Form 1 Social Support

Public reporting burden for this collection of information is estimated to average 03 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: NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0584). Do not return the
completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2 Social Support
ID
NUMBER:

FORM CODE: SSE
VERSION: 1, 12/10/2013

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION

/

0a. Completion Date:
Month

/
Day

0b. Staff ID:
Year

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to
code 'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

Social Support
This scale is made up of a list of statements each of which may or may not be true about you. For each
statement respond "definitely true" if you are sure it is true about you and "probably true" if you think it is
true but are not absolutely certain. Similarly, you should respond "definitely false" if you are sure the
statement is false and "probably false" if you think it is false but are not absolutely certain.
Definitely Probably Probably Definitely
False
False
True
True
1. If I wanted to go on a trip for a day (for example to the
beach, the country or mountains), I would have a hard
time finding someone to go with me.

1

2

3

4

2. I feel that there is no one I can share my most private
worries and fears with.

1

2

3

4

3. If I were sick, I could easily find someone to help me with
my daily chores.

1

2

3

4

4. There is someone I can turn to for advice about handling
problems with my family.

1

2

3

4

5. If I decide one afternoon that I would like to go to a movie
that evening, I could easily find someone to go with me.

1

2

3

4

6. . When I need suggestions on how to deal with a
personal problem, I know someone I can turn to.

1

2

3

4

7. I don't often get invited to do things with others.

1

2

3

4

8. If I had to go out of town for a few weeks, it would be
difficult to find someone who would look after my house
or apartment (the plants, pets, garden, etc.).

1

2

3

4

9. . If I wanted to have lunch with someone, I could easily
find someone to join me.

1

2

3

4

10. If I was stranded 10 miles from home, there is someone I
could call who could come and get me.

1

2

3

4

11. If a family crisis arose, it would be difficult to find
someone who could give me good advice about how to
handle it.

1

2

3

4

12. If I needed some help in moving to a new house or
apartment, I would have a hard time finding someone to
help me.

1

2

3

4

SSE-Social Support-12-10-2013.doc

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