Form 0920-xxxx Sample Instrument: Parent/Caregiver Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Attachment 6

Sample Instrument: Parent/Caregiver Survey

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

For each of the following questions, please select the single best response.

1. How much to you agree or disagree with the following statement? “Overall you are satisfied with your relationship with your child.”

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

2. All things considered, how is your child’s life going?

1. Very well

2. Fairly well

3. Not so well

4. Not well at all

3. Does your child have one, special girlfriend/boyfriend?

1. NoSkip to question 6

2. Yes

4. Have you met him/her in person?

1. No

2. Yes

5. Have you met his/her parents?

1. No

2. Yes

6. Have you talked with any of your child’s teachers about his/her school work this school year, either informally or in a regularly scheduled parent-teacher conference?

1. No

2. Yes

7. During this school year, have you participated in school fund-raising or done volunteer work for your child’s school—such as supervising lunch, chaperoning a field trip, etc.?

1. No

2. Yes

8. In the past week, have you and your child talked about his/her school work or grades?

1. No

2. Yes

9. In the past week, have you and your child talked about other things he/she is doing at school?

1. No

2. Yes

For questions 10-14, how often would it be true for you to make each of the following statements about (your child)?

10. You get along well with him/her.

1. Always

2. Often

3. Sometimes

4. Seldom

5. Never

6. Refused

11. (Your child) and you make decisions about his/her life together.

1. Always

2. Often

3. Sometimes

4. Seldom

5. Never

6. Refused

12. You just do not understand him/her.

1. Always

2. Often

3. Sometimes

4. Seldom

5. Never

6. Refused

13. You feel you can really trust him/her.

1. Always

2. Often

3. Sometimes

4. Seldom

5. Never

6. Refused

14. He/She interferes with your activities.

1. Always

2. Often

3. Sometimes

4. Seldom

5. Never

6. Refused

For questions 15-19, how much to you agree or disagree with each of the following statements?

15. You really don’t know enough about sex and birth control to talk about them with your child.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

16. It would embarrass your child to talk to you about sex and birth control..

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

17. It would be difficult for you to explain things if you talked with your child about sex and birth control.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

18. Your child will get the information somewhere else, so you don’t really need to talk to him/her about sex and birth control.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

19. Talking about birth control with your child would only encourage him/her to have sex.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

20. How much have you talked to your child about birth control?

1. Not at all

2. Somewhat

3. A moderate amount

4. A great deal

21. How much have you talked to your child about sex?

1. Not at all

2. Somewhat

3. A moderate amount

4. A great deal

For questions 22-25, how much do you agree or disagree with each of the following statements?

22. Overall you are satisfied with your relationship with your child.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

23. You disapprove of your child’s having sexual intercourse at this time in his/her life.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

24. If it was with someone who was special to him/her and whom he/she knew well such as a steady girlfriend/boyfriend, you would not mind if your child had sexual intercourse.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

25. You have recommended a specific method of birth control to your child.

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

26. In general, how easy or hard is it for you to get medical care for your family?

1. Very easy

2. Somewhat easy

3. Somewhat hard

4. Very hard

27. When your child sees a doctor or other health care provider, does he or she spend time alone with the doctor/provider without a parent or similar adult (grandparent, aunt, uncle, etc.) in the room?

A. Yes, on every visit

B. Yes, but only on some visits

C. No, not on any visit

Thank you for completing this questionnaire. Your feedback provides valuable input.