CHAPTER I
Appendix 1b: Form on situation within a family and living conditions
A survey about your family situation: Who are you?- let’s get to know each other. (author
Ms. Agnieszka Laskowska)
Read the survey and write your answers in the intended place or mark the answer by
writing „x” in a correct space. Thank you.
1. My name is ……………………………………………………………………………..
2. I was born on: day…….. month …….. year ….., in (birthplace)…………………………..
3. I live in …………………………, Street ……………………………………….
Me, my family, my home (mark the answers with X)
1. Do you have any siblings?
yes
no
2. If you have any siblings, how many are there?
1
2
3
4
5
3. Do you have your own room?
yes
no
4. If you marked „no” in question no 3, say who do you share the room with.
my siblings my parents
my grandparents other relative
5. I live with:
mom and dad
just mom
my mom and her boyfriend
just dad
dad and his girlfriend
grandparents
in a school dormitory
other, …………………………………………………………………………….
6. If I have some free time, just for me at home, I have homework to do or I just want to rest I
have a place at home where I can be alone, it is ……………………
don’t have a place where I can be alone at home
7. Mark the answer you agree with:
I like my home and my family
I don’t like my home and my family
I would like some things could change at my home and in my family