Mother Daughter Workshop Post-SurveyDaughter / 2016 /
  1. What is the name of your school?

______

  1. What is your 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. Do you intend to have an annual physical checkup with a doctor? Yes No I don’t know.
  2. Do you plan to have sex before graduating from high school? Yes No I don’t know.
  3. Do you plan to go to college? Yes No I don’t know.

Please think about what happened the last 4-6 weeks when answering the questions below.

  1. I can tell my mother if I have a problem.

Strongly Agree Agree Unsure Disagree Strongly Disagree

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

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. If I ask my mother questions about body changes, she answers me without feeling uncomfortable or embarrassed.

Strongly Agree Agree Unsure Disagree Strongly Disagree

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

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. My mother 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 I ask my mother questions about sexual behavior, she answers me without feeling uncomfortable or embarrassed.

Strongly Agree Agree Unsure Disagree Strongly Disagree

  1. Have you been talking to your mother about sexuality since you started this workshop?

I don’t know. Yes No

  1. My mother and I have discussed (You may check more than one option.):

Rules about going out with my friends

What to do if I like a boy

What to do if I do not like a boy that likes me

At what age I can start having a boyfriend

How a girl can get pregnant

  1. Please list all of the ways that you take care of your body.

______

  1. If a girl 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 girl 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 girl is still a virgin even if it tears accidentally.

I don’t know. True False

  1. A girl can get pregnanteven if she has sex standing up. I don’t know. True False
  2. A guy can tell whether or not a girl is a virgin by the way she walks. I don’t know. True False
  3. A girlcan get pregnant if she has sex in the water. I don’t know. True False
  4. A girl will never get pregnant the first time she has sex. I don’t know. True False
  5. Girls should not swim when they are on their period. I don’t know. True False
  6. A girl can get pregnant during her period. I don’t know. True False
  7. If a girl misses 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 did you learn during this workshop?______Thank you for completing ALL questions on the survey!

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