Social Isolation/Support

S

OMB No: ???: Exp Date: ???

_____________________

ocial Isolation/Support

These next questions ask you about people in your life who provide you with help or support.

	0	1	2	3	4	5	6	7	8	9	10+
How many close friends do you have that you feel at ease with, can talk to about private matters, and can call on for help?	O	O	O	O	O	O	O	O	O	O	O
How many relatives do you have that you feel close to?	O	O	O	O	O	O	O	O	O	O	O
How many of these friends or relatives do you talk to at least once a month?	O	O	O	O	O	O	O	O	O	O	O

4. Do you belong to any clubs, social groups, or organizations other than church or religious groups?

O Yes

O No (Go to Q6)

O Don’t Know/Not Sure

O Refused

5. How often do you participate in these activities?

O More than once a week

O Once a week

O Two – three times a month

O Once a month

O Less than once a month

O Don’t Know/Not Sure

O Refused

People sometimes look to others for companionship, assistance, or other types of support. How often do you have these kinds of support available to you if you need them? In times of need,

	All of the time	Most of the time	Some of the time	A little of the time	None of the time	Don’t Know/ Not Sure	Refused
6. How often would you have someone to help with daily chores if you were sick?	O	O	O	O	O	O	O
7. How often would you have someone to love you and make you feel wanted?	O	O	O	O	O	O	O
8. How often would you have someone to do something enjoyable with?	O	O	O	O	O	O	O
9. How often would you have someone to confide in or talk to about yourself or your problems?	O	O	O	O	O	O	O

T

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

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