Youth SFP 10-14 Retrospective Survey

In the first column, circle the phrase and number that shows how often you do each item NOW that you have attended SFP 10-14.

In the second column, circle the phrase and number that shows how often you did each item BEFORE you came to SFP 10-14.

Column 1—Now

/ Column 2—Before
NOW(today) –
How often is each item done? / BEFOREyou came to the program -How often was each item done?
1. How often does your parent(s)/caregiver(s) give up when you do not do what is asked of you? / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
2.When you break a rule, how often does your parent's/caregiver's mood affect the penalty given? / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
3. How often can you get out of a punishment? / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
4. My parent(s)/caregiver(s) tells me what they expect of me and holds me responsible. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
5. When I follow rules or do tasks well at home or at school, my parent(s)/caregiver(s) gives me praise. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
6. When my parent(s)/caregiver(s) is upset because I did not follow through with a rule or do a task at home or school, they calmly tell me how they are feeling. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
7. My parent(s)/caregiver(s) treats me with respect when they discipline me. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
NOW (today) –
How often is each item done? / BEFOREyou came to the program - How often was each item done?
8. I show my parent(s)/caregiver(s) that I appreciate the things they do for me. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
9. How often are you disciplined for something, and then at another time not disciplined for the same thing? / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
10. My parent(s)/caregiver(s) and I can sit down and work on a problem without yelling or getting mad. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
11. When I am stressed, I do something to calm myself, like take deep breaths. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
12. When my parent(s)/caregiver(s) is upset, I try to think about his/her feelings and point of view. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
13. When I am upset, I am likely to yell, swear, or hit someone or something. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
14. I feel truly loved and respected by my parent(s)/caregiver(s). / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
15. My family has a weekly meeting to talk about plans, schedules and rules. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
16. When we have a problem, my family works together to find a solution. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
17. My parent(s)/caregiver(s) does and says things to let me know I am loved. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
18. My parent(s)/caregiver(s) blames and criticizes me when I misbehave. / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4 / A little of the time
1 / Some of the time
2 / A good bit of the time
3 / Most of
the time
4
NOW (today) –
How much do you now agree? / BEFOREyoucame to the program - How muchdid you agree?
19. Making good decisions now will help me reach my goals in the future. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
20. My parent(s)/caregiver(s) talk to me about their values and beliefs. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
21. I know positive ways to help me feel better when I am under stress. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
22. My parent(s)/caregiver(s) has told me what they think about me using alcohol and drugs. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
23. I have thought of some goals I want to reach when I grow up. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
24. I can tell when I am starting to feel stress. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
25. I know some steps to take to reach my goals. / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4 / Strongly Disagree
1 / Disagree
2 / Agree
3 / Strongly Agree
4
26. If a friend is pressuring you to do something that could get you in trouble, how likely are you to:
NOW (today) –
How likely are you to do each item? / BEFOREyou came to the program - How likely were you to do each item?
a. do it / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4 / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4
b. tell your friend some of the negative things that could happen / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4 / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4
c. suggest something else to do / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4 / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4
d. stay calm even if your friend keeps pressuring you / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4 / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4
e. tell your friend you are going to do something else and go on your way / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4 / Very Unlikely
1 / Unlikely
2 / Likely
3 / Very Likely
4

What was the most valuable thing(s) you learned during this program?

______

Sites Can Insert Any Desired Additional Questions Here. See Below.

Please rate the facilitators by circling a number:

The highest score possible is a ‘5’ and it indicates that a facilitator had an effective teaching style, they encouraged participation, and they interacted with participants in a positive way. A ‘1’ is the lowest score possible.

Lowest Highest

Parent & Family Facilitator:
Insert Name / 1 / 2 / 3 / 4 / 5
Youth & Family Facilitator:
Insert Name / 1 / 2 / 3 / 4 / 5
Youth & Family Facilitator:
Insert Name / 1 / 2 / 3 / 4 / 5

Additional Comments:

Sample Additional Questions That Can Be Added To Inform Program Enhancements or Recruitment:

What did you like most about the program? ______

What was your favorite weekly gift? ______

How did you hear about the program? ______

Do you have suggestions for improving the program for future participants?______

______

If you are willing to, please provide a quote that can be used in recruitment materials to encourage other families to attend:

Survey created by the EPISCenter at Penn State University – July 2010.

This survey is based on a survey created by the SFP 10-14 developer at Iowa State University.1