Name: Email:

How many children do you have living at home now? Choose One 1 2 3 4+

When you grew up how many children in were in your family? Choose One 1 2 3 4+

Are you a two parent family? Choose One Yes No

Are you single parent? Choose One Yes No

What religion were you raised with? Choose One Christian Catholic Protestant Muslim Other None

What religion are you now? Choose One Christian Catholic Protestant Muslim Other None

What religion are you raising your kids by? Choose One Christian Catholic Protestant Muslim Other None

Were you spanked as a child? Choose One No Swatted lightly Slapped Spanked(with an object) Spanked(without object) Spanked Excessively

Do you have ill memories of being spanked? Choose One Yes No

Do you feel your parents were justified and you needed to be spanked? Choose One Yes No

Do you spank your child? Choose One Never Sometimes Severe

Do you think it is wrong? Choose One Yes No

Do you use time out for disciplining your child? Choose One Yes No

Do you have any comments that you would like to leave ?

Please Click on the submit button when finished, Thank You

To start over click Reset