Mother Daughter Workshop Pre-Survey_Mother / 2016 /
  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:______

Your Birthday:______

  1. In what country were you born?

United States Other ______

  1. How many years have you lived in the United States? ______Years
  2. In what country was the father of your daughter born?

United States Other ______

  1. In what country was your mother born?

United States Other ______

  1. In what country was your father born?

United States Other ______

  1. How many sons and daughters do you have?

Sons______Daughters______

  1. Most of the time, what languages do you speak at home?

English Spanish Both Other:______

  1. Which of these best categorizes your race/ethnic background (you may choose more than one)?

Hispanic or Latino White Asian African American or Black

American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

  1. What is the highest level of education that you completed? ______
  2. My daughter comes to me if she has a problem.

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. My daughter and I are able to discuss different beliefs and feelings without feeling uncomfortable or embarrassed.

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. If my daughter asks me questions about body changes, I answer her without feeling uncomfortable or embarrassed.

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. My daughter and I are able to discuss breast development and care without feeling uncomfortable or embarrassed.

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. 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

  1. If my daughter asks me questions about sexual behavior, I answer her without feeling uncomfortable or embarrassed.

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. What has prevented you from talking to your daughter about sexuality? (You may check more than one reason.)

It is against our religious beliefs.

I think that she is too young.

I feel embarrassed.

She is too uncomfortable or embarrassed.

It makes me mad.

I may not know the answers/have the wrong answers.

I do not understand what she means (sexuality words in English).

I am unsure about sexuality words in Spanish.

I would prefer her talk to a counselor/teacher at school or another female.

I will be concerned that she will be more likely to have sex if we talk about it.

Her father doesn’t approve.

There is no time/place to talk alone.

There is no problem; we always talk.

  1. 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

  1. Please list all of the ways that you have taught your daughter to take care of her body.

______

  1. 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

  1. 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

  1. If you have to change your pad or tampon, when should you wash your hands?

I don’t know. Before AfterBefore and After Never

  1. 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

  1. A womancan get pregnanteven if she has sex standing up. I don’t know. True False
  2. A man can tell whether or not a woman or a girlis a virgin by the way she walks. I don’t know. True False
  3. A womancan get pregnant if she has sex in the water. I don’t know. True False
  4. A womanwill never get pregnant the first time she has sex. I don’t know. True False
  5. Womenshould not swim when they are on their period. I don’t know. True False
  6. A womancan get pregnant during her period. I don’t know. True False
  7. If a womanmisses her period, she is definitely pregnant. I don’t know. True False
  8. HIV (Human Immunodeficiency Virus) is a virus that can be cured with treatment. I don’t know. True False
  9. You can get HIV/STDs(Sexually Transmitted Diseases) through vaginal intercourse (i.e. sex, sexual intercourse, relaciones sexuales). I don’t know. True False
  10. Abstinence (not having sex) is the only way to protect you from HIV/STDs. I don’t know. True False
  11. Condoms will protect you 100% of the time from getting HIV/STDs. I don’t know. True False
  12. There is a risk of getting HIV if you get a tattoo. I don’t know. True False
  13. 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
  14. What would you like to learn during this workshop?

______

Thank you for completing ALL questions on the survey!

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