1.5 Survey

ATTACHMENT 10 SLES CHECKLIST

OMB #: 0925-XXXX
EXPIRATION DATE: XX/XX/XXXX

Measurement of Maternal Life Experience Study
Stressful Life Events Schedule (Adult)
Interviewer: After I read each statement to you, please tell me whether the event occurred to you
within the last year (12 months). Then please rate how much of an effect the event had on you
based on the answer choices you see on the response card.
Study ID:

EVENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

I stopped going to school.
I did not get accepted to a
school.
I had trouble with grades
or school work.
I did poorly on a major
exam.
I fought with a professor
or administrator at school.
I had conflicts with a
classmate or neighbor.
A family member dropped
out of school.
A family member did
poorly on a major exam.
A family member had
problems at school.
I had problems with
someone at work.
I had problems at my job.
I was fired or dismissed
from a job.
I was sexually harassed
at work.
I testified in court
concerning my work/job.
My job affected other
aspects of my life.
I applied for a job and did
not get hired.
My spouse/partner had
problems at work.
My spouse/partner was
not home because of
work.
My spouse/partner was
fired from his/her job.

DATE:

CHECK THE BOX IF PARTICIPANT
ENDORSES THE EVENT

LowNone

Some

Moderate

Great

E1/E2

□

How did this affect you?

○1

○2

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○4

E-4

□

How did this affect you?

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E-5

□

How did this affect you?

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E-6

□

How did this affect you?

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E-8

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How did this affect you?

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E-9

□

How did this affect you?

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E-10

□

How did this affect you?

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E-11

□

How did this affect you?

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E-12

□

How did this affect you?

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W1/W2

□

How did this affect you?

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○4

W-3

□

How did this affect you?

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W-4

□

How did this affect you?

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W-5

□

How did this affect you?

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W-6

□

How did this affect you?

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W-7

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How did this affect you?

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W-8

□

How did this affect you?

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W-9

□

How did this affect you?

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W-10

□

How did this affect you?

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W-11

□

How did this affect you?

○1

○2

○3

○4

Public reporting burden for this collection of information is estimated to average 30 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 1
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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

EVENT
20.
21.

22.

23.

24.

25.
26.
27.
28.
29.
30.
31.
32.
33.

34.
35.
36.
37.
38.
39.

40.
41.

My spouse/partner has
been unemployed.
I am not eligible for a
job/career I want.
I was off work due to a
major strike, lay-off,
and/or major medical
illness/condition.
My spouse/partner has
been off work, but not
unemployed.
A family member or close
friend was demoted at
work.
A family member or close
friend was fired from
his/her job.
I quit my job and was
unable to get another job.
My spouse/partner quit
his/her job and was
unable to get another job.
I started a new job.
I had financial problems
I had problems with my
home (overcrowding,
needs to be fixed,
insects, rodents, etc.)
I moved.
I had problems buying or
selling a house.
My house was damaged
by fire, flood, storm,
tornado, or other event.
My neighborhood was not
safe (violence, crimes,
gangs).
I was evicted or received
an eviction notice.
I was evacuated from my
home or workplace.
I was a victim of a crime.
I was caught committing
a crime.
A close friend or family
member was a victim of a
crime.
A close friend or family
member was caught
committing a crime.
I witnessed a crime or
some other type of

CHECK THE BOX IF PARTICIPANT
ENDORSES THE EVENT

LowNone

Some

Moderate

Great

W-12

□

How did this affect you?

○1

○2

○3

○4

W-13

□

How did this affect you?

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W-14

□

How did this affect you?

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W-15

□

How did this affect you?

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W-16

□

How did this affect you?

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W-17

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How did this affect you?

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W-18

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How did this affect you?

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W-19

□

How did this affect you?

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W-20
M-1

□
□

How did this affect you?
How did this affect you?

○1
○1

○2
○2

○3
○3

○4
○4

H-1

□

How did this affect you?

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H-2

□

How did this affect you?

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H-3

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How did this affect you?

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H-4

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How did this affect you?

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H-5

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How did this affect you?

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H-6

□

How did this affect you?

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H-7

□

How did this affect you?

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C-1

□

How did this affect you?

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C-2

□

How did this affect you?

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C-3

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How did this affect you?

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C-4

□

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C-5

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How did this affect you?

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2

EVENT
42.
43.
44.
45.

46.

47.
48.

49.

50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.

violence.
I changed in physical
appearance and did not
like it.
I was in the hospital or
had an operation.
I had a bad accident or
health problems
I had long term health
problems.
A close friend or family
member was in the
hospital or had an
operation.
A close friend or family
member was badly hurt.
A close friend or relative
had health problems.
A close friend or family
member received
psychiatric or
psychological treatment.
A close friend or family
member tried to hurt or
kill themselves.
I gave birth.
There have been major
changes to my sleeping
habits.
An immediate family
member passed away.
A close relative passed
away.
A close friend passed
away.
A pet died or ran away.
I witnessed the death of a
stranger
I started dating someone
or resumed a
relationship.
I separated from my
partner/spouse.
I had relationship
problems with my
partner/spouse.
I was abused by my
partner/spouse.
I broke off an
engagement.
I lived with my
boyfriend/partner.

CHECK THE BOX IF PARTICIPANT
ENDORSES THE EVENT

LowNone

Some

Moderate

Great

HL-1

□

How did this affect you?

○1

○2

○3

○4

HL-3

□

How did this affect you?

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HL-4

□

How did this affect you?

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HL-5

□

How did this affect you?

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HL-6

□

How did this affect you?

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HL-7

□

How did this affect you?

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HL-8

□

How did this affect you?

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HL-9

□

How did this affect you?

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HL-10

□

How did this affect you?

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HL-11

□

How did this affect you?

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HL-12

□

How did this affect you?

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D-1

□

How did this affect you?

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D-2

□

How did this affect you?

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D-3

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How did this affect you?

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D-4

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How did this affect you?

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D-5

□

How did this affect you?

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RR-1

□

How did this affect you?

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RR-2

□

How did this affect you?

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RR-3

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How did this affect you?

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RR-4

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How did this affect you?

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RR-5

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How did this affect you?

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RR-6

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How did this affect you?

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3

EVENT
64.
65.
66.
67.
68.

69.
70.
71.
72.
73.
74.
75.

76.

77.
78.
79.

80.

81.
82.
83.

84.

85.
86.
87.

I had sex for the first time.
I got pregnant.
I lost my baby (abortion,
adoption, miscarriage,
etc).
I told someone that I was
bisexual or homosexual.
I (and/or my partner)
experienced sexual
difficulties.
My partner/spouse and I
had problems with
infertility or sterilization.
I got married.
I gained a new family
member.
Someone new moved
into my house.
Someone moved out of
my house.
My parents divorced or
separated.
My mother or father
remarried.
I had an increase in
arguments and/or
relationship problems
with a family member.
There was domestic
violence in my home.
I was physically abused.
I was sexually abused or
touched by someone.
I had an increase in
arguments and/or
relationship problems
with a close friend.
I stopped talking to a
good friend.
I got really bad news.
I told someone really bad
news.
I had problems with
family members, close
friends, coworkers, or
classmates.
I had problems with my
in-laws.
My spouse had problems
with my family.
I had a major change in

CHECK THE BOX IF PARTICIPANT
ENDORSES THE EVENT
RR-7
□ How did this affect you?
RR-8
□ How did this affect you?

LowNone
○1
○1

Some

Moderate

Great

○2
○2

○3
○3

○4
○4

RR-10

□

How did this affect you?

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○3

○4

RR-11

□

How did this affect you?

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○3

○4

RR-14

□

How did this affect you?

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○2

○3

○4

RR-15

□

How did this affect you?

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○2

○3

○4

RR-16

□

How did this affect you?

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○2

○3

○4

RR-17

□

How did this affect you?

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○2

○3

○4

O-1

□

How did this affect you?

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○4

O-2

□

How did this affect you?

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O-5

□

How did this affect you?

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○2

○3

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O-6

□

How did this affect you?

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○3

○4

O-10

□

How did this affect you?

○1

○2

○3

○4

O-11

□

How did this affect you?

○1

○2

○3

○4

O-12

□

How did this affect you?

○1

○2

○3

○4

O-13

□

How did this affect you?

○1

○2

○3

○4

O-14

□

How did this affect you?

○1

○2

○3

○4

O-16

□

How did this affect you?

○1

○2

○3

○4

O-17

□

How did this affect you?

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○3

○4

O-18

□

How did this affect you?

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○2

○3

○4

O-20

□

How did this affect you?

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O-21

□

How did this affect you?

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O-21

□

How did this affect you?

○1

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O-22

□

How did this affect you?

○1

○2

○3

○4

4

EVENT
activities (church, social,
recreational, etc).
My child had behavioral
problems.
I learned something
important about a family
member or close friend.
I was separated from my
spouse because of work
and/or travel.
Did any other problems
occur or did any other
important things happen?
If yes, please describe:

CHECK THE BOX IF PARTICIPANT
ENDORSES THE EVENT

LowNone

Some

Moderate

Great

O-23

□

How did this affect you?

○1

○2

○3

○4

O-24

□

How did this affect you?

○1

○2

○3

○4

How did this affect you?

○1

○2

○3

○4

1.

How did this affect you?

○1

○2

○3

○4

2.

How did this affect you?

○1

○2

○3

○4

3.

How did this affect you?

○1

○2

○3

○4

4.

How did this affect you?

○1

○2

○3

○4

88.
89.

90.

91.

O-25

AE-1

□

5