EVALUMETRICS RESEARCH PARENT RISK AND PROTECTIVE FACTOR SURVEY © 2004 Evalumetrics Research rlillis@rochester.rr.com Date: ____/____                Caller Initials ____                    Code _________________ 1.        First, would you tell me the current grade level and gender of your school age children?   (Include all children in the family - Record the grade and gender of each child on the matrices on last page) 2.        Do you have any children who have already graduated from high school?          Yes___ No___ 3.        Which school district do your children attend?   __________ (see list) Next I would like to ask about your perception of certain behaviors of young people. 4.        How much do you think people under 21 risk harming themselves if they smoke cigarettes?          1. ___No Risk          2. ___Slight Risk                  3. ___Moderate Risk                  4. ___Great Risk         5.        How much do you think people under 21 risk harming themselves if they smoke marijuana?          1. ___No Risk          2. ___Slight Risk                  3. ___Moderate Risk                  4. ___Great Risk         6.        How much do you think people under 21 risk harming themselves if they drink beer, wine or hard liquor?          1. ___No Risk                        ___(Check here if qualified with “If they don’t drive”)          2. ___Slight Risk                  3. ___Moderate Risk                  4. ___Great Risk         7.        How much do you think people under 21 risk harming themselves if they use illegal drugs or take drugs when they are not sick?          1. ___No Risk          2. ___Slight Risk                  3. ___Moderate Risk                  4. ___Great Risk         8a.        Which of the following best describes your attitude about alcohol use by your children? 1.___They should not use it ever 2.___They should not use it until they are 21 3.___They should be allowed to use it before they are 21 with adult supervision 4.___They should be taught to use it responsibly before they are 21 5.___They should be allowed to use it before they are 21 8b.        Which of the following best describes your attitude about tobacco use by your children? 1.___They should not use it ever 2.___They should not use it until they are 21 3.___They should be allowed to use it before they are 21 with adult supervision 4.___They should be taught to use it responsibly before they are 21 5.___They should be allowed to use it before they are 21 8c.        Which of the following best describes your attitude about marijuana use by your children? 1.___They should not use it ever 2.___They should not use it until they are 21 3.___They should be allowed to use it before they are 21 with adult supervision 4.___They should be taught to use it responsibly before they are 21 5.___They should be allowed to use it before they are 21 8d.        Which of the following best describes your attitude about other drug use by your? 1.___They should not use them ever 2.___They should not use them until they are 21 3.___They should be allowed to use them before they are 21 with adult supervision 4.___They should be taught to use them responsibly before they are 21 5.___They should be allowed to use them before they are 21 Next I would like to ask a series of questions about your oldest school age child. 9.        In the past four weeks, how many times have you attended a recreational or other activity with your oldest school age child at school or in the community?         ________ 10.        When your oldest school age child completes high school do you expect he or she will go on to college? Yes ____        No _____        Not Sure ______    He/she would not be able, e.g. learning disability or other disability ____ 11.        Which best describes your oldest school age child’s grades in the last marking period?  1. ___Mostly A’s  2. ___Mostly B’s  3. ___Mostly C’s  4. ___Mostly D’s  5. ___Mostly F’s 12.        Which best describes your feelings about your oldest school age child’s friends or peer group? 1.___ I think they are a good group and a positive influence              2. ___I think they are okay but they could be better                 3. ___I don’t approve of them, they are a negative influence         4. ___I don’t know enough about them to judge                         13.        In the past 30 days, how many times did your oldest school age child attend a religious service or activity?  _______ 14.        How often do you ask your oldest school age child if he or she has done his or her homework?  1. ___Never                   2. ___Sometimes          3. ___Usually          4. ___Always         15.        How often do you ask your oldest school age child to call you if he or she is going to be late getting home?  1. ___Never                  2. ___Sometimes          3. ___Usually          4. ___Always         16.        How likely is it that you would know if your oldest school age child did not come home on time?  1. ___Not likely          2. ___Somewhat likely  3. ___Most likely          4. ___Definite                 17.        When your oldest school age child is not at home how often do you or another adult in your home know where they are and who they are with?  1. ___Never          2. ___Sometimes  3. ___Usually          4. ___Always         18.        If your oldest school age child drank beer, wine or liquor without your permission how likely is it you would know?  1. ___Not likely                  2. ___Somewhat likely          3. ___Most likely                  4. ___Definite                 19.        If your oldest school age child skipped school how likely is it you would know?  1. ___Not likely          2. ___Somewhat likely          3. ___Most likely                  4. ___Definite         20.        If your oldest school age child carried a handgun without your permission how likely is it you would know?  1. ___Not likely          2. ___Somewhat likely  3. ___Most likely          4. ___Definite                 21.        How wrong do you feel it would be for your oldest school age child to drink beer, wine or liquor regularly?  1. ___Very wrong  2. ___Wrong          3. ___A little wrong          4. ___Not wrong at all         22.        How wrong do you think it would be for your oldest school age child to smoke cigarettes?  1. ___Very wrong          2. ___Wrong                  3. ___A little wrong          4. ___Not wrong at all         23.        How wrong do you think it would be for your oldest school age child to smoke marijuana?  1. ___Very wrong                  2. ___Wrong                          3. ___A little wrong                  4. ___Not wrong at all         24.        How wrong do you think it would be for your oldest school age child to steal anything worth more than $5?  1. ___Very wrong                  2. ___Wrong                          3. ___A little wrong                  4. ___Not wrong at all         25.        How wrong do you think it would be for your oldest school age child to draw graffiti, write things or draw pictures on buildings or property without the owner’s permission?  1. ___Very wrong                  2. ___Wrong                          3. ___A little wrong                  4. ___Not wrong at all         26.        How wrong do you think it would be for your oldest school age child to pick a fight with someone?  1. ___Very wrong                  2. ___Wrong                          3. ___A little wrong                  4. ___Not wrong at all         27.        In your family, how clear are the rules regarding children’s behavior?  1. ___Not clear at all          2. ___Somewhat clear  3. ___Very clear          4. ___Perfectly clear         28.        How often do members of your family have serious arguments?  1. ___Never                  2. ___Sometimes          3. ___Frequently          4. ___Always                 29.        How often do members of your family insult or yell at each other? 1. ___Never         2. ___Sometimes 3. ___Frequently                 4. ___Always         30.        Do members of your family argue about the same things over and over? Yes ____  No ____   Don’t Know ____ 31.        Has anyone in your family ever had a severe alcohol or drug problem? Yes ____ No ____  Don’t Know ____ 32.        How often do you ask your oldest school age child what he or she thinks before making decisions affecting them? 1. ___Never         2. ___Occasionally 3. ___Usually                 4. ___Always                 33.        How often do you tell your oldest child you are proud of them for something they have done? 1. ___Never         2. ___Occasionally 3. ___Usually                 4. ___Always                  The next question relates to your perception of your child’s alcohol, tobacco or other drug use.  As with all questions in this survey, your response will be confidential. Which of the following best describes your ____ grade son or daughter’s alcohol use? (If response is “don’t know”, indicate with DK in the “Never” column) Note: If use was part of religious service, put an “R” under NEVER USES (If answer is NOT “Never”….Ask Is their use a problem?) Child                        Never uses   Used once or twice   Uses Occasionally   Uses Frequently   Is use a problem? 1. grade_____M  F                                         2. grade_____M  F                                         3. grade_____M  F                                         4. grade_____M  F                                         5. grade_____M  F                                         6. grade_____M  F                                         Which of the following best describes your ____ grade son or daughter’s tobacco use? (If response is “don’t know”, indicate with DK in the “Never” column) (If answer is NOT “Never”….Ask Is their use a problem?) Child                        Never uses  Used once or twice   Uses Occasionally   Uses Frequently   Is use a problem? 1. grade_____M  F                                         2. grade_____M  F                                         3. grade_____M  F                                         4. grade_____M  F                                         5. grade_____M  F                                         6. grade_____M  F                                         Which of the following best describes your ___ grade son or daughter’s other drug use? (If response is “don’t know”, indicate with DK in the “Never” column) (If answer is NOT “Never”….Ask Is their use a problem?) Child                        Never uses   Used once or twice Uses Occasionally  Uses Frequently   Is use a problem? 1. grade_____M  F                                         2. grade_____M  F                                         3. grade_____M  F                                         4. grade_____M  F                                         5. grade_____M  F                                         6. grade_____M  F