Strengthening Families Program Caregiver Survey - 2021 Fall After

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* 1. Contact Information

First Name

Last Name

City

State

ZIP Code

Email Address

Phone Number

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* 2. Date of Birth

Date

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* 3. Gender

Male

Female

Other (prefer to self-describe)

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* 4. Do you have a partner/spouse?

Yes

Other (prefer to self-describe)

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* 5. Is your partner/spouse attending this program?

Yes

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* 6. Race (Please mark all that you identify with)

American Indian/Alaska Native

Asian-Asian Indian

Asian-Chinese

Asian-Filipino

Asian-Japanese

Asian-Korean

Asian-Vietnamese

Asian-Other

Black

Native Hawaiian/Other Pacific Islander-Guamanian or Chamorro

Native Hawaiian/Other Pacific Islander-Samoan

Native Hawaiian/Other Pacific Islander-Other

White

Two or More Races (Multiracial)

Other (prefer to self-describe)

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* 7. Which of these best describes the highest level of education you have completed?

6th Grade

9th grade

11th Grade

12th Grade/GED

Associate's Degree

Bachelor's Degree

Master's Degree

PhD/Professional Training (MD, DDS, JD)

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* 8. Hispanic, Latino/Latina or Spanish national origin

Not Hispanic, Latino(a), or Spanish

Mexican, Mexican American, Chicano

Puerto Rican

Cuban

Other Hispanic, Latino(a) or Spanish Origin

Hispanic Ethnicity Unknown

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* 9. Primary language spoken at home? (Please choose one)

English

Spanish

Unknown

Other (prefer to self-describe)

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* 10. Service in Military?

Currently serve in the armed forces

Currently serve in the reserves

Currently serve in the National Guard

Served in the past, but not currently

Never served in Armed Forces, Reserves, or National Guard

Military status unknown

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* 11. Children in program (Name, Age, gender, and ethnicity of each child- If more than 3, please add them to "additional information" question at end of survey)

Name of first child

Age of first child

Gender of first child

Ethnicity of first child

Name of second child

Age of second child

Gender of second child

Ethnicity of second child

Name of third child

Age of third child

Gender of third child

Ethnicity of third child

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* 12. Most parents and caregivers try to stay calm and loving when they guide and discipline their adolescent children. However, most parents fall short of these goals from time to time. Please take your time and answer the following questions candidly. Your answers will be kept completely confidential and will not be linked to your personal information.

The following questions are about you. We are interested to know which aspects of parenting are most challenging for you. Your answers to these questions will help us better understand how and for whom the Strengthening Families Program works.

How much do you agree or disagree with the following statements?

	Strongly Agree	Agree	Neutral or Mixed	Disagree	Strongly Disagree
I have clear and specific rules about my child's association with peers who use alcohol.	I have clear and specific rules about my child's association with peers who use alcohol. Strongly Agree	I have clear and specific rules about my child's association with peers who use alcohol. Agree	I have clear and specific rules about my child's association with peers who use alcohol. Neutral or Mixed	I have clear and specific rules about my child's association with peers who use alcohol. Disagree	I have clear and specific rules about my child's association with peers who use alcohol. Strongly Disagree
I have explained my rules about alcohol use to my child.	I have explained my rules about alcohol use to my child. Strongly Agree	I have explained my rules about alcohol use to my child. Agree	I have explained my rules about alcohol use to my child. Neutral or Mixed	I have explained my rules about alcohol use to my child. Disagree	I have explained my rules about alcohol use to my child. Strongly Disagree
I have explained the consequences of breaking my rules about alcohol use to my child.	I have explained the consequences of breaking my rules about alcohol use to my child. Strongly Agree	I have explained the consequences of breaking my rules about alcohol use to my child. Agree	I have explained the consequences of breaking my rules about alcohol use to my child. Neutral or Mixed	I have explained the consequences of breaking my rules about alcohol use to my child. Disagree	I have explained the consequences of breaking my rules about alcohol use to my child. Strongly Disagree
I can control my anger and frustration with my child.	I can control my anger and frustration with my child. Strongly Agree	I can control my anger and frustration with my child. Agree	I can control my anger and frustration with my child. Neutral or Mixed	I can control my anger and frustration with my child. Disagree	I can control my anger and frustration with my child. Strongly Disagree
I work hard with my child on ways to express and control their anger and frustration.	I work hard with my child on ways to express and control their anger and frustration. Strongly Agree	I work hard with my child on ways to express and control their anger and frustration. Agree	I work hard with my child on ways to express and control their anger and frustration. Neutral or Mixed	I work hard with my child on ways to express and control their anger and frustration. Disagree	I work hard with my child on ways to express and control their anger and frustration. Strongly Disagree
I find ways to keep my child involved with fun activities in our family.	I find ways to keep my child involved with fun activities in our family. Strongly Agree	I find ways to keep my child involved with fun activities in our family. Agree	I find ways to keep my child involved with fun activities in our family. Neutral or Mixed	I find ways to keep my child involved with fun activities in our family. Disagree	I find ways to keep my child involved with fun activities in our family. Strongly Disagree
I find ways to keep my child involved in family work activities (chores, for example).	I find ways to keep my child involved in family work activities (chores, for example). Strongly Agree	I find ways to keep my child involved in family work activities (chores, for example). Agree	I find ways to keep my child involved in family work activities (chores, for example). Neutral or Mixed	I find ways to keep my child involved in family work activities (chores, for example). Disagree	I find ways to keep my child involved in family work activities (chores, for example). Strongly Disagree
I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age.	I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age. Strongly Agree	I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age. Agree	I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age. Neutral or Mixed	I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age. Disagree	I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age. Strongly Disagree
I have discussed my child's dreams and goals with him/her on many occasions.	I have discussed my child's dreams and goals with him/her on many occasions. Strongly Agree	I have discussed my child's dreams and goals with him/her on many occasions. Agree	I have discussed my child's dreams and goals with him/her on many occasions. Neutral or Mixed	I have discussed my child's dreams and goals with him/her on many occasions. Disagree	I have discussed my child's dreams and goals with him/her on many occasions. Strongly Disagree
I often tell my child how I feel when he or she misbehaves.	I often tell my child how I feel when he or she misbehaves. Strongly Agree	I often tell my child how I feel when he or she misbehaves. Agree	I often tell my child how I feel when he or she misbehaves. Neutral or Mixed	I often tell my child how I feel when he or she misbehaves. Disagree	I often tell my child how I feel when he or she misbehaves. Strongly Disagree
When my child tells me something important, I let them know that I am trying to understand what they are feeling.	When my child tells me something important, I let them know that I am trying to understand what they are feeling. Strongly Agree	When my child tells me something important, I let them know that I am trying to understand what they are feeling. Agree	When my child tells me something important, I let them know that I am trying to understand what they are feeling. Neutral or Mixed	When my child tells me something important, I let them know that I am trying to understand what they are feeling. Disagree	When my child tells me something important, I let them know that I am trying to understand what they are feeling. Strongly Disagree
I let my child know that I care about them while setting limits and consequences.	I let my child know that I care about them while setting limits and consequences. Strongly Agree	I let my child know that I care about them while setting limits and consequences. Agree	I let my child know that I care about them while setting limits and consequences. Neutral or Mixed	I let my child know that I care about them while setting limits and consequences. Disagree	I let my child know that I care about them while setting limits and consequences. Strongly Disagree
I have discussed our family values with my child on many occasions.	I have discussed our family values with my child on many occasions. Strongly Agree	I have discussed our family values with my child on many occasions. Agree	I have discussed our family values with my child on many occasions. Neutral or Mixed	I have discussed our family values with my child on many occasions. Disagree	I have discussed our family values with my child on many occasions. Strongly Disagree
Getting my youth to hep with chores is a problem.	Getting my youth to hep with chores is a problem. Strongly Agree	Getting my youth to hep with chores is a problem. Agree	Getting my youth to hep with chores is a problem. Neutral or Mixed	Getting my youth to hep with chores is a problem. Disagree	Getting my youth to hep with chores is a problem. Strongly Disagree
Getting my youth to do homework is a problem.	Getting my youth to do homework is a problem. Strongly Agree	Getting my youth to do homework is a problem. Agree	Getting my youth to do homework is a problem. Neutral or Mixed	Getting my youth to do homework is a problem. Disagree	Getting my youth to do homework is a problem. Strongly Disagree

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* 13. Please show how you rate the tension among your family members.
Examples of "low tension" are:
Family members are peaceful and friendly
Talking with family is open and positive
Overall family mood is warm and loving
Examples of "High tension are:
Family members are "on edge" and impatient with each other
Talking with family is stressful
Overall, family mood is negative, angry and not agreeable

1 (Low)

10 (High)

Clear

i We adjusted the number you entered based on the slider’s scale.

Strengthening Families Program Caregiver Survey - 2021 Fall After

Question Title

* 1. Contact Information

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* 2. Date of Birth

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* 3. Gender

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* 4. Do you have a partner/spouse?

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* 5. Is your partner/spouse attending this program?

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* 6. Race (Please mark all that you identify with)

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* 7. Which of these best describes the highest level of education you have completed?

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* 8. Hispanic, Latino/Latina or Spanish national origin

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* 9. Primary language spoken at home? (Please choose one)

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* 10. Service in Military?

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* 11. Children in program (Name, Age, gender, and ethnicity of each child- If more than 3, please add them to "additional information" question at end of survey)

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* 14. What additional information would you like to provide to the program facilitators and/or funders?