Social Skills Questionnaire - Parent Form

Parent Report

Social Skills Questionnaire - PARENT FORM

Grades 1-6

Thank you, in advance, for responding to the following questions. This survey is designed for you to describe your child’s behavior and your social background. It should take approximately 15 minutes per to complete.

Please contact Dr. Barbara Dietsch with any questions at 562.799.5126 or by email at bdietsc@wested.org

Read each item (items 1-55) and think about your child’s present behavior. Decide how often your child does the behavior described.

If your child never does this behavior, circle the 0

If your child sometimes does this behavior, circle the 1

If your child very often does this behavior, circle the 2

Here are two examples:

	How Often?
	Never	Sometimes	Very Often
Shows a sense of humor.	1	2	3
Answers the phone appropriately.	1	2	3
This parent thought that the child very often showed a sense of humor. Also, this student sometimes asks questions when unsure of schoolwork. This parent also thought that the child never answered the phone appropriately.

There are no right or wrong answers. You may take as much time as you like. Please do not skip any items.

Social Skills	How Often?
	Never	Sometimes		Very Often
1. Uses free time at home in an acceptable way.	1	2	3
2. Keeps room clean and neat without being reminded.	1	2	3
3. Speaks in an appropriate tone of voice at home.	1	2	3
4. Joins group activities without being told to.	1	2	3
5. Introduces herself or himself to new people without being told.	1	2	3
6. Responds appropriately when hit or pushed by other children.	1	2	3
7. Asks sales clerks for information or assistance.	1	2	3
8. Attends to speakers at meetings such as in church or youth groups	1	2	3
9. Politely refuses unreasonable requests from others.	1	2	3
10. Invites others to your home.	1	2	3
11. Congratulates family members on accomplishments.	1	2	3
12. Makes friends easily.	1	2	3
13. Shows interest in a variety of things.	1	2	3
14. Avoids situations that are likely to result in trouble.	1	2	3
15. Puts away toys or other household property.	1	2	3
16. Volunteers to help family members with tasks.	1	2	3
17. Receives criticism well.	1	2	3
18. Answers the phone appropriately.	1	2	3
19. Helps you with household tasks without being asked.	1	2	3
20. Appropriately questions household rules that may be unfair.	1	2	3
21. Attempts household tasks before asking for your help.	1	2	3
22. Controls temper when arguing with other children.	1	2	3
23. Is liked by others.	1	2	3
24. Starts conversations rather than waiting for others to talk first.	1	2	3
25. Ends disagreements with you calmly.	1	2	3
26. Controls temper in conflict situations with you.	1	2	3
27. Gives compliments to friends or other children in the family.	1	2	3
28. Completes household tasks within a reasonable time.	1	2	3
29. Asks permission before using another family member’s property.	1	2	3
30. Is self-confident in social situations such as parties or group outings.	1	2	3
31. Requests permission before leaving the house.	1	2	3
32. Responds appropriately to teasing from friends or relatives of his or her own age.	1	2	3
33. Uses time appropriately while waiting for your help with homework or some other task.	1	2	3
34. Accepts friends’ ideas for playing.	1	2	3
35. Easily changes from one activity to another.	1	2	3
36. Cooperates with family members without being asked to do so.	1	2	3
37. Acknowledges compliments or praise from friends.	1	2	3
38. Reports accidents to appropriate persons.	1	2	3

Problem Behaviors	How Often?
	Never	Sometimes	Very Often
39. Fights with others.	1	2	3
40. Acts sad or depressed.	1	2	3
41. Appears lonely.	1	2	3
42. Has low self-esteem.	1	2	3
43. Threatens or bullies others.	1	2	3
44. Disturbs ongoing activities.	1	2	3
45. Shows anxiety about being with a group of children.	1	2	3
46. Argues with others.	1	2	3
47. Fidgets or moves excessively.	1	2	3
48. Disobeys rules or requests.	1	2	3
49. Talks back to adults when corrected.	1	2	3
50. Acts impulsively.	1	2	3
51. Doesn’t listen to what others say.	1	2	3
52. Is easily embarrassed.	1	2	3
53. Is easily distracted.	1	2	3
54. Gets angry easily.	1	2	3
55. Has temper tantrums.	1	2	3

Mark one choice
56.	Are you female or male?	1 Female
		2 Male
57.	What is your date of birth?
	   MONTH DAY YEAR
58.	What is this child’s date of birth?
	   MONTH DAY YEAR
59.	Is this child of Hispanic or Latino origin? (Mark only one answer)
	1 Yes
	2 No
60.	What is this child’s race? (Mark one or more to describe yourself)
	1 American Indian or Alaska Native
	2 Asian
	3 Black or African American
	4 Native Hawaiian or Other Pacific Islander
	5 White
61.	What is your marital status?
	1 Single
	2 Married
	3 Separated
	4 Divorced
	5 Widowed
	6 Living together
	7 Other (Please specify)__________________________________

62.	What is your relationship to this child
	1 Mother	9 Father
	2 Stepmother	10 Stepfather
	3 Foster mother	11 Foster father
	4 Grandmother	12 Grandfather
	5 Sister	13 Brother
	6 Other female relative	14 Other male relative
	7 Father’s partner/significant other/girlfriend	15 Mother’s partner/significant other/girlfriend
	8 Other adult female	16 Other adult male

63.	Who else lives with this child (mark all that apply)
	1 Mother	9 Father
	2 Stepmother	10 Stepfather
	3 Foster mother	11 Foster father
	4 Grandmother	12 Grandfather
	5 Sister	13 Brother
	6 Other female relative	14 Other male relative
	7 Father’s partner/significant other/girlfriend	15 Mother’s partner/significant other/girlfriend
	8 Other adult female	16 Other adult male

64.	In all, how many people live in the household of this child? (Include yourself and your child in this count
		 PEOPLE

65.	What is the highest grade or year of school that you have completed?
	1 8th grade or less
	2 Some high school (but did not graduate)
	3 High school equivalency (GED)
	4 High school graduate
	5 Vocational, trade, or business school after completing or leaving high school
	6 Some college (but did not receive a degree)
	7 Associate degree (AA or other 2-year degree)
	8 Bachelor’s degree
	9 Post-graduate education or degree
	10 Other (Specify) ________________________________________________

66.	What is the highest grade or year of school that anyone in your household, including yourself, have completed?
	1 8th grade or less
	2 Some high school (but did not graduate)
	3 High school equivalency (GED)
	4 High school graduate
	5 Vocational, trade, or business school after completing or leaving high school
	6 Some college (but did not receive a degree)
	7 Associate degree (AA or other 2-year degree)
	8 Bachelor’s degree
	9 Post-graduate education or degree
	10 Other (Specify) ________________________________________________

67.	What category best describes your employment? (Mark only one answer)
	1 Employed or self-employed full-time
	2 Employed or self-employed part-time
	3 Homemaker or caregiver
	4 Out of work or unable to work
	5 Student
	6 Student and employed
	7 Retired
	8 Other (Specify) ________________________________________________

68.	What was your total household income from all sources before taxes in 2006? (If you are not sure about the amount, please estimate.)
	1 Under $5,000
	2 $5,000 to $9,999
	3 $10,000 to $19,999
	4 $20,000 to $29,999
	5 $30,000 to $39,999
	6 $40,000 to $49,999
	7 $50,000 to $59,999
	8 $60,000 to 69,999
	9 $70,000 or more

73

Permission to use specific items may be required