LIFE SKILLS INSTRUMENT PROTECTIVE FACTORS SURVEY

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					                                    LIFE SKILLS INSTRUMENT
                            PROTECTIVE FACTORS SURVEY

1. Program Name:                                                                    3. Enrollment Date:

2. Family Name:                                                                     4. Exit Date:

5. Date Survey Completed:

6. Race/Ethnicity (Please choose the ONE that best describes what you consider yourself to be):
          A. Native American or Alaskan Native                                     B. Native Hawaiian/Pacific Islanders
          C. African American                                                      D. Multi-racial
          E. Hispanic or Latino                                                    F. Asian
          G. White                                                                 H. Other

7. Marital Status:
          A. Married                                       B. Partnered                                     C. Single
          D. Divorced                                      E. Widowed                                       F. Separated

8. Household Size:
          A. 2                                             B. 3                                             C. 4
          D. 5                                             E. 6                                             F. Greater than 6

9. Family Income:
          A. $0 - $10,000                                  B. $10,001 - $20,000                             C. $20,001 - $30,000
          D. $30,000 - $40,000                             E. $40,001 - $50,000                             F. $50,000 - $60,000
          G. More than $60,000

10: Highest Level of Education:
          A. Elementary or middle                                                    B. Some high school
          C. High school diploma/GED                                                 D. Trade/Vocational Training
          E. Some college                                                            F. 2-year college degree (Associate’s)
          G. 4-year college degree (Bachelor’s)                                      H. Master’s degree or above

11. Number of children 0-5:
          A. 1                                             B. 2                                             C. 3
          D. 4                                             E. 5                                             F. Great than 5

12. Number of home visits:
          A. 1-3                                           B. 4-6                                           C. 7-12
          D. 13-16                                         E. 17-24                                         F. 25-36
          G. Greater than 36

13. Number of group parent ed/support:
          A. 1                                             B. 2-4                                           C. 5-8
          D. 9-12                                          E. Greater than 13

This survey was developed by the FRIENDS National Resource Center for Community-Based Child Abuse Prevention in partnership with the University of
       Kansas Institute for Educational Research & Public Service through funding provided by the US Department of Health and Human Services.