Form Approved
OMB No. 0920-1235
Exp. Date 06/30/2019
Attachment 6
Sample Instrument: Parent/Caregiver Survey
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.”
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
2. All things considered, how is your child’s life going?
Very well
Fairly well
Not so well
Not well at all
3. Does your child have one, special girlfriend/boyfriend?
NoSkip to question 6
Yes
4. Have you met him/her in person?
No
Yes
5. Have you met his/her parents?
No
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?
No
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.?
No
Yes
8. In the past week, have you and your child talked about his/her school work or grades?
No
Yes
9. In the past week, have you and your child talked about other things he/she is doing at school?
No
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.
Always
Often
Sometimes
Seldom
Never
Refused
11. (Your child) and you make decisions about his/her life together.
Always
Often
Sometimes
Seldom
Never
Refused
12. You just do not understand him/her.
Always
Often
Sometimes
Seldom
Never
Refused
13. You feel you can really trust him/her.
Always
Often
Sometimes
Seldom
Never
Refused
14. He/She interferes with your activities.
Always
Often
Sometimes
Seldom
Never
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.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
16. It would embarrass your child to talk to you about sex and birth control..
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
17. It would be difficult for you to explain things if you talked with your child about sex and birth control.
Strongly agree
Agree
Neither agree nor disagree
Disagree
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.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
19. Talking about birth control with your child would only encourage him/her to have sex.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
20. How much have you talked to your child about birth control?
Not at all
Somewhat
A moderate amount
A great deal
21. How much have you talked to your child about sex?
Not at all
Somewhat
A moderate amount
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.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
23. You disapprove of your child’s having sexual intercourse at this time in his/her life.
Strongly agree
Agree
Neither agree nor disagree
Disagree
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.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
25. You have recommended a specific method of birth control to your child.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
26. In general, how easy or hard is it for you to get medical care for your family?
Very easy
Somewhat easy
Somewhat hard
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.
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