Form Parents Night Out Parents Night Out Parents Night Out Questions

OMB No. 0930-0316

Expiration Date: XX/XX/XXXX

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 0930­-0316. Public reporting burden for this collection of information is estimated to average 60 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 15E45, Rockville, Maryland, 20857.

Parents’/Caregivers Night Out Evaluation Survey

Introduction

Thank you for attending "Parents’ Night Out.” We value your feedback. Please take 5-7 minutes to complete this survey to help SAMHSA continue to develop resources that best meet the needs of parents/caregivers. Your participation is voluntary, and you may quit or skip any question at any time. All of your answers will be kept strictly confidential. No individual results will be published; only summary information from all responses will be reported.

Demographic Information

Q1: First name:

Q2: Last name:

Q3.1: Please provide your email address:

Q3.2: If you prefer to receive follow-up communication and/or resources by text, please provide your cell phone number:

Q4: What sex were you assigned at birth, on your original birth certificate?

• Female

• Male

• Don’t know

• Prefer not to answer

Q5: What is your current gender?

• Female

• Male

• Transgender

• Two-spirit

• I use a different term: (open text option)

• Don’t know

• Prefer not to answer

Q6: Which of the following best represents how you think of yourself?

• Straight, that is, not gay or lesbian

• Gay or Lesbian

• Bisexual

• Two-Spirit

• I use a different term:

• Don’t know/Prefer not to answer
  
  

Q6: What is your race and/or ethnicity? Please select all that apply and feel free to enter any additional details in the text option space below.

• American Indian or Alaska Native (Open text option “Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.”

• Asian – Please provide details below.

  • Chinese

  • Asian Indian

  • Filipino

  • Vietnamese

  • Korean

  • Japanese

  • Enter, for example, Pakistani, Hmong, Afgan, etc. (open text option)

• African American or Black – Please provide details below.

  • African American

  • Jamaican

  • Haitian

  • Nigerian

  • Ethiopian

  • Somali

  • Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. (Open text option)

• Hispanic or Latino – Please provide details below.

  • Mexican

  • Cuban

  • Puerto Rican

  • Dominican

  • Salvadorian

  • Guatemalan

  • Enter, for example, Colombian, Honduran, Spaniard, etc. (Open text option)

• Middle Eastern or North African – Please provide details below.

  • Lebanese

  • Iranian

  • Egyptian

  • Syrian

  • Iraqi

  • Israeli

  • Enter, for example, Moroccan, Yemeni, Kurdish, etc. (Open text option)

• Native Hawaiian or Pacific Islander – Please provide details below.

  • Native Hawaiian

  • Samoan

  • Tongan

  • Fijian

  • Chamorro

  • Marshallese

  • Enter, for example, Chuukese, Palauan, Tahitian, etc. (Open text option)

• White

  • English

  • German

  • Italian

  • Polish

  • Irish

  • Scottish

  • Enter, for example, French, Swedish, Norwegian, etc. (Open text option)

Q7: Role:

• Parent

• Caregiver

• Community member

Q7.1: If “parent” or “caregiver” in Q7.1, then display: What grade is your child in?

• 5^th or 6^th grade

• 7^th or 8^th grade

• 9^th or 10^th grade

• 11^th or 12^th grade

• Other: (open text option)

PNO Event Information

Q7: Date you attended “Parents’ Night Out” (mm/dd/yyyy)

Q8: Which format of “Parents’ Night Out” did you participate in?

• 1-hour virtual

• 1-hour in-person

• 3-hour in-person

Q9: Please provide any additional feedback on the length or delivery of the “Parents’ Night Out” event.

Questions

Q10: Have you previously talked to your child about alcohol and other drug use?

• Yes

• No

Q11: To the best of your knowledge, which statement describes your child's current relationship with substance use?

• My child is NOT currently using substances.

• I suspect that my child is using substances, but do not know for sure.

• I know that my child is using substances.

• I do not know whether my child is engaging in current substance use.

• Other (please explain):

Q12: Which of the following substances do you suspect or know your child is using? (Select all that apply.)

• Alcohol

• Tobacco Products (cigarettes, vapes, smokeless tobacco, hookah, etc.)

• Prescription medications (this could be medications that are prescribed that they are not taking per instructions from a physician, or medications they are taking that they are not prescribed)

• Opioids (prescription or non-prescription, heroin, fentanyl, etc.)

• Cannabis products (medical or recreational, including cannabis cigarettes, vapes, edibles, cannabinoid products, etc.)

• Stimulants (cocaine, methamphetamine, amphetamine, etc.)

• Something else (please describe):

Q13: What part of "Parents' Night Out" was most useful to you? Which part was least useful?

Q14: Please state your level of agreement with the following statements.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
The information was presented in a logical way that helped me better understand the topics.
The presentation contained facts about alcohol and other drug use I did not know before.
My questions or concerns were addressed by the presentation and/or presenters.

Q15: Please state your level of agreement with the following statements.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
I am more aware of the prevalence rates associated with underage alcohol and other drug use.
I am more knowledgeable about the harms associated with alcohol and other drug use, particularly for children and teens.
I am more aware of the potential impact my thoughts and actions have on my child's decision-making regarding underage alcohol and other drug use.
I am more knowledgeable about best practices for how to talk with my child about alcohol and other drug use.
I am more confident in my ability to have effective conversations with my child about alcohol and other drug use.

Q16: How likely are you to engage in the following future behaviors?

	Very likely	Likely	Neutral	Unlikely	Very unlikely
I will engage in more frequent discussions about alcohol and other drug use with my child. OR I will engage in discussions about alcohol and other drug use with my child. *
I will share the knowledge I have learned today with other adults/parents.
I will continue learning more about how to discuss alcohol and other drug use with my child.

*Prompt displayed will correlate with response to question 10.

Q17: Please use the space below to provide any additional feedback you may have about “Parents’ Night Out."

Thank You Message

Thank you so much for your time. The “Talk. They Hear You.” campaign team will use your responses to improve the presentation.