Form Attachment D Attachment D Childhood Experiences Survey

Measuring Preferences for Quality of Life for Child Maltreatment

Attachment D - Survey Instrument 3-29-2012

Measuring Preferences for Quality of Life for Child Maltreatment Survey Instrument: Ages 18+

OMB: 0920-0930

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Attachment D


Survey Instrument




OMB No. 0920-XXXX

Exp. Date:



Shape1

Public Reporting burden of this collection of information is estimated at 27 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).











Childhood Experiences Survey


On this survey, we will ask you some questions about your health, relationships, and behaviors. We will ask about these during 3 different time periods: now (as an adult), and thinking back to when you were a teenager and when you were a child.


You will also be asked to compare some different health experiences and to choose which you would prefer. Finally, we will ask some questions about your childhood experiences.


Your responses are very important to public health. Your answers will help us to improve the health of others in the future.

There are no right or wrong answers. We are only interested in your experiences and opinions.





Your Health Status



Would you say that in general your health is…?


Excellent

Very good

Good

Fair

Poor


Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?


____


Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?


____


During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?


____





In the past 30 days, how often did the following things happen? Please select one box per row.




Often

Sometimes

Rarely

Never

I was so angry that I felt like throwing things, screaming at someone, or picking a fight


I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities


I felt depressed, afraid, or worthless


I felt like my emotions were out of control


I could not trust or maintain healthy relationships with other people


Illness, injuries, or accidents interfered with my daily activities


I felt limited by pain, discomfort, or my physical ability
















Health as an Adult


Now please think about your health from age 18 to the present day.


From age 18 to the present day, on average, would you say that in general your health was…?


Excellent

Very good

Good

Fair

Poor





From age 18 to the present day, on average, how often did the following things happen? Please select one box per row.



Often

Sometimes

Rarely

Never

I was so angry that I felt like throwing things, screaming at someone, or picking a fight


I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities


I felt depressed, afraid, or worthless


I felt like my emotions were out of control


I could not trust or maintain healthy relationships with other people


Illness, injuries, or accidents interfered with my daily activities


I felt limited by pain, discomfort, or my physical ability















Health as a Teenager (Ages 12-17)


Now please think about your health as a teenager (ages 12-17).


As a teenager (ages 12-17), on average, would you say that in general your health was…?


Excellent

Very good

Good

Fair

Poor





As a teenager (ages 12-17), on average, how often did the following things happen? Please select one box per row.



Often

Sometimes

Rarely

Never

I was so angry that I felt like throwing things, screaming at someone, or picking a fight


I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities


I felt depressed, afraid, or worthless


I felt like my emotions were out of control


I could not trust or maintain healthy relationships with other people


Illness, injuries, or accidents interfered with my daily activities


I felt limited by pain, discomfort, or my physical ability














Health as a Child (Ages 5-11)


Now please think about your health as a child (ages 5-11).


As a child (ages 5-11), on average, would you say that in general your health was…?


Excellent

Very good

Good

Fair

Poor


As a child (ages 5-11), on average, how often did the following things happen? Please select one box per row.



Often

Sometimes

Rarely

Never

I was so angry that I felt like throwing things, screaming at someone, or picking a fight


I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities


I felt depressed, afraid, or worthless


I felt like my emotions were out of control


I could not trust or maintain healthy relationships with other people


Illness, injuries, or accidents interfered with my daily activities


I felt limited by pain, discomfort, or my physical ability













Comparing Health



So far, we have asked you to describe your health in the past.


Now we are going to ask about what type of health you would like to have.


We will show you two different health profiles side-by-side.


We’ll then ask you to pick which you would prefer to have—if you had to pick between the two profiles.


Let’s begin with an example.



Comparing Health as an Adult


For each question, we will show you two profiles with the health aspects we just asked you about. For example:



As an adult with Profile A, you would often feel depressed, afraid or worthless, and never feel limited by pain, discomfort, or physical ability.


As an adult with Profile B, you would never feel depressed, afraid, or worthless, and often feel limited by pain, discomfort, or physical ability.



We will show this information side-by-side in a table like this.


Aspects


Profile A

Profile B

Feel depressed, afraid, or worthless



Often

Never

Feel limited by pain, discomfort, or physical ability



Never

Often


Then, we’ll ask you which profile you would prefer—if you had to choose between the two.


Which would you prefer?





Next, we’ll add one additional aspect. Suppose that your choice limited the number of years you live from today.


In the profile you chose, you would live 4 years from today, followed by death.



In the profile you did not choose, you would live 8 years from today, followed by death.


Thinking about this additional aspect, please choose which you would prefer.




Profile A

Profile B

Years you would live from today followed by death


Live for 4 years

Live for 8 years

Which would you prefer?




The next questions will add the other aspects of health.




Adult Comparison #1


Compare the following two new health profiles for an adult. Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Never

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Often

Never

Feel like emotions are out of control



Sometimes

Rarely

Cannot trust or maintain healthy relationships with other people



Never

Never

Illness, injuries, or accidents interfere with daily activities



Rarely

Sometimes

Feel limited by pain, discomfort, or physical ability



Never

Often

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Never

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Often

Never

Feel like emotions are out of control



Sometimes

Rarely

Cannot trust or maintain healthy relationships with other people



Never

Never

Illness, injuries, or accidents interfere with daily activities



Rarely

Sometimes

Feel limited by pain, discomfort, or physical ability



Never

Often

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 4 years

Live for 8 years

Which would you prefer?





Adult Comparison #2


Compare the following two new health profiles for an adult. Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Rarely

Never

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Never

Never

Feel like emotions are out of control



Sometimes

Rarely

Cannot trust or maintain healthy relationships with other people



Never

Never

Illness, injuries, or accidents interfere with daily activities



Never

Rarely

Feel limited by pain, discomfort, or physical ability



Rarely

Sometimes

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Rarely

Never

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Never

Never

Feel like emotions are out of control



Sometimes

Rarely

Cannot trust or maintain healthy relationships with other people



Never

Never

Illness, injuries, or accidents interfere with daily activities



Never

Rarely

Feel limited by pain, discomfort, or physical ability



Rarely

Sometimes

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 8 years

Live for 10 years

Which would you prefer?






Adult Comparison #3


Compare the following two new health profiles for an adult. Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Rarely

Often

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Rarely

Rarely

Feel depressed, afraid, or worthless



Never

Never

Feel like emotions are out of control



Never

Sometimes

Cannot trust or maintain healthy relationships with other people



Sometimes

Sometimes

Illness, injuries, or accidents interfere with daily activities



Often

Rarely

Feel limited by pain, discomfort, or physical ability



Sometimes

Never

Which would you prefer?





Suppose that your choice limited the number of years you live from today.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Rarely

Often

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Rarely

Rarely

Feel depressed, afraid, or worthless



Never

Never

Feel like emotions are out of control



Never

Sometimes

Cannot trust or maintain healthy relationships with other people



Sometimes

Sometimes

Illness, injuries, or accidents interfere with daily activities



Often

Rarely

Feel limited by pain, discomfort, or physical ability



Sometimes

Never

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 6 years

Live for 7 years

Which would you prefer?





Comparing Health as a Teenager


Now we will ask about how you would compare health during ages 12-17. Again, we will show you two profiles. For example:



As a teenager with Profile A, you would often feel depressed, afraid or worthless, and never feel limited by pain, discomfort, or physical ability.


As a teenager with Profile B, you would never feel depressed, afraid, or worthless, and often feel limited by pain, discomfort, or physical ability



We will show this information side-by-side in a table like this.


Aspects


Profile A

Profile B

Feel depressed, afraid, or worthless



Often

Never

Feel limited by pain, discomfort, or physical ability



Never

Often


Then, we’ll ask you which profile you would prefer to have had as a teenager—if you had to choose between the two.


Which would you prefer?





Next, we’ll add one additional aspect. Suppose that your choice limited the number of years you live from today.


In the profile you chose, you would live 4 years from today, followed by death.



In the profile you did not choose, you would live 8 years from today, followed by death.


Thinking about this additional aspect, please choose which you would prefer.




Profile A

Profile B

Years you would live from today followed by death


Live for 4 years

Live for 8 years

Which would you prefer?





Teenage Comparison #1


Compare the following two new health profiles that you could have had as a teenager (ages 12-17). Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Never

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Sometimes

Rarely

Feel depressed, afraid, or worthless



Sometimes

Often

Feel like emotions are out of control



Rarely

Sometimes

Cannot trust or maintain healthy relationships with other people



Often

Sometimes

Illness, injuries, or accidents interfere with daily activities



Never

Never

Feel limited by pain, discomfort, or physical ability



Never

Never

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Never

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Sometimes

Rarely

Feel depressed, afraid, or worthless



Sometimes

Often

Feel like emotions are out of control



Rarely

Sometimes

Cannot trust or maintain healthy relationships with other people



Often

Sometimes

Illness, injuries, or accidents interfere with daily activities



Never

Never

Feel limited by pain, discomfort, or physical ability



Never

Never

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 6 years

Live for 10 years

Which would you prefer?





Teenage Comparison #2


Compare the following two new health profiles that you could have had as a teenager (ages 12-17). Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Rarely

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Rarely

Often

Feel depressed, afraid, or worthless



Sometimes

Never

Feel like emotions are out of control



Often

Rarely

Cannot trust or maintain healthy relationships with other people



Never

Sometimes

Illness, injuries, or accidents interfere with daily activities



Sometimes

Sometimes

Feel limited by pain, discomfort, or physical ability



Rarely

Rarely

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Rarely

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Rarely

Often

Feel depressed, afraid, or worthless



Sometimes

Never

Feel like emotions are out of control



Often

Rarely

Cannot trust or maintain healthy relationships with other people



Never

Sometimes

Illness, injuries, or accidents interfere with daily activities



Sometimes

Sometimes

Feel limited by pain, discomfort, or physical ability



Rarely

Rarely

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 8 years

Live for 10 years

Which would you prefer?





Teenage Comparison #3


Compare the following two new health profiles that you could have had as a teenager (ages 12-17). Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Sometimes

Sometimes

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Sometimes

Rarely

Feel depressed, afraid, or worthless



Never

Sometimes

Feel like emotions are out of control



Rarely

Often

Cannot trust or maintain healthy relationships with other people



Often

Sometimes

Illness, injuries, or accidents interfere with daily activities



Rarely

Rarely

Feel limited by pain, discomfort, or physical ability



Rarely

Rarely

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Sometimes

Sometimes

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Sometimes

Rarely

Feel depressed, afraid, or worthless



Never

Sometimes

Feel like emotions are out of control



Rarely

Often

Cannot trust or maintain healthy relationships with other people



Often

Sometimes

Illness, injuries, or accidents interfere with daily activities



Rarely

Rarely

Feel limited by pain, discomfort, or physical ability



Rarely

Rarely

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 5 years

Live for 6 years

Which would you prefer?





Comparing Health as a Child


Finally, we will ask about how you would compare health during ages 5-11. Again, we will show you two profiles. For example:



As a child with Profile A, you would often feel depressed, afraid or worthless, and never feel limited by pain, discomfort, or physical ability.


As a child with Profile B, you would never feel depressed, afraid, or worthless, and often feel limited by pain, discomfort, or physical ability



We will show this information side-by-side in a table like this.


Aspects


Profile A

Profile B

Feel depressed, afraid, or worthless



Often

Never

Feel limited by pain, discomfort, or physical ability



Never

Often


Then, we’ll ask you which profile you would prefer to have had as a child—if you had to choose between the two.


Which would you prefer?





As before, we’ll add one additional aspect. Suppose that your choice limited the number of years you live from today.


In the profile you chose, you would live 4 years from today, followed by death.



In the profile you did not choose, you would live 8 years from today, followed by death.


Thinking about this additional aspect, please choose which you would prefer.




Profile A

Profile B

Years you would live from today followed by death


Live for 4 years

Live for 8 years

Which would you prefer?





Childhood Comparison #1


Compare the following two new health profiles that you could have had as a child (ages 5-11). Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Often

Sometimes

Feel like emotions are out of control



Never

Never

Cannot trust or maintain healthy relationships with other people



Sometimes

Often

Illness, injuries, or accidents interfere with daily activities



Never

Never

Feel limited by pain, discomfort, or physical ability



Rarely

Never

Which would you prefer?







Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Often

Sometimes

Feel like emotions are out of control



Never

Never

Cannot trust or maintain healthy relationships with other people



Sometimes

Often

Illness, injuries, or accidents interfere with daily activities



Never

Never

Feel limited by pain, discomfort, or physical ability



Rarely

Never

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 4 years

Live for 7 years

Which would you prefer?





Childhood Comparison #2


Compare the following two new health profiles that you could have had as a child (ages 5-11). Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Often

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Rarely

Rarely

Feel depressed, afraid, or worthless



Never

Sometimes

Feel like emotions are out of control



Sometimes

Sometimes

Cannot trust or maintain healthy relationships with other people



Sometimes

Never

Illness, injuries, or accidents interfere with daily activities



Sometimes

Sometimes

Feel limited by pain, discomfort, or physical ability



Rarely

Often

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Often

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Rarely

Rarely

Feel depressed, afraid, or worthless



Never

Sometimes

Feel like emotions are out of control



Sometimes

Sometimes

Cannot trust or maintain healthy relationships with other people



Sometimes

Never

Illness, injuries, or accidents interfere with daily activities



Sometimes

Sometimes

Feel limited by pain, discomfort, or physical ability



Rarely

Often

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 6 years

Live for 8 years

Which would you prefer?





Childhood Comparison #3


Compare the following two new health profiles that you could have had as a child (ages 5-11). Please choose which you prefer.


Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Often

Rarely

Feel like emotions are out of control



Rarely

Rarely

Cannot trust or maintain healthy relationships with other people



Rarely

Sometimes

Illness, injuries, or accidents interfere with daily activities



Rarely

Rarely

Feel limited by pain, discomfort, or physical ability



Sometimes

Never

Which would you prefer?






Aspects


Profile A

Profile B

Are so angry that you feel like throwing things, screaming at someone, or picking a fight



Never

Rarely

Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities



Never

Never

Feel depressed, afraid, or worthless



Often

Rarely

Feel like emotions are out of control



Rarely

Rarely

Cannot trust or maintain healthy relationships with other people



Rarely

Sometimes

Illness, injuries, or accidents interfere with daily activities



Rarely

Rarely

Feel limited by pain, discomfort, or physical ability



Sometimes

Never

Which would you prefer?



Suppose that your choice limited the number of years you live from today.


Years you would live from today followed by death


Live for 4 years

Live for 8 years

Which would you prefer?






Childhood Experiences


For the last few sections of this survey, we would like to ask questions about your childhood experiences. Some of the questions may make you uncomfortable.


We recommend that you complete this section of the survey in a private place.


You may also take a break at any time. You may close your web browser and resume the survey later if you choose.


Remember that you can refuse to answer any question by leaving it blank.





































These questions ask about some of your experiences growing up as a child and a teenager. Although these questions are of a personal nature, please try to answer as honestly as you can. For each question, place check the response that best describes how you feel.


When I was growing up …

Never True

Rarely True

Some-times True

Often True

Very Often True

 

 

 

 

 

 

  1. I didn't have enough to eat.





 


 

 

 

 

 

  1. I knew that there was someone to take care of me and protect me.





 


 

 

 

 

 

  1. People in my family called me things like "stupid," "lazy," or "ugly."





 


 

 

 

 

 

  1. My parents were too drunk or high to take care of the family.





 


 

 

 

 

 

  1. There was someone in my family who helped me feel that I was important or special.





 


 

 

 

 

 

  1. I had to wear dirty clothes.





 


 

 

 

 

 

  1. I felt loved.





 


 

 

 

 

 

  1. I thought that my parents wished I had never been born.





 


 

 

 

 

 

  1. I got hit so hard by someone in my family that I had to see a doctor or go to the hospital.





 


 

 

 

 

 

  1. There was nothing I wanted to change about my family.





 


 

 

 

 

 

  1. People in my family hit me so hard that it left me with bruises or marks.





 


 

 

 

 

 

  1. I was punished with a belt, a board, a cord, or some other hard object.





 


 

 

 

 

 

  1. People in my family looked out for each other.





 


 

 

 

 

 

  1. People in my family said hurtful or insulting things to me.





 


 

 

 

 

 

  1. I believe that I was physically abused.





 


 

 

 

 

 

  1. I had the perfect childhood.





 


 

 

 

 

 

  1. I got hit or beaten so badly that it was noticed by someone like a teacher, neighbor, or doctor.





 


 

 

 

 

 

  1. I felt that someone in my family hated me.





 


 

 

 

 

 

  1. People in my family felt close to each other.





 


 

 

 

 

 

  1. Someone tried to touch me in a sexual way, or tried to make me touch them.





 


 

 

 

 

 

  1. Someone threatened to hurt me or tell lies about me unless I did something sexual with them.





 


 

 

 

 

 

  1. I had the best family in the world.





 


 

 

 

 

 

  1. Someone tried to make me do sexual things or watch sexual things.





 


 

 

 

 

 

  1. Someone molested me.





 


 

 

 

 

 

  1. I believe that I was emotionally abused.





 


 

 

 

 

 

  1. There was someone to take me to the doctor if I needed it.





 


 

 

 

 

 

  1. I believe that I was sexually abused.





 


 

 

 

 

 

  1. My family was a source of strength and support.

 

 

 

 

 




For respondents with scores indicating emotional abuse, physical abuse, sexual abuse, or physical neglect the following question is shown:


You indicated the following about yourself:


  • Bullet point 1

  • Bullet point 2

  • Bullet point 3

……


Thinking about these childhood events in particular, approximately when did any of these events first begin to occur?

    1. Before age 5

    2. Ages 5-11

    3. Ages 12-17, and not earlier

    4. Don’t know or not sure


For respondents with scores indicating emotional neglect the following question is shown:


You indicated the following about yourself:


  • Bullet point 1

  • Bullet point 2

  • Bullet point 3


Approximately when did these events first stop occurring?


  1. Before age 5

  2. Ages 5-11

  3. Ages 12-17, and not earlier

  4. Don’t know or not sure



Other Experiences Before Age 18


You are now at the final section of the survey. To finish, we have a few other questions about your childhood before 18 years of age.



Were you ever put in foster care or put up for adoption?

  • Yes

  • No



When you were growing up, would you say your family was… ?

  • Pretty well off

  • About average financially

  • Poor



For most of the time, did your family own their home?

  • Yes

  • No

  • Not Sure



Did either of your parents or guardians ever receive public assistance, such as welfare, food stamps, or a food bank?

  • Yes

  • No

  • Not Sure



What is the highest level of education that your mother (or main female caregiver) completed?

  • Didn’t go to high school

  • Some high school

  • High school degree or GED

  • Some college or technical school

  • 4-year college degree or higher

  • Not Sure



For most of the time, did your mother (or main female caregiver) work outside the home for pay?

  • Yes

  • No

  • Not Sure




Was there a time of several months or more when your father (or main male caregiver) had no job?

  • Yes

  • No

  • Not Sure



How old was your mother when you were born?

  • 16 or younger

  • 17-19

  • 20-29

  • 30-39

  • 40 or older



As a child, did you ever see or hear one of your parents or guardians being hit, slapped, punched, shoved, kicked, or otherwise physically hurt by their spouse or partner?

  • Yes

  • No

  • Not Sure



Which of the following best describes your parents’ marital status before you were 18?

  • Always married or lived together

  • Married until widowed or death

  • Separated or divorced

  • Never lived together



Were you an only child?

  • Yes

  • No



Did you live with anyone who suffered from mental illness or depression?

  • Yes

  • No

  • Not Sure


Did you live with anyone who was a problem drinker or alcoholic?

  • Yes

  • No

  • Not Sure



Did you live with anyone who used illegal drugs?

  • Yes

  • No

  • Not Sure



Did you live with anyone who went to prison or committed a serious crime?

  • Yes

  • No

  • Not Sure



About how many times did you move residences, even in the same town?

  • 0 to 2

  • 3 to 5

  • 6 to 9

  • 10 or more

  • Not sure



Your own health state today


Finally, for the following questions, please indicate which statement in each group best describes your own health state today.


Mobility

  • I have no problems in walking about

  • I have some problems in walking about

  • I am confined to bed


Self-Care

  • I have no problems with self-care

  • I have some problems washing and dressing myself

  • I am unable to wash or dress myself


Usual Activities (e,g., work, study, housework, family or leisure activities)

  • I have no problems with performing my usual activities

  • I have some problems with performing my usual activities

  • I am unable to perform my usual activities


Pain/Discomfort

  • I have no pain or discomfort

  • I have moderate pain or discomfort

  • I have extreme pain or discomfort


Anxiety/Depression

  • I am not anxious or depressed

  • I am moderately anxious or depressed

  • I am extremely anxious or depressed












About You



Finally, we have a few simple questions about you.



How many children, if any, have you had? Please include all for which you are the parent or legal guardian.

  • None (0 children)

  • 1 child

  • 2 children

  • 3 children

  • 4 children

  • 5 children

  • 6 or more children



Which of the following describes your health insurance? Please check all that apply.

  • Private health insurance, often provided by an employer

  • Medicaid or other public insurance

  • TRICARE (military health)

  • No health insurance

  • Not sure





Thank you for your help with this survey. We appreciate your responses.


Childhood Trauma Questionnaire™: A Retrospective Self-Report (CTQ™). Copyright © 1998 NCS Pearson, Inc. Computer adaption copyright © 2010 NCS Pearson, Inc. Adapted and reproduced with permission. All rights reserved. Childhood Trauma Questionnaire” and “CTQ” are trademarks in the US and/or other countries of Pearson Education, Inc. or its affiliates.


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