Survey

(PLEASE PRINT)

ID # ___________________________

Date:___/___/__

Your age: _____ Your birth date: ____/____/____

Your sex: (A) Male (B) Female

What grade are you currently in at your school?

(A) 9th grade (Freshman) (C) 11th grade (Junior)

(B) 10th grade (Sophomore) (D) 12th grade (Senior)

What is your current overall school grade average?

(A) F (D) B

(B) D (E) A

(C) C

How many hours do you work at a paid job each week?

(A) 0 (D) 11-15

(B) 1- 5 (E) 16-20

(C) 6-10 (F) 20 +

Do you plan to attend college, vocational, or trade school when you graduate? (Circle one):

(A) yes (B) no

Your race/ethnic status (Circle all that apply):

(A) Black/African American (D) Native American

(B) Hispanic/Mexican American (E) White/Caucasian

(C) Asian American (F) Other

How many brothers and sisters do you have, including any step or half brothers and sisters, not including yourself?

(A) 0 (C) 2 (E) 4

(B) 1 (D) 3 (F) 5 or more

What is the order of your birth?

(A) Only child (C) Middle child (or one of the middle children)

(B) First child (D) Last child

Please circle the one that best describes your current relationship situation:

(A) Not dating and single (C) Dating Exclusively (Only one person)

(B) Dating various people (D) Recently broke up

Do you have any children of your own? (A) yes (B) no

If yes, how many? ______

What are your current living arrangements?

(A) Living with both your biological/adoptive parents

(B) Living with one of your biological/adoptive parents

(C) Living with other family members

(D) Living with other friends/roommates

Has one or both of your biological parents/guardians ever been divorced?

(A) yes (B) no

*If yes, how many times has your mother been divorced? _____

*If yes, how many times has your father been divorced? _____

*How old were you at the time of this/these divorces? (Give your age at each divorce if more than one):

age(s): _____ _____ _____

*Were you living with either of the divorcing parents at the time of any of these divorces?

(A) yes (B) no

Approximately what is your parent’s annual income? (Circle one):

(A) Under $10,000 (C) $20-30,000 (E) $40-60,000 (G) $80,000 +

(B) $10-20,000 (D) $30-40,000 (F) $60-80,000

Do you follow a specific religion or spiritual belief system? (Circle one):

(A) yes (B) no

If yes, what religion/denomination do you practice (Lutheran, Catholic, Jewish, Baptist, 7th Day Adventist, etc.)?

(religion): ________________________________________________________

How many times each month do you attend a church or religious activity or meeting? _____ (# of times each month)

Directions: Using the following scale as a guide, describe yourself. Circle one number for each statement.

1	2	3	4	5
Almost never (AN)	Once in a while (OW)	Sometimes (S)	Frequently (F)	Almost always (AA)

	AN	OW	S	F	AA
1. I feel that I’m a person of worth, at least on an equal basis with others………	1	2	3	4	5
2. I feel that I have a number of good qualities………………………………….	1	2	3	4	5
3. All in all, I am inclined to feel that I am a failure……………………………..	1	2	3	4	5
4. I am able to do things as well as most other people…………………………..	1	2	3	4	5
5. I feel I do not have much to be proud of………………………………………	1	2	3	4	5
6. I take a positive attitude toward myself……………………………………….	1	2	3	4	5
7. On the whole, I am satisfied with myself……………………………………..	1	2	3	4	5
8. I wish I could have more respect for myself…………………………………..	1	2	3	4	5
9. I certainly feel useless at times. At times I think I am no good at all………...	1	2	3	4	5

No matter how well two people get along, there are times when they disagree, get annoyed with the other person, or just have spats or fights because they’re in a bad mood or tired or for some other reason. They also use many different ways of trying to settle their differences. The following are a list of some things you might do when you have an argument with your (boyfriend/girlfriend (or best friend) if you aren’t currently dating). Indicate how many times (once, twice, 3-5 times, 6-10 times, 11-20 times, more than 20 times, or never) in the past 2 months you have done each of the following.

Please complete both columns when

necessary (when you answer ‘0’) Use the following scale:

1 = once

2 = twice If you circled ‘0’ for

3 = 3-5 times any items, have you

4 = 6-10 times ever done it in your

5 = 11-20 times life with this person?

6 = more than 20 times 1 = Yes

0 = never 0 = No

A. Discussed an issue calmly........................................................ B. Got information to back up my side of things.......................... C. Brought in, or tried to bring in, someone to help settle things D. Insulted or swore at him or her................................................. E. Argued heatedly but did not yell............................................... F. Yelled at him or her................................................................... G. Sulked or refused to talk about an issue................................... H. Stomped out of the room or house or yard............................... I. Cried........................................................................................... J. Did or said something to spite him or her................................ K. Threatened to hit or throw something at him or her................. L. Threw or smashed or hit or kicked something (not the person) M. Threw something at him or her................................................ N. Pushed, grabbed, or shoved him or her..................................... O. Slapped him or her.................................................................... P. Kicked, bit, or hit him or her with a fist.................................... Q. Hit or tried to hit him or her with something........................... R. Beat him or her up....................................................................

1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0

1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0

Using the following scale as a guide, indicate how much you agree or disagree with each statement. Circle only one response for each statement. Answer as honestly as you can.

YES! yes no NO!

Strongly Agree (SA) Somewhat Agree (sa) Somewhat Disagree(sd) Strongly Disagree (SD)

SA sa sd SD

1. Marriage is a good and desirable thing....................................................................................... YES! yes no NO!

2. I will likely get married some day............................................................................................... YES! yes no NO!

3. My parent(s)/guardian think(s) marriage is a good and desirable thing………………………. YES! yes no NO!

4. My parents have a good marriage……………………………………………………………… YES! yes no NO!

5. Divorce is an important option for married people to have......................................................... YES! yes no NO!

6. I will probably get divorced at least once if I ever marry............................................................ YES! yes no NO!

7. It’s O.K. for a couple WITH NO children to divorce if one spouse cheats on the other........... YES! yes no NO!

8. It’s O.K. for a couple WITH children to divorce if one spouse cheats on the other................. YES! yes no NO!

9. It’s O.K. for a couple WITH NO children who fight all the time to divorce…….................... YES! yes no NO!

10. It’s O.K. for a couple WITH children who fight all the time to divorce …............................. YES! yes no NO!

11. It’s O.K. to divorce if a couple WITH NO children just has unsolvable differences................ YES! yes no NO!

12. It’s O.K. to divorce if a couple WITH children just has unsolvable differences....................... YES! yes no NO!

13. I will take a compatibility test with my fiancé before I get married...................................... YES! yes no NO!

14. I will take a marriage preparation course with my fiancé before I get married.................... YES! yes no NO!

15. I will go to premarital counseling with my fiancé before I get married................................ YES! yes no NO!

16. After I’m married, I will attend a marriage enrichment class with my spouse.................... YES! yes no NO!

17. After I’m married, if we are having trouble in our marriage, we will go to counseling...... YES! yes no NO!

18. My parents understand me......................................................................................................... YES! yes no NO!

19. I can go to my parents for help with personal situations........................................................... YES! yes no NO!

20. If a marriage is having problems, having a baby will improve the marriage relationship........ YES! yes no NO!

21. It’s O.K. to live with a dating partner and not be married......................................................... YES! yes no NO!

22. Do you personally talk to your parent or guardian when something is bothering you?….. YES! yes no NO!

23. Does your parent or guardian listen to you when you want to tell them something?............... YES! yes no NO!

24. Do you talk to your parent or guardian about having a girlfriend/boyfriend? ……................... YES! yes no NO!

25. If my boyfriend/girlfriend wanted to have sex, but I didn’t, I would find it pretty hard to

say no ………………………………………………………………………………………….. YES! yes no NO!

26. It is too risky for teens to have sex …………………………………………...……………….. YES! yes no NO!

27. If my girlfriend/boyfriend wanted to have sex, but I didn’t, I would find it pretty hard to

say no ………………………………………………………………………………………….. YES! yes no NO!

28. Not having sex until marriage is the best choice a teen can make ……………………………. YES! yes no NO!

29. I think many of my friends are having sex …………………………………………………… YES! yes no NO!

30. I have talked to my parents about sex ………………………………………………………… YES! yes no NO!

31. I feel good enough about myself that I can say “no” to sex even if my friends are pressuring

me to say “yes” ………………………………………………………………………………... YES! yes no NO!

SA sa sd SD

32. I feel I can ask my parents about sex ………………………………………………………... YES! yes no NO!

33. I intend to talk to my parents or guardian about sex ………………………………………… YES! yes no NO!

34. I intend to say “no” if I am being pressured to have sex ……………………………………. YES! yes no NO!

35. I intend to NOT have sex until I am married ………………………………………………. YES! yes no NO!

36. People should not pressure others into having sex with them ………………………………. YES! yes no NO!

37. It’s okay for a boy to tell a girl that he loves her so he can have sex with her………………. YES! yes no NO!

38. My friends think a person should not have sex until marriage ……………………………… YES! yes no NO!

39. My parents think a person should not have sex until marriage ………………………………. YES! yes no NO! 40. I am currently sexually active ………………………………………………………………… YES! yes no NO!

Write your answer to each question in the blanks provided. Your answer should be what YOU think about each item.

1. About how many times have you gotten into trouble at school in the past 2 months? _____

2. About how many times have you gotten into trouble at home with your parents/guardian in the past 2 months?

3. About how many times have you gotten into trouble with other family members in the past 2 months?________

4. At what age will you likely get married? _____

5. How many years should a couple wait after marriage before having a baby? _____

6. What percent of marriages end in divorce? _____

7. When you get married, what percent chance is there that your marriage or future marriage will end in divorce? _____

8. How long should two people date each other before getting married? _____

9. In today’s society, slapping a spouse or dating partner is understandable under some circumstances...YES! yes no NO!

10. In today’s society, pushing a spouse or dating partner is understandable under some circumstances…YES! yes no NO!

Circle the best answer

If you are concerned about what to say or do in a certain dating situation…

1. just say what you are thinking and it will be ok
2. you can practice what you are going to say/do beforehand
3. don’t worry about it until it actually happens
4. avoid it and then you won’t have to worry

When you begin a new relationship …

1. It is important to speed up how well you know each other in a dating relationship so you can build a foundation quickly
2. It is not helpful to take time to learn about each other since you will get to know each other over time
3. It is helpful to take time to learn about each other and take things slowly
4. It is not important to get to know a lot about the other person because relationships are for fun

If you begin to see problems in a dating relationship

1. It is likely that what is wrong will get worse
2. It just means you will need to work harder
3. It is likely that things will get better
4. Problems can go away if they are ignored long enough

If you are in an abusive relationship

1. You need to break it off
2. You need to give the other person time to change
3. You need to change which will help the other person stop being abusive
4. If you really love each other, things will likely work out

If there is a misunderstanding between you and boyfriend/girlfriend/best friend…

1. it is not important to apologize, this shows weakness
2. it is not important to compromise if you are right
3. it is important to consider the other person’s feelings
4. it is important to make sure you get your way

How do you know if you are mature enough to go on a date?

1. you begin to be interested in dating and having relationships
2. you are old enough to drive yourself on a date
3. you are 14 years old
4. you have the ability to consider someone else’s needs not just your own

Which of the following is a good reason to date?

1. to feel loved and needed
2. to fill a gap in our lives
3. to have friendship and offer strength

Not attempting to connect with others may lead to what emotions?

1. loneliness, isolation, rejection, depression
2. contentment, solitude, acceptance, happiness

What is stonewalling?

1. building a “wall” around yourself through friends and support networks
2. pretending that nothing the other person says will hurt you in any way
3. withdrawing emotionally from a conversation

What is a main sign of trouble in a relationship?

1. Spending less time with each other, because you have an after school job
2. Changes in communication
3. Spending time with friends instead of together
4. Doing more things with his/her family

Sally and Joe have been dating for a year, but Sally is interested in dating Sam instead. Soon she finds out that Sam is interested in dating her. What would be Sally’s best move?

1. Break up with Joe and start dating Sam while she has the opportunity
2. Break up with Joe and wait several months before dating anyone else
3. Talk things over with Joe before making any decision
4. Talk things over with Sam and tell him that she’s still in a committed relationship right now

What is active listening?

1. Talking and listening to each other at the same time just as long as you are not both talking at the same time
2. actively participating in the conversation by first listening and sometimes talking about your own ideas
3. being willing to set aside the things you want to discuss until later and concentrate on what the other person is saying

Being sensitive to and understanding another’s feeling, situations, and motives is

1. symphony
2. empathy
3. pathology
4. dystrophy

One way to show respect to your boyfriend/girlfriend/bestfriend is by

1. making sure you are popular so they can be proud of hanging out with you
2. considering their safety
3. always talking about what is important to you
4. controlling the conversation so they don’t have to

True or False. In order to be nice to your partner, it is best to avoid talking about significant problems in your relationship that will upset your partner.

True or False. One important element for a good dating relationship is to spend all your free time with each other.

True or False. Jealousy is a normal and healthy emotion.

True or False. A relationship in trouble always needs to end.

True or False. If you decide to break up with someone and then after the breakup you feel anger, sadness, confusion, emptiness, guilt, disappointment, sadness regret, rejection and failure; then you probably made the wrong decision.

True or False. If breaking up will make your partner really sad or mad, it is easiest to just avoid them and let them figure it out rather than telling them face to face.

You are done! Thank you for your time!