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Sample of ReCAPP Parent-Child Connectedness Survey

  1. What is your e-mail address? (required)
  2. What best describes your current occupation?

    o Elementary School Teacher
    o Middle School Teacher
    o High School Teacher
    o Health Educator
    o School Nurse
    o Social Worker
    o Counselor
    o Health Care Provider (other than in school)
    o Program Manager/Administrator
    o Academic/Professor
    o Researcher
    o Student
    o Parent
    o Other (please specify):_____________________
  3. How many years have you been working in adolescent pregnancy prevention or related field?

    o Less than one year
    o 1-2 years
    o 3-5 years
    o 6-10 years
    o more than 10 years
  4. What age group BEST describes the people you serve?

    o 0-5
    o 6-11
    o 12-18
    o 19-24
    o 25 and older
  5. Had you heard of the term "parent-child connectedness" before taking this survey? (If no, skip to Question 7.)

    o Yes
    o No
  6. If you have heard of the term "parent-child connectedness" before, please tell us about HOW you learned heard about it.
  7. What does the term "parent-child connectedness" mean to you?
  8. Based on your professional experiences, list the three most important factors that you believe STRENGTHEN parent-child connectedness.

    Strengthening Factor #1________________
    Strengthening Factor #2________________
    Strengthening Factor #3________________
  9. Based on your professional experiences, list the three most important factors that you believe BREAK DOWN parent-child connectedness.

    Break Down Factor #1________________
    Break Down Factor #2________________
    Break Down Factor #3________________
  10. Rate the statement below:
    "Parent-child connectedness" is relevant to the work I do.

    o 1 = Strongly disagree
    o 2 = Disagree
    o 3 = Agree
    o 4 = Strongly agree
    o NS = Not sure
  11. Have you IMPLEMENTED interventions designed to strengthen parent-child connectedness?
    o Yes
    o No
  12. Have you been involved in DEVELOPING an intervention explicitedly designed to strengthen parent-child connectedness?

    o Yes
    o No
  13. Describe program activities that you and/or your organization are conducting that you believe strengthen parent-child connectedness, if any.
  14. Of the 24 possible PROTECTIVE factors (factors that strengthen) associated with parent-child connectedness listed below, which do you think you and/or your organization could realistically impact? (Select all that apply.)

    o Parents supervise and monitor their child
    o Parents set expectations for their child
    o Parents provide rules and structure
    o Parents provide family leadership
    o Parents support child's autonomy
    o Parents respect child's needs, differences and boundaries
    o Parents provide encouragement and support to child
    o Parents provide guidance to child
    o Parents protect child
    o Parents provide care giving in an emotionally responsive way
    o Family works together towards common goals
    o Family is flexible and open to change
    o Family has positive outlook (hope, optimistic view, confidence in overcoming odds)
    o Family maintains a strong sense of family values, traditions and/or rituals
    o Family makes time for positive activities
    o Family is connected to community and relatives
    o Parents have knowledge of child's lifestyle and peer pressures
    o Family members talk open and clearly about themselves
    o Parents have good listening skills
    o Parents give clear and consistent messages
    o Family is financially secure
    o Parents have happy marriage
    o Parents maintain a close relationship with their parents
    o Family stress is low
  15. Of the 13 possible RISK factors (factors that weaken) associated with the lack of parent-child connectedness listed below, which do you think you and/or your organization could realistically impact? (Select all that apply.)

    o Loss of caregiver due to separation, divorce or death
    o Rejection of child by parent
    o Physical abuse of child by parent
    o Sexual abuse of child by parent
    o Neglect of child by parent
    o Family violence/domestic violence
    o Psychological control of child by parent
    o Over protection of child by parent
    o Use of punitive discipline
    o Family conflict
    o Poor parent-child communication
    o Maternal depression
    o Parental abuse of alcohol and/or other substances
  16. Rate each of the following statements:

    My interest in learning more about parent-child connectedness and its influence on preventin adolescent pregnancy is best described as:
    o 1= High
    o 2= Medium
    o 3= Low
    o NS= Not Sure


    My interest in incorporating parent-child connectedness program activities into my work is best described as:
    o 1= High
    o 2= Medium
    o 3= Low
    o NS= Not sure
  17. Is there anything else you would like to tell us?

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