1. What is your daughter’s school identification number (ID#) and grade level? ID#______Grade Level______
2. Please enter the following information. (MM/DD/YY)
Today’s Date:______
Please think about what happened the last 4-6 weeks when answering the questions below.
3. My daughter comes to me if she has a problem.
Strongly Agree Agree Unsure Disagree Strongly Disagree
4. My daughter and I are able to discuss different beliefs and feelings without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
5. If my daughter asks me questions about body changes, I answer her without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
6. My daughter and I are able to discuss breast development and care without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
7. My daughter and I are able to discuss beliefs related to sexual behavior without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
8. If my daughter asks me questions about sexual behavior, I answer her without feeling uncomfortable or embarrassed.
Strongly Agree Agree Unsure Disagree Strongly Disagree
9. Have you been talking to your daughter about sexuality since you started this workshop?
I don’t know. Yes No
10. My daughter and I have discussed (You may check more than one reason.):
Rules about going out with her friends
What to do if she likes a boy
What to do if a boy likes her and she doesn’t like him
At what age she can start having a boyfriend
How a girl can get pregnant
11. Please list all of the ways that you have taught your daughter to take care of her body.
______
12. If a woman has her period, how often should she change her pad (i.e. sanitary napkin, feminine hygiene product)?
I don’t know. Every 2 hours Every 4 hours Every 6 hours Every 12 hrs
13. If a woman has her period, how often should she change her tampon?
I don’t know. Every 2 hours Every 4 hours Every 6 hours Every 12 hrs
14. If you have to change your pad or tampon, when should you wash your hands?
I don’t know. Before After Before and After Never
15. There is a thin piece of tissue (hymen) that covers the vagina. A woman is still a virgin even if it tears accidentally.
I don’t know. True False
16. A woman can get pregnant even if she has sex standing up. I don’t know. True False
17. A man can tell whether or not a woman or a girl is a virgin by the way she walks. I don’t know. True False
18. A woman can get pregnant if she has sex in the water. I don’t know. True False
19. A woman will never get pregnant the first time she has sex. I don’t know. True False
20. Women should not swim when they are on their period. I don’t know. True False
21. A woman can get pregnant during her period. I don’t know. True False
22. If a woman misses her period, she is definitely pregnant. I don’t know. True False
23. HIV (Human Immunodeficiency Virus) is a virus that can be cured with treatment. I don’t know. True False
24. You can get HIV/STDs (Sexually Transmitted Diseases) through vaginal intercourse (i.e. sex, sexual intercourse, relaciones sexuales). I don’t know. True False
25. Abstinence (not having sex) is the only way to protect you from HIV/STDs. I don’t know. True False
26. Condoms will protect you 100% of the time from getting HIV/STDs. I don’t know. True False
27. There is a risk of getting HIV if you get a tattoo. I don’t know. True False
28. There is a risk of getting HIV if you have a cut and come in contact with infected blood. I don’t know. True False
29. What did you learn during this workshop?
______
Thank you for completing ALL questions on the survey!
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