Form Pre- and Post-Pare Pre- and Post-Pare Pre- and Post-Parent and Caretaker Survey

Attachment 1: Parent/Caregiver Pre-Test/Post-Test Survey

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Parent/Caregiver Survey Instrument

Thank you for agreeing to participate in this survey about concerns parents have for their children. Your responses will help SAMHSA improve its programs to help families. This survey will take 10–12 minutes to complete. Your participation in this survey is voluntary, and you may quit the survey or skip any question at any time. All your answers will be kept strictly confidential. No individual results will be published; only summary information from all responses will be reported.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is XXXX-XXXX, and it expires XX/XX/XXXX. Public reporting burden for this collection of information is estimated to average 10-12 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57B, Rockville, MD 20857.

Section I: Screener

1. Are you a parent or caregiver of one or more children attending XX Middle School? Please include children living in your household part time or full time.

• Yes

• No

If “No” Is selected ABOVE, please TERMINATE. This survey is for parents or caregivers with children from XX Middle School living part time or full time in their household.

2. Please indicate in the grid below the age of each child ages 9 through 15 living in your household either part time or full time.

If you have more than one child, please mark in order of youngest to oldest as indicated in the column headers.

Age Range	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
9
10
11
12
13
14
15

3. Please indicate the genders of the children (ages 9 through 15) living in your household either part time or full time.

As before, if you have more than one child, please mark in order of youngest to oldest.

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Male
Female

Section II: Attitudes on Underage Drinking

Questions 4–6 will require answers for each child ages 9 through 15 living in the household either part time or full time.

4. In your opinion, what are the three most important issues to discuss with your children ages 9 through 15 today? Please check the three boxes that apply to each child.

As before, if you have more than one child, please mark in order of youngest to oldest.

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Academic achievement and performance
Health (e.g., nutrition, physical activity, etc.)
Risky sexual behavior
Violence (e.g., violence in your neighborhood, physical or sexual abuse, bullying, school safety, etc.)
Mental health (e.g., ADHD, depression, anxiety, eating disorders, suicide, etc.)
Making friends/maintaining positive relationships with family and/or peers
Peer pressure
Abuse/overuse of electronics (e.g., gaming/social media use via smartphone, iPad, or computer)
Negative social media influence (e.g., online bullying, peer pressure, predators)
Drug use (including prescription drug misuse)
Underage drinking (i.e., drinking alcohol before the legal age of 21)
Use of tobacco products. Select all that apply.
cigarettes
e-cigarettes (e.g., blu, JUUL, Logic, MarkTen XL, and Vuse)
smokeless tobacco (defined as chewing tobacco, snuff, or dip)
hookahs
Something else, please specify:
I do not believe that there are any issues that I need to discuss with my child today

5. How strongly do you agree or disagree with the following statements for each of your children ages 9 through 15?

5a. “Underage drinking is an important issue to discuss with my child.”

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

5b. “Talking to my child about underage drinking is likely to make a difference in the decisions he or she makes.”

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

6. How confident do you feel in your ability to influence each of your 9- to 15-year-old children’s decisions about drinking alcohol?

   	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
   Not at all confident
   Somewhat confident
   Confident
   Very confident

7. What percentage of children in the United States between the ages of 9 and 15 do you think have drunk alcohol in the past year without their parents’ permission?

_____%

8. How susceptible do you feel that your __-year-old child is to drinking alcohol without your permission in the next 6 months?

   	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
   Not at all susceptible
   Somewhat susceptible
   Susceptible
   Very susceptible

9. Each year in the United States, more people die of alcohol-related causes than drugs.

• True

• False

Section III: The “Talk. They Hear You.”® Campaign

RECALL

“Talk. They Hear You.” is a national media campaign to prevent underage drinking by encouraging parents and caregivers to talk to their children early about the risks and dangers of alcohol use. Some campaigns are similar to “Talk. They Hear You.”

The “Talk. They Hear You.” campaign features the following logo:

10. Before this survey, had you heard of “Talk. They Hear You.”?

• Yes

• No . . . please skip to Question 14

• Not sure

11. Do you remember seeing the following ads?

• I remember seeing this ad.

• I don’t remember seeing this ad.

• I remember seeing this ad.

• I don’t remember seeing this ad.

• I remember seeing this ad.

• I don’t remember seeing this ad.

• I remember seeing this ad.

• I don’t remember seeing this ad.

12. When did you first see messages from the “Talk. They Hear You.” campaign?

• Before the beginning of this school year

• After the beginning of this school year

• Don’t know or can’t recall

13. Where have you seen or heard ads from the “Talk. They Hear You.” campaign? Select all that apply.

• A public service announcement (PSA) on TV

• A poster or billboard

• A pamphlet or other reading materials

• Social media (including Facebook, Twitter, YouTube, and a mobile app)

• Email or other communications

• An ad on the radio

• An ad in the newspaper

• In my child’s middle school

• Other, please specify: __________________________

• Don’t know or don’t remember

14. How familiar would you say you were with the “Talk. They Hear You.” campaign before taking this survey today?

• Not at all familiar

• Somewhat familiar

• Familiar

• Very familiar

ENVIRONMENTAL INFLUENCES

15. Besides messages that you might have seen or heard from the “Talk. They Hear You.” campaign, do you recall seeing or hearing other messages in the past related to the importance of talking to your kids about underage drinking?

• Yes

• No . . . please skip to Question 17

16. Where did you see or hear these messages outside of the “Talk. They Hear You.” campaign that discussed the importance of talking to your children about underage drinking? Select all that apply.

• Personally, from school counselors/teachers/staff

• Parenting workshop/lectures

• Print, radio, television, or online ads from national or local campaigns other than “Talk. They Hear You.”

• Don’t know or don’t remember

• Other, please specify: __________________________

Section IV: Having the Conversation

17. Have you ever had a conversation with any of your children ages 9 through 15 about underage drinking?

As before, if you have more than one child, please mark in order of youngest to oldest.

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Yes
No

If selected “Yes” and have had a conversation about underage drinking with ALL of their children, proceed directly to Question X. Otherwise, please answer the following question.

18. Which of the following reasons explains why you have not had a conversation with your __-year-old child about underage drinking? Select all that apply.

• I am certain that my child is not drinking.

• I am waiting until my child is older to talk to him or her.

• I don’t think that underage drinking is a big problem.

• I don’t know enough about underage drinking to talk to my child about it.

• I’m not sure what to say to help my child avoid underage drinking.

• Talking to my child about underage drinking will not prevent him or her from drinking.

• Other, please specify: __________________________

If talked to any of their children about underage drinking, answer Questions X–X.

If HAVE NOT spoken to ANY of their children about underage drinking, skip to Question X.

19. Since the start of the school year, how often have you talked to your children ages 9 through 15 about underage drinking?

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Not at all in the past 3 months
Once
Twice
Three times
Four times
Five times or more

20. When you talked to your children ages 9 through 15 about underage drinking, how much did you emphasize each of the following?

SCALE: 1 = Not at all emphasized 2 = Somewhat emphasized 3 = Emphasized
4 = Strongly emphasized

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Underage drinking is not acceptable
You want your child to be happy and safe
You know about alcohol and can be counted on to answer their questions
You will know if your child starts to drink
You can help your child figure out ways to avoid drinking
Underage drinking can have serious consequences
Underage drinking can be dangerous for your health

21. Is there a point you generally emphasize when talking to your children ages 9 through 15 about underage drinking that is not reflected in the grid above? (e.g., personal experience or family history)

• Yes

• No

Please detail that point you emphasized here:

Only answer Questions X–X below IF REPORTED BEING FAMILIAR with the “Talk. They Hear You.” campaign earlier in the survey.

If reported NOT BEING FAMILIAR with the campaign, skip to Question X.

22. Earlier, you said that you were familiar with the “Talk. They Hear You.” Underage Drinking Prevention National Media Campaign. Did you FIRST talk to your __-year-old about underage drinking before or after you saw the campaign?

• Before I saw the campaign

• After I saw the campaign

• Don’t know or don’t remember

23. When you first saw or heard these ads, did you consider the need to discuss underage drinking with your children ages 9 through 15?

    	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
    Yes
    No
    Don’t know or don’t remember

24. After you saw the campaign, did you then talk to your children ages 9 through 15 again (or for the first time) about underage drinking?

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Yes
No
Don’t know or don’t remember

IF SELECTED “No,” did NOT talk to ANY of their children about underage drinking, skip to Question X.

25. How helpful was the information from the “Talk. They Hear You.” campaign in talking to your children ages 9 through 15 about underage drinking?

    	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
    Not at all helpful
    Somewhat helpful
    Helpful
    Very helpful
    I did not discuss drinking with this child

26. What information from the campaign, if anything, did you find to be most helpful when talking to your children ages 9 through 15?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Section V: Closing

27. To what extent do you agree or disagree with the following statement for each of your children ages 9 through 15?

“In the near future, I intend to discuss underage drinking with my child.”

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Strongly disagree
Disagree
Agree
Strongly agree

27a. If you selected “Strongly Disagree” or “Disagree” that you will discuss underage drinking with your child/children in the near future, please explain why.

28. Now that you’ve taken this survey, do you feel an urge to discuss underage drinking with your children ages 9 through 15?

	Child #1 (youngest/ only)	Child #2 (second youngest)	Child #3 (third youngest)	Child #4 (fourth youngest)
Yes
No
Not sure

Section VI: Demographics

29. What is your age? Please write your age below.

________

30. What is your gender?

• Male

• Female

31. Are you of Hispanic, Latino, or Spanish origin?

• Yes

• No

32. What is your race? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

33. What is the highest degree or level of education you have completed?

• Less than a high school diploma

• Regular high school diploma or GED or alternative credential

• Some college credit or trade school, no degree

• Associate’s degree or trade school diploma/certificate

• Bachelor’s degree

• Master’s degree or higher

34. What is your annual household income?

• Less than $10,000

• $10,000–$19,999

• $20,000–$29,999

• $30,000–$39,999

• $40,000–$49,999

• $50,000–$59,999

• $60,000–$69,999

• $70,000–$79,999

• $80,000–$89,999

• $90,000–$99,999

• $100,000–$149,000

• $150,000 or more

• Prefer not to answer

35. Overall, how many children (other than those ages 9 through 15) are living in your household part time or full time from each age category?

______ 8 years old or younger

______ 16–20 years old

______ 21 years old or older

In finalizing this survey, and to ensure the confidentiality of your information, please create a code ONLY FOR YOUR CHILDREN who are enrolled in XX Middle School. This code will help us track your responses while keeping your information completely confidential.

For your children who are enrolled in XX Middle School, please enter the following information below.

Child #1 (youngest/only)

The first letter of your child’s legal¹ first name ___________

The last letter of your child’s legal first name ___________

The last letter of your child’s legal last name ___________

The two-digit month your child was born ___________

The two-digit DAY your child was born ___________

Child #2 (second youngest)

The first letter of your child’s legal first name ___________

The last letter of your child’s legal first name ___________

The last letter of your child’s legal last name ___________

The two-digit month your child was born ___________

The two-digit DAY your child was born ___________

Child #3 (third youngest)

The first letter of your child’s legal first name ___________

The last letter of your child’s legal first name ___________

The last letter of your child’s legal last name ___________

The two-digit month your child was born ___________

The two-digit DAY your child was born ___________

Child #4 (fourth youngest)

The first letter of your child’s legal first name ___________

The last letter of your child’s legal first name ___________

The last letter of your child’s legal last name ___________

The two-digit month your child was born ___________

The two-digit DAY your child was born ___________

Example: This is the code that would result if your child was commonly referred to as “Bill,” but his legal name is William Garcia-Lopez, born May 9.

MONTH and DAY of your child’s BIRTHDAY (i.e., if your child was born May 9, you would enter “05” for the month and “09” for the day).

The FIRST and LAST letters of your child’s legal FIRST NAME (i.e., if your child goes by “Bill,” but his legal name is “William,” you would enter the letters “W” and “M”).

W M Z 05 09

LAST letter of your child’s legal LAST NAME (i.e., if your child’s legal last name is “Garcia-Lopez,” you would enter the letter “Z”).

ONLY ASKED OF INTERVENTION STUDY SAMPLE & ONLY IN THE POST-TEST SURVEY

This survey is now complete. Would you agree to participate in a follow-up interview by phone lasting no longer than 1 hour? Those who are chosen for participation will receive $35 as a token of appreciation for their time. If so, please provide your email address and phone number in the spaces provided on the next page. Please note that, if selected, your interview will take place by the second week in May.

Your confidentiality is our priority. The information you provided in this survey and in the follow-up interview will NOT be available to anyone beyond the “Talk. They Hear You.” evaluation team. All findings from this effort will be reported only in the aggregate and will not include any personal identifiers.

Email address: _________________________________________________________

Phone number: ________________________________________________________

Best days/times to conduct the 1-hour interview: ____________________________

Thank you for completing this survey!

1 By “legal,” we mean the name that your child was born with. This may or may not be the same name that he or she is referred to by family and friends (such as a nickname). See the example provided below for more information.

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