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Mental Health Survey Instrument

Demographics

I would just like to ask some general background information – first about you and then about your household.

What year were you born?  
YEAR OF BIRTH 19__
DON'T KNOW 8
REFUSE 9
Have you had your birthday already this calendar year?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
DM1. What is the highest grade or year of school you have completed? [Read choices 1 – 7 if necessary.]  
Eighth grade or less 1
Some high school 2
High school graduate or GED certificate 3
Some post high school 4
College graduate (Associate or Bachelor's) 5
Post graduate education or degree 6
Other (Specify) 7
DON'T KNOW 98
REFUSE 99
DM2. What is the highest grade or year of school that anyone else in your household has completed? [Read choices 1 – 7 if necessary.]  
Eighth grade or less 1
Some high school 2
High school graduate or GED certificate 3
Some post high school 4
College graduate (Associate or Bachelor's) 5
Post graduate education or degree 6
Other (Specify) 7
DON'T KNOW 98
REFUSE 99
DM3. Are you currently: [Read answers 1-8.]  
Employed or self-employed full-time 1
Employed or self-employed part-time 2
Homemaker or caregiver 3
Out of work or unable to work 4
Student 5
Student and employed 6
Retired 7
Something else (Specify) 8
DON'T KNOW 98
REFUSE 99
DM4. Are you currently: [Read answers 1-7.] [Prompt if necessary, “Pick the one that you feel best describes your current status.”]  
Married 1
Partnered 2
Divorced 3
Widowed 4
Separated 5
Never married 6
Other (Specify) 7
DON'T KNOW 98
REFUSE 99
DM5. Do you consider yourself of Hispanic or Latino origin, including Mexican, Latin American, Puerto Rican, or Cuban descent?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
DM6. What is your race? Please select one or more of the following. [Read answers 1 – 6 and code all that apply.]  
Native American or Alaskan Native 1
Asian 2
African American or Black 3
Native Hawaiian or Other Pacific Islander 4
Caucasian or White 5
Other (Specify) 6
DON'T KNOW 98
REFUSE 99
DM7. Would you tell me what category best represents the total gross income (income brought in before taxes) during the past 12 months by all members of your household? Please stop me when I read the right category. [Read answers 1-5.]  
Less than $20,000 1
$20,000 - <$35,000 2
$35,000 - <$50,000 3
N$50,000 - <$100,000 4
$100,000 or more 5
DON'T KNOW 8
REFUSE 9

Exposure to Event

The following questions are about the [TRAUMATIC EVENT].

The next two questions [P1-P2] assess personal exposure to traumatic event.
P1. Which best describes your personal exposure to [TRAUMATIC EVENT]? Would you say (READ ANSWERS)?  
You were in or around [TRAUMATIC EVENT] and you saw at least some of this happen 1
You were in or around the [TRAUMATIC EVENT] but did not see any of it happen 2
You were not in or around any of the [TRAUMATIC EVENT] 3
DON'T KNOW 8
REFUSE 9
P2. As a result of your exposure to the [TRAUMATIC EVENT] did you feel that you were at risk of being injured or killed?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
The next six questions [P3-P8] assess known others' exposure to traumatic event.
P3. When you first heard about the [TRAUMATIC EVENT], did you fear that a family member or close friend who was in or around the site of the [TRAUMATIC EVENT] might be killed, injured, or missing?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P4. As a result of the [TRAUMATIC EVENT], did you actually have a family member or close friend who was killed, injured, or missing?  
YES 1
NO (skip to P6) 2
DON'T KNOW (skip to P6) 8
REFUSE (skip to P6) 9
P5. What was this person's relationship to you?  
CURRENT OR FORMER SPOUSE 1
CURRENT OR FORMER BOYFRIEND/GIRLFRIEND) 2
PARENT OR STEP PARENT 3
SIBLING OR STEP-SIBLING 4
CHILD OR STEP CHILD 5
GRANDPARENT 6
GRANDCHILD 7
OTHER FAMILY MEMBER (AUNT/UNCLE, COUSIN, NEPHEW/NIECE ETC.) 8
CLOSE FRIEND 9
OTHER (SPECIFY) 10
MULTIPLE PEOPLE (SPECIFY) 95
DON'T KNOW 98
REFUSE 99
N/A (SKIP) 97
P6. Was anyone else you personally know killed, injured, or missing, as a result of the [TRAUMATIC EVENT]?  
YES 1
NO (skip to P8) 2
DON'T KNOW (skip to P8) 8
REFUSE (skip to P8) 9
P7. What was this person's relationship to you?  
FRIEND 1
NEIGHBOR 2
CO-WORKER 3
OTHER (SPECIFY) 4
MULTIPLE PEOPLE (SPECIFY) 95
DON'T KNOW 98
REFUSE 99
N/A (SKIP) 97
P8. Do you know someone who had a family member or close friend who was killed, injured, or missing as a result of the [TRAUMATIC EVENT]?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9

Assessment of Symptoms

 
The next seven questions [P9-P15] assess PTSD symptoms.
 
The next questions are about the time after the [TRAUMATIC EVENT]. Please answer yes or no for each question. After the [TRAUMATIC EVENT]…
P9. Did you avoid being reminded of this experience by staying away from certain places, people, or activities?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P10. Did you lose interest in activities that were once important or enjoyable?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P11. Did you begin to feel more isolated or distant from other people? (PROMPT: Other people with whom you normally interact.)  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P12. Did you find it hard to have love or affection for other people?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P13. Did you begin to feel that there was no point in planning for the future? (PROMPT: I mean long-term future, such as planning for a career, children, or retirement.)  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P14. After this experience, were you having more trouble than usual falling asleep or staying asleep? (PROMPT: By this experience I mean the [TRAUMATIC EVENT].)  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P15. Did you become jumpy or get easily startled by ordinary noises or movements?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
The next six questions [P16-P21] assess anxiety symptoms.
Since [TRAUMATIC EVENT] have you been distressed or bothered by…
P16. Feelings of nervousness or shakiness inside?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P17. Suddenly scared for no good reason?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P18. Feeling fearful?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P19. Feeling tense or keyed up?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P20. Spells of terror or panic?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P21. Feeling so restless you couldn't sit still?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
The next six questions [P22-P27] assess anxiety symptoms.
P22. Thoughts of taking your life?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P23. Feeling lonely?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P24. Feeling blue?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P25. Difficulty making decisions?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P26. Feeling hopeless about the future?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
P27. Feelings of worthlessness?  
YES 1
NO 2
DON'T KNOW 8
REFUSE 9
The next question [P28] assesses frequency of symptoms.
P.28 Are you currently having these reactions at least a few times a week?  
YES (skip to P29) 1
NO 2
DON'T KNOW 8
REFUSE 9
N/A (SKIP) 7
The next question [P29] assesses professional help-seeking.
P29. Have you discussed these reactions with a doctor, nurse, psychologist, or other health professional?  
YES (skip to P29) 1
NO 2
DON'T KNOW 8
REFUSE 9
N/A (SKIP) 7
The next two questions [P30-P31] assess heavy drinking.
P30. How many drinks did you have on a typical day since the [TRAUMATIC EVENT]?  
None 0
1 to 2 drinks 0
3 to 4 drinks 1
7 to 9 drinks 2
10 or more drinks 4
DON'T KNOW 8
REFUSE 9
N/A (SKIP) 7
P31. How often did you have 6 or more drinks on one occasion since the [TRAUMATIC EVENT]?  
Never 0
Once 1
2 to 3 times 2
4 to 5 times 3
6 or more times 4
DON'T KNOW 8
REFUSE 9
N/A (SKIP) 7

Page last reviewed July 26, 2005
Page last modified March 27, 2003

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