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Page 1 of 44
Parent Survey
Start of Block: STUDY ELIGIBILITY CRITERIA
Survey participation is voluntary. You can skip questions you choose not to answer and you can stop
participating at any time.
1. NUMBER OF CHILDREN
How many children do you have? Please include biological, adoptive, foster, step children, and children for
whom you have legal guardianship. _____ children (dropdown response) [IF '0' END SURVEY]
2. CHILD AGE(S)
Please record the age(s) of your child(ren) from oldest to youngest.
____ years old (dropdown response for each child) [IF NO CHILDREN 11-17 YEARS OLD, END SURVEY]
3. PARENT RELATIONSHIP TO CHILD
What is your relationship to your XX year old child? If you have multiple children of the same age, please think
about the oldest child first. [QUESTION ASKED FOR EACH CHILD 11-17 YEARS OLD]
o Biological parent
o Adoptive parent
o Foster parent
o Stepparent
o Legal guardian
o I am not the parent or legal guardian of this child. [END SURVEY]
4. ADOLESCENT MILITARY LIFE EXPOSURE
Did your XX year old child ever live with you in the same household while you were serving in the U.S.
military? [QUESTION ASKED FOR EACH CHILD 11-17 YEARS OLD]
o NO [END SURVEY]
o Yes
5. ADOLESCENT LENGTH OF TIME EXPOSED TO MILITARY LIFE
How many years did your XX year old child live with you in the same household during your military service?
_____ years (dropdown response) [QUESTION ASKED FOR EACH CHILD 11-17 YEARS OLD]
Page 2 of 44
6. PARENT CURRENT CONTACT WITH ADOLESCENT
What proportion of the time does your XX year old child currently live in your household? [QUESTION ASKED
FOR EACH CHILD 11-17 YEARS OLD]
o None of the time
o Less than half of the time
o Half of the time
o More than half of the time
o Full time
7. IF NONE OF THE TIME: How often have you had contact with your XX year old child during the last 12
months? [QUESTION ASKED FOR EACH CHILD 11-17 YEARS OLD]
o Never [END SURVEY]
o Less than once a month
o About once or twice a month
o About once a week
o Almost daily
8. OTHER PARENT
Which of the following people do you most consider to be your XX year old child's other parent or legal
guardian? If there are multiple people who are a parent figure to your XX year old child, please select the one
Page 3 of 44
person who spends the most time with your XX year old child. [QUESTION ASKED FOR EACH CHILD 11-17
YEARS OLD]
o Biological parent
o Adoptive parent
o Foster parent
o Step parent
o Legal guardian
o Other (please specify):____________________
o I am the sole parent or legal guardian of this child. [SKIP TO PARENT DEMOGRAPHICS SECTION]
9. OTHER PARENT IN HOUSEHOLD: Does your XX year old child's other parent or legal guardian currently
live in your household? [QUESTION ASKED FOR EACH CHILD 11-17 YEARS OLD]
o Yes [ASK FOR CONTACT INFORMATION]
o No, they live elsewhere. [ASK FOR CONTACT INFORMATION]
o No, they are not alive or their whereabouts are unknown.
o No, I am the sole parent or legal guardian.
Note: A focal child will be selected based on meeting all study eligibility criteria listed above. If more than one
child is eligible, a random child will be selected for the study.
End of Block: STUDY ELIGIBILITY CRITERIA
Start of Block: PARENT DEMOGRAPHICS
Note: Millennium Cohort Study participant's date of birth, gender, race/ethnicity, military status, service branch,
pay grade, component, service length, deployment dates, and health records for TRICARE recipients will be
obtained from archival data sources.
Source: Family Study Survey
Before asking you about your XX year old child, we would like to ask you some questions about yourself.
Page 4 of 44
10. AGE
What is your date of birth? ___/___/_____ (dropdown responses)
11. SEX AT BIRTH
What sex were you assigned at birth, meaning on your original birth certificate?
o Male
o Female
12. GENDER IDENTITY
How would you describe your current gender?
o Male
o Female
o Transgender, male to female
o Transgender, female to male
o Something else (please specify): ________________________________________________
o Prefer not to answer
13. ETHNICITY
Are you of Hispanic, Latino, or Spanish origin?
o No
o Yes
Page 5 of 44
14. RACE
What is your race? Please select all that apply.
▢
▢
▢
▢
▢
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
15. BORN IN U.S.
Were you born in the United States (U.S.)?
o No
o Yes
16. ENGLISH PROFICIENCY
Is English your primary or native language?
o No
o Yes
Page 6 of 44
17. HIGHEST EDUCATION LEVEL
What is the highest level of education that you have completed? Choose the single best answer.
o Less than high school (did not obtain a diploma)
o High school diploma, GED, or equivalent
o Vocational or technical diploma
o Some college, no degree
o Associate's degree
o Bachelor's degree
o Master's degree
o Doctorate or professional school degree
18. STUDENT
Are you currently a student enrolled in a degree and/or licensure/certificate program?
o No
o Yes, degree program
o Yes, licensure/certificate program
o Yes, degree and licensure/certificate program
19. EMPLOYMENT STATUS
Which of the following best describes your current paid employment status? Choose the single best answer.
o Full-time work (30 or more hours per week)
o Part-time work (Less than 30 hours per week)
o Not employed, looking for work in the last 4 weeks
o Not employed, not looking for work in the last 4 weeks
Page 7 of 44
20. HOUSEHOLD INCOME
What is your total annual household income? Please include Basic Allowance for Housing (BAH), even if you
live in base housing, and any other regular income that your family receives.
o Less than $25,000
o $25,000-$49,999
o $50,000-$74,999
o $75,000-$99,999
o $100,000-$124,999
o $125,000-$149,999
o $150,000 or more
21. BASE HOUSING
What best describes your current household situation?
o Military housing, on base
o Military housing, off base
o Civilian housing
22. MARITAL STATUS
What is your current marital status?
o Never married
o Married
o Separated
o Divorced
o Widowed
Page 8 of 44
IF MARRIED, SEPARATED, DIVORCED, OR WIDOWED: How many times have you been married?
_____ times (dropdown response)
Note: If the respondent has been married more than 1 time, they will see the following text: Please think about
your most recent marriage when responding to the next question.
23. IF MARRIED: On what date did you get married? ___/___/____ (dropdown responses)
24. IF SEPARATED: On what date did you get separated?___/___/_____ (dropdown responses)
25. IF DIVORCED: On what date did you get divorced?___/___/_____ (dropdown responses)
26. IF WIDOWED: On what date did your spouse die?___/___/_____ (dropdown responses)
28. RELATIONSHIP STATUS
IF NEVER MARRIED, SEPARATED, DIVORCED, OR WIDOWED: Which of the following best describes your
current relationship status?
o Not dating
o Dating casually
o In a committed relationship, living separately
o In a committed relationship, living together
29. IF IN A COMMITTED RELATIONSHIP: On what date did your most recent relationship begin?
___/___/___ (dropdown responses)
30. MILITARY PARENT MILITARY STATUS
Are you currently in the U.S. military? Note: The "other parent" will be asked this item, but response choices
will be those provided in Q31.
o No
o Yes, currently Active Duty
o Yes, currently Reserve or National Guard
Page 9 of 44
31. OTHER PARENT MILITARY STATUS
[ITEM ONLY ASKED OF PARTICIPANTS WHO REPORT "OTHER PARENT OR LEGAL GUARDIAN"]
Has your XX year old child's other parent or legal guardian ever served in the U.S. military?
o No
o Yes, but not currently serving
o Yes, currently Active Duty
o Yes, currently Reserve or National Guard
32. HOUSEHOLD COMPOSITION
Including yourself, how many people currently live in your household? Please do not include anyone who does
not live and sleep in your household most of the time, such as visiting relatives. If you live in more than one
household, please think about the household where you spend the most time.
____adults (18 years or older) _____ children (17 years or younger) (dropdown responses)
33. MILITARY FAMILY SERVICE HISTORY
How much of your childhood was spent growing up in a U.S. military family (in other words, your parent or legal
guardian served on Active Duty or in the Reserve or National Guard)?
o None
o Less than 4 years
o 4-8 years
o 9-13 years
o 14 or more years
End of Block: PARENT DEMOGRAPHICS
Start of Block: PARENT PHYSICAL AND PSYCHOLOGICAL HEALTH
Source: Family Study Survey
The next section of questions is about your health and how you feel. Please answer as honestly as you can.
There are no right or wrong answers. Your answers are confidential and will not be shared with anyone outside
of the research team.
Page 10 of 44
34. HEALTH CONDITIONS/DIAGNOSES
Has a doctor or other health professional ever told you that you have any of the following conditions?
No
Depression
Anxiety
Posttraumatic stress disorder
Eating disorder
o
o
o
o
Yes
o
o
o
o
35. OVERALL HEALTH
In general, would you say your health is:
o Excellent
o Very good
o Good
o Fair
o Poor
36. HEIGHT
How tall are you?____ feet ____inches (dropdown responses)
37. WEIGHT
What is your current weight? If you are currently pregnant, please provide your weight prior to your
pregnancy.____ pounds (dropdown response)
38. PREGNANCY
Are you or your spouse/partner currently pregnant with your child?
o No
o Yes
Page 11 of 44
39. DEPRESSION: Patient Health Questionnaire (PHQ-2)
During the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all
Several days
More than half
the days
Nearly every day
Little interest or
pleasure in doing
things
o
o
o
o
Feeling down,
depressed, or
hopeless
o
o
o
o
40. ANXIETY: Generalized Anxiety Disorder Screen (GAD-2)
During the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all
Several days
More than half
the days
Nearly every day
Feeling nervous,
anxious, or on
edge
o
o
o
o
Not being able to
stop or control
worrying
o
o
o
o
41. Posttraumatic Stress Disorder (PTSD): Post-Deployment Health Assessment
Have you ever had any experience that was so frightening, horrible, or upsetting that, during the last 30 days,
you:
No
Yes
Have had nightmares about it
or thought about it when you
did not want to?
o
o
Tried hard not to think about it
or went out of your way to
avoid situations that remind
you of it?
o
o
Were constantly on guard,
watchful, or easily startled?
o
o
Felt numb or detached from
others, activities, or your
surroundings?
o
o
Page 12 of 44
42. MEDICATION USE
Are you currently taking any prescription medication for anxiety or depression?
o No
o Yes
End of Block: PARENT PHYSICAL AND PSYCHOLOGICAL HEALTH
Start of Block: PARENT MILITARY AND GENERAL LIFE EXPERIENCES
Note: MILLENNIUM COHORT PARTICIPANT WILL REPORT ON THEIR OWN MILITARY EXPERIENCES
USING THE LANGUAGE "YOU OR YOUR," AND THE "OTHER PARENT OR LEGAL GUARDIAN" WILL
REPORT ON THE MILLENNIUM COHORT PARTICIPANT'S MILITARY EXPERIENCES USING THE
LANGUAGE "YOUR SPOUSE/PARTNER."
Source: Family Study Survey
The next section of questions is about your military and life experiences. Please be as honest as you can.
There are no right or wrong answers. Your answers are confidential and no one will see your responses
outside of the research team.
43. DEPLOYMENT EXPERIENCE
Have you/your spouse/partner ever deployed for more than 30 consecutive days?
o No
o Yes
44. COMBAT DEPLOYMENT EXPERIENCE: Post-Deployment Health Assessment
IF EVER DEPLOYED (ASKED OF THE SERVICE MEMBER ONLY): During any of your deployments:
No
Yes
Did you ever feel like you
were in great danger of being
killed?
o
o
Did you encounter dead
bodies or see people killed or
wounded?
o
o
Did you engage in direct
combat where you discharged
a weapon?
o
o
Page 13 of 44
45. IF EVER DEPLOYED: How stressful was your/your spouse/partner's most recent deployment for you?
o Not at all stressful
o Slightly stressful
o Moderately stressful
o Very stressful
46. IF EVER DEPLOYED: How stressful was your/your spouse/partner's most recent reunion/reintegration
process?
o Not at all stressful
o Slightly stressful
o Moderately stressful
o Very stressful
47. IF SEPARATED FROM THE MILITARY (BASED ON Q30): How stressful was your/your spouse/partner's
transition from the military?
o Not at all stressful
o Slightly stressful
o Moderately stressful
o Very stressful
Page 14 of 44
48. MILITARY PRIDE: How much do you agree with the following statement:
Overall, I am proud to be affiliated with the U.S. military.
o Strongly disagree
o Disagree
o Neither agree nor disagree
o Agree
o Strongly agree
49. MILITARY SERVICES
During the last 12 months, have you used any of the following sources of support to help you or your family
cope with difficult challenges or solve problems?
No
Yes
Page 15 of 44
Online social networking (e.g.,
blogs, chat groups, Facebook)
o
o
In-person support groups
(e.g., military and family
readiness, military spouse,
parenting support)
o
o
Military and Family Life
Counselor (MFLC)
o
o
Self-help information (e.g.,
Combat Operational Stress
Control website, WebMD,
books, downloadable apps)
o
o
Military OneSource (e.g., nonmedical counseling, financial
counseling, spouse education
and career support)
o
o
Nonprofit agencies (e.g., Red
Cross, Goodwill, Service relief
societies, Military Serving
Organizations)
o
o
Federal or State agencies
(e.g., Child and Family
Services, WIC)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Religious or spiritual leader
(e.g., pastor, chaplain, rabbi)
Military and family support
center
Youth/child development
center professionals
School personnel (e.g.,
teachers, counselors, liaisons)
Command leadership (e.g.,
commander, first sergeant)
Military installation/base
support
Veterans Affairs
Page 16 of 44
50. MILITARY SUPPORT
Overall, how would you rate the military's efforts to help your family deal with the stresses of military life?
o Poor
o Fair
o Good
o Very good
o Excellent
51. MILITARY SATISFACTION
What is your overall feeling about military life?
o Negative
o Somewhat negative
o Neither positive nor negative
o Somewhat positive
o Positive
52. STRESSFUL LIFE EVENTS
Have you ever had any of the
following life events happen to
you?
No
Yes
IF YES: Did this event occur during
the last 12 months?
No
Yes
Page 17 of 44
You were fired, laid-off, or
changed employers/careers?
o
o
o
o
You or your partner had an
unplanned pregnancy?
o
o
o
o
You experienced infidelity or
unfaithfulness in a committed
relationship?
o
o
o
o
You suffered major financial
problems?
o
o
o
o
You suffered forced sexual
relations or a violent physical
assault (e.g., hit, slapped,
kicked)?
o
o
o
o
You had a family member or
loved one who became
severely ill or died?
o
o
o
o
You suffered a disabling illness
or injury?
o
o
o
o
You slept in a shelter, on the
streets, or in another nonresidential setting?
o
o
o
o
Page 18 of 44
53. ADVERSE CHILDHOOD EXPERIENCES
The next items are about when you were growing up, before you were 18 years old.
Never
Once or twice
Sometimes
Often
Very often
How often did
a parent or
other adult
living in your
home swear
at you, insult
you, or put
you down?
o
o
o
o
o
How often did
a parent or
other adult
living in your
home push,
grab, shove,
slap, or throw
something
at you?
o
o
o
o
o
How often did
a parent or
other adult
living in your
home push,
grab, shove,
slap, or throw
something at
each other?
o
o
o
o
o
How often did
an adult ever
touch you
sexually or try
to make you
touch them
sexually?
o
o
o
o
o
54. ADVERSE CHILDHOOD EXPERIENCES
No
Yes
Did you live with someone
who was depressed or
mentally ill?
o
o
Did you live with someone
who was a problem drinker or
alcoholic?
o
o
Page 19 of 44
55. CAREGIVING
During the last 12 months, have you been a caregiver to any of the following people because of a special
medical need (e.g., illness, injury, or emotional/behavioral problem)?
No
Your spouse/partner
Your child(ren)
Other relative
Non-relative
o
o
o
o
Yes, unpaid
o
o
o
o
Yes, paid
o
o
o
o
56. IF YES TO CAREGIVING: Overall, how stressful would you say providing this care is for you?
o Not at all stressful
o Slightly stressful
o Moderately stressful
o Very stressful
57. IF YES TO CAREGIVING FOR SPOUSE/PARTNER: Is your spouse/partner's special medical need the
result of a combat-related injury?
o No
o Yes
End of Block: PARENT MILITARY AND GENERAL LIFE EXPERIENCES
Start of Block: PARENT BEHAVIORAL HEALTH
This section contains questions about your health behaviors. There are no right or wrong answers. Your
responses are confidential and will not be shared with anyone outside of the study team.
Page 20 of 44
58. ALCOHOL USE
One drink = one 12-ounce beer, one 4-ounce glass of wine, or one 1.5-ounce shot of liquor.
During the last 12 months, how often did you typically drink any type of alcoholic beverage?
o Never [SKIP TO TOBACCO USE SECTION]
o Rarely
o Monthly
o Weekly
o Daily
59. BINGE DRINKING
During the last 12 months, how often did you typically have 4 or more drinks of alcoholic beverages within a 2hour period (if female), or 5 or more drinks of alcoholic beverages within a 2-hour period (if male)?
o Never
o Monthly or less
o 2-4 times per month
o More than 4 times per month
60. ALCOHOL DEPENDENCE
During the last 12 months, have you felt any of the following?
No
Yes
You needed to cut back on
your drinking
o
o
Annoyed at anyone who
suggested you cut back on
your drinking
o
o
o
o
o
o
You needed an "eye-opener"
or early morning drink
Guilty about your drinking
Page 21 of 44
61. TOBACCO USE
During the last 12 months, have you used any of the following tobacco/nicotine products?
No
Cigarettes
Electronic cigarettes or vape
Cigars or pipes
Smokeless tobacco (chew,
dip, snuff)
Hookah
o
o
o
o
o
Yes
o
o
o
o
o
62. CIGARETTE USE
During your lifetime, have you smoked at least 100 cigarettes (5 packs)?
o No
o Yes
63. IF YES TO CIGARETTE USE: Do you currently smoke cigarettes?
o No, not at all
o Yes, some days
o Yes, every day
64. IF YES TO CURRENT CIGARETTE USE: When smoking cigarettes, how many packs per day do you
smoke?
o Less than half a pack per day
o Half to 1 pack per day
o 1 to 2 packs per day
o More than 2 packs per day
Page 22 of 44
65. SLEEP
During the last 30 days, how many hours of sleep did you get in an average 24-hour period?
o 4 hours or less
o 5 hours
o 6 hours
o 7 hours
o 8 hours
o 9 hours
o 10 or more hours
66. PHYSICAL ACTIVITY
During the last 7 days, on how many days were you physically active for a total of at least 30 minutes per day?
(Add up all the time you spent in any kind of physical activity that increased your heart rate and made you
breathe hard some of the time.)
o 0 days
o 1 day
o 2 days
o 3 days
o 4 days
o 5 days
o 6 days
o 7 days
o I cannot physically exercise.
End of Block: PARENT BEHAVIORAL HEALTH
Start of Block: PARENTS' RELATIONSHIP
Page 23 of 44
Note: PARENTING ALLIANCE: Parenting Alliance Inventory (PAI)
[ITEMS ARE ONLY ASKED OF PARTICIPANTS WHO REPORT "OTHER PARENT OR LEGAL GUARDIAN"]
67. The questions below are about co-parenting with your XX year old child's other parent or legal guardian.
While you may not find an answer that exactly describes what you think, please mark the answer that comes
closest to what you think. Your first reaction should be your first answer.
Strongly
disagree
Disagree
Neither agree
nor disagree
Agree
Strongly
agree
My child's coparent is
willing to
make
personal
sacrifices to
help take
care of our
child(ren).
o
o
o
o
o
My child's coparent pays a
great deal of
attention to
our child(ren).
o
o
o
o
o
My child's coparent knows
how to
handle our
child(ren)
well.
o
o
o
o
o
My child's coparent and I
are a good
team.
o
o
o
o
o
My child's coparent makes
my job of
being a
parent easier.
o
o
o
o
o
Source: Family Study Survey
[ITEMS ARE ONLY ASKED OF PARTICIPANTS WHO REPORT BEING MARRIED OR IN A COMMITTED
RELATIONSHIP]
The next set of questions is about your relationship with your current spouse/partner. Please answer these
items as honestly as you can. There are no right or wrong answers. Your responses will be kept confidential
and will not be shared with anyone outside of the study team.
Page 24 of 44
68. MARITAL/RELATIONSHIP QUALITY: Quality of Marriage Index (QMI)
Please rate the following statements about your relationship with your current spouse/partner:
Strongly
disagree
Disagree
Neither agree
nor disagree
Agree
Strongly
agree
My relationship
with my
spouse/partner
is very stable.
o
o
o
o
o
I really feel like
part of a team
with my
spouse/partner.
o
o
o
o
o
I feel that I can
trust my
spouse/partner
completely.
o
o
o
o
o
69. MARITAL INSTABILITY AND COUNSELING
IF MARRIED: During the last 12 months, have you or your spouse seriously suggested the idea of divorce or
permanent separation?
o No
o Yes
Page 25 of 44
70. IF MARRIED: Have you and your spouse received marital counseling?
o Never
o Once or twice
o 3-5 times
o 6-10 times
o 11 or more times
71. SEXUAL IDENTITY
Do you consider yourself to be…?
o Heterosexual or straight
o Gay or lesbian
o Bisexual
o Something else (please specify): _________________________________________________
o Prefer not to answer
72. SEXUAL CONTACT
Who have you ever had sex with?
o Men only
o Women only
o Both men and women
o I have not had sex
o Prefer not to answer
End of Block: PARENTS' RELATIONSHIP
Start of Block: ADOLESCENT PHYSICAL AND PSYCHOLOGICAL HEALTH - PARENT REPORT
Page 26 of 44
The next section of questions is about your XX year old child's health and how they feel. Please answer as
honestly as you can. There are no right or wrong answers. Your answers are confidential and will not be
shared with anyone outside of the research team.
73. HEALTH CONDITIONS/DIAGNOSES: Family Study Survey
Has a doctor or health professional ever told you that your XX year old child has any of the following
conditions:
No
Attention Deficit Disorder or
Attention Deficit Hyperactive
Disorder (ADD or ADHD)
Yes
o
o
o
o
o
o
o
o
Autism, Asperger’s Disorder,
pervasive development
disorder, or other autism
spectrum disorder (ASD)
o
o
Developmental delay or
intellectual disability
o
o
Chronic health condition (e.g.,
diabetes, asthma,
hearing/vision problems)
o
o
o
o
o
o
o
o
Depression
Anxiety (or other emotional
problems)
Behavior or conduct problems
Overweight or obese
Disruptive Mood
Dysregulation Disorder
Posttraumatic Stress Disorder
(PTSD)
Page 27 of 44
74. EMOTIONAL SYMPTOMS, CONDUCT PROBLEMS, HYPERACTIVITY, PEER PROBLEMS, AND
PROSOCIAL BEHAVIORS: Strengths and Difficulties Questionnaire/Family Study Survey
Please provide your answers on the basis of your XX year old child's behavior during the last 30 days.
Page 28 of 44
Not true
Somewhat true
Certainly true
My child is
considerate of other
people’s feelings.
o
o
o
My child is restless,
overactive, and
cannot stay still for
long.
o
o
o
My child often
complains of
headaches, stomachaches or sickness.
o
o
o
My child shares
readily with other
young people, for
example clothes or
food.
o
o
o
My child often loses
his/her temper.
o
o
o
My child would rather
be alone than with
other young people.
o
o
o
My child is generally
well behaved and
usually does what
adults request.
o
o
o
My child has many
worries or often
seems worried.
o
o
o
My child is helpful if
someone is hurt,
upset or feeling ill.
o
o
o
My child is constantly
fidgeting or
squirming.
o
o
o
My child has at least
one good friend.
o
o
o
My child often fights
with other young
people or bullies
them.
o
o
o
My child is often
unhappy, depressed
or tearful.
o
o
o
Page 29 of 44
My child is generally
liked by other young
people.
o
o
o
My child is easily
distracted and his/her
concentration
wanders.
o
o
o
My child is nervous in
new situations and
easily loses
confidence.
o
o
o
My child often lies or
cheats.
o
o
o
o
o
o
My child is picked on
or bullied by other
young people.
o
o
o
My child often
volunteers to help
others (parents,
teachers, children).
o
o
o
My child thinks things
out before acting.
o
o
o
My child steals from
home, school or
elsewhere.
o
o
o
My child gets along
better with adults than
with other young
people.
o
o
o
My child has many
fears and is easily
scared.
o
o
o
My child has a good
attention span and
sees work through to
the end.
o
o
o
My child is kind to
younger children.
Page 30 of 44
75. COUNSELING USE: Youth Risk Behavior Survey (YRBS) 2021
When was the last time your XX year old child had counseling, psychological testing, or any mental health or
therapy service? Please include Military and Family Life Counselors and Military OneSource.
o Never
o During the last 12 months
o Between 12 and 24 months ago
o More than 24 months ago
o Not sure
76. EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP): Family Study Survey
Is your XX year old child currently enrolled in the Exceptional Family Member Program (EFMP)?
o No
o Yes
77. IF YES TO EFMP: What special medical and/or educational needs does your XX year old child have? Mark
all that apply.
▢
▢
▢
Physical health
Mental health
Educational
End of Block: ADOLESCENT PHYSICAL AND PSYCHOLOGICAL HEALTH - PARENT REPORT
Start of Block: ADOLESCENT ACADEMICS AND EXTRACURRICULAR ACTIVITIES - PARENT REPORT
The next section of questions is about your XX year old child's experiences in school and participation in
extracurricular activities. If your XX year old child is not currently in school, please think about the last school
year that they completed. Please include homeschooling as well.
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78. SCHOOL ATTENDANCE: YRBS 2021
Is your XX year old child currently attending school?
o No
o Yes
79. SCHOOL TYPE: Survey of Active Duty Spouses (ADSS) 2017
What type of school does your XX year old child attend?
o Public traditional school
o Public charter school
o Department of Defense School (DoDEA)
o Home school
o Private school
o Other (please specify) ________________________________________________
80. SCHOOL ABSENCES: National Survey of Children’s Health 2019 (NSCH 2019) During the last 12 months,
about how many days did your XX year old child miss school because of illness or injury? Include days missed
from any formal home schooling.
o No missed school days
o 1-3 days
o 4-6 days
o 7-10 days
o 11 or more days
o This child was not enrolled in school.
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81. SCHOOL CONTACT: NSCH 2019
How many times has your XX year old child's school contacted you or another adult in your household about
any problems your XX year old child is having with school?
o None
o 1 time
o 2 or more times
82. REPEATED GRADES: NSCH 2019
Since starting school, has your XX year old child repeated any grades?
o No
o Yes
83. SPECIAL EDUCATION: NSCH 2019
Has your XX year old child ever had a special education or early intervention plan? Children receiving these
services often have an Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP).
o No
o Yes
84. IF YES TO SPECIAL EDUCATION: Is your XX year old child currently receiving services under one of
these plans?
o No
o Yes
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85. EXTRACURRICULAR ACTIVITIES: Family Study Survey
During the last 12 months, how often has your XX year old child participated in the following types of youth
programs?
Never
Once or twice
Once a
month
Once a week
More than
once a week
Leadership and
community service
(e.g., Youth of the
Year,
Congressional
Awards, youth
councils, 4-H,
Scout programs)
o
o
o
o
o
Education, STEM,
and career
development (e.g.,
homework
assistance,
tutoring, mentor
programs,
internships, college
fairs)
o
o
o
o
o
Health and
wellness (e.g.,
financial readiness,
cooking)
o
o
o
o
o
Art programs (e.g.,
art classes, music
lessons, band,
dance classes,
theater)
o
o
o
o
o
Sports or recreation
programs (e.g.,
individual or team
sports, fishing,
swimming lessons,
geo-hunt)
o
o
o
o
o
86. IF > NEVER TO EACH YOUTH PROGRAM: Was the program military-sponsored or on a military
installation?
o No
o Yes
End of Block: ADOLESCENT ACADEMICS AND EXTRACURRICULAR ACTIVITIES - PARENT REPORT
Page 34 of 44
Start of Block: ADOLESCENT MILITARY AND GENERAL LIFE EXPERIENCES - PARENT REPORT
The next section of questions is about your XX year old child’s experiences being connected with the military
and their life experiences. Please be as honest as you can. There are no right or wrong answers. Your
answers are confidential and no one will see your responses outside of the research team.
87. MILITARY EXPERIENCES: Family Study Survey
PCS MOVES
How many PCS moves has your XX year old child experienced since they were born?
_____ PCS moves (dropdown response)
88. IF >0 PCS MOVES: How old was your XX year old child during the most recent PCS move?
_____ years old (dropdown response)
89. CHANGED SCHOOLS
How many times has your XX year old child changed schools due to a PCS move?
_____ times (dropdown response)
90. MILITARY SEPARATIONS
How many times have you/your spouse/partner been deployed or away from home due to military duties for
more than 30 consecutive days since your XX year old child was born? ____ times (dropdown response)
91. IF >0 MILITARY SEPARATIONS: What is the longest amount of time you/your spouse/partner have been
away from your XX year old child due to military duties? ____ months (dropdown response)
92. IF >0 MILITARY SEPARATIONS: How old was your XX year old child during the most recent time you/your
spouse/partner were away from home due to military duties for more than 30 consecutive days?
____ years old (dropdown response)
Page 35 of 44
93. ADOLESCENT REACTIONS TO MILITARY EXPERIENCES: Family Study Survey
How much was your XX year old child disturbed or upset by the following?
Not at all
Only a little
A moderate
amount
More than
just a
moderate
amount
A lot
IF >0 PCS MOVES:
Child’s most recent
PCS move?
o
o
o
o
o
IF >0 CHANGED
SCHOOLS: Child’s
most recent change
in school?
o
o
o
o
o
IF >0 MILITARY
SEPARATIONS:
Your/your
spouse/partner’s
most recent time
away from home due
to military duties?
o
o
o
o
o
IF >0 MILITARY
SEPARATIONS:
Reunion/reintegration
with you/your
spouse/partner after
the most recent time
away from home due
to military duties?
o
o
o
o
o
IF SEPARATED
FROM MILITARY:
Your/your
spouse/partner’s
transition from the
military?
o
o
o
o
o
Page 36 of 44
94. ADOLESCENT MILITARY RESILIENCE: Family Study Survey
IF >0 MILITARY SEPARATIONS: Considering your/your spouse/partner's most recent time away from home
due to military duties, rate how much you agree or disagree with the following statements about your XX year
old child:
Strongly
Disagree
Disagree
Neither agree
nor disagree
Agree
Strongly
agree
My child
became more
independent.
o
o
o
o
o
My child
increased
their ability to
deal with
stress.
o
o
o
o
o
My child is
mentally
ready for
future
separations
from their
parent.
o
o
o
o
o
95. Since your XX year old child was born, how often has it been very hard to get by on your family’s income,
for example, it was hard to cover the basics like food or housing?
o Very often
o Somewhat often
o Not very often
o Never
Page 37 of 44
96. CHILDHOOD TRAUMA/STRESS: Family Study Survey
Please think about your XX year old child when responding to the following items.
No
Yes
Did your child ever live with a
parent or guardian who got
divorced or separated after
they were born?
o
o
Did your child ever live with a
parent or guardian who died?
o
o
Did your child ever live with a
parent or guardian who
served time in jail or prison
after they were born?
o
o
Did your child ever see or
hear parents, guardians, or
any other adults in their home
slap, hit, kick, punch, or beat
each other up?
o
o
Was your child ever the victim
of violence or witnessed any
violence in their
neighborhood?
o
o
Did your child ever live with
anyone who was mentally ill
or suicidal, or was severely
depressed for more than a
couple of weeks?
o
o
Did your child ever live with
anyone who had a problem
with alcohol or drugs?
o
o
97. CAREGIVING: National Alliance for Caregiving Youth Study
During the last 12 months, has your XX year old child helped care for any of the following people in your
Page 38 of 44
household who are sick, elderly, frail, disabled, or mentally ill? This may include help with personal needs,
meals, household chores, shopping, paperwork, medication, getting around, or providing emotional support.
Child’s father
Child’s mother
Child’s brother(s)/sister(s)
Child’s grandparent(s)
Other (please specify): _______________
No
Yes
o
o
o
o
o
o
o
o
o
o
98. IF YES TO CAREGIVING:
Does your XX year old child provide any of the following types of help when caring for people in your
household who are sick, elderly, frail, disabled, or mentally ill?
Household chores or meal preparation
Dressing or feeding
Taking medicine or talking to doctors and nurses
Keeping the person company or providing emotional
support
Shopping
Paperwork, bills, or arranging outside services
Moving around the house or getting around in the
community
Bathing or using the bathroom
Other (please specify): _______________
No
Yes
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 39 of 44
End of Block: ADOLESCENT MILITARY AND GENERAL LIFE EXPERIENCES - PARENT REPORT
Start of Block: PARENT-ADOLESCENT RELATIONSHIP - PARENT REPORT
The next section of questions is about your relationship with your XX year old child.
99. MONITORING/SUPERVISION/DISCIPLINE/PRAISE: Alabama Parenting Questionnaire - Short Form
Page 40 of 44
The following are a number of statements about your XX year old child. Please rate each item as to how often
it typically occurs in your home.
Page 41 of 44
Never
Rarely
I let my child
know when
they are
doing a good
job with
something.
o
o
I threaten to
punish my
child and
then do not
actually
punish them.
o
My child fails
to leave a
note or let me
know where
they are
going.
Sometimes
Often
Always
o
o
o
o
o
o
o
o
o
o
o
o
My child talks
me out of
being
punished
after they
have done
something
wrong.
o
o
o
o
o
My child
stays out in
the evening
after the time
they are
supposed to
be home.
o
o
o
o
o
I compliment
my child after
they have
done
something
well.
o
o
o
o
o
I praise my
child if they
behave well.
o
o
o
o
o
My child is
out with
friends I don’t
know.
o
o
o
o
o
Page 42 of 44
I let my child
out of a
punishment
early (like lift
restrictions
earlier than I
originally
said).
o
o
o
o
o
100. COMMUNICATION: NSCH 2019
How much do you agree or disagree with the following statements about your relationship with your XX year
old child?
Strongly
disagree
Disagree
Neither agree
nor disagree
Agree
Strongly
agree
My child and I
communicate
well with
each other.
o
o
o
o
o
My child and I
can share
ideas or talk
about things
that really
matter.
o
o
o
o
o
When my
child has a
problem, they
can discuss it
with me
openly and
honestly.
o
o
o
o
o
101. CONFLICT: National Survey on Drug Use and Health (NSDUH) 2020
During the last 12 months, how often have you argued or had a disagreement with your XX year old child?
o Never
o Rarely
o Sometimes
o Often
o Always
Page 43 of 44
102. SEDENTARY BEHAVIORS: NSCH 2019
On a typical day, about how much time does your XX year old child spend in front of a TV, computer, cell
phone, or other electronic device watching programs, playing games, accessing the internet, or using social
media? Do not include time spent doing schoolwork.
o Less than 1 hour
o 1 hour
o 2 hours
o 3 hours
o 4 or more hours
103. PARENTING STRESS: Family Study Survey
In general, how well do you feel you are coping with the day-to-day demands of parenthood/raising children?
o Very poorly
o Poorly
o Fair
o Somewhat well
o Very well
End of Block: PARENT-ADOLESCENT RELATIONSHIP - PARENT REPORT
Page 44 of 44
| File Type | application/pdf |
| File Title | Parent Survey |
| Author | Qualtrics |
| File Modified | 2022-01-19 |
| File Created | 2021-10-15 |