SEEDID:___________________
IID:____________________
SEED PARENT INTERVIEW
WAVE # 3
THANK YOU for filling out this questionnaire. We want to understand more about American Indian
children and their parents.
 Many questions are very sensitive and personal. We truly appreciate your honest answers.
 You can skip any question.
 You can stop at any time.
 Please answer exactly as you think and feel.
 Your answers will be kept CONFIDENTIAL.
 Your identity and the identity of your community will not be revealed.
 There are no right or wrong answers.
 Some questions may not seem to apply to you, but please don't skip them unless you’re asked to.

Choose the response that best fits your situation.
 Some questions ask you to skip to different places in the booklet depending on the answer you
give.
This will prevent you from having to answer questions that do not apply to you.
 Be aware that there are several styles of questions.
For most, you'll circle or check only one answer; but some ask you to CIRCLE ALL THE
ANSWERS THAT APPLY.
 If there is not an appropriate answer for your situation or feelings, feel free to write your own
answers below or next to the question.
Your responses will help us and your community to understand the needs of American Indian families
better, so that more helpful programs can be developed.
THANK YOU FOR YOUR TIME!
BACKGROUND INFORMATION
1.
What is today's date? ________/________/________
2.
What is your date of birth? ________/________/________
CIRCLE OR CHECK THE ANSWER THAT BEST FITS YOUR SITUATION.
3.
I am...
0.
male.
1.
female.
4.
What is your degree of Indian blood? Please write in.__________________
NOTE: Please answer BOTH Questions 5 and 6.
5. Are you Spanish/Hispanic/Latino? Please check “NO” if you are not Spanish/Hispanic/Latino.
___ No, not Spanish/Hispanic/Latino.
___ Yes, Mexican, Mexican Am., Chicano
6. What is your race? Check one or more races to indicate what you consider yourself to be.
CHECK ALL THAT APPLY.
___ White
___ Black, African American, or Negro
___ American Indian or Alaska Native—Print name of enrolled or
principal tribe below.__________________________
___ AsianSpecify.______________________________
___ Pacific IslanderSpecify.______________________
___ Some other race-Specify______________________
7.
Are you currently in a romantic relationship; that is, do you have a boyfriend, girlfriend,
husband or wife (a partner)?
___ No
___ Yes
NOTE: If you are not currently in a relationship, please circle the answer that says that you do not have a
partner at this time.
8.
How long have you been romantically involved with your current partner?
_________ Years
88.
_________ Months
_________ Weeks
I do not have a partner at this time.
3
9.
I am currently...
1.
married (including a traditional Indian marriage) and living with my spouse.
2.
married (including a traditional Indian marriage) but not living with my spouse.
3.
legally separated.
4.
living with my partner but not married.
5.
divorced.
6.
widowed.
7.
single. I have never been married.
10.
My partner is...
0.
male.
1.
female.
88.
I do not have a partner at this time.
11.
How old is your partner? _________ years old
88.
I do not have a partner at this time.
12.
My partner is...
1.
not Indian Skip to 14
2.
Indian  Degree of Indian Blood ______________
3.
I know my partner is part Indian, but I don't know how much.
4.
I don’t know if my partner is Indian.
5.
I don’t have a partner at this time.
13.
Where are you living?
1.
Indian reservation.
2.
near an Indian reservation.
3.
off the Indian reservation.
14.
I am living...
1.
in a town or city.
2.
in the country or a rural area.
15.
My community is...
1.
mostly American Indian.
2.
mostly White.
3.
mostly Hispanic or Mexican.
4.
mostly African-American.
5.
mixed.
4
INDIAN CULTURE
If your family speaks more than one tribal language, please refer to the language spoken most often.
1.
How often was your tribal language spoken in your house when you were growing up?
1.
rarely/never
2.
sometimes
3.
often
4.
almost always
8.
I don't have a tribal language.
2.
How well can you understand your tribal language when it is spoken?
1.
I cannot understand my tribal language when it is spoken.
2.
I can understand my tribal language a little when it is spoken.
3.
I understand my tribal language when it is spoken.
8.
I don't have a tribal language.
3.
How well can you speak your tribal language?
1.
I cannot speak my tribal language.
2.
I can speak it a little.
3.
I can carry on a conversation in my tribal language.
8.
I don't have a tribal language.
4.
How often do you currently speak your tribal language?
1.
rarely/never
2.
sometimes
3.
often
4.
almost always
8.
I don't have a tribal language.
WHEN YOU WERE GROWING UP, HOW MUCH DID YOUR FAMILY LIVE BY OR FOLLOW...
Not at all
A little
Some
A lot
1.
the American Indian way of life? .........1........................2....................... 3……………..4
2.
the White or Anglo way of life? ...........1........................2....................... 3……………..4
3.
Other way of life
(African American, Hispanic, etc.)…..1………………2………………3……………..4
HOW MUCH DO YOU NOW LIVE BY OR FOLLOW...
Not at all
A little
Some
A lot
4.
the American Indian way of life? .........1........................2....................... 3 ...................... 4
5.
the White or Anglo way of life? ...........1........................2....................... 3 ...................... 4
6.
Other way of life
(African American, Hispanic, etc.)…..1………………2………………3……………...4
5
HOW IMPORTANT IS IT TO YOU TO FOLLOW RELIGIOUS OR SPIRITUAL BELIEFS WHICH
ARE BASED ON...
Not at all
Not very
Somewhat
Very
Important
Important
Important
Important
7.
traditional Indian beliefs? ........... ........ 1 ............. .......... 2 ............... ...... 3 ................. .... 4
(sweats, ceremonies, etc.)
8.
the beliefs of the Native
American Church? ..................... ........ 1 ............. .......... 2 ............... ...... 3 ................. .... 4
9.
Christian beliefs such
as Catholic, Baptist,
Mormon, etc.?.............................. ...... 1 ................ ....... 2 ...................... 3 ................. .... 4
10.
How important is it for you to
have an Indian partner? ............... ...... 1 ................ ....... 2 ...................... 3 ................. .... 4
11.
How proud are you to be an American Indian?
1.
not at all proud
2.
not very proud
3.
somewhat proud
4.
very proud
8.
I do not consider myself to be an American Indian.
6
WORK AND FAMILY INCOME
1.
LAST WEEK, did you do ANY work for either pay or profit? Check “yes” even if you worked
only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or was on
active duty in the Armed Forces.
___ Yes  Skip to 4
___ No  Skip to 2a.
2.
a. LAST WEEK, were you on layoff from a job?
___ Yes Skip to 2b
___ No  Skip to 2c
b. Have you been informed that you will be recalled to work within the next 6 months OR
been given a date to return to work?
___ Yes  Skip to 2e
___ No  Skip to 2d
c. LAST WEEK, were you TEMPORARILY absent from a job or business?( for any reason,
sick leave, maternity, etc.)
___ Yes  Skip to 3
___ No  Skip to 2d
d. Have you been looking for work during the last 4 weeks?
___ Yes  Skip to 2e
___ No Skip to 3
e. LAST WEEK, could you have started a job if offered one, or returned to work if recalled?
___ Yes
___ No, because of own temporary illness
___ No, because of all other reasons (in school, etc.)
3.
When did you last work, even for a few days?
___ 2000-Present
___ 1995-2000
___ 1994 or earlier, or never worked
4.
a. LAST YEAR, did you work at a job or business at any time?
___ Yes
___ No  Skip to 5
b. How many weeks did you work last year? Count paid vacation, paid sick leave, and military
service. Number of weeks: ______
c. During the weeks WORKED last year, how many hours did you usually work each week?
Usual hours work each week. Numbers of hours: _________
d. What was your hourly wage? $ ________ Per Hour
7
5. INCOME
Please tell me which number best represents the total income before taxes of all persons living in
your household in the calendar year of 2004. What was the total income for all your family
combined that year? By family, I mean, those who share your house.
This should include not only wages, salaries, tips, and commissions, but also net income per
capita payments from a business or farm, social security, pensions, unemployment or
disability compensation, alimony or child support, welfare, dividends, interest, rent or sale of
property, and any other money income received by all family members--by you or anyone else
in the family living with you.
NOTHING, OR LOSS .........................................01
LESS THAN 1,000 .................................................. 02
$1,000 - 4,999 ......................................................03
$5,000 - 9,999 .......................................................... 04
$10,000 - 14,999 ..................................................05
$15,000 - 19,999 ...................................................... 06
$20,000 - 29,999 ..................................................07
$30,000 - 39,999 ...................................................... 08
$40,000 - 49,999 ..................................................09
$50,000 - OR MORE ............................................... 10
DON'T KNOW ....................................................99
5a.
What was the total monthly income for all persons living in your house for the
past month?
TOTAL $__________________
5b.
Was this more, the same, or less than usual?
MORE ................................................1
ABOUT THE SAME ............................. 2  SKIP TO # 6
LESS ..................................................3
5c.
How much more or less than usual? $_________________
8
6.
How much of this annual household income was earned or brought in by YOU
PERSONALLY LAST YEAR?
IF DON'T KNOW: [Give me your best estimate.]
NOTHING, OR LOSS .........................................01
LESS THAN 1,000 .................................................. 02
$1,000 - 4,999 ......................................................03
$5,000 - 9,999 .......................................................... 04
$10,000 - 14,999 ..................................................05
$15,000 - 19,999 ...................................................... 06
$20,000 - 29,999 ..................................................07
$30,000 - 39,999 ...................................................... 08
$40,000 - 49,999 ..................................................09
$50,000 - OR MORE ............................................... 10
DON'T KNOW ....................................................99
6a.
What was your total monthly income for the past month?
TOTAL $______________
6b.
Was this more, the same, or less than usual?
MORE ................................................1
ABOUT THE SAME ............................. 2
LESS ..................................................3
6c.
How much more or less than usual? $______________
9
HOUSING
Please answer the next questions for where you currently live.
1. Are you…..
____renting your home
____buying your home
____already own your home
____living with family
2. Which best describes the place where you live? Include all homes even if vacant.
___ A mobile home
___ A one-family house detached from any other house
___ A one-family house attached to one or more houses (like duplex)
___ Apartment building
___ Boat, RV, Van, etc.
3. How many rooms do you have in your house, apartment, or mobile home? Do NOT count
bathrooms, porches, balconies, foyers, halls, or half-rooms.
___ 1 room
___ 6 rooms
___ 2 rooms
___ 7 rooms
___ 3 rooms
___ 8 rooms
___ 4 rooms
___ 9 or more rooms
___ 5 rooms
4. How many bedrooms do you have; that is, how many bedrooms would you list if this house,
apartment, or mobile home were on the market for sale or rent?
___ No bedroom
___ 3 bedrooms
___ 1 bedroom
___ 4 bedrooms
___ 2 bedrooms
___ 5 or more bedrooms
5. Do you have COMPLETE plumbing facilities in the place where you live; that is 1) hot and cold
piped water 2) a flush toilet 3) a bathtub or shower?
___ Yes, have all three facilities
___ No
6. Do you have COMPLETE kitchen facilities in the place where you live, that is, 1) a sink with
piped water 2) a range or stove 3) a refrigerator?
___ Yes, have all three facilities
___ No
7. Is there telephone service available in your house, apartment, or mobile home from which you
can both make and receive calls?
___ Yes
___ No
10
8. How many working automobiles, vans, and trucks, are kept at home for use by members of your
household?
___ None
___ 2
___ 4
___ 6 or more
___ 1
___ 3
___ 5
9. What are the annual costs of utilities and fuels for the place where you live?
If you have lived here less than 1 year, estimate the annual cost.
a. Electricity
Annual Amount-Dollars:$ ___________
OR
__________ Included in rent or no charge
b. Gas
Annual Amount-Dollars:$ ___________
OR
__________Included in rent or no charge
c. Water and sewer
Annual Amount-Dollars:$ ____________
OR
__________ Included in rent or no charge
d. Oil, coal, kerosene, wood, etc.
Annual Amount-Dollars:$ ____________
OR
__________ Included in rent or no charge
e. Garbage
Annual Amount-Dollars: $ ____________
OR
___________ Included in rent or no charge
10.
In the past year, how often did you not have enough money for food, clothing or housing?
1.
never
2.
rarely
3.
sometimes
4.
often
11
HOUSEHOLD
Who currently lives in the same house as you?
Please list each person’s first name, relationship to you, gender, and age.
FIRST NAME
RELATIONSHIP
GENDER
12
AGE
EDUCATION
1.
Have you ever received a degree or certificate from any of the following types of schools?
CIRCLE ALL THAT APPLY
NO
YES
high school ................................ ................ ................... ............... 0 .................. ..1
Adult Basic Education classes (for GED) .. ................... ............... 0 .................. ..1
technical or trade school ............ ................ ................... ............... 0 .................. ..1
military occupational training ... ................ ................... ............... 0 .................. ..1
junior or community college ..... ................ ................... ............... 0 .................. ..1
four-year college or university .. ................ ................... ............... 0 .................. ..1
graduate or professional school (e.g., medical or law school) ....... 0 .................. ..1
other (Please write in.)
_________________________________________________________________
2.
Did you ever drop out of high school?
0.
no
1.
yes
3.
I would like to learn a traditional trade or craft.
1.
not at all
2.
not much
3.
somewhat
4.
very much
5.
I already know or am learning a traditional trade or craft.
13
NEIGHBORHOODS
1. How likely is it that you would move out of the area where you live if you could?
1 = very unlikely,
2 = somewhat unlikely,
3 = a 50-50 chance,
4 = somewhat likely, or
5 = very likely?
2. How likely is it that your neighbors would do something about children who were skipping school
and hanging out ?
1 = very unlikely,
2 = somewhat unlikely,
3 = a 50-50 chance,
4 = somewhat likely, or
5 = very likely?
3. How likely is it that your neighbors would do something about children who were spray- painting
graffiti on a local building?
1= very unlikely,
2= somewhat unlikely,
3 = a 50-50 chance,
4= somewhat likely, or
5 = very likely
4. How likely is it that your neighbors would do something about children who were showing
disrespect to an adult?
1= very unlikely,
2= somewhat unlikely,
3 = a 50-50 chance,
4= somewhat likely, or
5 = very likely
5. How likely is it that your neighbors would do something about a fight that broke out in
front of their house?
1 = very unlikely,
2 = somewhat unlikely,
3 = a 50-50 chance,
4 = somewhat likely, or
5 = very likely
6. How likely is it that your neighbors would do something if the school or community buildings
closest to their home was threatened with budget cuts?
1 = very unlikely,
2 = somewhat unlikely,
3 = a 50-50 chance,
4 = somewhat likely, or
5 = very likely
14
Please tell me how much you agree or disagree with each of the following statements.
7. The area where you live is it a good place to raise kids. Do you…
1 = strongly disagree,
2 = disagree,
3 = agree, or
4 = strongly agree
8. People around here are willing to help neighbors? Do you...
1 = strongly disagree,
2 = disagree,
3 = agree, or
4 = strongly agree
9. The area where you live is a close-knit place.
1 = strongly disagree,
2 = disagree,
3 = agree, or
4 = strongly agree
10. People in the area where I live can be trusted.
1 = strongly disagree,
2 = disagree,
3 = agree, or
4 = strongly agree
11. Altogether, how long have you lived in this area?
YEARS: _____
MONTHS: ________ DAYS: _______
For the next questions, please tell me how much of a problem each of the following is in the area where
you live.
12. High unemployment?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
13. Run down houses or abandoned cars?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
14. Burglaries and thefts?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
15
15. Assaults, domestic violence?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
16. Gangs?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
17. Drug dealing in the open, alcohol consumption, bootlegging?
1 = not a problem,
2= somewhat of a problem, or
3 = a big problem
18. Unsupervised children?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
19. Teenage pregnancy?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
20. Cultural/historical trauma?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
21. Feeling safe outdoors due to others?
1 = not a problem,
2 = somewhat of a problem, or
3= a big problem
22. Police not being available?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
23. Children that you don’t want your child/children to associate with?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem?
16
24. Overall, would you say that conditions in your area have gotten worse, remained the same, or
gotten better over the past 2 years?
1 = gotten worse
2 = remained the same
3 = gotten better
4 = don’t know
Now please answer the next set of questions about the area where you live.
31. How much of a problem is black mold in the area where you live?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
32. How much of a problem is contaminated drinking water in the area where you live?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
33. How much of a problem is asbestos in the area where you live?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
34. How much of a problem is lead-based paint in the area where you live?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
35. How much of a problem are pestcides and herbicides in the area where you live?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
36. How much of a problem are rodents, like mice?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
37. How much of a problem are stray dogs?
1 = not a problem,
2 = somewhat of a problem, or
3 = a big problem
17
ABOUT YOUR CHILD
On the following questions PLEASE CIRCLE THE NUMBER that is most typical of your child.
“About average” means how you think the typical child would be scored.
1.
How easy or difficult is it for you to calm or soothe your child when he/she is upset?
1
2
3
very easy
2.
5
6
about average
7
difficult
How consistent is your child in sticking to his/her sleeping routine?
1
2
3
very consistent;
little or no variability
3.
4
4
5
6
some variability
7
very inconsistent
highly variable
How consistent is your child in sticking to his/her eating routine?
1
2
3
very consistent;
little or no variability
4
5
6
some variability
7
very inconsistent;
highly variable
4.
How easy or difficult is it for you to know what’s bothering your child when he/she cries
or fusses?
1
2
3
very easy
4
5
6
about average
7
difficult
5.
How many times per day, on the average, does your child get fussy and irritable—for either
short or long periods of time?
1
never
2
1-2 times
per day
3
3-4 times
per day
4
5-6 times
per day
18
5
7-9 times
per day
6
7
10-14 times more than 15
per day
times per day
6.
1
How much does your child cry and fuss in general?
2
3
very little; much
less than the
average child
7.
1
1
1
2
3
1
7
a lot; much
more than the
average child
4
5
6
responds favorably about
half the time, or is
always neutral
7
always responds
negatively or
fearfully
How does your child typically respond to new foods?
2
3
4
5
6
responds favorably about
half the time, or is
always neutral
7
always responds
negatively or
fearfully
How does your child typically respond to a new person?
2
3
always responds
favorably
10.
6
How does your child typically respond to new playthings?
always responds
favorably
9.
5
average amount; about as
much as the average child
always responds
favorably
8.
4
4
5
6
responds favorably about
half the time, or is
always neutral
7
always responds
negatively or
fearfully
How does your child typically respond to being in a new place?
2
always responds
favorably
3
4
responds favorably about
half the time, or is
always neutral
19
5
6
7
always responds
negatively or
fearfully
11.
How well does your child adapt to new experiences (such as items 7-10) eventually?
1
2
3
very well,
always likes it
12.
2
7
almost always
dislikes it
in the end
3
4
5
6
7
very easily upset
by things that
wouldn’t bother
other children.
When your child gets upset, how vigorously or loudly does he/she cry and fuss?
1
2
about average
3
very mild intensity
or loudness
4
5
6
moderate intensity
or loudness
7
very loud or
intense, really
cuts loose
How does your child react when you are dressing him/her?
1
2
3
very well-likes it
15.
6
ends up liking it about
half the time
eventually
very hard to upset-even by things that
upset most children
14.
5
How easily does your child get upset?
1
13.
4
4
5
6
7
doesn’t like
it at all
about average—doesn’t
mind it
How active is your child in general?
1
very calm
and quiet
2
3
4
average
20
5
6
7
very active
and vigorous
16.
How much does your child smile and make happy sounds?
1
2
3
a great deal,
much more than
most children
17.
2
7
very little,
much less than
most children
3
4
5
6
neither serious
nor cheerful
7
serious
How much does your child enjoy playing with you?
1
2
3
a great deal,
really loves it
1
6
an average amount
very happy
and cheerful
19.
5
What kind of mood is your child generally in?
1
18.
4
4
5
6
about average
7
very little,
doesn’t like
it very much
How much does your child want to be held?
2
3
wants to be free
most of the time
4
5
sometimes wants to be held,
sometimes not
6
7
a great deal-wants to be held
almost all the time
20.
How does your child respond to disruptions and changes in everyday routine, such as when
you go to church or a meeting, on trips, etc.?
1
2
3
very favorably,
doesn’t get upset
21.
1
4
5
about average
6
7
very unfavorably,
gets quite upset
How changeable is your child’s mood?
2
changes seldom, and
changes slowly when
he/she does change
3
4
about average
21
5
6
7
changes often
and rapidly
22.
How excited does your child become when people play with or talk to him/her?
1
2
3
very excited
4
5
6
about average
7
not at all
23.
On the average, how much attention does your child require, other than for caregiving
(feeding, diaper changes, etc.)?
1
2
3
very little—much
less than average
24.
2
7
a lot—much
more than the
average child
3
4
5
about half the time
6
7
almost neverwon’t play by self
How does your child react to being confined (as in a carseat, infant seat, playpen, etc.)?
1
2
3
very well-likes it
4
5
6
7
doesn’t like
it at all
minds a little or
protests once in awhile
How much does your child cuddle and snuggle when held?
1
2
3
a great deal-almost every time
27.
6
average amount
almost always
26.
5
When left alone, your child plays well by himself/herself?
1
25.
4
4
5
6
average, sometimes does
and sometimes does not
7
very little
seldom cuddles
How easy or difficult is it to take your child places?
1
easy; fun to
2
3
4
okay; child may fuss
22
5
6
7
difficult; child is
take child with me
28.
but no real trouble
usually disruptive
Does your child persist in playing with objects when he/she is told to leave them alone?
1
2
3
rarely or
never persists
4
5
6
7
sometimes does and
sometimes not
almost always
persists
29.
Does your child continue to go someplace even when told something like “stop”, “come
here”, or “no-no”?
1
2
3
rarely or never
4
5
6
sometimes does and
sometimes not
7
almost always
30.
When removed from something he/she is interested in but should not be getting into, your
child gets upset.
1
2
3
Never
31.
6
7
always gets
very upset
How persistent is your child in trying to get your attention when you are busy?
2
3
doesn’t persist
at all
4
5
6
will try, but will only
mildly persist
7
very persistent
will do anything
to get attention
Please rate the overall degree of difficulty your child would present for the average mother.
1
2
3
super easy
33.
5
sometimes does and
sometimes doesn’t
1
32.
4
4
ordinary, some
problems
Did your baby have colic?
(Unexplained fussiness for long periods for time)
______YES
_____ NO
23
5
6
7
highly difficult
to deal with
CHILD’S HEALTH & SAFETY
The next questions are about your child’s health & safety.
1. Overall, would you say your child’s health has been…
1.
Excellent
2.
Very good
3.
Good
4.
Fair
5.
Poor
2. Has your child had any reoccurring health problems?
0.
NO
1.
YES What are they?
_______________________________________________________
3. a. How many different times has your child stayed in a hospital for at least one night?
# of_________ times [IF ZERO, Skip to 4]
b. Altogether, how many nights did your child stay in a hospital?
# of ___________nights
4.
Since child’s birth, how many times has he/she gone for well-baby checkups? These are visits to
the doctor when (he/she) isn’t sick, but to get (him/her) checked over or to get vaccinations?
0. Never
1. Once
2. Twice
3. 3 or more times
The next few questions are about ways in which children can get hurt.
5.
a. If your child swallows something dangerous or poisonous, do you have anything in the house
to make (him/her) vomit?(Dangerous or poisonous products such as drain opener, cleansers, dish
detergents, floor cleaners, rug cleaners, disinfectants, adult medications, etc.)
0.
no Skip to 6
1.
yes
b. What do you use?
1. ipecac
2. other, (specify)_____________________
3. finger/tongue depressor
4. milk
5. castor oil
6.
a. If you had to get the phone number of the poison control center in an emergency, do you
know how to find it? (This is a hotline that provides information to callers on what to do for
specific types of poisoning.)
0. noSkip to 7
1. yes
24
b. What would you do?
1. dial 0, 411, or 911
2. would have to look it up
3. call hospital/clinic/ER
7.
Do you use gates for the top of the stairs or use something else so your child stays off them?
1.
has gates
0.
has something else (specify)__________________________
1.
don’t need
2.
need but don’t have
3.
door
8.
Do you use guards or gates for your windows?
(Do not include gates for burglars.)
1.
have gates
2.
don’t have gates
3.
Don’t need gates
4.
Have screens or storm windows, doesn’t need gates
9.
Do you have covers on all your electrical outlets that don’t have plugs in them?
(Covers can be plastic safety covers, tape or other coverings.)
0.
no
1.
yes
10.
a. Does your (house/trailer/apartment) have smoke alarms?
0.
nogo to #11
1.
yes
b. As far as you know, are the batteries working in the smoke alarms?
0.
no
1.
yes
2.
hard wired to electrical system
9.
don’t know
11.
a. When you take your child in a car, do you usually put (him/her) in ….
1. car seat
2. booster seat
3. regular seatbelt
4. parent’s lap
5. no restraint
b. When you take your child in a car, does he/she usually sit in the front seat or back seat?
1. front
2. back
3. varies
25
12.
How do you keep your child away from heating units? Please write in.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
26
THE HOME ENVIRONMENT
We are interested in your family’s lifestyle and rules.
Some questions you answer are YES or NO others are words or phrases. Please circle the number that goes with
the answer you choose.
Other questions have boxes for you to write an answer.
If any questions is not clear, please circle the questions and ask the interviewer about it when you have finished.
1.
About how often does your child have a chance to get out of the house (either by himself/herself,
or with an older person)? (CIRCLE ONE)
Does not go yet, too young………..01
About once a month or less……….02
A few times a month…………........03
About once a week……………. …04
4 or more times a week……………05
Every day………………………….06
2. About how many children’s books does your child have of his/her own? (CIRCLE ONE)
None, too young..................................01
1 or 2 books………………………….02
3 or 9 books………………………….03
10 or more books…………………….04
3. How often do you get a chance to read stories to your child? (CIRCLE ONE)
Never………………………………….01
Several times a year…………………...02
Several times a month………………...03
Once a week…………………………..04
About 3 times a week…………………05
Every day……………………………...06
4. About how often do you take your child to the grocery store? (CIRCLE ONE)
Never………………………………….01
Several times a year…………………...02
Several times a month………………...03
Once a week…………………………..04
About 3 times a week…………………05
Every day……………………………...06
5. Does your child have any cuddly, soft or role-playing toys ( like a doll) ?
____YES ____NO
27
6. Does your child have any push or pull toys?
____YES ____NO
7.
Some parents spend time teaching their children new skills while other parents believe children
learn best on their own. Which of the following best describes your attitude? (CIRCLE ONE)
“Parents should always spend time teaching their children”……………………………..……..1
“Parents should usually spend time teaching their children”…………………………..…….....2
“Parents should usually allow their children to learn on their own”…………………………...3
“Parents should always allow their children to learn on their own”……………………......….4
8. Does your child see his/her father or father-figure on a daily basis?
Yes……………………1
No…………………….2
IF YES: How often does your child eat a meal with both mother and father or father-figure?
(CIRCLE ONE)
More than once a day ...................................................... 1
Once a day ...................................................................... 2
Several times a day ......................................................... 3
About once a week .......................................................... 4
About once a month ........................................................ 5
Never
...................................................................... 6
No father, step-father, or father-figure ............................ 7
9.
10.
Children seem to demand attention when their parents are busy, doing housework, for example.
How often do you talk to your child while you are working?
Always talk to child when I’m working………1
Often talk to child when I’m working………. .2
Sometimes talk to child when I’m working…..3
Rarely talk to child when I’m working……..…4
Never talk to child when I’m working………...5
Sometimes kids mind pretty well and sometimes they don’t. Have you had to spank your child
in the past week?
Yes…………..1
No…………...2
IF YES: About how many times in the past week? (WRITE IN NUMBER OF TIMES)
Number of times: ___ ____
11.
How many hours a day does your child watch television?
Number of hours ____________
12.
How many times per month does your child participate in religious/spiritual activities?
Number of times ____________
28
ALCOHOL
The following questions ask about the way your life may be affected by alcohol. Please circle the number
next to your answer.
None
A few
Some
Most
1.
How many of your friends regularly
drink alcohol? .................... .............................. 1…………..2 . ……………...3 .. ……………4
2.
How many of your friends regularly
get drunk? .......................... .............................. 1…………..2 . ……………...3 .. ……………4
3.
How many of your friends are living
alcohol-free lives? ............. ………………….1……………2……………….3……...………4
4.
In your opinion, how many of your
friends have a serious drinking problem ……1………........2……………….3……………...4
5.
How many of your friends drink alcohol,
but it does not cause problems for them?.......1 …………...2…………….....3……………...4
6.
How many people in your family
regularly drink alcohol? .............……………1 …………...2…………….…3……………...4
7.
How many people in your family
regularly get drunk? ...................……………1 …………..2………………..3……………...4
.
8.
How many people in your family
are living alcohol-free lives? ......……………1 …………..2………………..3……………...4
9.
In your opinion, how many people in
your family have a serious
drinking problem? ................................. ....... 1 .................. 2 ... ....................... 3 . .................... 4
10.
How many people in your family drink
alcohol, but it does not cause
problems for them?................................ ....... 1 .................. 2 ... ....................... 3 . .................... 4
11.
How often does your partner drink alcohol?
1.
never
2.
rarely
3.
sometimes
4.
often
5.
almost all of the time
8.
I don't have a partner.
9.
I don't know.
29
12.
Did you ever drink alcohol, such as beer, wine or hard liquor?
0.
no  Skip to 36
1.
yes
13.
Have you had a drink of alcohol in the past year?
0.
no  Skip to 36
1.
yes
14.
In the past month, how many days did you drink alcohol?
(PLEASE CHOOSE BETWEEN 0 - 31 DAYS.)
Number of days: __________
15.
On those days during the past month when you drank alcohol, about how many drinks did you
usually have each day? Sometimes it's hard to count drinks, so...
one 12 ounce can of beer
= 1 drink
one 40 ounce beer
= 3 drinks
a whole six-pack of beer
= 6 drinks
a wine cooler
= 1 drink
a bottle of Zima
= 1 drink
a shot or gulp of straight hard liquor
= 1 drink
(like whiskey or vodka)
a full glass of a mixed drink
= 1 drink
(like Everclear in punch)
Number of drinks: _____ _____
14.
During the past month, what was the most you had to drink in any one day? (Use above list to
help you count.)
Number of drinks: __________
17.
During the past month, how often did you get drunk (sick, staggering, or passed out)?
0. 0 times
1. 1-2 times
2. 3-5 times
3. 6-10 times
4. 11-20 times
5. more than 20 times
8. I didn't drink in the past month.
18. During the past month, how often did you blank out or black out (not remember what you did
when you were drinking)?
0. 0 times
1. 1-2 times
2. 3-5 times
3. 6-10 times
4. 11-20 times
5. more than 20 times
8. I didn't drink in the past month.
30
19. When you drank alcohol in the past year, how much did you usually drink?
1. a little, but not enough to feel it
2. enough to feel it a bit
3. enough to feel it a lot
4. until I get really drunk (sick, staggering, or passed out)
20. In the past year, did you ever stay drunk for two whole days or more?
0. no
1. yes
21. In the past year, has anyone thought you had a problem with alcohol?
0. no
1. yes
9. I don't know.
22. In the past year, have you tried to quit drinking?
0. no
1. yes
Please circle the number that comes closest to what you've done during the past month.
Rarely or
Almost
never
Sometimes
Often
always
I didn't
drink in the
past month
During the past month...
23.
Did you drink more
than you thought you
would?
……………1 ..................... 2 ................... 3 ................... 4 ................. 8
24.
Did you end up drinking
even when you had
decided not to? ............................... 1 ...................... 2 ................... 3 ................... 4 ................. 8
25.
Were you sick or did you have
a hangover after drinking? .............. 1 ...................... 2 ................... 3 ................... 4 ................. 8
26.
Did you go to class or work
drunk or with a hangover? .............. 1 ...................... 2 ................... 3 ................... 4 ................. 8
27.
Did you get sick or have
any physical problems when
you stopped drinking? .................... 1 ...................... 2 ................... 3 ................... 4 ................. 8
28.
After drinking too much, did
you drink again to get
rid of a sick or uncomfortable
feeling? .......................................... 1 ...................... 2 ................... 3 ................... 4 ................. 8
31
Please circle the number that comes closest to what you've done during the past month.
Rarely or
never
Sometimes
Often
Almost
always
I didn't
drink in the
past month
29.
Did you fight with your
family while you were drinking?.... 1 ...................... 2 ................... 3 ................... 4 ................. 8
30.
Did you fight with a friend or
friends while you were drinking? ... 1 ...................... 2 ................... 3 ................... 4 ................. 8
31.
In the past month, did you fight with your partner while you were drinking?
1.
rarely or never
2.
sometimes
3.
often
4.
almost always
8.
I didn't drink in the past month.
9.
I don't have a partner.
32.
In the past year, has anyone suggested that you should get treatment for an alcohol problem?
0. no
1. yes
33.
In the past year, have you received treatment for your use of alcohol from a counselor, or a
treatment program, or an AA meeting?
0. no
1. yes
34.
Have you ever used any traditional healing such as participating in a sweat lodge or a sing, or
received help from a medicine man, for an alcohol abuse problem?
0. no
1. yes
35.
In the past year, have you used any traditional healing such as participating in a sweat lodge or
a sing, or received help from a medicine man, for an alcohol abuse problem?
0. no
1. yes
IF YOU SKIPPED FROM #12 or #13, YOU'RE IN THE RIGHT SPOT!
36.
Do you have anyone to give you guidance and support for living an alcohol-free and drug-free
life? 0. no
1. yes
If so, how is this person related to you? (Example: partner, friend, teacher, or relative)
Relationship____________________________________________________________
32
DRUGS
For the following drugs, please circle the number indicating whether you have ever tried the drug and write
in the number of times you used it in the past month.
Do not include using drugs as prescribed for you by a doctor or nurse or times that you have used peyote in
a ceremony. If you have never tried the drug, please circle the number for "no" and go to the next question.
Have you ever tried...
No
Yes
If yes,
# times used in
the past month
1.
marijuana ......................................... ......... ............... 0 .............1......................... ________ times
2.
crack or cocaine ............................... ......... ............... 0 .............1......................... ________ times
3.
crank .. ............................................. ......... ............... 0 .............1......................... ________ times
4.
inhalants (glue, gasoline,
paint, aerosols, etc.) ........................ ......... ............... 0 .............1......................... ________ times
5.
amphetamines or speed (methadrine,
crystal, uppers, white cross, etc.) .... ......... ............... 0 .............1......................... ________ times
6.
barbiturates or downers (librium,
valium, reds, quaaludes, sleeping
pills, pain killers, etc.) ..................... ......... ............... 0 .............1......................... ________ times
7.
prescription drugs, not as prescribed …………..…..0 ..............1......................... ________ times
8.
other drugs such as those on the list below ……….0 ..............1......................... ________ times
hallucinogens (LSD, acid, peyote (not including in a ceremony), etc.)
PCP (angel dust)
heroin, morphine or other opiates/narcotics (codeine)
amyl or butyl nitrates
Ecstasy, MDA, or MDMA
9.
Since 1980, have you used a needle to inject (shot up) any drugs such as
amphetamines/stimulants, cocaine, heroin, meth, hashish?
0. no
1. yes
10.
How often do you smoke cigarettes?
0.
not at all
1.
once in a while, but not every day
2.
1-5 cigarettes per day
3.
6-10 cigarettes per day
4.
11-20 cigarettes per day
5.
more than one pack per day but less than two packs
6.
two packs or more per day
33
THINGS I DO WELL
Rarely or
never
Sometimes
Often
Almost
always
1.
I am easy for others to
be around......................................... 1 ........................ 2 .......................... 3 ...................... 4
2.
When I'm not busy, I find
lots of fun things to do. ................... 1 ........................ 2 .......................... 3 ...................... 4
3.
I am good at ceremonial skills
or traditional practices such as
singing, drumming, hunting
or dancing. ...................................... 1 ........................ 2 .......................... 3 ...................... 4
4.
I can make other people laugh. ........ 1 ........................ 2 .......................... 3 ...................... 4
5.
I am good at traditional crafts
or skills such as rug-making,
beadwork, or quilting. ..................... 1 ........................ 2 .......................... 3 ...................... 4
6.
I am good at sports and
athletic games. ................................ 1 ........................ 2 .......................... 3 ...................... 4
7.
I can easily make friends
with people...................................... 1 ........................ 2 .......................... 3 ...................... 4
8.
I am good at creative things,
like acting, art, or music.................. 1 ........................ 2 .......................... 3 ...................... 4
9.
I stand up for what I believe. ........... 1 ........................ 2 .......................... 3 ...................... 4
10.
I am considerate of others. ............... 1 ........................ 2 .......................... 3 ...................... 4
11.
Other good things about me are:_________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
34
YOUR FEELINGS
Please circle the number which best describes how you felt during the past week.
Rarely or
none of the
time
(0-1 days)
A little
of
the time
(1-2 days)
Some
of
the time
(3-4 days)
Most or
all of
the time
(5-7 days)
1.
I felt that I could not shake off the
blues even with help from my family
or friends. ....................................... ................. 0 ..................... 1 .................... 2 ................... 3
2.
I felt depressed. ............................... ................. 0 ..................... 1 .................... 2 ................... 3
3.
I thought my life had been a failure…...………0 ..................... 1 .................... 2 ................... 3
4.
I felt fearful. .................................... ................. 0 ..................... 1 .................... 2 ................... 3
5.
I felt lonely. ..................................... ................. 0 ..................... 1 .................... 2 ................... 3
6.
I had crying spells. .......................... ................. 0 ..................... 1 .................... 2 ................... 3
7.
I felt sad. ......................................... ................. 0 ..................... 1 .................... 2 ................... 3
8.
I felt crabby. .................................... ................. 0 ..................... 1 .................... 2 ................... 3
9.
I felt hopeless. ................................. ................. 0 ..................... 1 .................... 2 ................... 3
10.
I felt like no one cared. ................... ................. 0 ..................... 1 .................... 2 ................... 3
11.
I felt discouraged. ........................... ................. 0 ..................... 1 .................... 2 ................... 3
DURING THE PAST WEEK...
NO
YES
12.
have you often worried that you have made a fool of yourself in front
of other people? ............................. ........................ .......................... ........................ 0 ............. 1
13.
have you often worried that you have made a mistake or done
something the wrong way? ............ ........................ .......................... ........................ 0 ............. 1
14.
have you been almost always worried about something? ................... …………...….0 .............. 1
15.
have you been very worried about whether other people like you? ... ………………0 .............. 1
16.
have you often gotten worried or nervous? ............. .......................... ........................ 0 ............. 1
35
HOW DO YOU VIEW YOURSELF?
Disagree
Somewhat
Disagree
Neither agree
nor disagree
Somewhat
Agree
Agree
1.
I feel that I have
many good qualities. .................. 1 ................... 2 ....................... 3 ......................... 4 .................5
2.
I feel that I am
a failure. ..................................... 1 ................... 2 ....................... 3 ......................... 4 .................5
3.
I have a positive attitude
about myself. .............................. 1 ................... 2 ....................... 3 ......................... 4 .................5
4.
I feel worthless. .......................... 1 ................... 2 ....................... 3 ......................... 4 .................5
5.
I am satisfied with myself. .......... 1 ................... 2 ....................... 3 ......................... 4 .................5
6.
I think I am no good at all. .......... 1 ................... 2 ....................... 3 ......................... 4 .................5
36
COPING WITH PROBLEMS I
Below is a list of things people may do when faced with a problem. for each item, select the answer that
best describes how often you did the behavior in the past month.
Never
Sometimes
Often
Most of
the time
1.
I tried to make things better by
changing what I did.......................... .................... 1 ................... 2 ................. 3 ................. 4
2.
I tried to stay away from the problem…………….1 ................... 2 ................. 3 ................. 4
3.
I tried to stay away from things that
made me feel upset. ......................... .................... 1 ................... 2 ................. 3 ................. 4
4.
I did something to make things better…………...1 ..................... 2 ................. 3 ................. 4
5.
I avoided the problem by going off by myself. ...... 1 ................... 2 ................. 3 ................. 4
6.
I avoided the people that made me feel bad. .......... 1 ................... 2 ................. 3 ................. 4
7.
I did something to solve the problem……………1..................... 2 ................. 3 ................. 4
8.
I tried to focus on the good that might
come out of the problem. ................. .................... 1 ................... 2 ................. 3 ................. 4
9.
I got drunk or took drugs. ................. .................... 1 ................... 2 ................. 3 ................. 4
10.
I prayed. ............................................ ……………1 .................... 2 ................. 3 ................. 4
11.
I talked about it with someone. ......... .................... 1 ................... 2 ................. 3 ................. 4
12.
My family had a ceremony or sing done
for me.……………………………………………1 ................... 2 ................. 3 ................. 4
13.
I took a drive. .................................... .................... 1 ................... 2 ................. 3 ................. 4
14.
I did something active (like take a walk/excerise)..1……………2…………..3…………..4
37
COPING WITH PROBLEMS II
Think about the times that you have done something big, such as moving to a new house, or preparing for a
ceremony or family reunion.
When preparing for these types of activities, how often do you do the following?
Rarely
or
Never
Sometimes
Often
Almost
Always
1.
I go to other people for advice .............. 1 ...................... 2 ...................... 3 ...................... 4
2.
I think about problems I had in
similar situations and try to
avoid them............................................ 1 ...................... 2 ...................... 3 ...................... 4
3.
I wait quite a while, because I
work better under pressure ................... 1 ...................... 2 ...................... 3 ...................... 4
4.
I try to involve other people .................. 1 ...................... 2 ...................... 3 ...................... 4
5.
I think of several ways to do
it, in case my first plan
didn't work ........................................... 1 ...................... 2 ...................... 3 ...................... 4
6.
I pray for guidance and help ................. 1 ...................... 2 ...................... 3 ...................... 4
7.
I make very detailed plans .................... 1 ...................... 2 ...................... 3 ...................... 4
8.
I just let things happen .......................... 1 ...................... 2 ...................... 3 ...................... 4
9.
I don't think about it too
much because I know it
would get done ..................................... 1 ...................... 2 ...................... 3 ...................... 4
10.
I plan for things that other
people wouldn't worry about................ 1 ...................... 2 ...................... 3 ...................... 4
11.
I talk with friends about how
I am going to go about it ...................... 1 ...................... 2 ...................... 3 ...................... 4
12.
I decide to figure things out
as they occur rather than
trying to think of everything
that might happen................................. 1 ...................... 2 ...................... 3 ...................... 4
38
PARENTING STRESS
Having a child can sometimes be stressful. The next questions are about how stressful your child has been for
you and the ways in which you have had to adjust your life. For each statement, please tell me if you strongly
agree with it, mildly agree, mildly disagree, or strongly disagree.
STRONGLY
AGREE
MILDLY
AGREE
NOT SURE
MILDLY
DISAGREE
STRONGLY
DISAGREE
Your child rarely does
things for you that make
you feel good.
1
2
3
4
5
Most times you feel that
your child does not like
you and does not want to
be close to you.
1
2
3
4
5
He/She smiles at you much
less than you expected.
1
2
3
4
5
When you do things for
your child you get the
feeling that your efforts are
not appreciated very much.
1
2
3
4
5
When playing, your child
rarely giggles or laughs.
1
2
3
4
5
He/She seems to learn
slowly.
1
2
3
4
5
He/She doesn’t seem to
smile a lot.
1
2
3
4
5
Your child is able to do
less than you expected.
1
2
3
4
5
It takes a long time and it
is very hard for your child
to get used to new things
1
2
3
4
5
39
STRONGLY
AGREE
MILDLY
AGREE
NOT SURE
(DON’T
READ)
MILDLY
DISAGREE
STRONGLY
DISAGREE
You expected to have
closer and warmer feelings
for your child than you do
and this bothers you.
1
2
3
4
5
Sometimes does your child
do things that bother you
just to be mean.Does
things knowing it will
upset you or make you
mad.
1
2
3
4
5
Please tell me which statement describes how you feel about yourself as a parent.
Do you feel that you are...
1.
2.
3.
4.
5.
Not very good at being a parent.
A person who has some trouble being a parent
An average parent
A better than average parent
A very good parent
40
SOCIAL SUPPORT
IF MARRIED OR LIVING WITH SOMEONE: GO TO #1, IF NOT GO TO #19.
NOT
MUCH
1.
SOME
A LOT
How much does your [husband/wife/partner]
really care about you—not much, some, a lot? ............ 1 .............. ….2 ........ ……..3
2.
How much does [he/she] understand the way
you feel about things? .................................................... 1 .............. ….2 ........ ……..3
3.
How much does [he/she] appreciate you? ..................... 1 .............. ….2 ........ ……..3
4.
How much can you rely on [him/her] for
help if you have a serious problem? .............................. 1 .............. ….2 ........ ……..3
5.
How much can you talk about
your worries with [him/her]? ......................................... 1 .............. ….2 ........ ……..3
6.
How much can you relax and be yourself
around [him/her]? .......................................................... 1 .............. ….2 ........ ……..3
7.
How much do you and your husband/wife/partner
share interests or activities…………………………….1…………….2……………3
NEVER SOMETIMES OFTEN
8.
How often does your [husband/wife/partner]
make too many demands on you--often,
sometimes, or never? .................................................. 0 ..................... 1 ...................2
9.
How often does [he/she] argue with you? .................... 0 ..................... 1 ...................2
10.
How often does [he/she] criticize you?......................... 0 ..................... 1 ...................2
11
How often does [he/she] let you down
when you are counting on [him/her]? ........................... 0 ..................... 1 ...................2
12.
How often does [he/she] get on your
nerves? .......................................................................... 0 ..................... 1 ...................2
13.
How often does your [husband/wife/partner]
show affection to you? .................................................. 0 ..................... 1 ...................2
14.
How often does your [husband/wife/partner]
drink or use drugs too much? ........................................ 0 ..................... 1 ...................2
15.
How often does [he/she] gamble too much? ................. 0 ..................... 1 ...................2
16.
How often are your sexual needs
fulfilled by this relationship? ........................................ 0 ..................... 1 ...................2
41
17.
How often have you discussed or considered divorce, separation, or ending your
relationship?
often ..................................................... 2
sometimes ............................................ 1
never ..................................................... 0
18.
How happy are you in your marriage/relationship?
very happy ............................................ 3
a little happier than average ................. 2
not too happy........................................ 1
The next questions are about your friends and other relatives.
19.
How often do you talk on the phone or get together with friends or relatives who do not
live with you?
every day .............................................. 5
a few times a week ............................... 4
a few times a month ............................. 3
once a month ........................................ 2
less than once a month, or .................... 1
never (IF VOL.) ................................... 0
NOT MUCH
AT ALL
SOME
A LOT
20.
How much do your friends or relatives
really care about you—not much, some, a lot?.............. 1 .................. 2 .................... 3
21.
How much do they understand the way you
feel about things? ........................................................... 1 .................. 2 .................... 3
22.
How much do they appreciate you? ............................... 1 .................. 2 .................... 3
23.
How much can you rely on them for help
if you have a serious problem? ...................................... 1 .................. 2 .................... 3
24.
How much can you talk to them
about your worries? ....................................................... 1 .................. 2 .................... 3
25.
How much can you relax and be yourself
around them? ................................................................. 1 .................. 2 .................... 3
26.
NEVER SOMETIMES OFTEN
How often do your friends or relatives
make too many demands on you—
never, sometimes, often? ......................................... 0 .......................1...................... 2
27.
How often do they argue with you? ......................... 0 .......................1...................... 2
28.
How often do they criticize you? ............................. 0 .......................1...................... 2
42
29.
NEVER
SOMETIME
OFTEN
How often do they let you down when
you are counting on them? ....................................... 0 .......................1...................... 2
30.
How often do they get on your nerves? ................... 0 .......................1...................... 2
31.
How often do they drink or use drugs
too much?................................................................. 0 .......................1...................... 2
32.
How isolated do you feel?
very isolated ......................................... ….3
somewhat isolated ................................ .... 2
not very isolated at all .......................... ….1
33.
How often do you purposely avoid family gatherings? .
a lot ....................................................... ….3
sometimes, or ....................................... .... 2
not very much at all.............................. ….1
34.
Of those family gatherings you go to, how likely are you to leave early?
very likely ............................................. ….3
somewhat likely, or .............................. .... 2
not at all likely ..................................... ….1
35.
Would you say that in your case, being a parent has nearly always been enjoyable;
sometimes been enjoyable; or hardly ever been enjoyable?
nearly always ....................................... ….3
sometimes, or ....................................... .... 2
hardly ever ........................................... ….1
36.
Many [men/women] feel they're not as good [fathers/mothers] as they would like to be.
Have you ever felt this way?
nearly always ....................................... ….3
sometimes, or ...................................... .... 2
hardly ever .......................................... ….1
37.
How satisfied or pleased are you with how you get along with your children?
very satisfied ........................................ ….2
somewhat satisfied, or .......................... .... 1
not satisfied .......................................... ….0
38.
How satisfied or pleased are you as a parent with how your children are turning out?
very satisfied ........................................ ….2
somewhat satisfied, or .......................... .... 1
not satisfied .......................................... ….0
43
LIFETIME
The next questions are about things many people think are stressful. I'd like to ask you about things that
may have happened to you.
First, I'd like to ask about the time when you were growing up. During your growing up years, many
people are separated from one or both of their parents for some reason.
YES
1.
Was one of your parents ever so seriously ill
that he or she was not able to take care of you
on a regular basis?
2.
Did you ever have to go live with your
relatives because of problems in your family?
3.
Were you ever in a Mormon placement?
4.
Were you ever sent to reform school or
another institution?
5.
Were you ever placed in foster care?
6.
Were you ever put up for adoption?
7.
Other than these situations, were you ever
separated from your parents against your will
while you were growing up?
8.
Did you ever have to do a year of school over
again?
9.
Did you ever fail school or a training program,
or drop out of school?
10. Did your parents or anyone acting as your
parents ever end their relationship or get a
divorce while you were living with them?
44
NO
YES
NO
YES
NO
YES
NO
11. Did you ever have to go to the hospital for a
week or more?
12. Did you family participate in the BIA location
program?
13. Did you ever go to boarding school as a
boarder ?
Have any of the following people close to you
ever died? Check YES OR NO.
14. MOTHER/STEPMOTHER
15. FATHER/STEPFATHER
16. BROTHER OR SISTER
17. SPOUSE OR ROMANTIC PARTNER
18. A CHILD OF RESPONDENT
19. ANOTHER LOVED ONE
20. Have you ever witnessed a lot of deaths from
serious illness--for example, epidemics of
polio, influenza, tuberculosis, or pneumonia?
21. Have you/Has your partner ever had an
unexpected or unwanted pregnancy?
22. Have you/Has your partner ever had a
miscarriage?
23. Have you/Has your partner ever had an
abortion?
45
RECENT EVENTS
The next questions are about recent things that might have happened to you in the last 12 months.
YES
NO
1. Did you move your household?.........................................1……………………0
2. Was your house or car broken into? ………………… ...1……………………0
3. Did a child or another relative
move out of the house?………………………… ….…...1……………………0
4. Did a child or another
relative move into the house? …………………………...1……………………0
5. Did you apply for welfare benefits? ………… …………...1……………………0 GO TO 6
5a. Were you turned down for welfare benefits?.....1……………………0
6. Have you been in a romantic relationships?……………....1……………………0GO TO 7
6a. Did a romantic relationship end?.......................1……………………0
7.
Did you or anyone close to you
have a serious accident or injury?............................ .1……………..……0
7a. Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
The next set of question swill be yes or no answers.
YES
8.
NO
Have a serious illness? ......................................................................... 1……………………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
46
9.
YES
NO
Have trouble with the law?............................................................. 1……………………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
12.
In the past year, were you or anyone close to you robbed,
or have something taken by force? ................................................ 1……………………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
13.
Did anyone close to you have an
unexpected or unwanted pregnancy? ............................................ .1………… ...... ……0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
14.
Did you or anyone close to you
have a miscarriage or abortion? .................................................... .1………………...…0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
15.
Did you or anyone close to you
separate or get a divorce? ............................................................... 1……………..………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
47
16.
YES
NO
Did you or someone close to you have
a major financial crisis? ................................................................. 1………………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
17.
Did you or someone close to you drop out of school,
or fail school or a training program? ............................................. 1………………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
18.
Did you or anyone close to you lose a home
to fire, flood, or some other disaster? ............................................ 1………………0
Who was that?
___Spouse or partner
___Child
___Parent
___Other relative
___Friend
___You
48
ONGOING PROBLEMS
Here are some situations that come up in people's everyday lives.
Please tell me whether they are true or false for you at this time.
TRUE
FALSE
1.
You're trying to take on too
many things at once…………………………………….…... ..1………………0
2.
There is too much pressure on you to be like other people….....1………………0
3.
Too much is expected of you by others…………………… …..1………………0
4.
 IF EMPLOYED: Here are some situations at work. Are they true/false for you?
IF NOT EMPLOYED GO TO #11.
TRUE
FALSE
Your job often leaves you feeling both mentally
and physically tired. ………………………………….……….1………………0
5.
6.
You have more work than you can handle. ……………...…….1………………0
7.
You do not have a lot of freedom to decide how
you do your work. …………………………………………….1………………0
8.
Your working conditions are poor--for example,
noisy, dirty, or dangerous…………………………………..….1………………0
9.
You and your co-workers do not communicate well… ……….1………………0
10.
You are not sure your job is secure. …………………… …….1………………0
11.

IF GOING TO SCHOOL: Here are some situations people have at school.
Are they true or false for you?
IF NOT IN SCHOOL  GO TO #18.
TRUE
FALSE
12.
Your schoolwork often leaves you feeling both
mentally and physically tired…………………………….1………………0
13.
You have more work at school than you can handle… ….1………………0
14.
You do not have a lot of freedom to decide how…….. ….1………………0
you do your schoolwork.
49
15.
TRUE
FALSE
The conditions at school are poor--for example,
noisy, dirty, or there are not enough supplies…………………...1………………0
16.
You do not communicate well with the people
at school. ………………………………………………………..1………………0
17.
You are not sure your place at school is secure
[for example, you are not sure you will have
the resources to complete your studies] …………………….….1………………0
18.
 Here are some situations that come up in a person's social life and family life.
Are any of them TRUE or FALSE for you?
TRUE
FALSE
You avoid going to social events because
you would have to go alone………………………………….….1………………0
19.
20.
You have to go to social events alone
when you don't want to………………………………………….1………………0
21.
Your friends are a bad influence……………………………...….1………………0
22.
You don't have enough friends………………………………….1………………0
23.
You can't find enough to do…………………………… ……….1………………0
TRUE
FALSE
24.
Someone close to you has a health problem and
needs almost more help than you can provide………………….1………………0
25.
Someone in your family has an alcohol or
drug problem…………………………………………………….1………………0
50
The next questions are about the place where you live. Here are some problems that sometimes
come up. Would you say they are not a problem, there are some problems, or there are a lot of
problems like these in the place where you live?
NOT A
SOME LOT OF
PROB
PROBS PROBS
26.
The place where you live is too noisy or too polluted.......... 0 ................ 1 ................2
27.
You have conflicts with your neighbors .............................. 0 ................ 1 ................2
28.
Roads are often impassable. ................................................. 0 ................ 1 ................2
29.
You get your mail infrequently. ........................................... 0 ................ 1 ................2
30.
You have to go too far to get things done,
like shopping, banking, buying gas, or
going to school or work events. .......................................... 0 ................ 1 ................2
Here are some situations of prejudice and discrimination. How much are you experiencing them
these days? Not at all, some, or a lot?
NOT AT
A
ALL
SOME
LOT
31.
You have problems with police because
you are Indian. ..................................................................... 0 ................ 1 ................2
32.
You have problems in stores or restaurants
because you are Indian. ....................................................... 0 ................ 1 ................2
33.
You cannot find work because you are Indian. .................... 0 ................ 1 ................2
34.
You experience prejudice from Whites. ............................... 0 ................ 1 ................2
35.
You experience prejudice from Indians in
your own tribe or other tribes. ............................................. 0 ................ 1 ................2
36.
You experience prejudice within your own family. ............. 0 ................ 1 ................2
We have been talking about a lot of different kinds of ongoing problems, stresses, and strains in your
life right now.
NO
YES
37.
Have you had any other ongoing problems like
these that I did not mention?...........................................................0…………………1
37a.What were they?
___________________________________________________________
___________________________________________________________
51
Here are some problems that come up in communities? How big a problem are they in your
community? Would you say not a problem, there are some problems, or there are a lot of
problems like these?
NOT A
SOME LOT OF
PROB
PROBS PROBS
38.
Broken homes and family breakup....................................... 0 ................ 1 ................2
39.
Physical violence, abuse, and neglect .................................. 0 ................ 1 ................2
40.
Alcohol abuse ....................................................................... 0 ................ 1 ................2
41.
Drug abuse............................................................................ 0 ................ 1 ................2
42.
Gambling. ............................................................................. 0 ................ 1 ................2
43.
A lack of knowledge about tribal history,
tradition, and language. ....................................................... 0 ................ 1 ................2
44.
Problems in tribal government, like
favoritism and tribal politics. .............................................. 0 ................ 1 ................2
45.
Not enough good housing. ................................................... 0 ................ 1 ................2
46.
Not enough jobs in your community. ................................... 0 ................ 1 ................2
47.
Car accidents ........................................................................ 0 ................ 1 ................2
NOT AT
ALL
48.
49.
VERY
How familiar are you with tribal history--say,
for the past 150 years or so? Would you say
not at all, somewhat, or very familiar? ............................ 0 ................ 1 ................2
How big an impact has tribal history had on your
community? None, some, or a lot? .................................... 0 ................ 1 ................2
NOT AT
ALL
50.
SOME
WHAT
SOME
A
LOT
How much do you think about events like these? ................ 0 ................ 1 ................2
52
51.
Were any of your ancestors involved in significant?
historical events? YES_____
NO________
51a.
IF YES: Which events?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
53
SPIRITUALITY
1.
How important is spirituality in your life? . . .
very important ....................................3
somewhat ............................................... 2
not very, or .........................................1
not at all.................................................. 0
2.
How often do you spend time on religious or spiritual practices? . . .
every day or almost everyday ............3
several times a month............................. 2
from time to time,
occasionally, or .................................1
very rarely or not at all ........................... 0
3.
How important is it to you that your children participate in some kind of religious or
spiritual practice? . . .
very important ....................................3
somewhat ............................................... 2
not very, or .........................................1
not at all.................................................. 0
4.
How often do you seek comfort or guidance through religious or spiritual means?. . .
often ...................................................3
sometimes .............................................. 2
rarely, or .............................................1
never ....................................................... 0
54
CHILD’S BEHAVIOR
Section A:
These are sentences about young children. Many describe normal feelings and behaviors, but some
describe things that can be problems. Some may seem too young or too old for your child. Please do your
best to answer every question.
Directions:
For each statement, please circle the answer that best describes your child in the LAST MONTH.
0:
Not True
or Rarely
1:
Somewhat True or Sometimes
2:
Very True
or Often
N: No opportunity
Child has never had the chance to behave this way.
Example:
“Quiets if given a bottle.”
0
1
2
N
*N would mean that your child has not used a bottle in the last month.
0 = NOT TRUE/RARELY 1 = SOMEWHAT TRUE/SOMETIMES 2 = VERY TRUE/OFTEN
Please choose the answer that best describes your child in the LAST MONTH:
1.
Is bothered by loud noises or bright lights ......................................................
0
1
2
2.
Takes a while to feel comfortable in new places (10 minutes or more). .........
0
1
2
3.
Gets hurt so often that you can’t take your eyes off him/her. ..........................
0
1
2
4.
Acts aggressive when frustrated. .....................................................................
0
1
2
5.
Is quiet or less active in new situations. ...........................................................
0
1
2
6.
Gets upset when left with a new baby-sitter. (N: Never used babysitter). .....
0
1
2
8. Shows pleasure when s/he succeeds (For example, claps for self). ..................
0
1
2
9. Puts toys away after playing. ..............................................................................
0
1
2
10. Seems nervous, tense or fearful. .........................................................................
0
1
2
11. Is restless and can’t sit still. ................................................................................
0
1
2
12. Gets very “wound up” or silly when playing. ...................................................
0
1
2
13. Acts bossy. ..........................................................................................................
0
1
2
14. Is constantly moving...........................................................................................
0
1
2
15. Dislikes some foods because of how they feel. ..................................................
0
1
2
16. Follows rules. .....................................................................................................
0
1
2
17. Is bothered by certain odors (smells)..................................................................
0
1
2
18. Wakes up at night and needs help to fall asleep again. ......................................
0
1
2
1
N
0 = NOT TRUE/RARELY
1 = SOMEWHAT TRUE/SOMETIMES
Please choose the answer that best describes your child in the LAST MONTH:
2 = VERY TRUE/OFTEN
19. Gets upset when left with a baby-sitter or relative s/he knows.
(N: Have not used a sitter/relative in the last month) ........................................
0
1
2
20. Quiets down when you say “Shh”. .....................................................................
0
1
2
21. Cries or tantrums until s/he is completely tired out. ...........................................
0
1
2
22. Refuses to eat foods that require chewing. .........................................................
0
1
2
23. Misbehaves to get attention from adults. ............................................................
0
1
2
24. Tries to do as you ask. ........................................................................................
0
1
2
25. Plays with toys for 5 minutes or longer. .............................................................
0
1
2
28. Is afraid of certain animals. ................................................................................
What animal(s)?:____________________________________
0
1
2
29. Is afraid of certain things. ...................................................................................
What thing(s)?: ____________________________________
0
1
2
30. Is afraid of certain places, like stores, elevators, parks, or cars..........................
What place(s)?: ____________________________________
0
1
2
31. Hangs on you or wants to be in your lap when with other people. ....................
0
1
2
32. Rolls a ball back to you (or someone else). (N: Physically unable). .................
0
1
2
33. Has less fun than other children. ........................................................................
0
1
2
35. Is very loud. Shouts or screams a lot. ................................................................
0
1
2
36. Reaches for you when you are not holding him/her.
(N: Physically unable) ........................................................................................
0
1
2
37. Spits out food(s). ................................................................................................
0
1
2
38. Is disobedient or defiant. For example, refuses to do as you ask. .....................
0
1
2
39. Cries if doesn’t get own way. .............................................................................
0
1
2
41. Goes from toy to toy faster than other children his/her age. ..............................
0
1
2
42. Keeps trying even when something is hard. .......................................................
0
1
2
43. Is sneaky. Hides misbehavior. ...........................................................................
0
1
2
44. Looks at picture books by self. ...........................................................................
0
1
2
45. Helps with dressing. For example, puts arm in sleeve. .....................................
0
1
2
46. Cries or hangs onto you when you try to leave. .................................................
0
1
2
47. Worries a lot or is very serious. ..........................................................................
0
1
2
48. Feels sick when nervous or upset. ......................................................................
0
1
2
49. Pretends to do grown-up things, like shave. .......................................................
0
1
2
50. Is bothered by how some things feel on his/her skin.
(For example, clothing seams, certain fabrics, etc.). ..........................................
0
1
2
53. Is easily startled (scared). ...................................................................................
0
1
2
55. Is well-behaved...................................................................................................
0
1
2
2
N
N
N
0 = NOT TRUE/RARELY
1 = SOMEWHAT TRUE/SOMETIMES
Please choose the answer that best describes your child in the LAST MONTH:
2 = VERY TRUE/OFTEN
57. Laughs easily or a lot. .........................................................................................
0
1
2
58. Is stubborn. .........................................................................................................
0
1
2
59. Won’t touch some things because of how they feel. ..........................................
0
1
2
60. Is hard to soothe/calm when upset. ....................................................................
0
1
2
62. Sleeps through the night. ....................................................................................
0
1
2
63. Often gets very upset. .........................................................................................
0
1
2
64. Gags or chokes on food. .....................................................................................
0
1
2
65. Wants to do things for self..................................................................................
0
1
2
68. Is bothered by being in motion. For example, swinging, spinning,
being tossed in the air, or bouncing. ...................................................................
0
1
2
69. Wakes up grouchy or in a bad mood. .................................................................
0
1
2
70. Has trouble falling asleep or staying asleep. ......................................................
0
1
2
71. Tries to make you feel better when you’re upset................................................
0
1
2
72. Stays still while being changed, dressed or bathed. ...........................................
0
1
2
73. Has trouble calming down when upset. ..............................................................
0
1
2
74. Demands a lot of attention. .................................................................................
0
1
2
75. Sits for 5 minutes while you read a story. ..........................................................
0
1
2
76. Is worried or upset when someone is hurt. .........................................................
0
1
2
77. Tries to “make-up” after misbehaving. ..............................................................
0
1
2
78. Must be held to go to sleep. ................................................................................
0
1
2
79. Is impatient or easily frustrated. .........................................................................
0
1
2
81. Likes figuring things out, like stacking blocks. ..................................................
0
1
2
82. Can pay attention for a long time. (Not including TV) .....................................
0
1
2
84. Is aware of other people’s feelings. ....................................................................
0
1
2
86. Has trouble adjusting to changes. .......................................................................
0
1
2
87. Tries to help when someone is hurt. For example, gives a toy. .........................
0
1
2
88. Is shy with new adults. .......................................................................................
0
1
2
89. Is able to wait for things s/he wants ...................................................................
0
1
2
90. Cries a lot............................................................................................................
0
1
2
91. Imitates playful sounds when you ask him/her to. .............................................
0
1
2
92. Pretends that things are something else.
For example, uses banana as phone. ...................................................................
0
1
2
93. Accepts new foods right away. ...........................................................................
0
1
2
94. Enjoys challenging activities. .............................................................................
0
1
2
95. Hugs or feeds dolls or stuffed animals. ..............................................................
0
1
2
3
0 = NOT TRUE/RARELY
1 = SOMEWHAT TRUE/SOMETIMES
Please choose the answer that best describes your child in the LAST MONTH:
2 = VERY TRUE/OFTEN
96. Is a perfectionist. ................................................................................................
0
1
2
97. Imitates clapping or waving “bye-bye.” (N: Physically unable) ......................
0
1
2
99. “Jokes” or gives you things to make you smile or laugh...................................
0
1
2
100. Is irritable or grouchy. ......................................................................................
0
1
2
101. Pays careful attention when being taught something new. ...............................
0
1
2
102. Looks unhappy or sad without any reason. .......................................................
0
1
2
104. Refuses to eat.....................................................................................................
0
1
2
105. Is curious about new things. ..............................................................................
0
1
2
107.Is whiny or fussy when s/he is NOT tired. ........................................................
0
1
2
108. Feels bad about self. ..........................................................................................
0
1
2
109. Is a good eater....................................................................................................
0
1
2
110. Is shy with new children. ...................................................................................
0
1
2
111. Is destructive. Breaks or ruins things on purpose. ............................................
0
1
2
112. Seems to have no energy. ..................................................................................
0
1
2
113. Gets angry or pouts............................................................................................
0
1
2
114. Wakes up from scary dreams or nightmares. ....................................................
0
1
2
115. Wants to sleep in someone else’s room or bed.
(N: Always shares a room or bed) .....................................................................
0
1
2
116. Has temper tantrums. .........................................................................................
0
1
2
117. Hits, bites or kicks you (or other parent). ..........................................................
0
1
2
118. Is a picky eater. ..................................................................................................
0
1
2
120. Seems withdrawn. .............................................................................................
0
1
2
121. Seems very unhappy, sad or depressed. ............................................................
0
1
2
122. Obeys when asked to stop being aggressive......................................................
0
1
2
123. Refuses to eat certain food(s) for 2 days or more. .............................................
0
1
2
124. Purposely tries to hurt you (or other parent). ....................................................
0
1
2
4
N
N
Section B:
Please circle the number in this box that best indicates the answer to the following question:
Has your child begun to combine words yet, such as “more juice” or “doggie bite?”
0:
Not yet
-> Please go to Section C on the next page.
1:
Sometimes -> Please answer questions 2, 3, & 4 below.
2:
Often
-> Please answer questions 2, 3, & 4 below.
0 = NOT TRUE/RARELY 1 = SOMEWHAT TRUE/SOMETIMES 2 = VERY TRUE/OFTEN
Please choose the answer that best describes your child in the LAST MONTH:
2. Swears. ...............................................................................................................
0
1
2
3. Takes a while to talk in new situations. ..............................................................
0
1
2
4. Talks about other people’s feelings (like “Mommy mad”) ................................
0
1
2
Section C:
EXPERIENCES WITH OTHER YOUNG CHILDREN
In the last month, about how much time did your child spend with other
young children each week (not including brothers and sisters)? .............................. ________ hours
If your child did not have any contact with young children in the last month,
please go to Section D on the next page.
0 = NOT TRUE/RARELY1 = SOMEWHAT TRUE/SOMETIMES2 = VERY TRUE/OFTEN
Please choose the answer that best describes your child in the LAST MONTH:
1. Takes turns when playing with others. ...............................................................
0
1
2
2. “Tests” other children to see if they will get angry. ...........................................
0
1
2
3. Asks for things nicely when playing with children. ...........................................
0
1
2
4. Hits, shoves, kicks, or bites children (not including brother/sister). ..................
0
1
2
5. Has at least one favorite friend (a child). ...........................................................
0
1
2
6. Picks on or bullies other children. ......................................................................
0
1
2
7. Plays well with other children. ...........................................................................
0
1
2
8. Teases other children. .........................................................................................
0
1
2
9. Plays “house” with other children. .....................................................................
0
1
2
10. Won’t let other children play with his/her group. ..............................................
0
1
2
11. Hurts other children on purpose. ........................................................................
0
1
2
5
Section D: The questions in the next section ask about feelings and behaviors that can be problems for young
children. Some of the questions may be a bit hard to understand especially if you have not seen them in a child.
Please do your best to answer them anyway.
0 = NOT TRUE/RARELY1 = SOMEWHAT TRUE/SOMETIMES2 = VERY TRUE/OFTEN
Please choose the answer that best describes your child in the LAST MONTH:
1.Avoids physical contact. ........................................................................................
0
1
2
2. Does not make eye contact. ................................................................................
0
1
2
3. Holds food in cheeks. .........................................................................................
0
1
2
4. Hurts animals on purpose. ..................................................................................
0
1
2
5. Is very worried about getting dirty. ....................................................................
0
1
2
6. Needs things to be clean or neat. ........................................................................
0
1
2
7. Worries about own body. ...................................................................................
0
1
2
8. Puts things in a special order, over and over. .....................................................
0
1
2
Section E:
Does your child spend time with any siblings (brothers & sisters) or cousins regularly?
0: NO  Please go to next section.
1: YES Please answer questions below.
0 = NOT TRUE/RARELY
1 = SOMEWHAT TRUE/SOMETIMES2 = VERY TRUE/OFTEN
Please choose the answer that best describes your child in the LAST MONTH:
9. Acts bossy with sibling(s) or cousin(s). .............................................................
0
1
2
10. Acts jealous of sibling(s) or cousin(s). ...............................................................
0
1
2
11. Enjoys playing with sibling or cousin(s). ...........................................................
0
1
2
12. Is affectionate with sibling(s) or cousin(s). ........................................................
0
1
2
13. Hits, shoves, kicks, or bites sibling or cousin(s). ...............................................
0
1
2
14. Is hit, shoved, kicked or bitten by sibling(s) or cousin(s)...................................
0
1
2
15. Is teased or picked on by sibling(s) or cousin(s). ...............................................
0
1
2
16. Shares with sibling(s) or cousin(s) .....................................................................
0
1
2
17. Teases or picks on sibling(s) or cousin(s).. ........................................................
0
1
2
6
Section F: Now, we are interested in events that are sometimes stressful for children.
Please indicate whether each of the events listed below has EVER happened to your child in his/her
WHOLE LIFE. Also write in how old s/he was the last time it happened.
In your child’s WHOLE LIFE, has s/he ever…
1. gotten a new baby (brother, sister, or cousing)?
0: No
1: Yes 
child was ______months old
2. had a loved one die?
0: No
1: Yes 
child was ______months old
3. been bitten by a dog, or injured by an animal?
0: No
1: Yes 
child was ______months old
4. experienced the divorce or
separation of his/her parents?
0: No
1: Yes 
child was ______months old
1: Yes 
child was ______months old
1: Yes 
child was ______months old
5. been in a car accident?
0: No
6. been separated from parent or
guardian for 1 week or more
0: No
7. seen violence in the area where you live? ..
0: No
1: Yes 
child was______months old
8. seen someone use a weapon to
threaten or hurt a family member?
0: No
1: Yes 
child was______months old
9. seen someone hit, push, or kick a family member?
0: No
1: Yes 
child was______months old
seen or heard adult family members
arguing very loudly or fighting?
0: No
1: Yes 
child was______months old
a. Experienced any other upsetting event?
0: No
1: Yes 
child was______months old
10.
11
b. What was the event? _________________
FINAL QUESTIONS (YOU’RE ALMOST DONE)
Have you had any parenting classes?
_____YES
_____ NO
Do you wrap your child in a traditional way to calm them down or put them a sleep?
_____YES
______NO
How many hours does your child sleep, on average, per day?________________
7
Lifetime Events, July 26, 2016
Do you have any special routines with your child? ______ YES
_______NO
What are they?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What are the 3 most positive things about your life?
1.__________________________________________________________________________________
2.__________________________________________________________________________________
3.__________________________________________________________________________________
8
Lifetime Events, July 26, 2016