Men's Impact Event Survey 2
RequiredRequired Question(s)
Required 1.
How do you learn about this event?
Care Net center
local church
Step by Step
Other  
  • Comment:

  • 500 characters left.
Required 2.
Please enter the information indicated below.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
City:

Fatherhood Survey
 
Required 3.
I try to think about my choices and their consequences before I make a decision. 
Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 4.
I do things that I regret later. 
Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 5.
I take my child/children to fun places like the zoo or sporting events
Never    Sometimes     Often  
 
  • Comment:

  • 500 characters left.
Required 6.

I currently/plan to read books to my child throughout the month.

Never    Sometimes     Often  
 
Required 7.

Each month, I play/plan to play with my child through toys, games, or puzzles

Never    Sometimes     Often  
 
Required 8.
I try to be proactive rather than reactive as a father. 
Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 9.

Each month I play/plan to play physically with my child, like when wrestling or roughhousing. 

Never    Sometimes     Often  
 
Required 10.
I have thought about my personal values. I have a mental list of them. 
Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 11.
I have several roles: friend, dad, employee. I have thought about which roles are most important. 
Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 12.
I am actively working on each element of myself: body, mind, heart, and spirit.
Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 13.

I have a personal mission, and I know what it is. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 14.

I spend time and do things with my child rather than doing things with my friends. 

Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 15.

I believe I have all the skills necessary to be a good father. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 16.

I know how to prioritize the most important tasks to be a good father. 

Not true at all        Very true   
  
  • Comment:

  • 500 characters left.
Required 17.

Providing financial support to the mother of my child is very important to me. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 18.

Providing love to the mother of my child is important to me.

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 19.

Being a father is the most important thing in my life. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 20.

During pregnancy, I should support the mother of my baby and actively express desire to co-parent. 

Completely disagree    Sort of agree     Completely Agree  
 
  • Comment:

  • 500 characters left.
Required 21.

I feel that I should work closely with the mother of my child to help care and raise our child. 

Completely disagree    Sort of agree     Completely agree  
 
  • Comment:

  • 500 characters left.
Required 22.

Being part of a men's group is important to succeeding in my role as a father. 

Completely disagree    Sort of agree     Completely agree  
 
  • Comment:

  • 500 characters left.
Required 23.

I feel good about my role as a dad. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 24.

I am happy to be a father. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 25.
I feel that I am doing a good job being a dad. 
Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 26.

I like being around other men with similar hobbies as me. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 27.

I like being around other men going through the challenges of raising kids. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 28.

I know and use listening skills to be a good father. 

Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 29.

I believe a man can be a good father even if he doesn't live with his child. 

Not true at all         Very true  
 
  • Comment:

  • 500 characters left.
Required 30.

I use a weekly calendar to plan and prioritize my time with my child. 

Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 31.

I manage my time successfully to spend time with my child. 

Never    Sometimes     Always  
 
  • Comment:

  • 500 characters left.
Required 32.

I have a vision for my family in mind.

Not at all true.         Very true  
 
  • Comment:

  • 500 characters left.