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  1. Surveys
  2. 2014
  3. January
  4. F
  5. FASD, RAD, PTSD
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Exit Survey
 
 
Hello:
You are invited to participate in our survey on prenatal and postnatal influences on behavior. In this survey, parents/caregivers of children aged 6 - 18 years old will be asked to complete a survey that asks questions about their child's pre and postnatal history and current behavioral characteristics. It will take approximately [Approximate Time] minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Ettina by email at the email address specified below.

[email protected]

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
 
 
Introduction
Thank you for agreeing to participate. First, I would like to get some background data on you and your child.
 
 
How old is your child?
   
 
 
What gender is your child?
 
Male
 
Female
 
Other
 
 
 
Does your child have any of the following diagnoses?
 
Post-Traumatic Stress Disorder
 
complex Post-Traumatic Stress Disorder
 
Dissociative Disorder (any)
 
Reactive Attachment Disorder
 
Disinhibited Attachment Disorder
 
Adjustment Disorder
 
Fetal Alcohol Syndrome
 
Fetal Alcohol Spectrum Disorder
 
Fetal Alcohol Effects
 
partial Fetal Alcohol Syndrome
 
Alcohol Related Neurodevelopmental Disorder
 
Alcohol Related Birth Defects
 
None of these

 
 
If your child has any of these diagnoses, how old were they when they were diagnosed?
   
 
 
Does your child have any other conditions affecting learning and/or behavior? (please list all)
   
 
 
What is your gender?
 
Male
 
Female
 
Other
 
 
 
What is your relationship to this child?
 
Biological parent
 
Stepparent
 
Foster parent
 
Adoptive parent
 
Extended family member (grandparent, aunt/uncle, cousin, etc)
 
Other
 
 
 
Are there other adults who live in the home with you and your child? What is their relationship to the child?