Name of parent __________________________

Address__________________________

_________________________________

_________________________________

Daytime Telephone________________ Evening telephone _______________

Dates marking the beginning and end of the period of time during which your child was exposed to the risk of corporal punishment at school:
Date beginning ___________
Date ending__________

Your child was enrolled in (name of school)______________________
Name of school district ___________________
In the the state of __________________.
From (date)___________ to (date)___________.

1. How did you learn about the practice of corporal punishment in your child's school?
   [ ] From your child
   [ ] From the school
   [ ] From other party.

2. Did the school have policies regarding its use of corporal punishment?
   [ ] Yes
   [ ] No
   [ ] Don't know.
   If you answered yes to this question, describe in Attachment A when and from whom you learned about the policies, and in general terms what those policies stated. If you have information from the school, e.g., letter, bulletin, public notice or other, regarding the use of corporal punishment, please photocopy same, mark 'Attachment A' and return copies with this questionnaire. DO NOT send originals.

3. Did you communicate with your child's school about your concerns regarding the use of corporal punishment?
   [ ]Yes
   [ ]No
   If you answered yes to this question, describe in Attachment B in general terms what you told the school and how the school responded. If you have correspondence to or from the school in this regard, please photocopy same, mark 'Attachment B' and return copies with this questionnaire. DO NOT send originals.

4. Was your child bruised or injured physically and/or made to suffer emotionally as a consequence of the school's use of corporal punishment?
   [ ] Yes
   [ ] No
   If you answered yes to this question, describe in Attachment C and return with this questionnaire.

5. Were there changes in your child's behavior at home that coincided with your child's experience of corporal punishment, or being put at risk of receiving corporal punishment, at school?
   [ ] Yes
   [ ] No
   If you answered yes to this question, describe those changes in Attachment D and return with this questionnaire.

6. Were there changes in your child's attitude toward school and/or academic performance that coincided with your child's experience of corporal punishment, or being put at risk of receiving corporal punishment, at school?
   [ ] Yes
   [ ] No
   If you answered yes to this question, describe those changes in Attachment E and return with this questionnaire.

7. Did you seek medical treatment, psychotherapy, counseling, or other professional help for your child as a consequence of your child's experience of corporal punishment, or experience of the risk of being corporally punished, at school?
   [ ] Yes
   [ ] No
   If you answered yes to this question, describe the kind of treatment you sought, and the duration of that treatment in Attachment F and return it with this questionnaire.

8. Are there ongoing medical, emotional or other health concerns for your child that you believe are a consequence of your child's experience of corporal punishment, or exposure to the risk of corporal punishment, at school?
   [ ] Yes
   [ ] No
   If you answered yes to this question, describe in Attachment G and return it with this questionnaire.
   

9. Do you believe that other members of the household experienced negative effects as a result of your child's experience with corporal punishment at school?
   [ ] Yes
   [ ] No
   If you answered yes to this question, describe these effects in Attachment H and return it with this questionnaire.

10. Do you have documentation relating to your child's experience of corporal punishment at school such as: medical or psychological reports, receipts for professional fees paid by you, insurance forms, hospital reports, prescriptions for medication, x-rays, photographs, police reports, correspondence from the school or from the school's representatives, or other?
    [ ] Yes
    [ ] No
    If you answered yes to this question, list these documents in Attachment I and return it with this questionnaire. DO NOT send documents.

11. Did you sustain costs that resulted from your child's experience of corporal punishment, or exposure to the risk of corporal punishment, at school such as: costs for treatment, counselling, medication, cost of transferring your child to a different school district, fees for private school, fees for tutoring, cost of moving, interruption or loss of income associated with any of the above, or other?
    [ ] Yes
    [ ] No
    If you answered yes to this question, list these items, but DO NOT give dollar amounts or estimates, in Attachment J and return it with this questionnaire.

12. Do you consider one or more of the following offensive to your religious/philosophical beliefs?
    
    1. For your child to be corporally punished at school.
       [ ] Yes
       [ ] No
       
    2. For your child to be at risk of being corporally punished at school.
       [ ] Yes
       [ ] No
       
    3. For your child to witness others being corporally punished at school.
       [ ] Yes
       [ ] No
       
    4. For your child to be aware that corporal punishment is being carried out against schoolmates.
       [ ] Yes
       [ ] No