Single Mother's SurveySingle Mother's Survey

1. The following demographic information is optional.

The following demographic information is optional. Name:
City/Town:
State:
Email Address:

2. What is the age range of your son(s)? Please check all that apply

What is the age range of your son(s)? Please check all that apply 0-5

6-10

11-14

15-21

3. Below are 5 concerns that have been expressed by single mothers raising boys across the country, and we would like to know what concerns you most.On a scale of 1 to 5 please rate the following concerns. 1 being the least concern and 5 being the greatest concern.

	1	2	3	4	5
Academic Achievement	*Below are 5 concerns that have been expressed by single mothers raising boys across the country, and we would like to know what concerns you most.On a scale of 1 to 5 please rate the following concerns. 1 being the least concern and 5 being the greatest concern. Academic Achievement 1	Academic Achievement 2	Academic Achievement 3	Academic Achievement 4	Academic Achievement 5
Father Involvement	Father Involvement 1	Father Involvement 2	Father Involvement 3	Father Involvement 4	Father Involvement 5
Finding Male Mentors	Finding Male Mentors 1	Finding Male Mentors 2	Finding Male Mentors 3	Finding Male Mentors 4	Finding Male Mentors 5
Peer Pressure	Peer Pressure 1	Peer Pressure 2	Peer Pressure 3	Peer Pressure 4	Peer Pressure 5
School Environment	School Environment 1	School Environment 2	School Environment 3	School Environment 4	School Environment 5
Finances	Finances 1	Finances 2	Finances 3	Finances 4	Finances 5
Day Care/Child Care	Day Care/Child Care 1	Day Care/Child Care 2	Day Care/Child Care 3	Day Care/Child Care 4	Day Care/Child Care 5

Other (please specify)

4. Do you feel that your son has a positive male role model? (Ex.Other family members, teachers, mentors,etc.)

Do you feel that your son has a positive male role model? (Ex.Other family members, teachers, mentors,etc.)

5. Are there free or affordable after school activities and resources available for your son in your community? (Recreation Center, Sports Team, clubs, etc.)

Are there free or affordable after school activities and resources available for your son in your community? (Recreation Center, Sports Team, clubs, etc.)

6. Do you have free/personal time to do something for yourself (Ex. relaxing, exercise, hobby). If not, how does this effect your daily life?

Do you have free/personal time to do something for yourself (Ex. relaxing, exercise, hobby). If not, how does this effect your daily life?

7. Do you have any concerns about your housing or neighborhood? (Crime, Gang Activity, etc.)

Do you have any concerns about your housing or neighborhood? (Crime, Gang Activity, etc.)

8. What kinds of support/activities would you like to receive from your son's school related to academic achievement?

What kinds of support/activities would you like to receive from your son's school related to academic achievement?

9. During these troubling economic times are you and your son's basic needs being met? Such as (food, clothes, etc.)

During these troubling economic times are you and your son's basic needs being met? Such as (food, clothes, etc.) Yes

No

Somewhat

Other (please specify)

10. How would you rate your son and his father's relatioship?

How would you rate your son and his father's relatioship? Outstanding (Father involved in all aspects of your son's life)

Positive & healthy

Father makes some attempts

Father is not involved at all (Father absence)

Other (please specify)

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