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pdfAttachment 9 – Community Member, Survey – Adult Instruments
Document E.1: C-KABS Adult
OMB No. XXXX-XXXX
Expiration Date: Month Year
Public Burden Statement: 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. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this
collection of information is estimated to average 45 minutes per client per year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
Evaluation of the Native Aspirations Program
Document E.1: Community Knowledge, Awareness, and Behaviors – Adult
Version
(C-KABS-A)
You are being asked to participate in this survey because your community, along with other tribal
communities across the country, received federal funding to prevent violence, bullying, and suicide
among Native American youth. As part of the Cross-community Evaluation of the Native Aspirations
Project, we are asking that you complete this Community Knowledge, Awareness, and Behaviors Survey
(C-KABS). This survey includes a series of questions asking you about your community, attitudes, beliefs,
and experiences. The survey also asks about your exposure to and knowledge about suicide, bullying,
violence, and substance abuse prevention. The information you give will be used to help Native
American youth, Native American communities, and the Native Aspirations program.
This is not a test. There are not right or wrong answers to this survey. Please answer the questions
based on what you really think and do. Your honest answers will help us, your community, and other
Indian communities to better understand the needs of young people. DO NOT write your name on this
survey. The answers you give will be anonymous. No one will know what you write.
Completing this survey is voluntary. If you are not comfortable answering a questions, just leave it blank.
The questions that ask about your background will be used only to describe the types of community
members completing this survey. The information will not be used to find out your name. No names will
ever be reported.
Please read every question and fill in the ovals completely. When you are finished, follow the
instructions of the person giving you the survey.
Contact information: If you have any concerns about your participation in this survey or have any
questions about the evaluation, please contact Christine Walrath at [email protected]
(646-695-8154) or Kara Riehman at [email protected] (404-592-2148). If you feel
upset because of the questions in the survey, please see Mr./Mrs. NAME who is here today and can
assist you.
Thank you very much for your help.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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C-KABS-A
Directions:
Use a #2 pencil.
Make dark marks
Fill in a response like this:
Yes
No
If you change your answer, erase your old answer completely
This section asks about your community and your experiences and involvement in your
community. We’d like to get a better sense of the community you live in. The following are
statements that describe some communities. Some of the statements may describe your
community, others will not. Please mark the answer that best matches how you feel.
STRONGLY
DISAGREE
DISAGREE
NEUTRAL
AGREE
STRONGLY
AGREE
DON’T KNOW
1. Please read the following statements about your community and indicate how much you
agree or disagree.
There are opportunities to participate in
traditional cultural and spiritual activities.
There are mental health services available
in my community.
There are substance abuse services available
in my community.
Suicide is a frequent problem in my community.
Domestic violence is a frequent problem
in my community.
Drug abuse is a frequent problem in my
community.
There are opportunities to interact with elders
in my community.
Bullying is a frequent problem in the schools
in my community.
Alcohol abuse is a frequent problem in my
community.
Gangs are a serious problem in my
community.
Drug use by youth is a frequent problem
in my community.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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C-KABS-A
Underage drinking is a frequent problem in my
community.
2. Mark each activity that you participated in during the past 12 months. Mark all that apply.
[ITEMS WILL BE TAILORED TO COMMUNITY SPECIFIC NATIVE ASPIRATIONS ACTIVITIES]
Community Specific Activity 1
Community Specific Activity 2
Community Specific Activity 3
Community Specific Activity 4
Community Specific Activity 5
Other (Please specify) ________________
I did not attend any of these activities
3. Please indicate whether you have been exposed to the following in your community in the
past 12 months. [ITEMS WILL BE TAILORED TO COMMUNITY SPECIFIC NATIVE
ASPIRATIONS ACTIVITIES]
Community Specific Product 1
Community Specific Product 2
Community Specific Product 3
Community Specific Product 4
Community Specific Product 5
Other (Please specify) _________________
I was not exposed to any of these
4. What services or organizations would you like to see in your community that do not
currently exist?______________________________________________________________
___________________________________________________________________________
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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C-KABS-A
This section contains statements about suicide and mental health. Some people agree with
these statements and others do not. We’d like to get your opinion about these statements.
Please mark the answer that best fits your thoughts and opinion.
I DON’T KNOW
FALSE
TRUE
5. Please indicate whether you believe the following statements are true or false.
People often attempt suicide without warning.
Sometimes a minor event can push an otherwise
normal person to attempt suicide.
Only crazy people attempt suicide.
If a person attempted suicide, his/her situation was
probably so bad that death was the best solution.
People who talk about or threaten suicide don’t do it.
People who really want to die will find a way; it
won’t help to try and stop them.
The tendency to attempt suicide is inherited and passed
on from one generation to the next.
You should not talk to depressed people about suicide;
it might give them the idea.
The majority of suicides are among people of lower
socioeconomic status.
Social isolation/withdrawal is a risk factor for suicide
attempt.
Most suicidal people never discuss their problems
with others.
Suicide rates for 15-24 year old American Indian and
Alaska Natives are higher than any other race.
The experience of physical, sexual, and/or emotional
abuse puts one at greater risk for attempting suicide.
Most suicide attempts occur late at night or early
in the morning.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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PROBABLY
WOULD
DEFINITELY
WOULD
DON’T KNOW
Mind your own business and let him/her
have privacy?
Ask him/her if something was bothering him/her?
Try to get him/her to go talk to you about
what’s bothering him/her?
Tell the youth’s parent/guardian about what
you noticed?
Get advice from an elder about the youth?
DEFINITELY
WOULD NOT
PROBABLY
WOULD NOT
We’d like to ask you some questions about how you might respond in various situations with
youth in your community. There are no right or wrong answers. Please mark the answer that
best fits how you think you would react.
6. If you noticed a youth began to lose interest in activities and friends and sometimes said
things like he or she wasn’t much good to anyone, would you:
PROBABLY
WOULD
DEFINITELY
WOULD
DON’T KNOW
Mind your own business and let the youth
handle the situation on his/her own?
Report the situation to the police?
Tell the parent(s)/guardian(s) of the youth being
attacked?
Tell the parent(s)/guardian(s) of the bully?
Get advice from an elder about the situation?
DEFINITELY
WOULD NOT
PROBABLY
WOULD NOT
7. If a youth was being threatened, bullied, picked on, or physically attacked by another youth
on a regular basis, would you:
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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C-KABS-A
DEFINITELY
WOULD
DON’T KNOW
Take the youth seriously?
Feel comfortable talking to the youth about
his/her problem?
Talk to the youth without getting anyone else’s help?
Get advice from an elder about what to do?
Get advice from another adult (not an elder)
about what to do?
Call a mental health services department in your
community?
Tell the youth’s parent(s)/guardian(s)?
PROBABLY
WOULD NOT
Tell the youth to call a hotline?
DEFINITELY
WOULD NOT
PROBABLY
WOULD
8. If a youth told you he/she was thinking about killing him or herself would you:
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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The next section asks about your thoughts about people who get mental health treatment as
well as your knowledge of resources for mental health treatment in your community. There
are no right or wrong answers.
STRONGLY
DISAGREE
DISAGREE
NEUTRAL
AGREE
STRONGLY
AGREE
9. Please read the following and indicate how much you agree or disagree.
It is a sign of personal weakness to receive
treatment for suicidal thoughts and behaviors.
I would think less of a person if I found out that
he/she received treatment for suicidal thoughts
and behaviors.
If you received mental health treatment, you
shouldn’t tell anyone about it.
I wouldn’t trust someone who received mental
health treatment.
10. Do you know of at least one crisis hotline number that you could give to a youth at risk for
suicide?
Yes
No
11. Do you know of at least one mental health service provider where you could refer a youth
at risk for suicide?
Yes (Go to question 20)
No (Go to question 21)
12. Where would you refer a youth at risk for suicide? _________________________________
We would like to ask you about your child or children and involvement with your child or
children. Please mark the answer that best fits your experiences or how you feel. If you do
not have a child or children 17 years of age or under, please continue to question 18.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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13. How important is it to you that your child or children do the following in school:
Very
Important
Somewhat
Important
Not very
Important
Not Important
at all
Make friends
Get good grades
Participate in extracurricular activities
Learn new things
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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STRONGLY
DISAGREE
DISAGREE
NEUTRAL
AGREE
STRONGLY
AGREE
14. Read the following statements and choose the answer that best describes how you feel.
My child is safe at school.
My child is safe on the way
to and from school.
I would know if my child was being bullied
in school.
I would know if my child was being bullied
to and from school.
I don’t mind if my child drinks alcohol (more than a few sips).
I don’t mind if my child smokes cigarettes.
If my child were feeling sad or blue, I would know it.
If my child was depressed and refused to get out of the
bed, I would get him professional mental health help.
It is important for my child to participate in community
events.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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RARELY
MOST OF THE
TIME
ALL THE TIME
When my child is not at home, I know where
he or she is.
I make a point to meet my child’s friends.
My child asks for permission before leaving the house.
My child regularly shares his or her thoughts with me.
If my child has a problem or struggle, he/she will come
to me first to talk through the problem.
I make my child work on his/her homework after school.
I know the kind of grades that my child gets in school.
I talk to my child about how his/her day went.
SOME OF THE
TIME
NEVER
15. Read the following statements and choose the answer that best describes how you feel.
16. If you thought your child was at risk for suicide, would you take him/her to get mental
health treatment?
Yes
No
I don’t know
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You are almost finished with the survey. We would like to ask you a few questions about
yourself that will help us understand all of the answers we receive. We will use this
information only to group you with others who are like you to see whether your answers are
similar. This information will not be used to identify any individual person completing the
survey.
17. What is your gender?
Female
Male
18. What is your age? __________
19. Are you married?
Yes
No
20. Are you Hispanic or Latino?
Yes [go to question 30]
No [go to question 31]
21. Which Hispanic or Latino group represents you? Are you…(Select one or more.)
Mexican, Mexican-American, or Chicano
Puerto Rican
Cuban
Dominican
Central American
South American
Other Hispanic Origin, please describe _________________
22. What is your race? (Select all that apply.)
American Indian
Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
23. Do you have children?
Yes
No
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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24. What is your yearly household income?
0 - $9,999
$10,000 – $19,999
$20,000 – $29,999
$30,000 – $39,999
$40,000 – $49,999
$50,000 – $59,999
$60,000 and over
25. Including yourself, how many people live with you? _______
English
Spanish
Other language
Please specify ______________________
ALWAYS
SOMETIMES
Tribal language
OFTEN
NEVER
26. What languages are spoken in your home?
27. Do you practice traditional Indian/Native beliefs and values?
Yes
No
I don’t know
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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RARELY
SOME OF THE
TIME
Gone hunting?
Gone fishing?
Gone digging for roots or gathered herbs
or medicines in a traditional Native way?
Gathered berries in a traditional Native way?
Gathered materials for baskets and done basket
weaving in a traditional Native way?
Gone canoeing?
Been to a pow-wow?
Done traditional native beading?
Participated in community celebrations?
Participated in potlatches?
Gone to church?
Gone to a sweat?
Smudged?
Participated in other cultural or spiritual activities?
Please describe
___________________________
___________________________
___________________________
___________________________
ALL THE TIME
NEVER
MOST OF THE
TIME
28. How often have you done the following with your child/children? [ITEMS WILL BE
TAILORED TO COMMUNITY SPECIFIC NATIVE ASPIRATIONS ACTIVITIES]
Thank you for your time and attention to this survey. The information you have provided is
extremely important to suicide, violence, and bullying prevention efforts in your community.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
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To request additional information or if you or someone you know is in
need of help, please dial 1-800-273-TALK
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Adult Version
Page 14
| File Type | application/pdf |
| Author | Jeremy.m.martinez |
| File Modified | 2010-06-04 |
| File Created | 2010-06-04 |