Atmt SSS Screen shots parent survey_11-22-11 BT

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Attachment SSS:

Screen Shots Parent Survey (of Attachment H)

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

School ID number:

Date:

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	Welcome!
	You should have received a Personal Identification Number (PIN) and a password.
	Please enter that information in the fields below. Your password is case sensitive, so
	please log in using the proper upper and lower case letters.
		PIN:			Password:
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	This survey is part of the Evaluation of CDC's Dating Matters: Strategies to Promote
	Healthy Teen Relationships™ Initiative.
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		For technical assistance, please contact [email protected]

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	Parent/Guardian Consent Form
	What am I being asked to do?
	We are asking you to participate in a research study – conducted by NORC at the
	University of Chicago on behalf of the Centers for Disease Control and Prevention - about
	middle school students and their parents/guardians. We’re interested in learning about
	what teenagers do, what they think about things, and their relationships with other people,
	including people they date or hang out with. We're interested in learning more about how
	parents/guardians parent teenagers and manage their own relationships. The purpose of
	this study is to help us learn more about these things and help us know how different
	programs in your community and your child's school are working.
	You were selected to participate in this study because your child is currently enrolled at
	[insert middle school name].
	CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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	What will I be doing?
	We are asking you to fill out surveys about things you do, what you think about things,
	and your relationships with other people. This survey should take 30-40 minutes to
	complete. We will do the surveys two times a year, at the beginning and end of the school
	year, while your child is in the 6th, 7th, and 8th grade.
	CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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	Who will see my answers?
	Your answers and any information we get from your school are confidential. That means that
	your answers and information are totally private. Your children, spouse, and child's teachers
	will never see your answers. Only the researcher will see your answers. After the researcher
	leaves here, they'll store your answers with a code instead of your name, so after that they
	won't know whose answers are whose. We have something called a "Certificate of
	Confidentiality." That means that even if your spouse or partner or anyone else demanded
	to see your answers, we would say now and be protected by law.
	The only exception to this is if you tell us that you are planning to hurt yourself or
	someone else. Then we will have to tell someone so we can get help.
	CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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	What if I don't know the answers?
	Some of the questions may be about things you've never thought about before. Some of the
	questions may seem like they don't apply to you. That is fine - just give the best answer
	you can. There are not right or wrong answers.
	How will the researchers contact me to do the next survey?
	We will collect some information from you that will help us stay in contact with you. We
	will ask things like your address and phone number so we can send you cards in the mail
	and call you, and for some names and numbers of people who would know how to contact
	you if you move. We will keep this information totally private and separate from your
	survey and school record information. It's just so we can contact you again.
					CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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	Do I have to do this?
	No, you don't. You can say that you don't want to do the survey and that is fine. You can also
	choose not to answer certain questions even if you do the surveys.
	What if the questions are upsetting?
	We don't think you'll be upset by filling out the survey, but if you are, [Local Resource]
	is available to talk to and to help. We will also give you a list of places in your community
	you can call to get help with any of the problems we ask about on the survey.
	Are there any benefits to participating?
	Although there may not be any direct benefits, you may benefit indirectly from knowing that
	you have made a contribution to research that will help other parents and teenagers in the
	future.
						CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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	OTHER INFORMATION
	All the information you give us as part of this study will be kept strictly confidential. Your
	name will appear on the survey cover sheet, but the name will be removed within [three
	hours] of the survey administration, and your name will be replaced with a number. The
	results of this project will be only reported in ways that do not identify individual
	participants. We will withdraw your responses at any time point, should you make the
	request.
	All questionnaires and records will be kept in locked files and will be retained for a
	minimum of [three years] after the end of the study. Data will be retained in identifiable
	form for a period of [three years]. Only researchers at NORC at the University of Chicago will
	ever have access to any personal data or other identifying information, except as noted
	below.
					CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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	Participation in the survey is completely voluntary. If you decide to not participate or to
	withdraw from the study at any time, there will be no penalties or consequences. Please
	keep a copy of this information sheet for your records. Feel free to contact us at
	<e-mail> or <phone> if you have any questions or concerns. The investigators are also
	willing to answer any questions or concerns that might arise after the survey and is
	willing to provide referral information if your son/daughter would need assistance
	related to teen dating issues, bullying, or sexual harassment, or if you would like assistance
	with parenting your teen or with your relationships. You may also contact NORC's
	Institutional Review Board Office (Michael Kuby, the NORC IRB Manager, toll-free at
	1-866-309-0542). We look forward to working with you. We do not anticipate any
	foreseeable risks to you and we think that our research will be helpful in designing better
	intervention programs to improve teen dating relationships.
					CLICK "NEXT" TO CONTINUE
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		For technical assistance, please contact [email protected]

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		BY CLICKING “OK” YOU ARE AGREEING TO THE FOLLOWING STATEMENT:
		“I HAVE READ AND UNDERSTAND THE INFORMATION ABOVE AND VOLUNTARILY AGREE TO PARTICIPATE IN THIS STUDY.”
				OK
					Please print this page for your records.
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		For technical assistance, please contact [email protected]

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	Thank you!
	Once in the survey, please use the 'Previous' and 'Next' buttons to move between
	screens within the survey. If you would like to suspend the questionnaire and return
	to it at another time, please hit 'Pause' in the upper right corner. You will be able to
	resume at a time that is convenient for you.
	If you need assistance with the questionnaire at any time, you can hit the 'Help' button
	in the upper right-hand corner for assistance with that question.
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		For technical assistance, please contact [email protected]

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	1.	What is your zip code?
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		For technical assistance, please contact [email protected]

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		2.	Sex:
			 Male
			 Female
			 Transgender
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		For technical assistance, please contact [email protected]

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	3.	How old are you?
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		For technical assistance, please contact [email protected]

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	4.	What is your race? You may mark one or more races, as appropriate:
		 American Indian or Alaska Native
		 Asian
		 Black or African American
		 Native Hawaiian or other Pacific Islander
		 White
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		For technical assistance, please contact [email protected]

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		5.	Are you Hispanic or Latino?
			 Yes
			 No
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		For technical assistance, please contact [email protected]

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	6.	Does this same child (the Middle School aged child that qualified you to take this survey) live with you?
		 Yes
		 No
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		For technical assistance, please contact [email protected]

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	7.	How often does your family attend religious activities, including services?
		 Never
		 A few times a year
		 Once or twice a month
		 Once a week
		 More than once a week
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		For technical assistance, please contact [email protected]

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	8.	How important are your religious beliefs to you?
		 Not at all important
		 Slightly important
		 Moderately important
		 Very important
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		For technical assistance, please contact [email protected]

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		9.	Have you ever been married?
			 Yes
			 No
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		For technical assistance, please contact [email protected]

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		9a.	How many times have you been married?
			 1
			 2
			 3 or more times
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		For technical assistance, please contact [email protected]

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		9a.	Are you currently married?
			 Yes
			 No
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		For technical assistance, please contact [email protected]

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		9c.	If yes, how many years have you been married to your current spouse?
			 < than 5 years
			 5-10 years
			 More than 10 years
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		For technical assistance, please contact [email protected]

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	10.	If you are not married, do you have a steady partner that you have been with for at least 3 months?
		 Yes
		 No
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		For technical assistance, please contact [email protected]

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		10a.	Do you live with this person?
			 Yes
			 No
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		For technical assistance, please contact [email protected]

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	11.	How many different romantic relationships that have lasted 3 or more months have you had in the past five years?
		 None
		 1-2 relationships
		 3-4 relationships
		 5 or more relationships
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		For technical assistance, please contact [email protected]

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	12.	Which of the following best describes your current employment status?
		 Work full-time
		 Work part-time
		 Work occasionally
		 Homemaker or stay-at-home parent
		 Unemployed
		 Student
		 Other
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		For technical assistance, please contact [email protected]

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	13.	What is your total family income per month (include earnings from all the people in your household)?
		 $0 to $199
		 $200 to $499
		 $500 to $999
		 $1,000 to $1,999
		 $2,000 to $2,999
		 $3,000 to $3,999
		 $4,000 or more
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		For technical assistance, please contact [email protected]

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	14.	On average, how much difficulty have you had paying your bills in the past year?
		 No difficulty at all
		 A little difficulty
		 Quite a bit of difficulty
		 A great deal of difficulty
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		For technical assistance, please contact [email protected]

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	15.	How far did you go in school?
		 Never attended high school
		 Attended high school but did not finish
		 Completed high school or GED
		 Some college
		 Technical, Associates, or 2-year degree
		 4-year college degree
		 Completed graduate or professional school
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		For technical assistance, please contact [email protected]

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	16.	In the past year, have you participated in any parenting skills programs regarding middle school students?
		(Check all that apply)
		 Healthy diet and/or exercise programs
		 Alcohol and drug use prevention
		 PTA or other school programs supporting parents
		 The Dating Matters parenting programs addressing teen
		dating violence
		 Other violence prevention programs
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	The next questions are about the people that live your household.
	1.	Including yourself, how many people currently live in your household?
		 2
		 3
		 4
		 5
		 6 or more
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	2.	How many biological children do you have?
		 None
		 1 child
		 2 children
		 3 children
		 4 children
		 5 or more
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	3.	How many other children that are not your biological children live with you in your household?
		 None
		 1 child
		 2 children
		 3 children
		 4 children
		 5 or more
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
		The next questions refer to your child. Please answer these and all other questions about the child that made you eligible to fill out this survey. Some parents have more than one child at this school. If that is the case, we are contacting you regarding your oldest middle school child.
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	4.	What is your relationship to the Middle School-aged child that qualified you to take this survey?
		 Biological mother or father
		 Stepmother or stepfather
		 Parent's girlfriend or boyfriend
		 Adoptive mother or adoptive father
		 Foster mother or foster father
		 Grandmother or grandfather
		 Aunt or uncle
		 Brother or sister
		 A different (child's legal guardian)
		 Other (not child's legal guardian)
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	5.	How many years have you lived in the same house with your child?
		 One year		 6 years		 11 years
		 2 years		 7 years		 12 years
		 3 years		 8 years		 13 years
		 4 years		 9 years		 14 years
		 5 years		 10 years		 15 years
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	6.	Is your child involved in any after-school or weekend activities, like school clubs, sports teams, music or dance groups, church groups, Girl Scouts or Boy Scouts, or girls club or boys club?
		 Yes
		 No
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		For technical assistance, please contact [email protected]

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	Family Composition and Relationships
	7.	If yes, how many different activities is he/she involved in over a typical school year?
		 None
		 1 activity
		 2 activities
		 3 activities
		 4 activities
		 5 or more activities
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		For technical assistance, please contact [email protected]

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	Gender Role Identity
		Please indicate how much you agree or disagree with the following statements:				Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
		1. A woman's place is in the home, not in the office or shop.							
		2. A woman who carries out her full family responsibilities does not have time for outside employment.							
		3. The employment of wives leads to more juvenile delinquency.							
		4. It is better for everyone concerned if the man is the achiever outside the home and the woman takes care of the home and the family.							
		5. Men should share the work around the house with women, such as doing dishes, cleaning, and so forth.							
		6. Women are much happier if they stay at home and take care of their children.							
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		For technical assistance, please contact [email protected]

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	Neighborhood & Organization Affiliation
	The following questions are about the neighborhood or community that you
	live in.
	1.	How long have you lived in this neighborhood? (If you have moved in and out, how long have you lived in this neighborhood since the last time you moved in?)
		 Less than 1 year
		 1-2 years
		 3-5 years
		 More than 5 years
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		For technical assistance, please contact [email protected]

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	Neighborhood & Organization Affiliation
		1a. How many times have you moved in the last year?
		 Once
		 Twice
		 3 or more moves
		 Did not move in the last year
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		For technical assistance, please contact [email protected]

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	Neighborhood & Organization Affiliation
	22..	How long has your child lived in this neighborhood? (If he/she has moved in and out, how long has he/she lived in this neighborhood since the last time he/she moved in?
		 Less than 1 year
		 1-2 years
		 3-5 years
		 More than 5 years
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		For technical assistance, please contact [email protected]

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	Neighborhood & Organization Affiliation
	2a.	How many times has your child moved in the last year?
		 Once
		 Twice
		 3 or more moves
		 Did not move in the last year
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		For technical assistance, please contact [email protected]

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	Neighborhood & Organization Affiliation
		These next questions are examples of things that can happen in neighborhoods. For each example, please indicate what you think people in your neighborhood would be most likely to do.
		In general, what would someone in your neighborhood most likely do if…			Do Nothing	Complain to or discuss with other neighbors	Talk to someone who can do something about it, for example the police, a landlord, or a parent	Do something directly, for example, step in and/or talk to the person or people involved
		1. …a group of teenagers has just started to fight?						
		2. …teenagers are drinking alcohol?						
		3. …teenagers are spray-painting graffiti (tagging)?						
		4. …a male teenager is verbally or physically abusing (yelling/ pushing/shoving/slapping) his romantic partner?						
		5. …a female teenager is verbally or physically abusing (yelling/ pushing/shoving/slapping) her romantic partner?						
		6. …a teenager is stealing from a store?						
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	These next questions are about your relationship with your spouse, partner, or
	someone you are dating. (If you are not currently in this kind of a relationship,
	skip to Question XX).
	1.	In the last three months, have you found that talking to your spouse, partner, or someone you are dating about important things going on in your family is…
		 Very easy
		 Somewhat easy
		 Somewhat hard
		 Very hard
		 I don't talk about important things going on in my family with my spouse, partner, or someone I am dating
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	2.	In the last three months, how satisfied have you been with the way you and your spouse, partner, or someone you are dating talk about important things going on in your family?
		 Very satisfied
		 Somewhat satisfied
		 Somewhat unsatisfied
		 Very unsatisfied
		 I don't talk about important things going on in my family with my spouse, partner, or someone I am dating
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	3.	During the last three months, how often did you and your spouse, partner, or someone you are dating have disagreements?
		 Very often
		 Sometimes
		 Rarely
		 Never
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	4.	During the last three months, how often did you feel angry at your spouse, partner, or someone you are dating?
		 Very often
		 Sometimes
		 Rarely
		 Never
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	5.	During the last three months when you were angry at your spouse, partner, or someone you are dating, how many of those times did you feel you handled your anger well?
		 All of the time
		 Most of the time
		 Some of the time
		 Little of the time
		 None of the time
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	6.	During the last three months when you were angry at your spouse, partner, or someone you are dating, how many of those times did you yell or shout at him/her?
		 All of the time
		 Most of the time
		 Some of the time
		 Little of the time
		 None of the time
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
		Please indicate how often each of the following statement was true of you in the last month. Would you say never, sometimes, usually, or always?
			Never	Sometimes	Usually	Always
		1. My {spouse, partner, or someone I am dating} is honest and truthful with me.				
		2. My {spouse, partner, or someone I am dating} and I are good at working out our differences.				
		3. When I have a serious disagreement with my {spouse, partner, or someone I am dating}, we discuss it respectfully.				
		4. My {spouse, partner, or someone I am dating} and I work as a team.				
		5. I enjoy spending time with my {spouse, partner, or someone I am dating}.				
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		For technical assistance, please contact [email protected]

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	The next questions are about things that your spouse, partner, or someone you
	are dating may have done to you. As you answer the questions, do not include
	things that were done in play or in self-defense.
	1.	How many times has your spouse, partner, or someone you are dating ever threatened to hurt you?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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		For technical assistance, please contact [email protected]

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	1a.	Has this occurred in the past three months?
		 Yes
		 No
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		For technical assistance, please contact [email protected]

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	2.	How many times has your spouse, partner, or someone you are dating ever slapped or scratched you?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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		For technical assistance, please contact [email protected]

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	2a.	Has this occurred in the past three months?
		 Yes
		 No
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		For technical assistance, please contact [email protected]

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	3.	How many times has your spouse, partner, or someone you are dating ever pushed, grabbed, shoved, or kicked you?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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		For technical assistance, please contact [email protected]

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	3a.	Has this occurred in the past three months?
		 Yes
		 No
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		For technical assistance, please contact [email protected]

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	Relationship with Partner
	4.	How many times has your spouse, partner, or someone you are dating ever hit you with his/her fist or with something hard?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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	Relationship with Partner
	4a.	Has this occurred in the past three months?
		 Yes
		 No
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	The next questions are about things that you may have done to your spouse,
	partner, or someone you are dating. As you answer the questions, do not
	include things you did that were in play or in self-defense.
	5.	How many times have you ever threatened to hurt him/her?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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	Relationship with Partner
	5a.	Has this occurred in the past three months?
		 Yes
		 No
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	6.	How many times have you ever slapped or scratched him/her?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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	Relationship with Partner
	6a.	Has this occurred in the past three months?
		 Yes
		 No
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	7.	How many times have you ever pushed, grabbed, shoved, or kicked him/her?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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	7a.	Has this occurred in the past three months?
		 Yes
		 No
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	8.	How many times have you ever hit him/her with your fist or with something hard?
		 Never
		 Once
		 2-4 times
		 More than 4 times
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	8a.	Has this occurred in the past three months?
		 Yes
		 No
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	Conflict Resolution Styles
	The following questions refer to times when you and your spouse, partner, or
	the person you are dating have disagreements. We want you to answer these
	questions about your spouse, partner, or dating partner if you have one. If
	you do not have a current or recent (in the last 6 months) partner, please
	think about a close friend, either a man or a woman.
	The person I am thinking about when filling out this questionnaire has these
	initials:		and was born in this month:
	This person is:
		A current or recent (in the last 6 months) spouse, partner, someone I am dating/dated (please select if you have a spouse, partner, or dating partner)
		A close friend (only if you do not have a spouse, partner, or dating partner)
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	Conflict Resolution Styles
		Using the scale below, rate how frequently you use each of the styles to deal with arguments or disagreements with the person you are thinking about.
		How often do YOU use these styles…	Never				Always
			1	2	3	4	5
		1. Launching personal attacks					
		2. Focusing on the problem at hand.					
		3. Remaining silent for long periods of time.					
		4. Not being willing to stick up for myself.					
		5. Exploding and getting out of control.					
		6. Sitting down and discussing differences constructively.					
		7. Reaching a limit, shutting down, and refusing to talk any further.					
		8. Being too compliant.					
		9. Getting carried away and saying things that aren't meant.					
		10. Finding alternatives that are acceptable to each of us.					
		11. Tuning the other person out.					
		12. Not defending my position.					
		13. Throwing insults and digs					
		14. Negotiating and compromising.					
		15. Withdrawing, acting distant, and not interested.					
		16. Giving in with little attempt to present my side of the issue.					
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	Parent-Child Communication
		For the next XX sections, we will be asking about your child. If you have more than one child in middle school, then we ask you to answer these questions about your oldest middle school child.
		Regarding your middle school child, how often…
			Almost Never	Once in a While	Sometimes	Often	Almost Always
		1. Can you discuss your beliefs with your child without feeling restrained or embarrassed?					
		2. Is your child a good listener?					
		3. Can your child tell how you are feeling without asking you?					
		4. Are you very satisfied with how you and your child talk together?					
		5. Does your child try to understand your point of view?					
		6. Are there things you avoid discussing with your child?					
		7. Do you discuss child-related problems with your child?					
		8. Does your child insult you when he/she is angry with you?					
		9. Do you think you can tell your child how you really feel about things?					
		10. Does your child tell you about his/her personal problems?					
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	Parent-Child Communication
		Regarding your middle school child, how often…
				Almost Never	Once in a While	Sometimes	Often	Almost Always
		11. Does your child keep his/her feelings to him/herself rather than talk about them with you?						
		12. Does your child hide being angry?						
		13. Do you encourage your child to think about things and talk about them so that he/she can establish his/her own opinion?						
		14. If your child is upset, is it difficult for you to figure out what he/she is feeling?						
		15. Does your child let things pile up without talking or dealing with them until they are more than you and he/she can handle?						
		16. Does your child let you know what is bothering him/her?						
		17. Are there certain topics which you do not allow your child to discuss with you?						
		18. Does your child admit mistakes without trying to hide anything?						
		19. Can your child have his/her say even if you disagree?						
		20. Do you and your child come to a solution when you talk about a problem?						
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The following are a number of statements about your family. Please rate each item as to how often it TYPICALLY occurs in your home. Remember, "your child" refers to the child that qualified you to this survey.

Never

Almost Never

Sometimes

Often

Always

1. You have a friendly talk with your child.

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2. You let your child know when he/she is doing a good job with something.

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3. You threaten to punish your child and then do not actually punish him/her.

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4. You volunteer to help with special activities that your child is involved in (such as sports, boy/girl scouts, church youth groups).

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5. You reward or give something extra to your child for obeying you or behaving well.

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6. Your child fails to leave a note or to let you know where he/she is going.

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7. You play games or do other fun things with your child.

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8. Your child talks you out of being punished after he/she has done something wrong.

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9. You ask your child about his/her day in school.

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10. Your child stays out in the evening past the time he/she is supposed to be home.

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11. You help your child with his/her homework.

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12. You feel that getting your child to obey you is more trouble than it's worth.

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		The following are a number of statements about your family. Please rate each item as to how often it TYPICALLY occurs in your home. Remember, "your child" refers to the child that qualified you to this survey.
			Never	Almost Never	Sometimes	Often	Always
		13. You compliment your child when he/she does something well.					
		14. You ask your child what his/her plans are for the coming day.					
		15. You drive (or take) your child to a special activity.					
		16. You praise your child if he/she behaves well.					
		17. Your child is out with friends you don't know.					
		18. You hug or kiss your child when he/she has done something well.					
		19. Your child goes out without a set time to be home.					
		20. You talk to your child about his/her friends.					
		21. Your child is out after dark without an adult with him/her.					
		22. You let your child out of a punishment early (like lift restrictions earlier than you originally said).					
		23. Your child helps plan family activities.					
		24. You get so busy that you forget where your child is and what he/she is doing.					
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		The following are a number of statements about your family. Please rate each item as to how often it TYPICALLY occurs in your home. Remember, "your child" refers to the child that qualified you to this survey.
			Never	Almost Never	Sometimes	Often	Always
		25. Your child is not punished when he/she has done something wrong.					
		26. You attend PTA meetings, parent/teacher conferences, or other meetings at your child's school.					
		27. You tell your child that you like it when he/she helps out around the house.					
		28. You don't check that your child comes home at the time he/she was supposed to.					
		29. You don't tell your child where you are going.					
		30. Your child comes home from school more than an hour past the time you expect him/her.					
		31. The punishment you give your child depends on your mood.					
		32. Your child is at home without adult supervision.					
		33. You spank your child with your hand when he/she has done something wrong.					
		34. You ignore your child when he/she is misbehaving.					
		35. You slap your child when he/she has done something wrong.					
		36. You take away privileges or money from your child as punishment.					
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		The following are a number of statements about your family. Please rate each item as to how often it TYPICALLY occurs in your home. Remember, "your child" refers to the child that qualified you to this survey.
			Never	Almost Never	Sometimes	Often	Always
		37. You send your child to his/her room as a punishment.					
		38. You hit your child with a belt, switch, or other object when he/she has done something wrong.					
		39. You yell or scream at your child when he/she has done something wrong.					
		40. You calmly explain to your child why his/her behavior was wrong when he/she misbehaves.					
		41. You use time out (make him/her sit or stand in a corner) as a punishment.					
		42. You give your child extra chores as a punishment.					
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		Next you will be asked whether you and your child have ever talked about different things and what kinds of things you might have said to him or her. Some of the topics are sensitive topics, like sex. Remember, your answers are private and will not be shown to anyone. Remember, "your child" refers to the child that qualified you to take this survey.
		In the past month,		Never	Once or Twice	3-4 times	5 or more times
		1. How many times have you talked to your child about getting physical exercise?					
		2. How many times have you talked to your child about eating the right kinds of foods?					
		3. How many times have you talked to your child about alcohol?					
		4. How many times have you talked to your child about drugs?					
		5. How many times have you talked to your child about dating or going out with a boy/girl?					
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		If you have ever talked to your child about dating….
		When you talked about dating, have you ever told your child…
						Yes	No
		5a. He/she is not allowed to date now?					
		5b. It's OK to date now?					
		5c. He/she can only go on group dates or double dates?					
		5d. He/she can only date boys/girls that you know?					
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In the past month,

Never

Once or Twice

3-4 times

5 or more times

6. How many times have you ever talked to your child about puberty or physical development? Puberty is how your child's body will change when he/she gets older.

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7. How many times have you ever talked to your child about menstruation? Menstruation is when a girl gets her period monthly.

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8. How many times have you ever talked to your child about what sex is?

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9. How many times have you ever talked to your child about reproduction or how babies are made?

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10. How many times have you ever talked to your child about what to do to keep from getting pregnant?

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11. How many times have you ever talked to your child about abstinence or waiting to have sex?

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12. How many times have you ever talked to your child about how a person knows when he or she is ready to have sex?

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13. How many times have you ever talked to your child about peer pressure? Peer pressure is when your child is talked into doing something that he/she might not want to do, or when he/she does something just to be cool.

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14. How many times have you ever talked to your child about condoms?

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15. How many times have you ever talked to your child about birth control?

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16. How many times have you ever talked to your child about HIV/AIDS?

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17. How many times have you ever talked to your child about other sexually transmitted diseases or STDs other than HIV or AIDS? Some STDs are syphilis, Chlamydia, or the clap.

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Pubertal Development Scale (PDS)

Does your son's/daughter's physical development seem to be earlier or later than most of the other boys/girls his/her age? Remember, answer about the child that qualified you to take this survey.

 Much earlier

 Somewhat earlier

 About the same

 Somewhat later

 Much later

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	Beliefs and Knowledge about TDV
		Please indicate whether you think the following statements are true or false.
						True	False
		1. Boys are the victims of dating abuse about as often as girls.					
		2. The majority of teens in abusive dating relationships have witnessed abuse between their parents.					
		3. About 5% of teenagers have been physically abused by a date.					
		4. Most teen rapes are by someone the teen does not know.					
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	Beliefs and Knowledge about TDV
		Please indicate how much you agree or disagree with the following statements.				Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
		5. Being insulted by a date is not that big a deal as long as there is not physical violence.							
		6. Hitting a date because of jealousy is just a natural part of dating.							
		7. Teens have to take the good and the bad from dating partners, even if the bad means getting hit every once in a while.							
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	Beliefs and Knowledge about TDV
	These next questions are about dating abuse as it relates to your middle
	school child.
	1.	How confident are you that you could recognize warning signs that your middle school child was being abused by a date?
		 Very confident
		 Somewhat confident
		 Not very confident
		 Not at all confident
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	Beliefs and Knowledge about TDV
	2.	How confident are you that you could recognize warning signs that your middle school child was abusing a date?
		 Very confident
		 Somewhat confident
		 Not very confident
		 Not at all confident
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	Beliefs and Knowledge about TDV
	3.	In your opinion, how likely is it that your middle school child could become a victim of dating abuse?
		 Very likely
		 Somewhat likely
		 Not very likely
		 Not at all likely
		 Teen has already been a victim
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	Beliefs and Knowledge about TDV
	4.	In your opinion, how likely is it that your middle school child could abuse someone he/she is dating?
		 Very likely
		 Somewhat likely
		 Not very likely
		 Not at all likely
		 Teen has already been an abuser
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	Beliefs about Dating
		The next questions are about your beliefs related to your teen's dating, or your teens' dating when he/she begins dating. Remember, please answer the questions about the child that qualified you to take this survey.
		Please indicate how strongly you agree or disagree with the following statements.			Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
		1. You believe that you should not get involved at all in your middle school child's dating. Getting involved can mean anything from talking to your child about dating to deciding who your child can date, where they can go, etc.						
		2. You believe it is important to provide your middle school child with guidance on dating.						
		3. You want to stay out of issues related to your middle school child's dating. Issues related to dating can be anything that has to do with your child's dating.						
		4. You believe it is important to set rules for your middle school child about dating.						
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	Rules about Dating
		The first few questions are about practices in your family related to teen dating. Many parents define two different kinds of dating: Group dating is where teens go out in groups but there is some pairing up, and solo dating is when a couple goes out alone. Remember, please answer the questions about your child that qualified you to take this survey.
						NO	YES	Middle school child is not interested in dating	It has never come up
		1. Is your middle school child allowed to go on group dates?							
		2. If your middle school child was interested in dating (and you marked above that they are not currently interested), would he/she be allowed to group date?					
		3. If it came up (and you marked above that it has not yet come up), would your middle school child be allowed to group date?					
		4. Is your middle school child allowed to go on solo dates?							
		5. If your middle school child was interested in dating (and you marked above that they are not currently interested), would he/she be allowed to solo date?					
		6. If it came up (and you marked above that it has not yet come up), would your middle school child be allowed to solo date?					
		7. Was your middle school child told how old he/she needed to be before he/she could group date?							
		8. Was your middle school child told how old he/she needed to be before he/she could go on solo dates?							
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	1.	Have you attended a Parents Matter! Program event?
		 Yes
		 No
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	Parents Matter! Program
	If you have attended a Parents Matter! Program event, please answer
	the following questions:
	1.	How long does it take you to get to a single Parents Matter! (Dating Matters) program event? (Estimate your average travel time one way.)
		 Less than 15 minutes
		 At least 15 minutes but less than 30 minutes
		 At least 30 minutes but less than 45 minutes
		 At least 45 minutes but less than 1 hour
		 1 or more hours
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	Parents Matter! Program
	2.	How far do you travel (mileage) to participate in a session of the Parents Matter! (Dating Matters) program? (Estimate your average travel distance one way.)
		 Less than 5 miles
		 At least 5 miles but less than 10 miles
		 At least 10 miles but less than 15 miles
		 At least 15 miles but less than 20 miles
		 20 or more miles
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	Parents Matter! Program
	3.	How many Parents Matter! (Dating Matters) program sessions have you attended this year?
		 1
		 2
		 3
		 4
		 5
		 6
		 Don't know yet (this is the first session)
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Attachment SSS: Screen Shots Parent Survey 64