Important Information

To help make the class a positive experience for you and others, we need to ask you a series of questions on a brief survey. We are doing this for these two important reasons:

1.

When you go to a doctor’s office, the doctor needs to know something about your medical history to know how to help you. Similar to this, by answering these

questions, we will be able to better prepare the class to meet participants’ needs.

2.

We have found from experience that parents who respond to these questions ahead oftime get more out of the class and are better able to meet their children’s needs.

There are no right or wrong answers. We simply ask that you respond to all thequestions and be as honest as you can when answering.

It takes most people about 20 minutes to answer all of the questions.

We know that you want the best for your children and appreciate you taking time to answer these questions.

Oklahoma State University, U.S. Department of Agriculture, State and Local Governments Cooperating. The Oklahoma Cooperative Extension Service offers its programs to all eligible persons regardless of age, race, color, religion, sex, sexual orientation, genetic information, gender identity, national

origin, disability or status as a veteran, and is an equal opportunity employer. -----------------------------------------------------------------------------------------------------------------------------------------

Return in person or mail the remaining pages to:

Class schedule and directions to office:http://oces.okstate.edu/seminole http://oces.okstate.edu/hughes

Holdenville OfficeOSU Extension 200 N. Broadway Suite 2 Holdenville, OK 74848 405-379-5470

Wewoka OfficeOSU Extension 12827 NS 3650 Wewoka, OK 74884 405-257-5433

Parenting Program

10/2019

Page 1

Active Parenting First Five Years

_____________________________________________ is taking the ____________________________________parenting class

on _________________________________ at ______________on/every ___________________________________.

Participants/your name Name of class

Date Time Dates/schedule

My Parenting Class Schedule

Class Dates:

___________________________________Day Time

___________________________________Day Time

___________________________________Day Time

___________________________________Day Time

___________________________________Day Time

___________________________________Day Time

___________________________________Day Time

___________________________________Day Time

10/2019

Page 2

Creating Your Parent ID

In order to keep your evaluation data confidential, but allow the Active Parenting team to learn the impact of

our educational programming on the lives of parents, we will help you develop a unique participant code that

will be easy for you to remember for future surveys. This participant code will help make sure the responses

you provide today link to those you give in the future.

Create your participant code by using the information you provide below:

First Two letters of Last Name First Letter of First Name Last Digit of Year of Birth

What is your dominant hand? What is your race? What is your ethnicity?

What is your gender?

PLEASE ENTER the final 8-character code in the space provided below for ID#. The first three characters will be

letters; the last five will be numbers for the (4) last digit of your birth year, (5) your dominant hand, (6) your

race, (7) your ethnicity, and (8) your gender.

ID #: _____ _____ _____ _____ _____ _____ _____ _____

1 2 3 4 5 6 7 8

___ ___ ___ ___

Gender

Male

Female

Dominant Hand

Left hand

Right hand

Both

Neither

Race

White

Asian

Black/African American

Hawaiian Pacific Islander

Native American

More than one race

Other

Ethnicity

Hispanic

Non-Hispanic

DATE : ________/________/________

DEMOGRAPHICS

We need to collect some basic information for our reporting:

1. Gender: Female Male

2. Ethnicity Are you Hispanic? ① No ② Yes

Race ① American Indian/Alaska Native ② Asian ③ Black/African American ④ Hawaiian/Pacific Islander ⑤ White ⑥ Other

3. Your age in years: _________________

4. Relationship to Target Youth (use one of the following codes): _______

01 Biological Mother

02 Biological Father

03 Adoptive Mother

04 Adoptive Father

05 Step Mother

06 Step Father

07 Foster Mother

08 Foster Father

09 Mother’s Boyfriend

10 Father’s Girlfriend

11 Mother’s Partner

12 Father’s Partner

13 Grandparent

14 Aunt

15 Uncle

16 Sibling

17 Cousin

18 Other

5. Current marital status: Married Living together Single Separated Divorced Widowed

6. Family income per year (not including public assistance):

_____ $10,000 or less

_____ $10,001 to $30,000

_____ $30,001 to $50,000

_____ $50,001 to $70,000

_____ $70,001 to $90,000

_____ Over $90,000

7. Have you received public assistance (e.g., welfare) in the past year? No Yes If yes, how much? $ _____________________

Family Education

History:

Don’t

Know

Grade

7-9

Grade

10-11

HS grad

or GED

Some college

or trade school

Completed four

years of college

Completed graduate

or professional school

8. Your Education

9. Spouse/Partner’s

Education

10. How many adults are living in your home? ______

11. How many children/adolescents are living in your home? ______

What are the ages of the children living in your home? ___________________________________________________

12. Target child’s age in years: ____________ Target child’s gender: Female Male

13. Does your target child have any developmental, intellectual, or physical disabilities? If so, please list them _______________________

CHILD BEHAVIOR

Fill out ONLY if your child is 2-4 years old.

For each item below, please mark the circle for Not True, Somewhat True or Certainly True of your target child.

It would help us if you answered all items as best you can even if you are not absolutely certain.

Not true Somewhat

true

Certainly

true

1. Considerate of other people’s feelings.

2. Restless, overactive, cannot stay still for long

3. Often complains of headaches, stomach-aches or sickness

4. Shares readily with other children, for example toys, treats, pencils

5. Often loses temper

6. Generally well behaved, usually does what adults request

7. Many worries or often seems worried

8. Helpful if someone is hurt, upset or feeling ill

9. Constantly fidgeting or squirming

10. Often fights with other children or bullies them

11. Often unhappy, depressed or tearful

12. Easily distracted, concentration wanders

13. Nervous or clingy in new situations, easily loses confidence

14. Kind to younger children

15. Often lies or cheats

16. Often offers to help others (parents, teachers, other children)

17. Thinks things out before acting

18. Steals from home, school or elsewhere

19. Many fears, easily scared

20. Good attention span, sees work through to the end

PARENTING YOUNG CHILDREN

Instructions: Below is a list of activities parents engage in. Rate how often you engage in these activities with

your child.

1 2 3 4 5 6 7

Not at all Most of the

time

Supporting Behavior 1 2 3 4 5 6 7

1. Play with your child in a way that was fun for both of you? O O O O O O O

2. Stand back and let your child work through problems s/he might be able to

solve?

O O O O O O O

3. Invite your child to play a game with you or share an enjoyable activity? O O O O O O O

4. Notice and praise your child’s good behavior? O O O O O O O

5. Teach your child new skills? O O O O O O O

6. Involve your child in household chores? O O O O O O O

7. Reward your child when s/he did something well or showed a new skill? O O O O O O O

Setting Limits 1 2 3 4 5 6 7

1. Stick to your rules and not change your mind? O O O O O O O

2. Speak calmly with your child when you were upset with him or her? O O O O O O O

3. Explain what you wanted your child to do in clear and simple ways? O O O O O O O

4. Tell your child what you wanted him or her to do rather than tell him/her to stop

doing something?

O O O O O O O

5. Tell your child how you expected him or her to behave? O O O O O O O

6. Set rules on your child’s problem behavior that you were willing/able to

enforce?

O O O O O O O

7. Make sure your child followed the rules you set all or most of the time? O O O O O O O

Proactive Parenting 1 2 3 4 5 6 7

1. Avoid struggles with your child by giving clear choices? O O O O O O O

2. Warn your child before a change of activity was required? O O O O O O O

1 2 3 4 5 6 7

Not at all Most of the

time

1 2 3 4 5 6 7

3. Plan ways to prevent problem behavior? O O O O O O O

4. Give reasons for your requests? O O O O O O O

5. Make a game out of everyday tasks so your child followed through? O O O O O O O

6. Break a task into small steps? O O O O O O O

7. Prepare your child for a challenging situation? O O O O O O O

Teaching 1 2 3 4 5 6 7

1. Repeat or expand your child’s words or sounds? O O O O O O O

2. Label objects or actions for your child? O O O O O O O

3. Engage in pretend play with your child? O O O O O O O

4. Talk about characteristics of objects? O O O O O O O

5. Read daily to your child? O O O O O O O

6. Talk about things you and your child do? O O O O O O O

CAREGIVING AND DEVELOPMENT KNOWLEDGE

When answering the questions, think about ‘babies’ as birth to 12 months (birth to one year). On a scale of 1 to

5, circle the number that best describes your agreement with each statement.

1 2 3 4 5

Strongly disagree Disagree Neither agree nor

disagree

Agree Strongly Agree

1 2 3 4 5

1. Responding quickly to a baby’s crying just encourages the baby to become

more demanding.

O O O O O

2. Babies often need help from caregivers to calm down O O O O O

3. The more you comfort crying babies by holding and talking to them, the more

you will spoil them.

O O O O O

4. Sometimes children need to be spanked. O O O O O

5. Spanking teaches children that it is okay to hit other people. O O O O O

1 2 3 4 5

1. Exploring the environment is necessary for the healthy development of babies

and toddlers.

O O O O O

2. Babies have other ways of communicating besides crying. O O O O O

3. Predictable routines are not important for babies and toddlers. O O O O O

4. A healthy relationship with a parent (or guardian) is critical to a baby and

toddler’s social and emotional development.

O O O O O

PARENTING ATTITUDES

Parents have different feelings about their parenting skills. For each of the following statements, rate how often

each applies to you.

Rarely Always

1. I feel sure of myself as a mother/father.

2. I know I am doing a good job as a mother/father.

3. I know things about being a mother/father that would be helpful to

other parents.

4. I can solve most problems between my child and me.

5. When things are going badly between my child and me, I keep

trying until things begin to change.

MINDFULNESS SCALE

People have a variety of ways of relating to their thoughts and feelings. For each of the items below, rate how

much each of these ways applies to you.

1 2 3 4

Rarely/Not at all Sometimes Often Almost always

1 2 3 4

1. It is easy for me to concentrate on what I am doing. O O O O

2. I am preoccupied by the future. O O O O

3. I can tolerate emotional pain. O O O O

4. I can accept things I cannot change. O O O O

5. I can usually describe how I feel at the moment in considerable detail. O O O O

6 I am easily distracted. O O O O

7. I am preoccupied by the past. O O O O

8. It’s easy for me to keep track of my thoughts and feelings. O O O O

9. I try to notice my thoughts without judging them. O O O O

10. I am able to accept the thoughts and feelings I have. O O O O

11. I am able to focus on the present moment. O O O O

12. I am able to pay close attention to one thing for a long period of time. O O O O

PARENTAL STRESS SCALE

The following statements describe feelings and perceptions about the experience of being a parent. Think of each

of the items in terms of how your relationship with your child or children typically is. Please indicate the degree

to which you agree or disagree with the following items by placing the appropriate number in the space provided.

1 2 3 4 5

Strongly disagree Disagree Undecided Agree Strongly agree

1 2 3 4 5

1 I am happy in my role as a parent O O O O O

2 There is little or nothing I wouldn't do for my child(ren) if it was necessary. O O O O O

3 Caring for my child(ren) sometimes takes more time and energy than I have to give. O O O O O

4 I sometimes worry whether I am doing enough for my child(ren). O O O O O

5 I feel close to my child(ren). O O O O O

6 I enjoy spending time with my child(ren). O O O O O

7 My child(ren) is an important source of affection for me. O O O O O

8 Having child(ren) gives me a more certain and optimistic view for the future. O O O O O

9 The major source of stress in my life is my child(ren). O O O O O

10 Having child(ren) leaves little time and flexibility in my life. O O O O O

11 Having child(ren) has been a financial burden. O O O O O

12 It is difficult to balance different responsibilities because of my child(ren). O O O O O

13 The behavior of my child(ren) is often embarrassing or stressful to me. O O O O O

14 If I had it to do over again, I might decide not to have child(ren). O O O O O

15 I feel overwhelmed by the responsibility of being a parent. O O O O O

16 Having child(ren) has meant having too few choices and too little control over my

life.

O O O O O

17 I am satisfied as a parent O O O O O

18 I find my child(ren) enjoyable O O O O O