Form 5 Attachment H: Parent Outcome Survey (Baseline)
Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships
Atmt H - Parent Outcome Baseline Survey
Parent Outcome Baseline Survey
OMB: 0920-0941
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 H:
Parent Outcome Survey (Baseline)
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
Parent name:
Parent ID number:
School ID number:
Student name:
Student ID number:
Program Year:
Survey Iteration:
Evaluation of CDC’s Dating Matters™:
Strategies to Promote Healthy Teen Relationships Initiative
PARENT/GUARDIAN SURVEY (Baseline)
Instructions
Use a pencil or blue or black pen.
Fill bubbles completely. Like this:
Do not mark answers with ’s or ’s.
1. What is your zip code? __________________
2. Sex: 3. How old are you? _______________
Male
Female
Transgendered
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
5. Are you Hispanic or Latino?
Yes
No
7. Does this same child (the Middle School aged child that qualified you to take this survey) live with you?
Yes
No
6. 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
7. How important are your religious beliefs to you?
Not at all important
Slightly important
Moderately important
Very important
8. Have you ever been married?
Yes
No {Skip to Question #9X}
If yes,
8a. How many times have you been married? ____________
1 |
2 |
3 or more times |
8b. Are you currently married?
Yes
No
8c. If yes, how many years have you been married to your current spouse?
<5 years |
5-10 years |
more than 10 years |
9. If you are not married, do you have a steady partner that you have been with for at least 3 months?
Yes
No
If yes,
9a. Do you live with this person?
Yes
No
10. 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
11. 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
12. 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
18. 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
19. 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
20. 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
Family Composition and Relationships
The next questions are about the people that live in your household.
1. Including yourself, how many people currently live in your household?
2 |
3 |
4 |
5 |
6 or more |
2. How many biological children do you have?
None |
1 child |
2 children |
3 children |
4 children |
5 or more |
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 |
****The next questions refer to your child. Please answer these and all other questions about the child that made you eligible 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. ****
6. 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)
5. How many years have you lived in the same house with your child?
-
one year
4 years
4 years
7 years
10 years
13 years
2 years
5 years
5 years
8 years
11 years
14 years
3 years
6 years
6 years
9 years
12 years
15 years
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
7. If yes, how many different activities is he/she involved in over a typical school year?
-
none
3 activities
1 activity
4 activities
2 activities
5 or more activities
Gender Role Identity
{From NLSY79}
Please indicate how much you agree or disagree with the following statements. |
Strongly agree |
Somewhat agree |
Somewhat disagree |
Strongly disagree |
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A woman’s place is in the home, not in the office or shop. |
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A woman who carries out her full family responsibilities does not have time for outside employment. |
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The employment of wives leads to more juvenile delinquency. |
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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. |
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Men should share the work around the house with women, such as doing dishes, cleaning and so forth. |
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Women are much happier if they stay at home and take care of their children. |
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Neighborhood & Organization Affiliation (Adapted from LONGSCAN)
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
1a. How many times have you moved in the last year?
Once
Twice
3 or more moves
Did not move in the last year
2. 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
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
{Source: Mike Schoeny}
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 |
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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
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
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
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 {skip to Question XX}
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
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
Please indicate how often each of the following statements was true of you in the last month. Would you say never, sometimes, usually, or always?
[source: Supporting Healthy Marriage Study]
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Never |
Sometimes |
Usually |
Always |
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My {spouse, partner, or someone I am dating} is honest and truthful with me. |
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My {spouse, partner, or someone I am dating} and I are good at working out our differences. |
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When I have a serious disagreement with my {spouse, partner, or someone I am dating}, we discuss it respectfully. |
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My {spouse, partner, or someone I am dating} and I work as a team. |
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I enjoy spending time with my {spouse, partner, or someone I am dating}. |
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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
1a. Has this occurred in the past three months?
No
Yes
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
2a. Has this occurred in the past three months?
No
Yes
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
3a. Has this occurred in the past three months?
No
Yes
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
4a. Has this occurred in the past three months?
No
Yes
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
5a. Has this occurred in the past three months?
No
Yes
6. How many times have you ever slapped or scratched him/her?
Never
Once
2-4 times
More than 4 times
6a. Has this occurred in the past three months?
No
Yes
7. How many times have you ever pushed, grabbed, shoved or kicked him/her?
Never
Once
2-4 times
More than 4 times
7a. Has this occurred in the past three months?
No
Yes
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
8a. Has this occurred in the past three months?
No
Yes
Conflict Resolution Styles Inventory (Kurdek, 1994)
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:
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A
current or recent (in the last 6 months) (please select if you have a spouse, partner, or dating partner) |
OR |
A
close friend |
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.
1 2 3 4 5
Never Always
How often do YOU use these styles… |
1 |
2 |
3 |
4 |
5 |
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1. |
Launching personal attacks |
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2. |
Focusing on the problem at hand. |
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3. |
Remaining silent for long periods of time |
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4. |
Not being willing to stick up for myself |
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5. |
Exploding and getting out of control |
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6. |
Sitting down and discussing differences constructively. |
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7. |
Reaching a limit, shutting down, and refusing to talk any further. |
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8. |
Being too compliant. |
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9. |
Getting carried away and saying things that aren’t meant. |
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10. |
Finding alternatives that are acceptable to each of us. |
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11. |
Tuning the other person out. |
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12. |
Not defending my position. |
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13. |
Throwing insults and digs. |
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14. |
Negotiating and compromising. |
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15. |
Withdrawing, acting distant, and not interested. |
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16. |
Giving in with little attempt to present my side of the issue. |
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Parent-Child Communication (Adapted from the Revised Parent-Adolescent Communication Form used in Pittsburgh Youth Study (Loeber, et al., 1995 and 1998).
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…..
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Almost Never |
Once in a While |
Sometimes |
Often |
Almost Always |
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1. |
Can you discuss your beliefs with your child without feeling restrained or embarrassed? |
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2. |
Is your child a good listener? |
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3. |
Can your child tell how you are feeling without asking you? |
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4. |
Are you very satisfied with how you and your child talk together? |
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5. |
Does your child try to understand your point of view? |
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6. |
Are there things you avoid discussing with your child? |
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7. |
Do you discuss child-related problems with your child? |
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8. |
Does your child insult you when he/she is angry with you? |
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9. |
Do you think you can tell your child how you really feel about things? |
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10. |
Does your child tell you about his/her personal problems? |
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11. |
Does your child keep his/her feelings to him/herself rather than talk about them with you? |
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12. |
Does your child hide being angry? |
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13. |
Do you encourage your child to think about things and talk about them so that he/she can establish his/her own opinion? |
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14. |
If your child is upset, is it difficult for you to figure out what he/she is feeling? |
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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? |
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16. |
Does your child let you know what is bothering him/her? |
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17. |
Are there certain topics which you do not allow your child to discuss with you? |
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18. |
Does your child admit mistakes without trying to hide anything? |
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19. |
Can your child has his/her say even if you disagree? |
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20. |
Do you and your child come to a solution when you talk about a problem? |
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Alabama Parenting Questionnaire (APQ)
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 take this survey.
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Never |
Almost Never |
Sometimes |
Often |
Always |
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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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13. |
You compliment your child when he/she does something well. |
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14. |
You ask your child what his/her plans are for the coming day. |
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15. |
You drive (or take) your child to a special activity. |
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16. |
You praise your child if he/she behaves well. |
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17. |
Your child is out with friends you don’t know. |
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18. |
You hug or kiss your child when he/she has done something well. |
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19. |
Your child goes out without a set time to be home. |
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20. |
You talk to your child about his/her friends. |
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21. |
Your child is out after dark without an adult with him/her. |
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22. |
You let your child out of a punishment early (like lift restrictions earlier than you originally said). |
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23. |
Your child helps plan family activities. |
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24. |
You get so busy that you forget where your child is and what he/she is doing.
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25. |
Your child is not punished when he/she has done something wrong. |
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26. |
You attend PTA meetings, parent/teacher conferences, or other meetings at your child’s school. |
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27. |
You tell your child that you like it when he/she helps out around the house. |
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28. |
You don’t check that your child comes home at the time she/he was supposed to. |
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29. |
You don’t tell your child where you are going. |
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30. |
Your child comes home from school more than an hour past the time you expect him/her. |
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31. |
The punishment you give your child depends on your mood. |
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32. |
Your child is at home without adult supervision. |
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33. |
You spank your child with your hand when he/she has done something wrong. |
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34. |
You ignore your child when he/she is misbehaving. |
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35. |
You slap your child when he/she has done something wrong. |
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36. |
You take away privileges or money from your child as a punishment. |
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37. |
You send your child to his/her room as a punishment. |
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38. |
You hit your child with a belt, switch, or other object when he/she has done something wrong. |
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39. |
You yell or scream at your child when he/she has done something wrong. |
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40. |
You calmly explain to your child why his/her behavior was wrong when he/she misbehaves. |
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41. |
You use time out (make him/her sit or stand in a corner) as a punishment. |
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42. |
You give your child extra chores as a punishment. |
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Communication about Sex Topics
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 |
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1. |
How many times have you talked to your child about getting enough physical exercise? |
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2. |
How many times have you talked to your child about eating the right kinds of foods? |
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3. |
How many times have you talked to your child about alcohol? |
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4. |
How many times have you talked to your child about drugs? |
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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 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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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.
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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 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
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. |
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2. |
The majority of teens in abusive dating relationships have witnessed abuse between their parents. |
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3. |
About 5% of teenagers have been physically abused by a date. |
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4. |
Most teen rapes are by someone the teen does not know. |
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Please indicate how much you agree or disagree with the following statements. |
Strongly agree |
Somewhat agree |
Somewhat disagree |
Strongly disagree |
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5. |
Being insulted by a date is not that big a deal as long as there is no physical violence. |
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6. |
Hitting a date because of jealousy is just a natural part of dating. |
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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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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
2. How confident are you that you could recognize warning signs that your middle school childwas abusing a date?
Very confident
Somewhat confident
Not very confident
Not at all confident
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
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
Beliefs about Dating
The next questions are about your beliefs related to your teen’s dating, or your teen’s dating when he/she beings 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 on dates, etc. |
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2. |
You believe it is important to provide your middle school child with guidance on dating. |
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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. |
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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 when 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? |
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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? |
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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? |
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4. |
Is your middle school child allowed to go on solo dates? |
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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? |
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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? |
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7. |
Was your middle school child told how old he/she needed to be before he/she could group date? |
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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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If you have attended a 6th or 7th grade parent program for Dating Matters (e.g., Parents Matter!) program event, please answer the following questions:
How long does it take you to get to a single 6th or 7th grade parent program for Dating Matters (e.g., Parents Matter!) 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
How far do you travel (mileage) to participate in a session of the 6th or 7th grade parent program for Dating Matters (e.g., Parents Matter!)? {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
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)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Wendy LiKamWa |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
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