Form Instrument for Par Instrument for Par Instrument for Partners-Fathers

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ATTACHMENT C-1:
C-1.1

INSTRUMENT FOR PARTNERS/FATHERS
Ferrans and Powers Quality of Life Index (for partners/fathers)

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Attachment C-1

Ferrans and Powers Quality of Life Index

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FEBRUARY 23, 2010 FORMAT
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:

Form Approved
OMB No. xxxx-xxxx
Expiration Date xx-xx-xxxx

2 0
|__|__| |__|__| |__|__|__|__|

START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|

FAMILY ID# 8 |__|__|

2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
RESPONDENT:

Mother |__|

Mother’s partner |__|

Child’s father |__|

Other |__| Specify: ________________

IF RESPONDENT IS NOT THE MOTHER, What are the Child IDs of the children he or she has a relationship with?
|__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__|
IF RESPONDENT IS THE BIOLOGICAL FATHER, What are the Child IDs of his biological children?
|__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__|
EVALUATION PHASE:

Intake |__|

6-mos post-Intake |__|
(MOTHER ONLY)

PERSON COMPLETING |_______________|

Discharge |__|
GRANT#

6-mos post-Discharge |__|
(MOTHER ONLY)

TI |__|__|__|__|__|__|

FERRANS AND POWERS QUALITY OF LIFE INDEX©
GENERIC VERSION – III
PART 1. For each of the following, please choose the answer that best describes how satisfied you are with that area of your life.
Please mark your answer by checking the box. There are no right or wrong answers.
Very
dissatisfied

How satisfied are you with:
1.

Your health? ......................................................

2.

Your health care? ..............................................

3.

The amount of pain that you have? ...................

4.

The amount of energy you have for everyday
activities? ..........................................................

5.

Your ability to take care of yourself without
help? .................................................................

6.

The amount of control you have over your life?

7.

Your chances of living as long as you would
like? ...................................................................

8.

Your family’s health? .........................................

9.

Your children? ...................................................

Moderately
dissatisfied

Slightly
dissatisfied

Slightly
satisfied

Moderately
satisfied

Very
satisfied

10. Your family’s happiness? ..................................
11. Your sex life? ....................................................
12. Your spouse, lover, or partner? .........................
13. Your friends? .....................................................
Public reporting burden for this collection of information is estimated to average 15 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. Send
comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1
Choke Cherry Road, Rockville, MD 20857. 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 control number for this project is 0930-0269.
© Copyright 1984 & 1998 Carol Estwing Ferrans and Marjorie J. Powers

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Very
dissatisfied

How satisfied are you with:

Moderately
dissatisfied

Slightly
dissatisfied

Slightly
satisfied

Moderately
satisfied

Very
satisfied

14. The emotional support you get from your
family? ...............................................................
15. The emotional support you get from people
other than your family? ......................................
16. Your ability to take care of family
responsibilities?.................................................
17. How useful you are to others?...........................
18. The amount of worries in your life? ...................
19. Your neighborhood? ..........................................
20. Your home, apartment, or place where you
live? ...................................................................
21. Your job (if employed)? .....................................
22. Not having a job (if unemployed, retired, or
disabled)?..........................................................
23. Your education? ................................................
24. How well you can take care of your financial
needs? ..............................................................
25. The things you do for fun?.................................
26. Your chances for a happy future? .....................
27. Your peace of mind? .........................................
28. Your faith in God? .............................................
29. Your achievement of personal goals? ...............
30. Your happiness in general?...............................
31. Your life in general? ..........................................
32. Your personal appearance? ..............................
33. Yourself in general? ..........................................

PART 2. For each of the following, please choose the answer that best describes how important that area of your life is to you. Please
mark your answer by checking the box. There are no right or wrong answers.
How important to you is:
1.

Your health? ...................................................

2.

Your health care? ...........................................

3.

Having no pain? .............................................

4.

Having enough energy for everyday
activities? .......................................................

5.

Taking care of yourself without help? .............

6.

Having control over your life? .........................

Very
unimportant

Moderately
unimportant

2

Slightly
unimportant

Slightly
important

Moderately
important

Very
important

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How important to you is:
7.

Living as long as you would like? ...................

8.

Your family’s health? ......................................

9.

Your children? ................................................

Very
unimportant

Moderately
unimportant

10. Your family’s happiness? ...............................
11. Your sex life? .................................................
12. Your spouse, lover, or partner? ......................
13. Your friends? ..................................................
14. The emotional support you get from your
family? ............................................................
15. The emotional support you get from people
other than your family? ...................................
16. Taking care of family responsibilities? ............
17. Being useful to others?...................................
18. Having no worries?.........................................
19. Your neighborhood? .......................................
20. Your home, apartment, or place where you
live? ................................................................
21. Your job (if employed)? ..................................
22. Having a job (if unemployed, retired, or
disabled)?.......................................................
23. Your education? .............................................
24. Being able to take care of your financial
needs? ...........................................................
25. Doing things for fun? ......................................
26. Having a happy future? ..................................
27. Peace of mind? ..............................................
28. Your faith in God? ..........................................
29. Achieving your personal goals? .....................
30. Your happiness in general?............................
31. Being satisfied with life? .................................
32. Your personal appearance? ...........................
33. Are you to yourself? .......................................

3

Slightly
unimportant

Slightly
important

Moderately
important

Very
important