Mother Daughter Workshop Post-Survey



What is the name of your school? ______________________________________________________________________________What is your school identification number (ID#) and grade level?ID#____________________ Grade Level_________________________Please enter the following information. (MM/DD/YY)Today’s Date:___________________________________________________________________Your Birthday:_________________________________________________________________Do you intend to have an annual physical checkup with a doctor? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX I don’t know.Do you plan to have sex before graduating from high school? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX I don’t know.Do you plan to go to college? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX I don’t know.Please think about what happened the last 4-6 weeks when answering the questions below.I can tell my mother if I have a problem. FORMCHECKBOX Strongly Agree FORMCHECKBOX Agree FORMCHECKBOX Unsure FORMCHECKBOX Disagree FORMCHECKBOX Strongly DisagreeMy mother and I are able to discuss different beliefs and feelings without feeling uncomfortable or embarrassed. FORMCHECKBOX Strongly Agree FORMCHECKBOX Agree FORMCHECKBOX Unsure FORMCHECKBOX Disagree FORMCHECKBOX Strongly DisagreeIf I ask my mother questions about body changes, she answers me without feeling uncomfortable or embarrassed. FORMCHECKBOX Strongly Agree FORMCHECKBOX Agree FORMCHECKBOX Unsure FORMCHECKBOX Disagree FORMCHECKBOX Strongly DisagreeMy mother and I are able to discuss breast development and care without feeling uncomfortable or embarrassed. FORMCHECKBOX Strongly Agree FORMCHECKBOX Agree FORMCHECKBOX Unsure FORMCHECKBOX Disagree FORMCHECKBOX Strongly DisagreeMy mother and I are able to discuss beliefs related to sexual behavior without feeling uncomfortable or embarrassed. FORMCHECKBOX Strongly Agree FORMCHECKBOX Agree FORMCHECKBOX Unsure FORMCHECKBOX Disagree FORMCHECKBOX Strongly DisagreeIf I ask my mother questions about sexual behavior, she answers me without feeling uncomfortable or embarrassed. FORMCHECKBOX Strongly Agree FORMCHECKBOX Agree FORMCHECKBOX Unsure FORMCHECKBOX Disagree FORMCHECKBOX Strongly DisagreeHave you been talking to your mother about sexuality since you started this workshop? FORMCHECKBOX I don’t know. FORMCHECKBOX Yes FORMCHECKBOX No My mother and I have discussed (You may check more than one option.): FORMCHECKBOX Rules about going out with my friends FORMCHECKBOX What to do if I like a boy FORMCHECKBOX What to do if I do not like a boy that likes me FORMCHECKBOX At what age I can start having a boyfriend FORMCHECKBOX How a girl can get pregnantPlease list all of the ways that you take care of your body.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If a girl has her period, how often should she change her pad (i.e. sanitary napkin, feminine hygiene product)? FORMCHECKBOX I don’t know. FORMCHECKBOX Every 2 hours FORMCHECKBOX Every 4 hours FORMCHECKBOX Every 6 hours FORMCHECKBOX Every 12 hrsIf a girl has her period, how often should she change her tampon? FORMCHECKBOX I don’t know. FORMCHECKBOX Every 2 hours FORMCHECKBOX Every 4 hours FORMCHECKBOX Every 6 hours FORMCHECKBOX Every 12 hrsIf you have to change your pad or tampon, when should you wash your hands? FORMCHECKBOX I don’t know. FORMCHECKBOX Before FORMCHECKBOX After FORMCHECKBOX Before and After FORMCHECKBOX Never There is a thin piece of tissue (hymen) that covers the vagina. A girl is still a virgin even if it tears accidentally. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX False A girl can get pregnant even if she has sex standing up. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX False A guy can tell whether or not a girl is a virgin by the way she walks. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX False A girl can get pregnant if she has sex in the water. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX False A girl will never get pregnant the first time she has sex. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseGirls should not swim when they are on their period. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseA girl can get pregnant during her period. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseIf a girl misses her period, she is definitely pregnant. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseHIV (Human Immunodeficiency Virus) is a virus that can be cured with treatment. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseYou can get HIV/STDs (Sexually Transmitted Diseases) through vaginal intercourse (i.e. sex, sexual intercourse, relaciones sexuales). FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX False Abstinence (not having sex) is the only way to protect you from HIV/STDs. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseCondoms will protect you 100% of the time from getting HIV/STDs. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseThere is a risk of getting HIV if you get a tattoo. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX False There is a risk of getting HIV if you have a cut and come in contact with infected blood. FORMCHECKBOX I don’t know. FORMCHECKBOX True FORMCHECKBOX FalseWhat did you learn during this workshop?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________Thank you for completing ALL questions on the survey! ................
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