Form Parent Questionnai Parent Questionnai Parent Questionnaire

OMB No. 0930-03xx

Expiration Date: xx/xx/xx

Parent Questionnaire

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

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 0930-0xxx. Public reporting burden for this collection of information is estimated to average xx minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Section I: Screener

1. Are you a parent or guardian of one or more children ages 9 through 20? Please include children living in your household part time or full time.

• Yes

• No

If you said “No,” please stop now. This questionnaire is for parents or guardians who have children ages 9 through 20 living part time or full time in their household.

2. Please indicate in the grid below the ages of each child ages 9 through 20 living in your household either part time or full time.

If you have more than one child, please mark in order of youngest to oldest as indicated in the column headers.

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
9
10
11
12
13
14
15
16
17
18
19
20

3. Please indicate the genders of the children (ages 9 through 20) living in your household either part time or full time.

As before, if you have more than one child, please mark in order of youngest to oldest.

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Male
Female

Section II: Attitudes on Underage Drinking and Other Substance Use

Questions 4–6 will require answers for each child ages 9 through 20 living in the household either part time or full time.

4. In your opinion, what are the three most important issues to discuss with your children ages 9 through 20 today? Please check the 3 boxes that apply to each child.

As before, if you have more than one child, please mark in order of youngest to oldest.

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Academic achievement and performance
Health (e.g., nutrition, physical activity, etc.)
Risky sexual behavior
Violence (e.g., violence in your neighborhood, physical or sexual abuse, bullying, school safety, etc.)
Mental health (e.g., ADHD, depression, anxiety, eating disorders, suicide, etc.)
Making friends/maintaining positive relationships with family and/or peers
Peer pressure
Abuse/overuse of electronics (e.g., gaming/social media use via smartphone, iPad, or computer)
Negative social media influence (e.g., online bullying, peer pressure, predators)
Drug use (including prescription misuse)
Underage drinking (i.e., drinking alcohol before the legal age of 21)
Use of tobacco products. Select all that apply.
cigarettes
e-cigarettes (e.g., blu, JUUL, Logic, MarkTen XL, and Vuse)
smokeless tobacco (defined as chewing tobacco, snuff, or dip)
hookahs
Something else, please specify:
I do not believe there are any issues that I need to discuss with my child today

5. How strongly do you agree or disagree with the following statements?

5a. “Underage drinking is an important issue to discuss with my ____ year-old child.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

5b. “Talking to my child about underage drinking is likely to make a difference in the decisions he or she makes.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

5c. How confident do you feel in your ability to influence each of your children’s decisions about drinking alcohol?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all confident
Somewhat confident
Confident
Very confident

6. How strongly do you agree or disagree with the following statements?

6a. “Other substance use (including prescription misuse) is an important issue to discuss with my ____ year-old child.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

6b. “Talking to my child about other substance use (including prescription misuse) is likely to make a difference in the decisions he or she makes.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

6c. How confident do you feel in your ability to influence each of your children’s decisions about using other substances (including prescription misuse)?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all confident
Somewhat confident
Confident
Very confident

7. How strongly do you agree or disagree with the following statements?

7a. “Tobacco product use (e.g. cigarette, e-cigarette, smokeless tobacco or hookah) is an important issue to discuss with my ____ year-old child.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

7b. “Talking to my child about tobacco product use (e.g. cigarette, e-cigarette, smokeless tobacco or hookah) is likely to make a difference in the decisions he or she makes.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

7c. How confident do you feel in your ability to influence each of your children’s decisions about using tobacco products?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all confident
Somewhat confident
Confident
Very confident

8. How susceptible do you feel that your __-year-old child is to drinking alcohol without your permission in the next 6 months?

   	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
   Not at all susceptible
   Somewhat susceptible
   Susceptible
   Very susceptible

9. How susceptible do you feel that your __-year-old child is to using other substances (including prescription misuse) in the next 6 months?

   	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
   Not at all susceptible
   Somewhat susceptible
   Susceptible
   Very susceptible

10. How susceptible do you feel that your __-year-old child is to using tobacco products (e.g. cigarette, e-cigarette, smokeless tobacco or hookah) in the next 6 months?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all susceptible
Somewhat susceptible
Susceptible
Very susceptible

Section III: Having the Conversation

11. Within the past 3 months, how often have you talked to your children ages 9 through 20 about underage drinking?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all in the past 3 months
Once
Twice
Three times
Four times
Five times or more

11a. What main point(s) do you generally emphasize when talking to your children ages 9 through 20 about underage drinking?

Please detail the point(s) you emphasize here:

12. Within the past 3 months, how often have you talked to your children ages 9 through 20 about other substance use (including prescription misuse)?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all in the past 3 months
Once
Twice
Three times
Four times
Five times or more

12a. What main point(s) do you generally emphasize when talking to your children ages 9 through 20 about other substance use?

Please detail that point you emphasized here:

13. Within the past 3 months, how often have you talked to your children ages 9 through 20 about tobacco product use (e.g. cigarette, e-cigarette, smokeless tobacco or hookah)?

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Not at all in the past 3 months
Once
Twice
Three times
Four times
Five times or more

13a. What main point(s) do you generally emphasize when talking to your children ages 9 through 20 about tobacco product use?

Please detail the point(s) you emphasized here:

Section IV: Product Testing

Rotate exposure to THREE TEST MATERIALS HERE [e.g., Conversation Starter Guide, Print PSA, and Video PSA]

14. PRODUCT #1

14a. How appealing is Product X?

	Product X
Very appealing
Appealing
Somewhat appealing
Not at all appealing

14b. Did you learn anything new from Product X or did it make you think differently about underage drinking/other substance use/tobacco product use?

• Yes

• No

Please provide specific details on what you learned or how the materials made you think differently:

_________________________________________________________________________

_________________________________________________________________________

14c. Overall, how effective is Product X in encouraging you to talk to your __-year-old child about underage drinking/other substance use/tobacco product use?

	Product X
Very effective
Effective
Somewhat effective
Not at all effective

14d. Does Product X convince you to talk to your child about underage drinking/other substance use/tobacco product use in the next 3 months?

• Yes

• No

14e. How might Product X be improved? Please be as specific as possible.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

15. PRODUCT #2

15a. How appealing is Product X?

	Product X
Very appealing
Appealing
Somewhat appealing
Not at all appealing

15b. Did you learn anything new from Product X or did it make you think differently about underage drinking/other substance use/tobacco product use?

• Yes

• No

Please provide specific details on what you learned or how the materials made you think differently:

_________________________________________________________________________

_________________________________________________________________________

15c. Overall, how effective is Product X in encouraging you to talk to your __-year-old child about underage drinking/other substance use/tobacco product use?

	Product X
Very effective
Effective
Somewhat effective
Not at all effective

15d. Does Product X convince you to talk to your child about underage drinking/other substance use/tobacco product use in the next 3 months?

• Yes

• No

15e. How might Product X be improved? Please be as specific as possible.

_________________________________________________________________________

_________________________________________________________________________

16. PRODUCT #3

16a. How appealing is Product X?

	Product X
Very appealing
Appealing
Somewhat appealing
Not at all appealing

16b. Did you learn anything new from Product X or did it make you think differently about underage drinking/other substance use/tobacco product use?

• Yes

• No

Please provide specific details on what you learned or how the materials made you think differently:

_________________________________________________________________________

_________________________________________________________________________

16c. Overall, how effective is Product X in encouraging you to talk to your __-year-old child about underage drinking/other substance use/tobacco product use?

	Product X
Very effective
Effective
Somewhat effective
Not at all effective

16d. Does Product X convince you to talk to your child about underage drinking/other substance use/tobacco product use in the next 3 months?

• Yes

• No

16e. How might Product X be improved? Please be as specific as possible.

_________________________________________________________________________

_________________________________________________________________________

Section V: Closing

17. Please indicate how much you agree or disagree with the following statement for each of your children ages 9 through 20:

“In the near future, I intend to discuss underage drinking with my child.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

17a. If you selected “Strongly disagree” or “Disagree” that you will discuss underage drinking with your child/children in the near future, please explain why.

18. Please indicate how much you agree or disagree with the following statement for each of your children ages 9 through 20:

“In the near future, I intend to discuss other substance use (including prescription misuse) with my child.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

18a. If you selected “Strongly disagree” or “Disagree” that you will discuss other substance use with your child/children in the near future, please explain why.

19. Please indicate how much you agree or disagree with the following statement for each of your children ages 9 through 20:

“In the near future, I intend to discuss tobacco product use (e.g. cigarette, e-cigarette, smokeless tobacco or hookah) with my child.”

	1st Child (youngest/ only)	2nd Child (second youngest)	3rd Child (third youngest)	4th Child (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

19a. If you selected “Strongly disagree” or “Disagree” that you will discuss tobacco product use with your child/children in the near future, please explain why.

Section VI: Demographics

20. What is your age? Please write your age below.

________

21. What is your gender?

• Male

• Female

22. Are you Hispanic or Latino?

• Yes

• No

23. What is your race? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

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

• Less than a high school diploma

• Regular high school diploma or GED or alternative credential

• Some college credit or trade school, no degree

• Associate’s degree or trade school diploma/certificate

• Bachelor’s degree

• Master’s degree or higher

25. What is your annual household income?

• Less than $10,000

• $10,000–$19,999

• $20,000–$29,999

• $30,000–$39,999

• $40,000–$49,999

• $50,000–$59,999

• $60,000–$69,999

• $70,000–$79,999

• $80,000–$89,999

• $90,000–$99,999

• $100,000–$149,000

• 150,000 or more

• Prefer not to answer

26. Overall, how many children are living in your household part time or full time from each age category?

______ 8 years old or younger

______ 9 to 12 years old

______ 13 to 15 years old

______ 16 to 17 years old

______ 18 to 20 years old

______ 21 years old or older

Thank you for completing this questionnaire!

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