P_ADD_DAYS. How many days per week does your child live at your address? __________ P_C_BDATE. Your child’s birth date: ______ _______ _______ Month Day Year P_C_GENDER. gender: 0. Male 1. Female P_C_RACE. Child’s race (you can check one or more): modify as needed to reflect your population. Caucasian 1. African-American or 2. Asian-American 3. Pacific Islander 4. American Indian or Alaskan Native 5. Other _____________ 6. P_C_LIC. Does your have a valid driver’s license? Yes 1. No 0. P_C_CARACC. Does your have access to a car to drive? Yes 1. No 0. P_C_GRADES. In school, your child makes the following grades: (check one answer only) modify as needed to reflect common grade assignations in your country. Mostly A's and B's 1. Mostly C's 2. Mostly D's and F's 3. Parent Demographics: Please respond about yourself. P_P_AGE. Your age: ________ P_P_GENDER. Your gender: Male 0. Female 1. P_P_RACE. Your race (you can check one or more): modify as needed to reflect your population. Caucasian 1. African-American or Black 2. Asian-American 3. Pacific Islander 4. American Indian or Alaskan Native 5. Other _____________ 6. P_MAR. What is your marital status? Married 1. Widowed/divorced/separated 2.
P_ADD_DAYS. How many days per week does your child live at your address? __________ P_C_BDATE. Your child’s birth date: ______ _______ _______ Month Day Year P_C_GENDER. gender: 0. Male 1. Female P_C_RACE. Child’s race (you can check one or more): modify as needed to reflect your population. 1. Caucasian 2. African-American or 3. Asian-American 4. Pacific Islander 5. American Indian or Alaskan Native 6. Other _____________ P_C_LIC. Does your have a valid driver’s license? 1. Yes 0. No P_C_CARACC. Does your have access to a car to drive? 1. Yes 0. No P_C_GRADES. In school, your child makes the following grades: (check one answer only) modify as needed to reflect common grade assignations in your country. 1. Mostly A's and B's 2. Mostly C's 3. Mostly D's and F's Parent Demographics: Please respond about yourself. P_P_AGE. Your age: ________ P_P_GENDER. Your gender: 0. Male 1. Female P_P_RACE. Your race (you can check one or more): modify as needed to reflect your population. 1. Caucasian 2. African-American or Black 3. Asian-American 4. Pacific Islander 5. American Indian or Alaskan Native 6. Other _____________ P_MAR. What is your marital status? 1. Married 2. Widowed/divorced/separated
IPEN%20Adolescent_PARENT%20Survey_v2_121712.docx