Form 1 STE-Chronic Stress-Eng

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

HCHS/SOL Visit 2 Chronic Stress
FORM CODE: STE
VERSION: 1, 12/10/13

ID NUMBER:

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.

A. Chronic Stress
Many people experience ongoing problems with their everyday lives. Please tell us whether any of the
following has been a problem for you.

1. Have you had a serious ongoing health problem?
No
Yes

 GO TO QUESTION 2

0
1

1a. Has this been a problem for six months or more?
No
Yes

0
1

1b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
2. Has someone close to you had a serious ongoing health problem?
No
Yes

 GO TO QUESTION 3

0
1

2a. Has this been a problem for six months or more?
No
Yes

0
1

2b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3

STE-Stress-12-10-2013.docx

Page 1 of 3

FORM CODE: STE
VERSION: 1, 12/10/13

ID NUMBER:

Contact
Occasion

0

2

SEQ #

3. Have you had ongoing difficulties with your job or ability to work?
No
Yes

 GO TO QUESTION 4

0
1

3a. Has this been a problem for six months or more?
No
Yes

0
1

3b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
4. Have you experienced ongoing financial strain?
No
Yes

 GO TO QUESTION 5

0
1

4a. Has this been a problem for six months or more?
No
Yes

0
1

4b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
5. Have you had ongoing difficulties in a relationship with someone close to you?
No
Yes

 GO TO QUESTION 6

0
1

5a. Has this been a problem for six months or more?
No
Yes

0
1

5b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
6. Has someone close to you had an ongoing problem with alcohol or drug use?
No
Yes

0
1

STE-Stress-12-10-2013.docx

 GO TO QUESTION 7

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FORM CODE: STE
VERSION: 1, 12/10/13

ID NUMBER:

Contact
Occasion

0

2

SEQ #

6a. Has this been a problem for six months or more?
No
Yes

0
1

6b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
7. Have you been helping someone close to you, who is sick, limited or frail?
No
Yes

 GO TO QUESTION 8

0
1

7a. Has this been a problem for six months or more?
No
Yes

0
1

7b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
8. Have you had another ongoing problem not listed here?
No
0
 GO TO QUESTION 9
Yes
1
If yes, please describe:
8a. Has this been a problem for six months or more?
No
Yes

0
1

8b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3

STE-Stress-12-10-2013.docx

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