parent survey v10

PNRC Quality Parenting Survey (V10) May 30, 2010 1

PNRC Parent Survey

This survey is about how you interact with your child or adolescent, and about your child’s health and health behavior. The information you give will be used to develop better health education for young people. DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write. Answer the questions based on what you really do. Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank. The questions that ask about your background will be used only to describe the types of parents completing this survey. The information will not be used to find out your name. No names will ever be reported. Please make sure to read every question. Answer the questions completely. When you are finished, follow the instructions of the person giving you the survey.

Thank you very much for your help.

1. First, three questions about this child or adolescent:

a. How old is the child or adolescent about whom you will answer these questions? _________

b. Is this child or adolescent a girl or a boy (circle one)? A. Girl B. Boy

c. What grade is this child or adolescent in at school? _________


2. Parent-child communication

About how often in the past month have you:

a. Told your child that you love him/her?...........

b. Spent time with your child doing one of

his/her favorite activities?...............................

c. Talked with your child about things he/she

is especially interested in?.............................

d. Talked with your child about his/her friends?.

e. Talked with your child about things going on

in the news?....................................................

f. Talked with your child about his/her day?......

3. Limit Setting

How often do you set rules or limits on:

a. Computer/video games, TV, or music your child

plays………………………………………………………………………………………

b. Your child’s time spent with friends………………………………………

c. How late your child can stay up at night…………………………………

d. When your child does homework…………………………………………

e. The amount of sweet or snack your child eats………………………

4. Discipline strategies

a. Once a discipline has been decided, how often do you stick

to it? --------------------------------------------------------------------------

b. When your child does something wrong, how often do you lose your temper and yell at or hit your child? ---------------------

c. How often do you ask your child to consider how others will feel if she/he misbehaves? ----------------------------------------------

d. How often do you discipline your child by reasoning, explaining or talking to your child? ------------------------------------

e. When your child has done something you like or approve of, how often do you let him/her know you are pleased about it? ------------------------------------------------------------------------------

f. How often do you give your child a reward like money or

something else she/he would like when she/he gets good

grades, does chores or something like that? -----------------------

Not in the past

month

1-2 times in the past month

About once a week

Several times a week

Everyday

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Never

Hardly Ever

Sometimes

Often

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

Never Sometimes

Often Always Refuse

to answer

1 2 3 4 8

1 2 3 4 8

1 2 3 4 8

1 2 3 4 8

1 2 3 4 8

1 2 3 4 8


5. Learning Related Activities

In the past school year:

a. I have helped my child with his/her homework…

b. I have checked my child’s homework

assignments…………………………………………………….

c. I have talked to my child about what goes on at

school………………………………………………………………..

d. In the past year, how often have you set up a time to talk with

your child’s teacher/principle/counselor?..................................

e. How active are you in the PTA/PTO or some other parent group

at your child’s school ?...................................................................

f. In the past year, how often have you visited your child’s school?..

6. Sleep

a. What time does your child usually go to bed in the evening on the week days

(turn out light in order to go to sleep)?................................................................. PM

b. What time does your child usually get out of bed in the morning on weekdays?.............. AM

c. Do you take your child to the dentist at least once a year for regular checkups?.................

d. Do you take your child to the doctor at least once a year for regular checkups?..................

7. Food

a. How often do you have fresh or frozen fruits and vegetables in

your home? --------------------------------------------------------------------

b. How often does your child eat breakfast? ------------------------------

c. How often does your family have a meal together that was

prepared in the home? ------------------------------------------------------

d. How often do you have low fat, skim milk in your home? ---------

Never

1-2 times in the past month

about once a week

several times a week

everyday

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

0 times

a year

1-2 times a

year

5-6 times a

year

more than 6 times a

year

1 2 3 4

1 2 3 4

1 2 3 4

No Yes

1 2 1 2

None of the time

Some of the time

All of the

time 1 2 3 4 5 1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

:

:


8. Parental monitoring

a. In general, how often do you know what your child is doing when s/he is away from home?.......................................................................

b. In general, how often do you know where your child is after school?...................................................................................................

c. In general, how often do you know your child’s interests, activities, whereabouts?........................................................................................

d. In general, how often do you know your child’s plans for the coming day?.......................................................................................................

e. In the last 2 days, how often did you know your child’s whereabouts and activities?......................................................................................

9. Family Cohesion

a. I'm available when others in the family want to talk with me…………

b. I listen to what other family members have to say, even when I

disagree…………………………………………………………………………………………

c. Family members ask each other for help………………………………………

d. Family members like to spend free time with each other……………

e. Family members feel very close to each other………………………………

f. We can easily think of things to do together as a family…………………

10. Family Conflict

a. In my family we often yell and insult each other………………………….

b. My family has serious arguments………………………………………………..

c. We argue about the same things over and over in my family………

11. Role models and positive influences a. Are there other people you think have a positive influence on how your child

thinks, feels, or acts?........................................................................................................

12. If yes, how are these people related to your child?

a. Adult family member ...........................................................................................

b. Older sibling or cousin ..........................................................................................

c. Family friend .........................................................................................................

d. Teacher or coach ..................................................................................................

e. Neighbor ...............................................................................................................

f. Member of community group or church ..............................................................

Never

sometimes Always

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Never

Always

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

Never

Always

1 2 3 4 1 2 3 4

1 2 3 4

No Yes

1 2

1 2

1 2

1 2

1 2

1 2

1 2


13. Development

Indicate how true each of the following statements is for your child:

a. Has trouble switching gears from one task or subject to another ----

b. Has trouble setting and acting on goals -------------------------------------

c. Gets used to new situations without any problem -----------------------

d. Has difficulty following instructions ------------------------------------------

e. Keeps doing something even when punished for it ----------------------

f. Is thrown off by little things or interruptions ------------------------------

g. Has trouble following instructions -------------------------------------------

h. Gives up quickly if things don’t go just right -------------------------------

i. Makes corrections to behavior to avoid repeating mistakes ----------

j. Has anyone ever expressed concern about your child’s development? -----------------------

k. Has anyone ever suggested that your child might benefit from special services to help

him/her do better in school? ----------------------------------------------------------------------------

l. During the past year, has your child taken any medication for a learning problem like

ADHD, hyperactivity, trouble paying attention, trouble controlling his/her own

behavior? -----------------------------------------------------------------------------------------------------

You are done! Thank you very much for your time.

Not

True

Somewhat

True

Certainly

True

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

No Yes

1 2

1 2

1 2

parent survey v10

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