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? _________
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2. 1-2
2. Parent-child communication Not in the About Several
times in Every
past once a times a
the past day
month week week
About how often in the past month have you: month
a. Told your child that you love him/her?........... 1 2 3 4 5
b. Spent time with your child doing one of
his/her favorite activities?............................... 1 2 3 4 5
c. Talked with your child about things he/she
is especially interested in?............................. 1 2 3 4 5
d. Talked with your child about his/her friends?. 1 2 3 4 5
e. Talked with your child about things going on
in the news?.................................................... 1 2 3 4 5
f. Talked with your child about his/her day?...... 1 2 3 4 5
3. Limit Setting
How often do you set rules or limits on: Hardly Sometimes
Often
a. Computer/video games, TV, or music your child Never Ever
plays……………………………………………………………………………………… 1 2 3 4
b. Your child’s time spent with friends……………………………………… 1 2 3 4
c. How late your child can stay up at night………………………………… 1 2 3 4
d. When your child does homework………………………………………… 1 2 3 4
e. The amount of sweet or snack your child eats……………………… 1 2 3 4
Refuse
4. Discipline strategies Some
Never Often Always to
times
answer
a. Once a discipline has been decided, how often do you stick 1 2 3 4 8
to it? --------------------------------------------------------------------------
b. When your child does something wrong, how often do you 1 2 3 4 8
lose your temper and yell at or hit your child? ---------------------
c. How often do you ask your child to consider how others will
1 2 3 4 8
feel if she/he misbehaves? ----------------------------------------------
d. How often do you discipline your child by reasoning,
explaining or talking to your child? ------------------------------------ 1 2 3 4 8
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? ------------------------------------------------------------------------------ 1 2 3 4 8
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? ----------------------- 1 2 3 4 8
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3. 1-2
about several
times in
once a times a everyday
the past
5. Learning Related Activities week week
Never month
In the past school year:
a. I have helped my child with his/her homework… 1 2 3 4 5
b. I have checked my child’s homework
assignments……………………………………………………. 1 2 3 4 5
c. I have talked to my child about what goes on at
school……………………………………………………………….. 1 2 3 4 5
0 more
1-2 5-6
times than 6
times a times a
a times a
year year
year year
d. In the past year, how often have you set up a time to talk with
your child’s teacher/principle/counselor?.................................. 1 2 3 4
e. How active are you in the PTA/PTO or some other parent group
at your child’s school ?................................................................... 1 2 3 4
f. In the past year, how often have you visited your child’s school?.. 1 2 3 4
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
No Yes
c. Do you take your child to the dentist at least once a year for regular checkups?................. 1 2
d. Do you take your child to the doctor at least once a year for regular checkups?.................. 1 2
7. Food None Some All of
of the of the the
a. How often do you have fresh or frozen fruits and vegetables in time time time
your home? -------------------------------------------------------------------- 1 2 3 4 5
b. How often does your child eat breakfast? ------------------------------ 1 2 3 4 5
c. How often does your family have a meal together that was
prepared in the home? ------------------------------------------------------ 1 2 3 4 5
d. How often do you have low fat, skim milk in your home? --------- 1 2 3 4 5
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4. Never sometimes Always
8. Parental monitoring
a. In general, how often do you know what your child is doing when
s/he is away from home?....................................................................... 1 2 3 4 5
b. In general, how often do you know where your child is after
school?................................................................................................... 1 2 3 4 5
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 1 2 3 4 5
day?.......................................................................................................
e. In the last 2 days, how often did you know your child’s whereabouts 1 2 3 4 5
and activities?......................................................................................
1 2 3 4 5
9. Family Cohesion Never Always
a. I'm available when others in the family want to talk with me………… 1 2 3 4
b. I listen to what other family members have to say, even when I
disagree………………………………………………………………………………………… 1 2 3 4
c. Family members ask each other for help……………………………………… 1 2 3 4
d. Family members like to spend free time with each other…………… 1 2 3 4
e. Family members feel very close to each other……………………………… 1 2 3 4
f. We can easily think of things to do together as a family………………… 1 2 3 4
10. Family Conflict Never Always
a. In my family we often yell and insult each other…………………………. 1 2 3 4
b. My family has serious arguments……………………………………………….. 1 2 3 4
c. We argue about the same things over and over in my family……… 1 2 3 4
11. Role models and positive influences No Yes
a. Are there other people you think have a positive influence on how your child
thinks, feels, or acts?........................................................................................................ 1 2
12. If yes, how are these people related to your child?
1 2
a. Adult family member ...........................................................................................
b. Older sibling or cousin .......................................................................................... 1 2
c. Family friend ......................................................................................................... 1 2
d. Teacher or coach .................................................................................................. 1 2
e. Neighbor ............................................................................................................... 1 2
f. Member of community group or church .............................................................. 1 2
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5. 13. Development
Not Somewhat Certainly
Indicate how true each of the following statements is for your child: True True True
a. Has trouble switching gears from one task or subject to another ---- 1 2 3
b. Has trouble setting and acting on goals ------------------------------------- 1 2 3
c. Gets used to new situations without any problem ----------------------- 1 2 3
d. Has difficulty following instructions ------------------------------------------ 1 2 3
e. Keeps doing something even when punished for it ---------------------- 1 2 3
f. Is thrown off by little things or interruptions ------------------------------ 1 2 3
g. Has trouble following instructions ------------------------------------------- 1 2 3
h. Gives up quickly if things don’t go just right ------------------------------- 1 2 3
i. Makes corrections to behavior to avoid repeating mistakes ---------- 1 2 3
No Yes
j. Has anyone ever expressed concern about your child’s development? ----------------------- 1 2
k. Has anyone ever suggested that your child might benefit from special services to help
him/her do better in school? ---------------------------------------------------------------------------- 1 2
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
1 2
behavior? -----------------------------------------------------------------------------------------------------
You are done! Thank you very much for your time.
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