1. Spanish Version

2. Gender

3. Age

4. Race

5. Ethnicity

6. Age of oldest child?

7. Please choose the response that best describes how you feel...

  Very true Somewhat true Not true
Drinking is an inevitable part of growing up.
Our child's school sets clear rules on using drugs at school.
Drug and alcohol use is a big problem facing youth in my community.
My child drinks alcohol.
I am home and awake when my child gets home.
I talk to my child about the harmful effects of using tobacco, alcohol and drugs.
I would closely chaperone any parties in our home.

8. Please choose the response that best describes how you feel...

  Yes No Sometimes
When my child goes out I know where they are and who they are with.
If my child had an important concern about drugs, alcohol, sex, or some other serious issue, they would talk to me about it.

9. Please choose the response that best describes how you feel...

  Very true Somewhat true Not true
I have very little control over whether my teen drinks.
I feel uncomfortable calling to check in with the parents of my child's friends.
I have set clear rules about drinking with my child.
I closely monitor the liquor in our home.
I have set clear rules about drug use with my child.
In my own choices around alcohol, I have considered the behavior I am modeling for my child.

10. Please respond...

  Very familiar Somewhat familiar Unfamiliar
How familiar are you with the CT Social Host Law that makes it illegal to provide a place for teens to drink?
How familiar are you with the marijuana possession laws?

11. Does your child have friends who...

  Never Seldom Sometimes Often A lot Do not know
Drink alcohol
Use tobacco (smoke, chew)
Use drugs
Take prescription drugs (not their own prescription)
Drive after consuming alcohol

12. How easy or hard do you think it is for students in your child's grade to get...

  Very easy Sort of easy Not easy/not hard Sort of hard Very hard
Alcohol
Tobacco/ Cigarettes
Marijuana
Prescription drugs (not their own)

13. How easy or hard do you think it would be for your child to get alcohol from the following locations?

  Very easy Sort of easy Not easy/not hard Sort of hard Very hard
From a store in Stratford
From store outside of Stratford
From a friend's house
From their own home
From an older sibling or friend
At a party

14. Do you think use of the following substances is harmful to your child's health?

  No harm Some harm Harmful Very harmful
Alcohol
CIgarettes
Marijuana
Prescription drugs

15. Your son/daughter is hosting a party and at some point you realize that alcohol has been brought into your house. What would you do?

16. Were you aware of Stratford's Partnership for Success Coalition that works on underage drinking prevention in the Town of Stratford?

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