Parent Behavior Checklist Template
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PBC
Behavior
Checklist
Robert A. Fox, Ph.D.
RECORD FORM
Parent and Child Information
1.
Today's Date:
__________Month
__________Day
__________Year
2.
Completed By:
__________Mom
__________Dad
__________Other
3.
Your Age:
__________Years
4.
Child's Name:
_______________________________________
a. Birth Date:
__________Month
__________Day
__________Year
b. Age:
__________Years
c. Sex:
__________Girl
__________Boy
d. Race/Ethnic Group:
________American Indian/Alaska/Native
________Asian/Pacific Islander
________Black
________Hispanic
________White
________Other
5.
Total Number of Children Living at Home:
__________
6.
Marital Status:
__________Divorced
__________Married
__________Separated
__________Single
__________Widowed
7.
Parent Employment - Please indicate job title for both parents (examples: homemaker, grade school teacher,
lawyer, truck driver, computer technician, etc.)
Mom's Employment:
_______________________________________________________
Dad's Employment:
_______________________________________________________
Instructions
The Parent Behavior Checklist includes statements about how parents raise young children. For each
statement, circle the letter A if the statement ALMOST ALWAYS OR ALWAYS applies to how you raise your
child. Circle the letter F if the statement FREQUENTLY applies. Circle the letter S if the statement
SOMETIMES apples. Circle the letter N if the statement ALMOST NEVER OR NEVER applies. Circle the NA
response if it is NOT AGE APPROPRIATE. A sample item is shown below.
I rock my child to sleep.
A
F
S
N
NA
Mark only one letter for each statement. Do not skip any item. Please turn the page now and begin with the
first item.
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