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Please take this parenting evaluation. This helps us evaluate effectiveness of the class and will ensure that you receive a certificate of completion. Please let us know if you have any questions. Thank you!

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* 1. Date Survey Was Taken

Date

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* 2. First Name

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* 3. Middle Initial

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* 4. Last Name (Or ID):

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* 5. Birthday

Date

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* 6. Gender:

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* 7. Race/Nationality:

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* 8. Marital Status:

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* 9. Number of children you have:

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* 10. Highest grade you completed:

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* 11. Current Employment-School status:

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* 12. Annual Household Income (estimate):

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* 13. Are/were you or your partner in the military?

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* 14. As a child, did you experience any type of physical, emotional or sexual abuse by someone outside your family?

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* 15. As a child, did you experience any type of physical, emotional or sexual abuse by someone inside your family?

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