| YES/NO | |
| _________ 1. | Recite his or her full name, address and telephone number including area code, city and state and know not to divulge this information to a stranger or passerby? |
| _________ 2. | Use a phone to make a long distance call, dial direct or get operator assistance? |
| _________ 3. | Does your child know to NEVER enter anyone's home without your permission? |
| _________ 4. | Know of any certain home where they are NOT to enter under any circumstances? |
| _________ 5. | If separated from you in a store, would your child go to the nearest check-out clerk? |
| _________ 6. | Could he or she verify that the person is in fact an employee of the store? |
| _________ 7. | Would he or she know not to go into the parking lot either alone or if encouraged by an adult? |
| _________ 8. | Know always when playing with others to go places on the "buddy-system?" |
| _________ 9. | Know that adults seldom ask for directions from children and that if approached by a car, they should never go near or get in an automobile with a stranger? |
| _________ 10. | Does your child know not to accept rides from a stranger or even acquaintances without your specific permission? |
| _________ 11. | If followed by an adult or stranger, would your child know to proceed immediately to a place where there are other people; e.g., a store or a neighbor's house |
| _________ 12. | If home alone, knows not to answer the door or tell anyone over the phone that he or she is alone? (Obviously, a young child should never be left alone.) |
| _________ 13. | Would your child yell "NO" or "911" and create a scene in public if he or she were being subjected to bad touches? |
| _________ 14. | Would your child report to you if asked by an adult to keep a secret from you? |
| _________ 15. | Do you and your child have a code word to exchange if your plans change? |
| _________ 16. | Do you and your child have a "panic" word they can text you if they need your help getting out of a bad situation?
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| _________ 17. | Does your child know never to talk or accept gifts of any kind from strangers? |
| _________ 18. | Is your family's computer in a "public room" such as the family room or kitchen? |
| _________ 19. | Would your child tell you if they found a pornographic image on their computer or cell phone? |
| _________ 20. | Would your child tell you if someone (including a teacher, a friend of yours, a family member, or a member of the clergy) made them uncomfortable or "feel creepy"? |
| _________ 21. | Does your child truly understand that everyone on the internet is not necessarily who they claim to be? |
| _________ 22. | Would your child know NOT to meet someone IRL (in real life) that they met on internet? |
| _________ 23. | Have you discussed bullying and cyberbullying with your child? |
| _________ 24. | Do you know your child's best friends? (Do they visit your home regularly? Do you know their parents? Have you seen their online profiles?) |
| _________ 25. | Do you know your child's friends' other friends? (These are the people they will be with at sleepovers, at the mall or movies, or in cars) |
