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This survey of parents of 6th-12th graders is being conducted by the Pittsfield Prevention Partnership and supported by the public schools in Pittsfield. Survey results will be used for educational programs to help us all encourage our young people to make healthy choices. This survey should take about 10 minutes to complete. Your voice is important!

As a token of appreciation for your participation, when you have finished the survey, you will have the opportunity to enter your name in a drawing to win a gift certificate (worth up to $50) to a local restaurant

Please fill out the survey ONLY ONCE.

Your participation is voluntary and anonymous. If you choose to participate, you are free to decline to answer any question on this questionnaire. If you have questions, please call (413) 442- 6948.

* 1. What town do you live in?

* 2. How many children in your household are in 6th through 12th grade at a school in Pittsfield?

* 3. If you have more than one child in grades 6th through 12th, answer the rest of the survey with regards to the child who had the most recent birthday. What is this child's gender?

* 4. What grade is he/she in?

* 5. What school does he or she attend?

As you complete this survey, continue to think about THIS CHILD, the one whose birthday most recently passed. Give answers that best match your beliefs and practices for this child (since you may have different answers for different children).

* 6. In our household, we usually have family dinners with our teen about...

* 7. Pick the answer that comes closest to your practices and beliefs:

  Always Usually Sometimes Seldom or never
I make sure to meet my teen’s closest friends.
I make sure to meet the parents of my teen's closest friends.
When my teen is not at home, I know where he/she is and who he/she is with.
I make sure that teen parties at my home are alcohol-free.
If another parent saw my teen drinking, I would want the parent to call to let me know.
If I saw a teen drinking, I would call to let the teen's parents know.

* 8. In the past 12 months, how often have you talked with your teen...

  once a month or more once every few months once or twice never
about sexuality, or about ways to prevent sexually transmitted diseases or pregnancy?
about standing up for someone who is being bullied?
about your rules or expectations about them drinking or using drugs?

* 9. Which of the following comes closest to your rule for your teen about drinking alcoholic beverages?

* 10. At what age do you think it is OK to drink alcohol (more than just a few sips?)

* 11. How likely are you to...?

  Very likely Somewhat likely Not at all likely
lock up alcohol in your home
monitor the amount of alcohol in your home
not let your child go to a party where there is alcohol
prohibit teens from drinking in your home
be a part of a parent network to reduce underage drinking
When a teen party is planned, call ahead to check on availability of alcohol

* 12. Now thinking about prescription medications, how likely are you to do the following?

  Very likely Somewhat likely Not at all likely
Talk to your child about the dangers of using prescription medications without a doctor's order
Talk to your child about the dangers of drugged driving
Lock up and monitor your prescription medications
Dispose of your unused prescription medications properly
Now switch gears for a moment and think about the parents of your teen's classmates.

* 13. Of course, you don't know for sure, but what's your best guess? How many parents of students in your child's grade at school...

  almost all (76-100%) most (51- 75%) some (25 - 50%) a few (0 - 24%)
have family dinners with their teens 4 or more nights a week?
make sure to meet their teens' closest friends?
know where their teens are and who they are with when they are not at home?
always make sure that teen parties at their home are alcohol-free?
would want you to call if you saw their teen drinking?
would call you if they saw your teen drinking?
do not allow their teens to drink alcohol at all, or allow only a few sips for religious ceremonies or special occasions?

* 14. How much influence do you think you have over your teen's decision about whether to use tobacco, alcohol, marijuana or other drugs?

For the next two questions, check the one response that describes whether you think each of the following statements is true or false.

* 15. In Massachusetts, you cannot give alcohol to your children's friends under age 21 in your home, even with their parents' permission.

* 16. In Massachusetts, others can sue you if you give alcohol to anyone under age 21 and they in turn hurt someone, hurt themselves, or damage property.

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