence

I can talk to my child about drugs, because a child is never too young to learn. (Choose one)
1
2
3
4
5
6
8

CC19.

If I told my child I wanted him/her to wait until he/she is older to have sex, it wouldn't make any difference; my child
will do what he/she wants anyway. (Choose one)
1
Very Strongly Agree
2
3
4
5
6
8

CC20.

CC22.

CC23.

Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

The way I teach my child about needles and drugs, s/he will do the right thing and won't get HIV/AIDS. (Choose one)
1
2
3
4
5
6
8

CC21.

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

If I talk to my child about condoms, s/he will know how to put them on when s/he needs to use them. (Choose one)
1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

1
2
3
4
5
6
8

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

If I tell my child about condoms, he/she will go out and have sex. (Choose one)

Even if I teach my child how to handle sharp objects, he/she could get a needle stick. (Choose one)
1
2
3
4
5
6
8

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Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

CC24.

Communication Confidence

No matter how much I talk about STDs, I can't get my child to use protection. (Choose one)
1
2
3
4
5
6
8

CC25.

Drugs are so powerful around here, my child will use them no matter what I say. (Choose one)
1
2
3
4
5
6
8

CC26.

Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer
Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

If I talk to my child about HIV/AIDS, I can help him/her avoid getting HIV/AIDS. (Choose one)
1
2
3
4
5
6
8

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Very Strongly Agree
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
Very Strongly Disagree
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

O'Leary-Porter Scale

O'Leary-Porter Scale
Please answer all of the following questions to the best of your ability. The questions refer to your child that is
participating in the study only.
OPS1.

It is difficult in these days of tight budgets to confine financial discussions to specific items and places. How often
would you say you and your spouse argue over money matters in front of this child? (Choose one)
2
3
4
5
8

OPS2.

Children often go to one parent for money or permission to do something after having been refused by another parent.
How often would you say this child approaches you or your spouse in this manner with rewarding results? (Choose
one)
1
2
3
4
5
8

OPS3.

Never
Rarely
Occasionally
Often
Very often
Refuse to Answer

How often does your spouse complain to you about your personal habits (drinking, nagging, sloppiness, etc.) in front
of this child? (Choose one)
1
2
3
4
5
8

OPS6.

Rarely
Occasionally
Often
Very often
Refuse to Answer

How often has this child heard you and your spouse argue about the wife's role in the family? (Housewife, employed
wife, etc.) (Choose one)
1
2
3
4
5
8

OPS5.

Never
Rarely
Occasionally
Often
Very often
Refuse to Answer

Husbands and wives often disagree on the subject of discipline. How often do you and your spouse argue over
disciplinary problems in this child's presence? (Choose one)
1
Never
2
3
4
5
8

OPS4.

Rarely
Occasionally
Often
Very often
Refuse to Answer

Never
Rarely
Occasionally
Often
Very often
Refuse to Answer

How often do you complain to your spouse about his/her personal habits in front of this child? (Choose one)
1
2
3
4
5
8

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Never
Rarely
Occasionally
Often
Very often
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

OPS7.

O'Leary-Porter Scale

In every normal marriage there are arguments. How often do arguments between you and your spouse take place in
front of this child? (Choose one)
1
2
3
4
5
8

OPS8.

How often do you and your spouse display verbal hostility in front of this child? (Choose one)
1
2
3
4
5
8

OPS9.

Never
Rarely
Occasionally
Often
Very often
Refuse to Answer
Never
Rarely
Occasionally
Often
Very often
Refuse to Answer

How often do you and your spouse display affection for each other in front of this child? (Choose one)
1
2
3
4
5
8

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Never
Rarely
Occasionally
Often
Very often
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PARENT-ADOLESCENT SEX COMMUNICATION SCALE

PARENT-ADOLESCENT SEX COMMUNICATION SCALE
PSC1.

I have talked to my child about sex. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC2.

I can discuss sex with my child without feeling embarrassed. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC3f.

If my daughter were pregnant, she would tell me.
If the child in the program with you is male, mark Not Applicable. (Choose one) 1

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer
Not Applicable

2
3
4
8
9

PSC3m.

If my son got a girl pregnant, he would tell me.
If the child in the program with you is female, mark Not Applicable. (Choose one)
1
2
3
4
8
9

PSC4.

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer
Not Applicable

When my child asks questions about sex, I give him/her honest answers. (Choose one)
1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC5.

My child is afraid to ask me about sex. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC6.

Sex is a topic my child avoids talking about to me. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC7.

I find it easy to discuss sex with my child. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

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PSC8.

PSC9f.

PARENT-ADOLESCENT SEX COMMUNICATION SCALE

If my child had a sexually transmitted disease, she/he would tell me. (Choose one)
1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

If the child in the program with you is male, mark Not Applicable. (Choose one) 1

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer
Not Applicable

I worry a lot about my daughter getting pregnant.

2
3
4
8
9

PSC9m.

I worry a lot about my son getting a girl pregnant.
If the child in the program with you is female, mark Not Applicable. (Choose one)

PSC10.

1
2
3
4
8
9

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer
Not Applicable

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

I do not trust that my child can make good decisions about sex. (Choose one)

PSC11.

I am always accusing my child of having sex. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC12.

I have talked to my child about HIV/AIDS. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC13.

I have talked to my child about safe sex. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

PSC14.

I have talked to my child about birth control. (Choose one)

1
2
3
4
8

Strongly Disagree
Moderately Disagree
Moderately Agree
Strongly Agree
Refuse to Answer

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Master Parent English - HEPI 2

Parent Relationship With Peer Group

Parent Relationship With Peer Group
PER1.

Do you know any of your son's /daughter's friends?

1
0
8

Yes
No
Refuse to Answer

PER2.

How well do you personally know your child's best friends? (Choose one)

1
2
3
4
5
8

Not at all
A little bit
Somewhat well
Pretty well
Extremely well
Refuse to Answer

PER3.

How often during a typical week do you supervise your child and his/her best friends spending time together?
(Choose one)
1
2
3
4
5
8

PER4.

How often during a typical week do you spend time talking with your child about his/her friends? (Choose one)
1
2
3
4
5
8

PER5.

Not at all
A little bit
Somewhat often
Pretty often
Extremely often
Refuse to Answer

How well do you personally know the PARENTS of your child's best friends? (Choose one)
1
2
3
4
5
8

PER6.

Not at all
A little bit
Somewhat often
Pretty often
Extremely often
Refuse to Answer

Not at all
A little bit
Somewhat well
Pretty well
Extremely well
Refuse to Answer

How often during a typical week do you see or talk to the PARENTS of your child's best friends? (Choose one)
1
2
3
4
5
8

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Not at all
A little bit
Somewhat often
Pretty often
Extremely often
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PEER BEHAVIORAL PROBLEM CHECKLIST

PEER BEHAVIORAL PROBLEM CHECKLIST
For each of the following problems, think about your child's FRIENDS (the child that is in this program with you). If
an item does not constitute a problem, or if you have had no opportunity to observe it, or have no knowledge about the
item, click on No Problem. If an item constitutes a Mild Problem or Severe Problem, click on the corresponding
response.
PPC1.

Restless; unable to sit still. (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC2.

Seeks attention; "shows off" (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC3.

Stays out late at night (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC4.

Self conscious; easily embarrassed (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC5.

Disruptive; annoys and bothers others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC6.

Feels inferior (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC7.

Steals in company with others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC8.

Preoccupied; "in a world of his own;" stares into space (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC9.

Shy, bashful (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC10.

Withdraws; prefers solitary activities (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC11.

Belongs to a gang (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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PEER BEHAVIORAL PROBLEM CHECKLIST

PPC12.

Repetitive speech; says the same thing over and over (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC13.

Short attention span; poor concentration (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC14.

Lacks self-confidence (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC15.

Inattentive to what others say (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC16.

Incoherent speech, what is said doesn't make sense (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC17.

Fights (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC18.

Loyal to delinquent friends (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC19.

Has temper tantrums (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC20.

Truant from school, usually in company with others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC21.

Hypersensitive; feelings are easily hurt (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC22.

Generally fearful; anxious (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC23.

Irresponsible, undependable (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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PPC24.

PEER BEHAVIORAL PROBLEM CHECKLIST

Has "bad" companions, ones who are always in some kind of trouble (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC25.

Tense; unable to relax (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC26.

Disobedient; difficult to control (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC27.

Depressed; always sad (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC28.

Uncooperative in group situations (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC29.

Passive, suggestible; easily led by others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC30.

Hyperactive; "always on the go" (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC31.

Distractible; easily diverted from the task at hand (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC32.

Destructive in regard to own and/or other's property (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC33.

Negative; tends to do the opposite of what is requested (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC34.

Impertinent, talks back (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC35.

Sluggish, slow moving, lethargic (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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PEER BEHAVIORAL PROBLEM CHECKLIST

PPC36.

Drowsy, not "wide awake" (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC37.

Nervous, jittery, jumpy, easily startled (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC38.

Irritable, hot-tempered, easily angered (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC39.

Expresses strange, far-fetched ideas (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC40.

Argues; quarrels (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC41.

Sulks and pouts (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC42.

Persists and nags, can't take "no" for an answer (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC43.

Avoids looking others in the eye (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC44.

Answers without stopping to think (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC45.

Unable to work independently; needs constant help and attention (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC46.

Uses drugs in company with others (Choose one)

PPC47.

Impulsive; starts before understanding what to do; doesn't stop and think (Choose one)
0
1
2
8

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No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

PEER BEHAVIORAL PROBLEM CHECKLIST

PPC48.

Chews on inedible things (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC49.

Tries to dominate others; bullies; threatens (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC50.

Picks at other children as a way of getting their attention; seems to want to relate but doesn't know how (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC51.

Steals from people outside the home (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC52.

Expresses beliefs that are clearly untrue (delusions) (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC53.

Says nobody loves him or her (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC54.

Freely admits disrespect for moral values and laws (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC55.

Brags and boasts (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC56.

Slow and not accurate in doing things (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC57.

Shows little interest in things around him or her (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC58.

Does not finish things; gives up easily; lacks perseverance (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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PPC59.

PEER BEHAVIORAL PROBLEM CHECKLIST

Is part of a group that rejects school activities such as team sports, clubs, projects to help others (Choose one)

PPC60.

Cheats (Choose one)

PPC61.

Seeks company of older, "more experienced" companions (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC62.

Knows what's going on but is listless and uninterested (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC63.

Resists leaving mother's (or other caretaker's) side (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC64.

Difficulty in making choices; can't make up mind (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC65.

Teases others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC66.

Absentminded; forgets simple things easily (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC67.

Acts like he or she were much younger; immature, "childish" (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC68.

Has trouble following directions (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC69.

Will lie to protect his/her friends (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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PEER BEHAVIORAL PROBLEM CHECKLIST

PPC70.

Afraid to try new things for fear of failure (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC71.

Selfish; won't share; always takes the biggest piece (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC72.

Uses alcohol in company with others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC73.

School work is messy, sloppy (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC74.

Does not respond to praise from adults (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC75.

Not liked by others; is a "loner" because of aggressive behavior (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC76.

Does not use language to communicate (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC77.

Cannot stand to wait; wants everything right now (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC78.

Refuses to take directions, won't do as told (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC79.

Blames others; denies own mistakes (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC80.

Admires and seeks to associate with "rougher" peers (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC81.

Punishment doesn't affect his or her behavior (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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PEER BEHAVIORAL PROBLEM CHECKLIST

PPC82.

Squirms, fidgets (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC83.

Deliberately cruel to others (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC84.

Feels he or she can't succeed (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC85.

Tells imaginary things as though true; unable to tell real from imagined (Choose one)

PPC86.

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

Does not hug and kiss members of the family; affectionless (Choose one)

PPC87.

Runs away; is truant from home (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC88.

Openly admires people who operate outside the law (Choose one)

0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

PPC89.

Repeats what is said to him or her; "parrots" others' speech (Choose one)
0
1
2
8

No Problem/Don't Know
Mild Problem
Severe Problem
Refuse to Answer

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Master Parent English - HEPI 2

Parent Substance Use Measure

Parent Substance Use Measure
The following questions have to do with the parents or primary caregivers of the adolescent in this study.
PSU1.

Have the parents or primary caregivers of the adolescent in this study ever smoked cigarettes?
1
0
8

PSU2.

Yes
No
Refuse to Answer
Yes
No
Refuse to Answer

Skip to PSU5

On average, how much do the parents or primary caregivers of the adolescent in this study smoke in one day?
(Choose one)
1
2
3
4
5
6
7
8

PSU5.

Skip to PSU5

Have the parents or primary caregivers of the adolescent in this study smoked cigarettes in the past 30 days?
1
0
8

PSU4.

Skip to PSU5

Have the parents or primary caregivers of the adolescent in this study smoked cigarettes in the past three months?
1
0
8

PSU3.

Yes
No
Refuse to Answer

none
less than 1 cigarette
1-5 cigarrettes
1/2 pack a day
1 pack a day
1.5 packs a day
2 or more packs a day
Refuse to Answer

On how many occasions (if any) have the parents or primary caregivers of the adolescent in this study been drunk or
very high from drinking alcoholic beverages in their lifetime? (Choose one)
1
0 occasions
2
3
4
5
6
7
8

1-2 times
3-5 times
6-9 times
10-19 times
20-39 times
40+ occasions
Refuse to Answer

If PSU5 is less than 2, then skip to PSU8.
PSU6.

On how many occasions (if any) have the parents or primary caregivers of the adolescent in this study been drunk or
very high from drinking alcoholic beverages in the past 3 months? (Choose one)
1
0 occasions
2
3
4
5
6
7
8

1-2 times
3-5 times
6-9 times
10-19 times
20-39 times
40+ occasions
Refuse to Answer

If PSU6 is less than 2, then skip to PSU8.

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PSU7.

Parent Substance Use Measure

On how many occasions (if any) have the parents or primary caregivers of the adolescent in this study been drunk or
very high from drinking alcoholic beverages in the past 30 days? (Choose one)
1
0 occasions
2
3
4
5
6
7
8

PSU8.

Have the parents or primary caregivers of the adolescent in this study ever used drugs?
1
0
8

PSU9.

Yes
No
Refuse to Answer

Skip to instruction before COL1

On how many occasions have the parents or primary caregivers of the adolescent in this study used drugs during their
lifetime? (Choose one)
1
2
3
4
5
6
7
8

PSU10.

0 occasions
1-2 times
3-5 times
6-9 times
10-19 times
20-39 times
40+ occasions
Refuse to Answer

Have the parents or primary caregivers of the adolescent in this study used drugs in the past 30 days?
1
0
8

PSU11.

1-2 times
3-5 times
6-9 times
10-19 times
20-39 times
40+ occasions
Refuse to Answer

Yes
No
Refuse to Answer

Skip to instruction before COL1

On how many occasions have the parents or primary caregivers of the adolescent in this study used drugs in the past 30
days? (Choose one)
1
2
3
4
5
6
7
8

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0 occasions
1-2 times
3-5 times
6-9 times
10-19 times
20-39 times
40+ occasions
Refuse to Answer

09/14/04

Master Parent English - HEPI 2

Colorado Service Utilization Questionnaire

Colorado Service Utilization Questionnaire
The following questions have to do with different types of services that you may have needed or received in the past 12
months. For each service mentioned, you will be asked if you have needed the service in the past 12 months and if you
have received the service in the past 12 months.
COL1.

During the last 12 months before this assessment did you have a need for "Hospital Emergency Room Care?
1
0
8

COL1a.

During the last 12 months before this assessment did you receive "Hospital Emergency Room Care"?
1
0
8

COL2.

COL2a.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Hospital Outpatient Care"?
1
0
8

COL3a.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you receive "Hospital Outpatient Care"?
1
0
8

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Hospital Inpatient Care"?
1
0
8

COL4a.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you receive "Hospital Inpatient Care"?
1
0
8

COL5.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you receive "Urgent Care"?
1
0
8

COL4.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Urgent Care"?
1
0
8

COL3.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Doctor Office/Community Clinic"?
1
0
8

COL5a.

During the last 12 months before this assessment did you receive "Doctor Office/Community Clinic"?
1
0
8

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Yes
No
Refuse to Answer

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Master Parent English - HEPI 2

COL6.

Colorado Service Utilization Questionnaire

During the last 12 months before this assessment did you have a need for "Home-based Health Care"?
1
0
8

COL6a.

During the last 12 months before this assessment did you receive "Home-based Health Care"?
1
0
8

COL7.

COL7a.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Outpatient Alcohol and/or Drug Abuse
Treatment"?
1
0
8

COL8a.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you receive "Outpatient Alcohol and/or Drug Abuse
Treatment"?
1
0
8

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Intensive Outpatient Alcohol and/or Drug
Abuse Treatment"?
1
0
8

COL9a.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you receive "Intensive Outpatient Alcohol and/or
Drug Abuse Treatment"?
1
0
8

COL10.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you receive "Dental Care"?
1
0
8

COL9.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Dental Care"?
1
0
8

COL8.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Structured Residential Outpatient
Treatment, (i.e. halfway-house)"?
1
0
8

Yes
No
Refuse to Answer

COL10a. During the last 12 months before this assessment did you receive "Structured Residential Outpatient
Treatment, (i.e. halfway-house)"?
1
0
8

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Yes
No
Refuse to Answer

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COL11.

Colorado Service Utilization Questionnaire

During the last 12 months before this assessment did you have a need for "Residential Inpatient Treatment"?
1
0
8

Yes
No
Refuse to Answer

COL11a. During the last 12 months before this assessment did you receive "Residential Inpatient Treatment"?
1
0
8

COL12.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Alcohol or Drug Detox"?
1
0
8

Yes
No
Refuse to Answer

COL12a. During the last 12 months before this assessment did you receive "Alcohol or Drug Detox"?
1
0
8

COL13.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Mental Health and Substance Abuse
Services from the Same Service Provider"?
1
Yes
0
8

No
Refuse to Answer

COL13a. During the last 12 months before this assessment did you receive "Mental Health and Substance Abuse
Services from the Same Service Provider"?
1
0
8

COL14.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Mental Health Outpatient Care"?
1
0
8

Yes
No
Refuse to Answer

COL14a. During the last 12 months before this assessment did you receive "Mental Health Outpatient Care"?
1
0
8

COL15.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Mental Health Inpatient Care"?
1
0
8

Yes
No
Refuse to Answer

COL15a. During the last 12 months before this assessment did you receive "Mental Health Inpatient Care"?
1
0
8

COL16.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Outpatient Psychiatric Medication
Reevaluation"?
1
0
8

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Yes
No
Refuse to Answer

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Master Parent English - HEPI 2

Colorado Service Utilization Questionnaire

COL16a. During the last 12 months before this assessment did you receive "Outpatient Psychiatric Medication
Reevaluation"?
1
0
8

COL17.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Housing Services (i.e. help finding
temporary shelter, dealing with a landlord/eviction, utility bills)"?
1
Yes
0
8

No
Refuse to Answer

COL17a. During the last 12 months before this assessment did you receive "Housing Services (i.e. help finding
temporary shelter, dealing with a landlord/eviction, utility bills)"?
1
Yes
0
8

COL18.

No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Employment Services (i.e. help finding a
job, job training)"?
1
0
8

Yes
No
Refuse to Answer

COL18a. During the last 12 months before this assessment did you receive "Employment Services (i.e. help finding
a job, job training)"?
1
0
8

COL19.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Transportation Services (i.e assistance
getting to work or appointments)"?
1
0
8

Yes
No
Refuse to Answer

COL19a. During the last 12 months before this assessment did you receive "Transportation Services (i.e assistance
getting to work or appointments)"?
1
0
8

COL20.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Childcare Services-Monetary Help (i.e.
childcare subsidy or other financial support)"?
1
Yes
0
8

No
Refuse to Answer

COL20a. During the last 12 months before this assessment did you receive "Childcare Services-Monetary Help (i.e.
childcare subsidy or other financial support)"?
1
Yes
0
8

COL21.

No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Childcare Services-Non-Monetary (i.e.
finding daycare/babysitter)"?
1
0
8

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No
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Master Parent English - HEPI 2

Colorado Service Utilization Questionnaire

COL21a. During the last 12 months before this assessment did you receive "Childcare Services-Non-Monetary (i.e.
finding daycare/babysitter)"?
1
0
8

COL22.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Parenting Services (i.e. classes or
counseling)"?
1
0
8

Yes
No
Refuse to Answer

COL22a. During the last 12 months before this assessment did you receive "Parenting Services (i.e. classes or
counseling)"?
1
0
8

COL23.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Case Management Services (i.e. from a
case manager or social service worker)"?
1
Yes
0
8

No
Refuse to Answer

COL23a. During the last 12 months before this assessment did you receive "Case Management Services (i.e. from a
case manager or social service worker)"?
1
0
8

COL24.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Legal Services from a Lawyer"?
1
0
8

Yes
No
Refuse to Answer

COL24a. During the last 12 months before this assessment did you receive "Legal Services from a Lawyer"?
1
0
8

COL25.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Legal Services, Paralegal/Other"?
1
0
8

Yes
No
Refuse to Answer

COL25a. During the last 12 months before this assessment did you receive "Legal Services, Paralegal/Other"?
1
0
8

COL26.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Food bank/meal assistance program"?
1
0
8

Yes
No
Refuse to Answer

COL26a. During the last 12 months before this assessment did you receive "Food bank/meal assistance program"?
1
0
8

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Yes
No
Refuse to Answer

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Master Parent English - HEPI 2

COL27.

Colorado Service Utilization Questionnaire

During the last 12 months before this assessment did you have a need for "Pastoral Counseling"?
1
0
8

Yes
No
Refuse to Answer

COL27a. During the last 12 months before this assessment did you receive "Pastoral Counseling"?
1
0
8

COL28.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Agencies servicing AIDS-related needs
(HCN, Center One, Comprehensive AIDS Program, La Liga Contra el SIDA, So. Fl. AIDS Network)"?
0
8

No
Refuse to Answer

COL28a. During the last 12 months before this assessment did you receive "Agencies servicing AIDS-related needs
(HCN, Center One, Comprehensive AIDS Program, La Liga Contra el SIDA, So. Fl. AIDS Network)"?
1
0
8

COL29.

No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "ARC Support Groups"?
1
0
8

Yes
No
Refuse to Answer

COL29a. During the last 12 months before this assessment did you receive "ARC Support Groups"?
1
0
8

COL30.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "HIV-Positive Group"?
1
0
8

Yes
No
Refuse to Answer

COL30a. During the last 12 months before this assessment did you receive "HIV-Positive Group"?
1
0
8

COL31.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Meditation and Relaxation Group"?
1
0
8

Yes
No
Refuse to Answer

COL31a. During the last 12 months before this assessment did you receive "Meditation and Relaxation Group"?
1
0
8

COL32.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "HIV/Substance Abuse Group"?
1
0
8

Yes
No
Refuse to Answer

COL32a. During the last 12 months before this assessment did you receive "HIV/Substance Abuse Group"?
1
0
8
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Yes
No
Refuse to Answer
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Master Parent English - HEPI 2

COL33.

Colorado Service Utilization Questionnaire

During the last 12 months before this assessment did you have a need for "Alcoholics Anonymous (AA)"?
1
0
8

Yes
No
Refuse to Answer

COL33a. During the last 12 months before this assessment did you receive "Alcoholics Anonymous (AA)"?
1
0
8

COL34.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Narcotics Anonymous (NA)"?
1
0
8

Yes
No
Refuse to Answer

COL34a. During the last 12 months before this assessment did you receive "Narcotics Anonymous (NA)"?
1
0
8

COL35.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "AA (Alcoholics Anonymous) Affiliates"?
1
0
8

Yes
No
Refuse to Answer

COL35a. During the last 12 months before this assessment did you receive "AA (Alcoholics Anonymous)
Affiliates"?
1
0
8

COL36.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Women's Church Ministries"?
1
0
8

Yes
No
Refuse to Answer

COL36a. During the last 12 months before this assessment did you receive "Women's Church Ministries"?
1
0
8

COL37.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Attending organized religious services
(church)"?
1
0
8

Yes
No
Refuse to Answer

COL37a. During the last 12 months before this assessment did you receive "Attending organized religious services
(church)"?
1
0
8

COL38.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Praying/Meditation"?
1
0
8

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Yes
No
Refuse to Answer

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Master Parent English - HEPI 2

Colorado Service Utilization Questionnaire

COL38a. During the last 12 months before this assessment did you receive "Praying/Meditation"?
1
0
8

COL39.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Reading religious material"?
1
0
8

Yes
No
Refuse to Answer

COL39a. During the last 12 months before this assessment did you receive "Reading religious material"?
1
0
8

COL40.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Personal grooming care regimens"?
1
0
8

Yes
No
Refuse to Answer

COL40a. During the last 12 months before this assessment did you receive "Personal grooming care regimens"?
1
0
8

COL41.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Insurance information and advocacy"?
1
0
8

Yes
No
Refuse to Answer

COL41a. During the last 12 months before this assessment did you receive "Insurance information and advocacy"?
1
0
8

COL42.

Yes
No
Refuse to Answer

During the last 12 months before this assessment did you have a need for "Financial planning"?
1
0
8

Yes
No
Refuse to Answer

COL42a. During the last 12 months before this assessment did you receive "Financial planning"?
1
0
8

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Yes
No
Refuse to Answer

09/14/04

File Type	application/pdf
File Title	Master Parent English - HEPI 2
File Modified	2010-11-22
File Created	2010-11-15