Form Parent & Caregiver Parent & Caregiver Parent & Caregiver Pre-test Post-test Survey

Attachment 1: Parent/Caregiver Pre-Test/Post-Test Survey

Intro OMB Control Number:  ______

Expires: ________

Logo for SAMHSA and CSAP

Public Burden Statement:  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.  The OMB control number for this project is ____, expires: _____.  Public reporting burden for this collection of information is estimated to average 10 minutes per respondent, including the time for reviewing instructions.  Send comments regarding this burden to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 16E89B, Rockville, MD  20857.

Thank you for agreeing to participate in this survey about concerns parents have for their children.  Your responses will help SAMHSA improve its programs to help families.  This survey will take less than 10 minutes to complete.  Your participation in this survey is voluntary, and you may quit the survey or skip any question at any time.  All of your answers will be kept strictly confidential.  No individual results will be published, only summary information from all responses.

Click the button below to begin the survey.

Q1 Are you a parent or caregiver of a child between the ages of 9 and 15 years old? Please include children and stepchildren living in your household part time or full time.

• Yes (1)

• No (2)

If No Is Selected, Then Skip To End of Block

Answer If: you are a parent or caregiver of a child between the ages of 9 and 15 years old? Please include c... Yes Is Selected

Q1a How many children (between the ages of 9 and 15) are currently living in your household, part time or full time?  Please enter the number of children below and their ages.

Q2intro For the following questions, think about your ${e://Field/Tense} who ${e://Field/Tense2} between the ages of 9 and 15 years old.

Q2 From the list below, in your opinion, which of these issues are the three most important facing your ${e://Field/Tense} today?  Select three.

• Underage drinking (1)

• Academics/school (including school attendance, school environment, school/parent partnerships, and others) (2)

• Bullying/cyber-bullying (3)

• Safety concerns (including violence in my neighborhood, physical or sexual abuse, school safety, and others) (4)

• Health (including asthma, allergies, immunizations, and others) (5)

• Mental health (including ADHD, depression, anxiety, eating disorders, and others) (6)

• Drug use (7)

• Risky sexual behavior (8)

• Peer relationships/friendships (9)

• Something else (10)

Answer If Something else Is Selected

Q2a What other issue?

Q3 How concerned are you about your ${e://Field/Tense} drinking alcohol?

• Not at all (1)

• Only a little (2)

• Somewhat (3)

• Very much (4)

Answer If How concerned are you about your ${e://Field/Tense} drinking alcohol? Only a little Is Selected Or How concerned are you about your ${e://Field/Tense} drinking alcohol? Somewhat Is Selected Or How concerned are you about your ${e://Field/Tense} drinking alcohol? Very much Is Selected

Q4 Do you think there is anything you could do to prevent your ${e://Field/Tense} from drinking alcohol?

• Yes (1)

• No (2)

Q5INTRO "Talk. They Hear You." is a campaign that encourages parents and caregivers to talk to their children about underage drinking.  Some campaigns are similar to "Talk.  They Hear You."  This campaign features the following logo: 

Q5 Before this survey, had you heard of "Talk. They Hear You."?

• Yes (1)

• No (2)

If No Is Selected, Then Skip To Have you ever had a conversation with...

Q6 How familiar are you with "Talk. They Hear You."?

• Not at all familiar (1)

• Only a little familiar (2)

• Somewhat familiar (3)

• Very familiar (4)

Q7 Where have you seen this ad campaign?  Mark all that apply.

• A public service announcement (PSA) on TV (1)

• A poster or billboard (2)

• A pamphlet or other reading materials (3)

• Social media (including Facebook, Twitter, YouTube, and a mobile app) (4)

• Email or other communications (5)

• An ad on the radio (6)

Answer If Where have you seen this ad campaign? Mark all that apply. q://QID18/SelectedChoicesCount Is Greater Than or Equal to 2

Q8 Where did you FIRST see this ad campaign?  Select only one.

• A public service announcement (PSA) on TV (1)

• A poster or billboard (2)

• A pamphlet or other reading materials (3)

• Social media (including Facebook, Twitter, YouTube, and a mobile app) (4)

• Email or other communications (5)

• An ad on the radio (6)

Q9 Have you ever had a conversation with your ${e://Field/Tense} about alcohol?

• Yes (1)

• No (2)

Q10 When you talked to your ${e://Field/Tense} about underage drinking, how much did you emphasize each of the following?

	Not at all (1)	Only a little (2)	Somewhat (3)	Very much (4)
Underage drinking is not acceptable (1)
You want your ${e://Field/Tense} to be happy and safe (4)
You know about alcohol and can be counted on to answer their questions (2)
You will know if your ${e://Field/Tense} ${e://Field/Tense3} to drink (5)
You can help your ${e://Field/Tense} figure out ways to avoid drinking (6)
Underage drinking can have serious consequences (3)

Q16 Within the last 3 months, how often have you talked to your ${e://Field/Tense} about the dangers of drinking alcohol?

• Once (1)

• Twice (2)

• Three times (3)

• Four times (4)

• Five times or more (5)

• Not at all in the last 3 months (6)

Answer If Before this survey, had you heard of the Talk. They Hear You. (TTHY) campaign? Yes Is Selected

Q17 Earlier, you said that you were familiar with the "Talk. They Hear You." underage drinking campaign.  Did you FIRST talk to your ${e://Field/Tense} about underage drinking before or after you saw the campaign?

• Before I saw the campaign (1)

• After I saw the campaign (2)

• Don't know or don't remember (3)

Answer If Before this survey, had you heard of "Talk. They Hear You."? Yes Is Selected And Earlier, you said that you were familiar with the "Talk. They Hear You." underage drinking campaign ... Before I saw the campaign Is Selected Or Earlier, you said that you were familiar with the "Talk. They Hear You." underage drinking campaign... Don't know or don't remember Is Selected

Q18 After you saw the campaign, did you talk to your ${e://Field/Tense} about underage drinking ${e://Field/saw}

• Yes (1)

• No (2)

Answer If Before this survey, had you heard of "Talk. They Hear You."? Yes Is Selected And After you saw the campaign, did you talk to your ${e://Field/Tense} about underage drinking ... Yes Is Selected Or Earlier, you said that you were familiar with the "Talk. They Hear You." underage drinking campaign ... After I saw the campaign is Selected:

Q19 How much did the campaign help you to talk to your ${e://Field/Tense} about underage drinking?

• Not at all (1)

• Only a little (2)

• Somewhat (3)

• Very much (4)

Answer If Before this survey, had you heard of "Talk. They Hear You."? Yes Is Selected

Q20 What information, if anything, from the "Talk.  They Hear You." campaign did you find to be most helpful?

Q21 Which of the following reasons explains why you have not had a conversation with your ${e://Field/Tense} about underage drinking?  Select all that apply.

• I am certain that my ${e://Field/Tense} ${e://Field/Tense2} not drinking. (1)

• I am waiting until my ${e://Field/Tense} ${e://Field/Tense2} older to talk to them. (2)

• I don't think that underage drinking is a big problem. (3)

• I don't know enough about underage drinking to talk to my ${e://Field/Tense} about it. (4)

• I'm not sure what to say to help my ${e://Field/Tense} avoid underage drinking. (5)

• Talking to my ${e://Field/Tense} about underage drinking will not prevent them from drinking. (6)

Q22 What is your sex?

• Male (1)

• Female (2)

Q23 What is your age?

• 18 to 24 years old (1)

• 25 to 34 years old (2)

• 35 to 44 years old (3)

• 45 to 54 years old (4)

• 55 to 64 years old (5)

• 65 years old or older (6)

Q24 What is the highest degree or level of education you have completed?

• Less than a high school diploma (1)

• Regular high school diploma or GED or alternative credential (2)

• Some college credit or trade school, no degree (3)

• Associates degree or trade school diploma/certificate (4)

• Bachelor's degree (5)

• Master's degree or higher (6)

Q25 Are you of Hispanic, Latino, or Spanish origin?

• Yes (1)

• No (2)

Q26 What is your race?  Select all that apply.

• American Indian or Alaska Native (3)

• Asian (4)

• Black or African American (2)

• Native Hawaiian or Other Pacific Islander (5)

• White (1)

Q27 Overall, how many children or stepchildren are living in your household full time or part time in each age category?  Enter 0 for none.

______ 8 years old or younger (1)

______ 9 to 10 years old (2)

______ 11 to 12 years old (3)

______ 13 to 14 years old (4)

______ 15 years old (5)

______ 16 to 17 years old (6)

______ 18 to 20 years old (7)

______ 21 years old or older (8)

Question for Post-Test Survey Only

Answer If Before this survey, had you heard of "Talk. They Hear You."? Yes Is Selected

Q28 Would you be willing to provide more information on your responses to this survey in a follow-up interview on the topic of underage drinking? Interviews will take no more than one hour and will be conducted by phone. For your participation, you will receive a $35 Visa gift card.    If you are interested in learning more about the interview or scheduling a time to participate, please share your first name and either a phone number or email address below so we may contact you.    Your name and contact information will NOT BE IDENTIFIED in any reports that result from this survey.  

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