4-H Parent Survey

During this 4-H Club year, your child was involved in healthy relationshipactivities.These are questions about these activities.

The questions are about your child who participates in a 4-H Club. If you have more than one child in 4-H, please fill out a survey for each child.

Please rate your opinion about each statement:

1. My child generally has healthy relationships with

family and friends:

___ Strongly agree

___ Agree

___ Disagree

___ Strongly disagree

___ Not sure

2. Mychild usually knowsgood qualities to look for in

a friend:

___ Strongly agree

___ Agree

___ Disagree

___ Strongly disagree

___ Not sure

Please turn over

3. My child is usually a good listener:

___ Strongly agree

___ Agree

___ Disagree

___ Strongly disagree

___ Not sure

4. Mychild usuallyuses words that help, not hurt:

___ Strongly agree

___ Agree

___ Disagree

___ Strongly disagree

___ Not sure

5. My childunderstands what makes a healthy and/or

unhealthy relationship:

___Strongly agree

___ Agree

___ Disagree

___ Strongly disagree

___ Not sure

6.My child usually knows when someone is not

respectful and crosses the line:

___ Strongly agree

___ Agree

___ Disagree

___ Strongly disagree

___ Not sure

Your child received a 4-H Health Planner.

These are questions about the planner.

7. Has your child talked to you about their planner?

___ no ___ yes ___ not sure

8.Did your child use theirplanner during the year?

___ no ___ yes ___ not sure

(If no, skip to Question #10.)

9. If yes to #8, how did your child usetheirplanner?

Put a check  in the column
with your best answer: / No / Yes / Not sure
a. used it as a calendar or schedule
b. kept track of monthly challenges
on planner
c. talked about healthy relationships
with parent or family members
d. talked about friends
e. talked about listening skills
f. talked about using words that help
g. talked about smart relationships
h. talked about healthy boundaries
i. talked about making the4-H club
even better

10. Did theclub activities or4-H Health Planner

help remind you and your familyabout ways

to practice relationship skills?

___ no ___ yes ___ not sure

11. Did you get4-HFamily Health Handouts?

___ no ___ yes ___ not sure

(If no, please skip to Question #14.)Please turn over

12. If yes to # 11, check  which handouts you got:

____Family Map ____ Smart Checkup

____Why We Are Friends ____Choose Respect

____Time to Listen ____ 4-H & Your Family

____ Family Circle

13. Which family handout activities did you complete?

Put a check  in the column with your best answer: / No, we did not do the activity / Yes, we did the activity / I’m not sure
Made a Family Map
Talked about friendships
Practiced listening skills
Talked about safe use of phones, email, and the internet
Took a quiz onbullying
Did a “Choose Respect Pledge”
Talked about 4-H and your club

14. Can you name specific changes in your child’s relationshiphabits due to their 4-H involvement this year?

______

______

______

______

15. Your child’s age: ____ years

16. How many years have they been in 4-H? ____years

17. Your child’s sex: ____ female ___ male

Thanks for completing the survey!