Supporting Healthy Marriage – Self Administered Questionnaire

OMB Control No.: 0970-0299

Expiration Date: 05/31/2009

Research ID:____________

Supporting Healthy Marriage – Self Administered Questionnaire

1. Have you and your current spouse ever attended a marriage education class, workshop, or counseling? Please check all that apply.

₁ Yes, before we got married

₂ Yes, since we got married

₃ No

2. Of the following, who could you turn to if you had an emergency and needed help? Please check all that apply.

₁ My spouse

₂ Someone else

₃ No one

3. Of the following, who could you turn to if you had a problem and needed advice or emotional support? Please check all that apply.

₁ My spouse

₂ Someone else

₃ No one

4. The following statements describe the way some people feel about families and marriage. Please indicate whether you strongly agree, agree, disagree, or strongly disagree with the following opinions. Check one answer for EACH statement.

	Strongly Agree	Agree	Disagree	Strongly Disagree
These days, it is hard for people who are married to trust one another.	1	2	3	4
Women are more trustworthy than men.	1	2	3	4
My friends place value and respect on marriage.	1	2	3	4
It is better for children if their parents are married.	1	2	3	4
It is much better for everyone if the man earns the main living and the woman takes care of the home and family.	1	2	3	4
Religion is a very important part of my life.	1	2	3	4
The personal happiness of an individual is more important than putting up with a bad marriage.	1	2	3	4
If a husband and wife both work full-time, they should share household tasks equally.	1	2	3	4

5. In the past 12 months, about how often have you attended a religious service? Was it….

₁ Never,

₂ A few times a year,

₃ A few times a month, or

₄ Once a week or more?

6. In the past 12 months, about how often have you attended a religious service with your spouse? Was it….

₁ Never,

₂ A few times a year,

₃ A few times a month, or

₄ Once a week or more?

7. All things considered, on a scale from 1 to 7, where 1 is “completely unhappy” and 7 is “completely happy”, how happy are you with your marriage? Please circle one.

1 2 3 4 5 6 7 Completely Moderately Slightly Not Happy Slightly Moderately Completely Unhappy Unhappy Happy or Unhappy Happy Happy Happy

8. The following statements describe the way some people feel about their spouse and their relationship in general. Please indicate whether you strongly agree, agree, disagree, or strongly disagree with the following statements. Check one answer for EACH statement.

	Strongly Agree	Agree	Disagree	Strongly Disagree
I can count on my spouse to be there for me.	1	2	3	4
I think that marriage education can help my marriage.	1	2	3	4
I view our relationship as lifelong.	1	2	3	4
My spouse is the type of parent I want for my child(ren).	1	2	3	4
I worry about my spouse cheating on me.	1	2	3	4
I believe this relationship can stay strong even through hard times.	1	2	3	4
My spouse is completely committed to being there for our child(ren).	1	2	3	4
My family respects and values my marriage.	1	2	3	4
It is hard for me to talk with my spouse about the important things in our life.	1	2	3	4

9. Please indicate whether each of the following happens all of the time, most of the time, some of the time, or none of the time. Check one answer for EACH statement.

   	All of the time	Most of the time	Some of the time	None of the time
   My spouse and I get along well together.	1	2	3	4
   Our arguments get very heated.	1	2	3	4
   My spouse and I have similar views about what is important in life.	1	2	3	4
   I am satisfied with the way we handle our problems and disagreements.	1	2	3	4
   We enjoy doing even ordinary, day-to-day things together.	1	2	3	4
   My spouse expresses love and affection toward me.	1	2	3	4
   My spouse listens to me when I need someone to talk to.	1	2	3	4

10. The following statements describe the way some people feel about their spouse and the way they handle problems or disagreements. Please indicate whether each of the following happens never, hardly ever, sometimes, or often. Check one answer for EACH statement.

    In the past year, how often has your spouse…	Never	Hardly ever	Sometimes	Often
    Yelled or screamed at you?	1	2	3	4
    Blamed you for his/her problems?	1	2	3	4

11. The following statements describe common problems that some couples argue about. Please indicate whether each of the following happens never, hardly ever, sometimes, or often. Check one answer for EACH statement.

How often do you and your spouse have arguments about…	Never	Hardly ever	Sometimes	Often
Household chores?	1	2	3	4
Sex?	1	2	3	4
Spending time together?	1	2	3	4
Managing money, bills and debt?	1	2	3	4
In-laws, other relatives, and friends?	1	2	3	4
Drinking or drugs?	1	2	3	4
Other women or men?	1	2	3	4
Religion?	1	2	3	4
Raising children?	1	2	3	4

12. In the past year, how often have your arguments become physical?

₁ Never

₂ Hardly ever

₃ Sometimes

₄ Often

13. In the past year, have you ever thought your marriage was in trouble?

₁ Yes

₂ No

14. Do you have any biological children who do NOT usually live in your household?

₁ Yes,  What are their ages? _____ _____ _____ _____

₂ No Child 1 Child 2 Child 3 Child 4

The next questions will ask about your childhood.

15. While you were growing up- that is, before you turned 18- did you live MOSTLY with:

₁ Both parents (biological or adopted)

₂ A biological parent and a stepparent

₃ One biological parent only  skip to question 17

₄ Other, please specify: __________________________________________

16. On a scale from 1 to 7, where 1 is “completely unhappy” and 7 is “completely happy, while you were growing up, how happy was the relationship between the parents or parent figures you reported in Question 15? Please circle one.

1 2 3 4 5 6 7 Completely Moderately Slightly Not Happy Slightly Moderately Completely Unhappy Unhappy Happy or Unhappy Happy Happy Happy

17. While you were growing up, how often did a parent, stepparent, or parent figure…

	Never	Hardly ever	Sometimes	Often
Swear at you, insult you, or put you down?	1	2	3	4
Hit, slap, or hurt you so badly you were bruised or cut?	1	2	3	4
Neglect you so that you did not get the attention and care you needed?	1	2	3	4

The next questions are about your health and health-related behaviors.

18. Would you say your health in general is…

₁ Excellent

₂ Very Good

₃ Good

₄ Fair, or

₅ Poor

19. Do you have a physical or mental health problem now that limits the amount or kind of work or activities that you can do in or outside the household?

₁ Yes

₂ No

20. These questions are about feelings you may have experienced over the past 30 days. During the past 30 days, how often did you feel...

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
...so sad that nothing could cheer you up?	1	2	3	4	5
...nervous?	1	2	3	4	5
...restless or fidgety?	1	2	3	4	5
...hopeless?	1	2	3	4	5
....that everything was an effort?	1	2	3	4	5
...worthless?	1	2	3	4	5

21. In the past 30 days, how often have you felt that you were unable to control the important things in your life?

₁ Always

₂ Often

₃ Sometimes

₄ Never

22. In the past 30 days, how often have you felt difficulties were piling up so high that you could not overcome them?

₁ Always

₂ Often

₃ Sometimes

₄ Never

23. In the past 12 months…

	Yes	No	I don’t drink
Have you felt you should cut down on your drinking?	1	2	3
Have people annoyed you by complaining about your drinking?	1	2	3
Have you ever felt bad or guilty about your drinking?	1	2	3
Have you felt you should cut down on your drug use?	1	2	3
Have people annoyed you by complaining about your drug use?	1	2	3
Have you ever felt bad or guilty about your drug use?	1	2	3

Next are some questions about unexpected experiences in your life.

24. In the past 12 months, have you…

	Yes	No
Not been able to pay your rent, mortgage or utility bills?	1	2
Felt threatened by someone or something in your neighborhood?	1	2
Gotten a pay raise or promotion?	1	2
Experienced an unplanned pregnancy?	1	2
Had any parenting or child-support problems with a former spouse or partner?	1	2
Been arrested, convicted of a crime or put in jail?	1	2
Moved into a better home or neighborhood?	1	2
Been fired or laid off from work?	1	2

25. There are good sides and bad sides to most marriages.

1. First, thinking only about the good side of your marriage, on a scale from 1 to 5, where 1 is “not at all good” and 5 is “completely good”, how would you rate the good side of your marriage?

1 2 3 4 5

Not at all Slightly Moderately Very Completely

Good Good Good Good Good

2. Now, thinking only about the bad side of your marriage, on a scale from 1 to 5, where 1 is “completely bad” and 5 is “not at all bad”, how would you rate the bad side of your marriage?

1 2 3 4 5

Completely Very Moderately Slightly Not at all

Bad Bad Bad Bad Bad

26. Thinking about being a parent, please tell us about some of the things you have most enjoyed.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank You For Completing The Survey! 

Supporting Healthy Marriage

Eligibility Check List

Date Collected: ____/____/______

mm / dd / yyyy

Eligibility Criteria (Please complete questions in order.) Is R. 18 years of age or older? 1 Yes 2 No (Ineligible) Does R. or R.’s spouse live with at least one biologically related or adopted child? 1 Yes 2 No (Ineligible) Is R. currently married? 1 Yes 2 No (Ineligible)

Is SHM offered in a language that R. can speak and understand? 1 Yes 2 No (Ineligible) Is there any indication of intimate partner violence in this couple’s relationship? 1 Yes (Ineligible) – Further follow-up needed 2 No 3 Not sure - Further follow-up needed SUPERVISOR ONLY: After further follow-up, are there any indications of intimate partner violence in this couple’s relationship:  1 Yes (Ineligible) 2 No (Eligible)

Name:

____________________________________________

First Last

SSN: |__|__|__|-|__|__|-|__|__|__|__|

Date of Birth: ____/____/______

mm / dd / yyyy

Spouse’s Name:

___________________________________________

First Last

Spouse’s Gender: ₁ Male ₂ Female

Spouse’s Date of Birth: ____/____/______

mm / dd / yyyy