Form 1 FCE-Family Cohesion-Eng

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

HCHS/SOL Visit 2 Family Cohesion
FORM CODE: FCE
VERSION: 1, 12/10/2013

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.

Family Cohesion
The following are statements about families. You are to decide which of these statements are true of your
family and which are false. If you think the statement is True or mostly True of your family, please respond
True. If you think the statement is False or mostly False of your family, please respond False. You may feel
that some of the statements are true for some family members and false for others. Respond True if the
statement is true for most members. Respond False if the statement is false for most members. If the members
are evenly divided, decide what is the stronger overall impression and answer accordingly. Remember, we
would like to know what your family seems like to you. So do not try to figure out how other members see your
family, but do give us your general impression of your family for each statement.
True

False

1. Family members really help and support one another.
2. We often seem to be killing time at home.
3. We put a lot of energy into what we do at home.
4. There is a feeling of togetherness in our family.
5. We rarely volunteer when something has to be done at home.
6. Family members really back each other up.
7. There is very little group spirit in our family.
8. We really get along well with each other.
9. There is plenty of time and attention for everyone in our family.

[The Family Cohesion questions are part of the Family Environment Scale© developed by B.S. Moos and R.H. Moos used by
permission of the authors as licensed by Mind Garden, Inc. No unauthorized reproduction of these materials is permitted.]

Household Composition
(Note – from U.S. Census. A household includes all the persons who occupy a housing unit as their usual
place of residence. A housing unit is a house, an apartment, a mobile home, a group of rooms, or a single
room that is occupied (or if vacant, is intended for occupancy) as separate living quarters. Separate living
quarters are those in which the occupants live and eat separately from any other persons in the building and
which have direct access from outside the building or through a common hall. The occupants may be a single
family, one person living alone, two or more families living together, or any other group of related or unrelated
persons who share living arrangements. Modified definition will be included on form or in Q x Q).
FCE-Family Cohesion-12-10-13.docx

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

ID NUMBER:

Contact
Occasion

0

2

SEQ #

10. Including yourself, how many people are currently (in terms of the last month) living in your household?
(If one, END QUESTIONNAIRE)
Could you please list each of the people who are currently living in your household. You don’t
need to tell me their names, just their relationship to you.
a. Relationship 1: _________________________________________
Age

b. Relationship 2: _________________________________________
Age

c. Relationship 3: _________________________________________
Age

d. Relationship 4: _________________________________________
Age

e. Relationship 5: _________________________________________
Age

f.

Relationship 6: _________________________________________
Age

g. Relationship 7: _________________________________________
Age

h. Relationship 8: _________________________________________
Age

i.

Relationship 9: _________________________________________
Age

FCE-Family Cohesion-12-10-13.docx

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