Form Baseline

Now Is the Time (NITT) - Healthy Transition (HT) Evaluation

Attachment 9_SYAI Baseline

Multi-Media Project Young Adult Probes

OMB: 0930-0360

Document [docx]

Download: docx | pdf

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Public Burden Statement: 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. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 40 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

ATTACHMENT 9: Supplemental Youth and Young Adult Interview - Baseline

STAFF Questions:

WELCOME

Welcome to the Baseline Supplemental Youth and Young Adult Interview, a part of the Now is the Time Healthy Transitions National Evaluation!

This interview should be started by a project staff member. If you are not a project staff member, please stop on this screen and provide this instrument to a staff member who will help you start the interview.

Project Staff, please select “NEXT” to begin the Baseline Interview. If this client is under 18 years old, confirm you have a signed copy of the Parent Permission form before beginning this interview.

S1CLIENTID

Please enter the Client’s ID

Question Type: ALPHANUMERIC

Logic After:

Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

S1GRANTEEID

Please select from the drop down menu your grantee state and ID.

AK – SM061910

CT – SM061971

DC – SM061903

DE – SM061931

FL – SM061898

KY – SM061899

MA – SM061850

MD – SM061917

ME – SM061843

NM – SM061905

NY – SM061900

OK – SM061842

PA – SM061915

RI – SM061885

TN – SM061867

UT – SM061974

WI – SM061916

Logic After:

Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

S1LABID

Please select from the drop down menu the local laboratory this client is primarily receiving services from.

AK Lab 1 – SM061910-01

AK Lab 2 – SM061910-02

CT Lab 1 – SM061971-01

CT Lab 2 – SM061971-02

CT Lab 3 – SM061971-03

DC Lab 1 – SM061903-01

DC Lab 2 – SM061903-02

DE Lab 1 – SM061931-01

DE Lab 2 – SM061931-02

FL Lab 1 – SM061898-01

FL Lab 2 – SM061898-02

FL Lab 3 – SM061898-03

KY Lab 1 – SM061899-01

KY Lab 2 – SM061899-02

MA Lab 1 – SM061850-01

MA Lab 2 – SM061850-02

MD Lab 1 – SM061917-01

MD Lab 2 – SM061917-02

ME Lab 1 – SM061843-01

ME Lab 2 – SM061843-02

NM Lab 1 – SM061905-01

NM Lab 2 – SM061905-02

NM Lab 3 – SM061905-03

NY Lab 1 – SM061900-01

NY Lab 2 – SM061900-02

OK Lab 1 – SM061842-01

OK Lab 2 – SM061842-02

OK Lab 3 – SM061842-03

PA Lab 1 – SM061915-01

PA Lab 2 – SM061915-02

PA Lab 3 – SM061915-03

RI Lab 1 – SM061885-01

RI Lab 2 – SM061885-02

TN Lab 1 – SM061867-01

TN Lab 2 – SM061867-02

UT Lab 1 – SM061974-01

UT Lab 2 – SM061974-02

UT Lab 3 – SM061974-03

UT Lab 4 – SM061974-04

UT Lab 5 – SM061974-05

UT Lab 6 – SM061974-06

WI Lab 1 – SM061916-01

WI Lab 2 – SM061916-02

Logic After:

Display response options in a drop down box, showing only the labs within each state based on their response to S1GRANTEEID. Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

S1CLIENTAGE

For any youth ages 16-17, parental permission must be given before the client can complete this questionnaire. Is this client under the age of 18?

Question Type: TYESNOCAPS

Logic After:

Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

S1UNDER18

[IF CLIENTAGE = 1] Do you have a signed copy of the parental permission form?

Question Type: TYESNOCAPS

Logic After:

Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

S1PPERMISSION

[IF UNDER18 = 2] Parental permission must be obtained before the client can begin this interview. Please exit this questionnaire by logging out of this instrument.

Logic After:

The questionnaire should end at this screen. The only option should be for respondents to Log Off or select Previous to return to a previous question. Final Code this case as [DETERMINE FINAL CODE]

S1BEGIN

The client is now ready to begin the questionnaire. Please return this tablet to the client, set up the ear buds for the client to listen to the interview, and provide them with the opportunity to move to a private space while they complete the interview.

Select “Next” and hand the tablet over to the client now.

S1CONSENT

[IF CLIENTAGE = 2] Consent scripting here……

Please select below whether you agree to participate in this research study.

___ I agree

___ I do not agree

Logic After:

Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

S1ASSENT

[IF UNDER18 = 1] Assent scripting here……

Please select below whether you agree to participate in this research study.

___ I agree

___ I do not agree

Logic After:

Hard Check, a response must be entered. If left blank display box stating “A response must be entered, please go back and enter a response to this question.”

Module 1: ACASI/Tablet tutorial

S1INTRO1

Form Approved

OMB No. XXXX-XXXX

Exp. Date XX/XX/XXXX

Welcome to RTI’s self-interviewing system, which lets you control the interview and answer in complete privacy.

First, you will learn how to use the system and complete some practice questions. You will learn how to enter answers and how to back-up if you make a mistake and want to change an answer.

Using your mouse, press the “Next” button on the bottom of the screen to move to the next screen.

S1INTRO2

In this system you can read the questions on the computer screen and hear them read through the headphones. If you would like to just see the questions on the screen, you can turn down the voice.

Press “Next” to continue.

S1GOTDOG

You answer questions by selecting the button that is shown next to your answer.

To answer a question, you first select the correct button and then press “Next.”

Practice Question #1: Do you have a dog?

Question Type: TYESNOCAPS

1 YES

0 NO

S1EYECOLOR

The last question was a Yes-No question. Other questions will have more answers to choose from, and you will pick your answer from a list.

Practice Question #2: What color are your eyes? Press the button that best fits you and press the “Next” key.

Question Type: TCOLOR

1 Blue

2 Brown

3 Gray

4 Green

5 Some other color

S1ALLAPPLY

Some questions will let you choose more than one answer. For these questions, you will be able to select more than one response option. Practice this now.

Practice Question #3: What kinds of music do you listen to?

To select more than one kind of music from the list, select the squares next to more than one type of music. When you have finished, press “Next” to go to the next question.

Question Type: TMUSIC

1 Classical

2 Country

3 Hip Hop

4 Jazz

5 Latin American/Spanish

6 Folk/Traditional

7 Pop/Rock

8 Soul/R&B

9 Something Else

S1NUMBER

Other questions will ask you to type in a number instead of choosing a number from a list.

Practice Question #4: In the past 30 days, on how many days did you eat breakfast? Click on the text box and when the blinking cursor appears, type in the number of days you ate breakfast and press “Next.”

If you enter an invalid response, a pop-up window will ask you to correct your response. If you get the pop-up window, click “Close” and then correct your response. Then, press “Next” again.

Question Type: Numeric Range [0-30]

________________ [RANGE: 0 - 30]

S1BACKUP

If you want to change or see your answer to a previous question, you can back up using the “Previous” button. Each time you press the “Previous” button, the computer will go back one question.

You can tell the computer to repeat a question by pressing [TBD].

When you are finished, press “Next” to continue.

Try this now.

S1PLAYINFO

In some questions, you can use the “Help” button to see and hear extra information to help you answer a question. First listen to the question.

Practice Question #5: In the past 30 days, on how many days did you eat any kind of fried potatoes?

Question Type: Numeric Range [0-30]

Now press “Help” to see and hear examples of fried potatoes.

• French fries

• Home fries

• Hash brown potatoes

Press “Close” to exit this box. Then, type in your response to the question.

Module 2: Demographic characteristics (Module Abbreviation DE)

S1QD01

Now that you have completed the tutorial, you are ready to begin the Supplemental Youth and Young Adult Interview.

To start, we would like to know some back ground information about you. The first few questions are for statistical purposes only, to help us analyze the results of the study.

What is your gender?

Question Type: GENDER

1 Male

2 Female

3 Different identity

S1QD03

Are you of Hispanic, Latino, or Spanish origin or descent?

Question Type: TYESNOCAPS

S1QD05

Which of these groups describes you? (You may select more than one response)

Question Type: Race

1 White

2 Black or African American

3 American Indian or Alaska Native (American Indian includes North American, Central American, and South American Indians)

4 Native Hawaiian

5 Guamanian or Chamorro

6 Samoan

7 Other Pacific Islander

8 Asian (Including: Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese)

9 Other

S1AGE1

What is your date of birth?

Question Type: DOB

Logic After:

Display date of birth month (January – December), day (1-31), and year (1989-2001) in drop down menus.

Using DOB and current date, calculate respondent’s age in how many years old they are. Create new variable S1AGE. Use as fill in S1AGE2.

S1AGE2

Based on your date of birth, your current age is [Fill from S1AGE1]. Is this correct?

Question Type: TYESNOCAPS

Logic After:

If S1AGE is less than 16 display a hard check that states “This interview was created for respondents age 16 and older. Based on your date of birth, you are not eligible to complete this interview. If you are 16 or older, please go back and check your response.

If you are less than 16 years of age, please close this box, select "Next" to complete the survey, and let the test administrator know that you are not eligible for this interview." If the age is confirmed as less than 16, skip to the end of the questionnaire.

S1DE5

Which of the following do you consider yourself to be?

Question Type: Sexual Orientation

1. Straight

2. Lesbian (if female) or Gay (if male)

3 Bisexual

Module 3: Living situation (Module Abbreviation LS)

S1LS1

These next few questions ask about your living situation.

In the past 30 days, where have you been living most of the time?

Question Type: Living

1 Place not meant for living in (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

2 Emergency shelter, including hotel or motel

3 Staying or living with family/friends (e.g., room, apartment or house)

4 Transition Housing

5 Substance abuse treatment facility or detox center

6 Residential treatment (substance abuse or mental health)

7 Therapeutic community or halfway house

8 Psychiatric hospital or other psychiatric facility

9 Long-term care facility or nursing home

10 Hospital or other residential non-psychiatric medical facility

11 Permanent supportive housing

12 Foster care home or foster care group home

13 Jail, prison, or juvenile detention facility

14 House rented by you

15 House owned by you

16 Other

S1NUMRES

Altogether, how many people live here now, including yourself? Please include anyone who has lived here most of the time in the last three months.

NOTE:

If you are living in a transient shelter, enter “1".

If you are living in a group quarters unit that is listed by room, enter the number of people living in the room.

Question Type: Numeric Range [1-25]

# IN HOUSEHOLD: [RANGE: 1 - 25]

S1REL1 – S1REL24

[IF S1NUMRES = 2 - 25] Now I need some additional information about each person who lives here. For each person who lives with you, please indicate which category best describes their relationship to you.

NOTE:

Exchange families (exchange students or people who are hosting exchange students) should be considered “other non-relatives.”

Question Type: Household Relationship

1 Self

2 Father or Mother (Includes Step, Foster, Adoptive)

3 Son or Daughter (Includes Step, Foster, Adoptive)

4 Brother or Sister (Includes Half, Step, Foster, Adoptive)

5 Husband or Wife

6 Unmarried Partner

7 Housemate or Roommate

8 Son-In-Law or Daughter-In-Law

9 Grandchild

10 Father-In-Law or Mother-In-Law

11 Grandfather or Grandmother

12 Boarder or Roomer

13 Other Relative

14 Other Non-Relative

Logic After:

A table should appear displaying the number of rows provided as a response to S1NUMRES. The response options are then displayed in a drop down menu to be selected for each row.

S1QD13

How many times in the past 12 months have you moved? Please include moves from one residence to another within the same city/town as well as those from one city/town to another.

NUMBER OF TIMES:

Question Type: Numeric Range [0-365]

[RANGE: 0 - 365]

Logic After:

[If S1QD13 > 10] Insert Soft Check “You have indicated that you have moved [Fill S1QD13] times in the past 12 months. Please confirm this is correct.”

S1LS5

In the past 30 days, how many nights have you been homeless?

NUMBER OF NIGHTS:

Question Type: Numeric Range [0-30]

Module 4: Education (Module Abbreviation ED)

S1ED1

These next questions are about school.

What is the highest grade or year of school you have completed?

NOTE: Include Junior or Community College Attendance; Do not include Technical Schools (Beautician, Mechanic, etc.)

Question Type: Education Completed

0 No Schooling Completed

1 1ST Grade Completed

2 2ND Grade Completed

3 3RD Grade Completed

4 4TH Grade Completed

5 5TH Grade Completed

6 6TH Grade Completed

7 7TH Grade Completed

8 8TH Grade Completed

9 9TH Grade Completed

10 10TH Grade Completed

11 11TH Grade Completed

12 Regular High School Diploma

13 12TH Grade, No Diploma

14 GED Certificate of High School completion

15 Some college credit, but no degree

16 Associate’s Degree (For example, AA, AS)

17 Bachelor’s Degree (For example, BA, BS)

18 Master’s Degree (For example, MA, MS, MENG, M. ED, MSW, MBA)

19 Doctorate Degree (For example, PHD, EDD)

20 Professional Degree beyond a Bachelor’s Degree (For example, MD, DDS, DVM, LLB, JD)

S1QD17

Are you now attending or are you currently enrolled in school? By “school,” we mean an elementary school, a junior high or middle school, a high school, or a college or university, or a technical or vocational school or GED program. Please include home schooling as well.

Question Type: TYESNOCAPS

S1QD17a

[IF S1QD17 = 2 OR Blank] Are you currently on a holiday or vacation break from school?

Question Type: TYESNOCAPS

S1QD17b

[IF S1QD17a = 1] Do you plan to return to school when your holiday or vacation is over?

Question Type: TYESNOCAPS

S1ED3

[IF S1QD17 = 1] What type of school are you currently attending?

[IF S1QD17b = 1] What type of school will you be attending?

Question Type: School Attending

1 Middle School/ Junior High School

2 High School

3 GED Program

4 Technical or Vocational School

5 2 year College or University

6 4 year College or University

S1QD19

[IF S1QD17 = 1] Are you a full-time student or a part-time student?

[IF S1QD17b = 1] Will you be a full-time student or a part-time student?

Question Type: Full/Part Time

1 Full-time

2 Part-time

S1ED5

The next questions are about school and classes. In answering these, please think about any types of classes that you might take. These could be in high school, college, GED classes, a vocational or certificate program, etc.

[IF S1QD17a = 2 OR S1QD17b = 2] You said earlier that you are not involved in any sort of school or classes now. Do you expect to be taking classes in the next month?

Question Type: Certain Scale

1 No

2 Probably Not

3 Don’t know/Uncertain

4 Probably

5 Certainly

S1ED6

These next questions ask about the educational back ground of two primary parental figures. A parent can mean many different things including a biological, foster, step, or adoptive parent. Please answer these next questions for up to two parental figures you feel were a parent to you.

Question Type: Number Parents

1 I have one primary parent figure

2 I have two or more primary parent figures

S1ED7

What is the highest grade or year of school your first primary parent has completed?

NOTE: Include Junior or Community College Attendance; Do not include Technical Schools (Beautician, Mechanic, etc.)

Question Type: Education Completed

S1ED8

[If S1ED6 = 2] What is the highest grade or year of school your second primary parent has completed?

NOTE: Include Junior or Community College Attendance; Do not include Technical Schools (Beautician, Mechanic, etc.)

Question Type: Education Completed

Module 5: Employment (Module Abbreviation EM)

S1QD26

These next questions ask about your experiences working.

Did you work at a job or business at any time last week? By last week, I mean the week beginning on Sunday and ending on Saturday.

Press “Help” to see and hear information about unpaid work.

Question Type: TYESNOCAPS

IF HELP IS PRESSED, PLEASE DISPLAY:

• Please include unpaid work in a family farm or business if you usually work more than 15 hours each week.

• If you are a student who is given a stipend do not count that as working.

• If you do volunteer work do not count that as working.

• If you provide personal labor in exchange for work done for you, rather than for pay, please count that as working.

Press “Close” to exit this box. Then, type in your response to the question.

S1QD27

[IF S1QD26 = 2] Even though you did not work at any time last week, did you have a job or business? Press “Help” to see and hear information about unpaid work.

Question Type: TYESNOCAPS

IF HELP IS PRESSED, PLEASE DISPLAY:

• Please include unpaid work in a family farm or business if you usually work more than 15 hours each week.

• If you are a student who is given a stipend do not count that as working.

• If you do volunteer work do not count that as working.

• If you provide personal labor in exchange for work done for you, rather than for pay, please count that as working.

Press “Close” to exit this box. Then, type in your response to the question.

S1EM1

[IF S1QD26 = 2 AND S1QD27 = 2] You indicated that you are not currently employed. Do you expect to be employed in the next month?

Question Type: Certain Scale

S1QD33

[IF S1QD26 = Blank OR S1QD27 = 2 OR Blank] Now, think about the past 12 months. Did you work at a job or business at any time during the past 12 months?

Question Type: TYESNOCAPS

S1EM5

[IF S1QD26 = 1] How satisfied are you with this job?

Question Type: Satisfied Scale

6 – Very satisfied

5 – Fairly satisfied

4 – A little satisfied

3 – A little dissatisfied

2 – Fairly dissatisfied

1 – Very dissatisfied

S1QD28

[IF S1QD26 = 1] How many hours did you work last week at all jobs or businesses?

# OF HOURS WORKED:

Question Type: Numeric Range [1-120]

[RANGE: 1 - 120]

S1QD29

[IF (S1QD28 = 1 - 120 OR Blank) OR S1QD27 = 1] Do you usually work 35 hours or more per week at all jobs or businesses?

Question Type: TYESNOCAPS

S1QD34

[IF S1QD26 = 1 OR S1QD33 = 1 OR S1QD27 = 1]. Have you been self-employed at any time during the past 12 months?

Question Type: TYESNOCAPS

S1QD37

[IF S1QD26 = 1 OR S1QD27 = 1] During the past 12 months, was there ever a time when you did not have at least one job or business?

Question Type: TYESNOCAPS

Module 6: Youth/Young Adult Income (Module Abbreviation YI)

S1Q103N

These next questions ask about income that you may earn.

Supplemental Security Income or SSI is a program administered by a government agency that makes assistance payments to low income, aged, blind, and disabled persons. This is not the same as Social Security. In 2015, did you receive Supplemental Security Income or SSI?

Question Type: TYESNOCAPS

S1YI2

Are you currently receiving or, within the next three months, do you intend to pursue Supplemental Security Income or SSI as a result of an emotional or behavioral health problem or related disability?

Question Type: TYESNOCAPS

S1YI3

[IF S1QD26=1 OR S1QD27 = 1] Thinking about your income earned at a job or business, about how much do you make per hour of work?

HOURLY WAGE:

Question Type: Numeric Range [0.00-100.00]

__________

S1YI3a

[IF S1YI3 = Blank] Income data are important in analyzing the health information we collect. For example, the information helps us to learn whether persons in one income group use certain types of mental health care services or have conditions more or less often than those in another group.

Using the ranges provide below, please indicate your approximate hourly wage.

Question Type: Wage Range

1 Less than $7.00 per hour

2 Between $7.00 and $7.99 per hour

3 Between $8.00 and $8.99 per hour

4 Between $9.00 and $9.99 per hour

5 Between $10.00 and $10.99 per hour

6 Between $11.00 and $12.99 per hour

7 Between $13.00 and $14.99 per hour

8 Between $15.00 and $19.99 per hour

9 $20.00 or more per hour

Module 7: General health (Module Abbreviation GH)

S1GH1

This question is about your overall health. Would you say your health in general is excellent, very good, good, fair, or poor?

Question Type: Good Range

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

Module 8: Health Insurance (Module Abbreviation HI)

S1HI1

These next questions ask about health care programs you might be enrolled in.

Are you currently covered by any kind of health insurance, that is, any policy or program that provides or pays for medical care?

Question Type: TYESNOCAPS

S1HI2

During the past 12 months, was there any time when you did not have any kind of health insurance or coverage?

Question Type: TYESNOCAPS

Module 9: Arrest/Criminal Justice involvement (Module Abbreviation CJ)

S1SP01

These next questions ask about your arrest history or any involvement with the criminal justice system.

Not counting minor traffic violations, have you ever been arrested and booked for breaking the law?

Being ‘booked’ means that you were taken into custody and processed by the police or by someone connected with the courts, even if you were then released.

Question Type: TYESNOCAPS

S1CJ1a

[IF S1SP01 = 1] Not counting minor traffic violations, in the past 12 months have you been arrested and booked for breaking the law?

Being ‘booked’ means that you were taken into custody and processed by the police or by someone connected with the courts, even if you were then released.

Question Type: TYESNOCAPS

S1YSU34

These next questions are about experiences with the justice system.

Have you ever stayed overnight or longer in any type of prison, jail, or juvenile detention center?

Question Type: TYESNOCAPS

S1CJ2a

[IF S1YSU34 = 1] During the past 12 months, did you stay overnight or longer in any type of prison, jail, or juvenile detention center?

Question Type: TYESNOCAPS

Module 10: General Mental Health [ITEMS 1A-1F FROM K6] (Module Abbreviation MH)

S1NERVE30

The following questions ask about how you have been feeling during the past 30 days. For each question, please select the number that best describes how often you had this feeling.

During the past 30 days, about how often did you feel…

nervous?

Question Type: Often Range

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

S1HOPE30

hopeless?

Question Type: Often Range

S1FIDG30

restless of fidgety?

Question Type: Often Range

S1NOCHR30

so depressed that nothing could cheer you up?

Question Type: Often Range

S1EFFORT30

that everything was an effort?

Question Type: Often Range

S1DOWN30

down on yourself, no good or worthless?

Question Type: Often Range

Logic After:

Display items S1NERVE30 – S1DOWN30 on the same screen in a table with the response options in columns on the right side.

DEFINE S1DISTRESS:

IF S1NERVE30 = 1-4 OR S1HOPE30 = 1-4 OR S1FIDG30 = 1-4, OR S1NOCHR30 = 1-4

OR S1EFFORT30 = 1-4 OR S1FOWN30 = 1-4, THEN S1DISTRESS = 1

ELSE, S1DISTRESS = 2 [IF S1DISTRESS = 2, S1MH2 = 4]

S1MH2

[IF S1DISTRESS =1] The last six questions asked about feelings that might have occurred during the past 30 days. Taking them altogether, did these feelings occur More often in the past 30 days than is usual for you, about the same as usual, or less often than usual? (If you never have any of these feelings, select response option “About the same as usual.”)

Question Type: Often Range 2

1 A lot more often than usual

2 Somewhat more often than usual

3 A little more often than usual

4 About the same as usual

5 A little less often than usual

6 Somewhat less often than usual

7 A lot less often than usual

S1MH3

[IF S1DISTRESS =1] During the past 30 days, how many days out of 30 were you totally unable to work or carry out your normal activities because of these feelings?

Number of Days:

Question Type: Numeric Range [0-30]

S1MH4

[IF S1DISTRESS =1]

[IFS1MH3 > 0]In the previous question you reported that you were totally unable to work or carry out your normal activities [Fill S1MH3] days a month because of these feelings.

Not counting the [Fill S1MH3] days you reported in the previous question, how many days in the past 30 were you able to do only half or less of what you would normally have been able to do, because of these feelings?

[IFS1MH3 = 0] How many days in the past 30 were you able to do only half or less of what you would normally have been able to do, because of these feelings?

Number of Days:

Question Type: Numeric Range [0-30]

S1MH5

[IF S1DISTRESS =1] During the past 30 days, how many times did you see a doctor or other health professional about these feelings?

Number of Times:

Question Type: Numeric Range [0-30]

S1MH6

[IF S1DISTRESS =1] During the past 30 days, how often have physical health problems been the main cause of these feelings?

Question Type: Often Range

Module 11: Functional Impairment [ITEMS FROM THE WHODAS]

S1LIKERT

[IF S1DISTRESS=1] The next questions are about how much your emotions, nerves, or mental health caused you to have difficulties in daily activities.

In answering, think of the one month in the past 12 months when your emotions, nerves, or mental health interfered most with your daily activities.

Press “Next” to continue.

S1LIREMEM

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have remembering to do things you needed to do?

Question Type: Difficulty Range

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

S1LICONCEN

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have concentrating on doing something important when other things were going on around you?

Question Type: Difficulty Range

S1LIGOOUT1

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have going out of the house and getting around on your own?

Question Type: Difficulty Range House

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 You didn’t leave the house on your own

S1LISTRAN1

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have dealing with people you did not know well?

Question Type: Difficulty Range People

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 You didn’t deal with people you did not know well

S1LISOC1

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have participating in social activities, like visiting friends or going to parties?

Question Type: Difficulty Range Social

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 You didn’t participate in social activities

S1LIHHRES1

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have taking care of household responsibilities?

Question Type: Difficulty Range Household

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 You didn’t take care of household responsibilities

S1LIWKRES1

[IF S1DISTRESS =1] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have taking care of your daily responsibilities at work or school?

Question Type: Difficulty Range Work

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 You didn’t work or go to school

S1LIWKQUIC

[IF S1DISTRESS =1 AND Q7 NE 5] During that one month when your emotions, nerves or mental health interfered most with your daily activities how much difficulty did you have getting your daily work or school work done as quickly as needed?

Question Type: Difficulty Range

Module 12: Psychotic Experiences [ITEMS FROM PQ-16] (Module Abbreviation PQ)

These next questions ask your daily experiences. When answering these questions, please indicate if these statements have been generally true or false for you in the past 12 months.

S1PQ1

I feel uninterested in the things I used to enjoy.

Question Type: True False

1 TRUE

2 FALSE

S1PQ2

I often seem to live through events exactly as they happened before (déjà vu).

Question Type: True False

S1PQ3

I sometimes smell or taste things that other people can’t smell or taste.

Question Type: True False

S1PQ4

I often hear unusual sounds like banging, clicking, hissing, clapping or ringing in my ears.

Question Type: True False

S1PQ5

I have been confused at times whether something I experienced was real or imaginary.

Question Type: True False

S1PQ6

When I look at a person, or look at myself in a mirror, I have seen the face change right before my eyes.

Question Type: True False

S1PQ7

I get extremely anxious when meeting people for the first time.

Question Type: True False

S1PQ8

I have seen things that other people apparently can’t see.

Question Type: True False

S1PQ9

The following questions ask your daily experiences. When answering these questions, please indicate if these statements have been generally true or false for you in the past 12 months.

My thoughts are sometimes so strong that I can almost hear them.

Question Type: True False

S1PQ10

I sometimes see special meanings in advertisements, shop windows, or in the way things are arranged around me.

Question Type: True False

S1PQ11

Sometimes I have felt that I am not in control of my own ideas or thoughts.

Question Type: True False

S1PQ12

Sometimes I feel suddenly distracted by distant sounds that I am not normally aware of.

Question Type: True False

S1PQ13

I have heard things other people can’t hear like voices of people whispering or talking.

Question Type: True False

S1PQ14

I often feel that others have it in for me.

Question Type: True False

S1PQ15

I have had the sense that some person or force is around me, even though I could not see anyone.

Question Type: True False

S1PQ16

I feel that parts of my body have changed in some way, or that parts of my body are working differently than before.

Question Type: True False

Logic After:

Display questions S1PQ1 – S1PQ8 on the same screen and S1PQ9 – S1PQ16 in a table with the response options in columns on the right side of the table.

Module 13: Behavior Disorders and Substance Use [ITEMS FROM GAIN-SS] (Module Abbreviation GSS)

S1GSSINTRO

The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can’t go on.

After each of the following questions, please tell us the last time that you had the problem, if ever, by answering, “In the past month,” “2-12 months ago,” “1 or more years ago,” or “never.”

S1GSS1a

When was the last time that you did the following things two or more times?

Lied or conned to get things you wanted or to avoid having to do something?

Question Type: Time Range

3 Past month

2 2 to 12 months ago

1 1+ years ago

0 Never

S1GSS1b

Had a hard time paying attention at school, work, or home?

Question Type: Time Range

S1GSS1c

Had a hard time listening to instructions at school, work, or home?

Question Type: Time Range

S1GSS1d

Were a bully or threatened other people?

Question Type: Time Range

S1GSS1e

Started physical fights with other people?

Question Type: Time Range

Logic After:

Display questions S1GSS1a – S1GSS1e on the same screen in a table with the response options in columns on the right side of the table.

S1GSS2a

When was the last time that you used alcohol or other drugs weekly or more often?

Question Type: Time Range

S1GSS2b

When was the last time that you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs?

Question Type: Time Range

S1GSS2c

When was the last time that you kept using alcohol or other drugs even through it was causing social problems, leading to fights, or getting you into trouble with other people?

Question Type: Time Range

S1GSS2d

When was the last time that your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home, or social events?

Question Type: Time Range

S1GSS2e

When was the last time that you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?

Question Type: Time Range

Module 14: Trauma Symptoms [ITEMS FROM THE PCL-6] (Module Abbreviation PCL)

S1PCL1

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each question carefully, and indicate how much you have been bothered by that problem in the past 30 days, ranging from not at all bothered to extremely bothered.

In the past 30 days,…

have you been bothered by repeated disturbing memories, thoughts, or images of a stressful experience from the past?

Question Type: Bothered Range

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

S1PCL2

have you been feeling very upset when something reminded you of a stressful experience from the past?

Question Type: Bothered Range

S1PCL3

have you avoided activities or situations because they remind you of a stressful experience from the past?

Question Type: Bothered Range

S1PCL4

have you been feeling distant or cut off from other people?

Question Type: Bothered Range

S1PCL5

have you been feeling irritable or having angry outbursts?

Question Type: Bothered Range

S1PCL6

have you been having difficulty concentrating?

Question Type: Bothered Range

Logic After:

Display questions S1PCL1 – S1PCL6 on the same screen in a table with the response options in columns on the right side of the table.

Module 15: Mental Health Service Use (Module Abbreviation MHSU)

S1ADINTRO

These next questions are about treatment and counseling for problems with emotions, nerves or mental health. Please do not include treatment for alcohol or drug use.

Press “Next” to continue.

S1ADMT13

The list below includes some of the places where people can get outpatient treatment or counseling for problems with their emotions, nerves, or mental health.

• An outpatient mental health clinic or center

• The office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic

• A doctor’s office that was not part of a clinic

• An outpatient medical clinic

• A partial day hospital or day treatment program

• Some other place

During the past 12 months, did you receive any outpatient treatment or counseling for any problem you were having with your emotions, nerves, or mental health at any of the places listed below? Please do not include treatment for alcohol or drug use.

Question Type: TYESNOCAPS

S1ADMT14

[IF ADMT13 = 1] Where did you receive outpatient mental health treatment or counseling during the past 12 months?

Question Type: Outpatient Treatment (allow for multiple responses)

1 An outpatient mental health clinic or center

2 The office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic

3 A doctor’s office that was not part of a clinic

4 An outpatient medical clinic

5 A partial day hospital or day treatment program

6 Some other place

S1ADMT16

[IF ADMT14 = 1] During the past 12 months, how many visits did you make to an outpatient mental health clinic or center for mental health care?

# OF VISITS:

Question Type: Numeric Range [1 – 366]

[RANGE: 1 - 366]

S1ADMT17

[IF ADMT14 = 2] During the past 12 months, how many outpatient visits did you make to a private therapist, psychologist, psychiatrist, social worker, or counselor for mental health care?

# OF VISITS:

Question Type: Numeric Range [1 – 366]

S1ADMT18

[IF ADMT14 = 3] During the past 12 months, how many outpatient visits did you make to a doctor’s office for mental health care?

# OF VISITS:

Question Type: Numeric Range [1 – 366]

S1ADMT19

[IF ADMT14 = 4] During the past 12 months, how many outpatient visits did you make to an outpatient medical clinic for mental health care?

# OF VISITS:

Question Type: Numeric Range [1 – 366]

S1ADMT20

[IF ADMT14 = 5] During the past 12 months, how many outpatient visits did you make to a partial day hospital or day treatment program for mental health care?

# OF VISITS:

Question Type: Numeric Range [1 – 366]

S1ADMT21

[IF ADMT14 = 6] During the past 12 months, how many outpatient visits did you make to some other type of facility for mental health care?

# OF VISITS:

Question Type: Numeric Range [1 – 366]

S1ADMT01

During the past 12 months, have you stayed overnight or longer in a hospital or other facility to receive treatment or counseling for any problem you were having with your emotions, nerves, or mental health? Please do not include treatment for alcohol or drug use.

Question Type: TYESNOCAPS

S1ADMT02

[IF ADMT01 = 1] Where did you stay overnight or longer to receive mental health treatment or counseling during the past 12 months?

Question Type: Overnight Treatment (allow for multiple responses)

1 A private or public psychiatric hospital

2 A psychiatric unit of a general hospital

3 A medical unit of a general hospital

4 Another type of hospital

5 A residential treatment center

6 Some other type of facility

S1ADMT04

[IF ADMT02 = 1] During the past 12 months, how many nights did you spend in a private or public psychiatric hospital for mental health care?

# OF NIGHTS:

Question Type: Numeric Range [1 – 366]

S1ADMT05

[IF ADMT02 = 2] During the past 12 months, how many nights did you spend in the psychiatric unit of a general hospital for mental health care?

# OF NIGHTS:

Question Type: Numeric Range [1 – 366]

S1ADMT06

[IF ADMT02 = 3] During the past 12 months, how many nights did you spend in the medical unit of a general hospital for mental health care?

# OF NIGHTS:

Question Type: Numeric Range [1 – 366]

S1ADMT07

[IF ADMT02 = 4] During the past 12 months, how many nights did you spend in some other type of hospital for mental health care?

# OF NIGHTS:

Question Type: Numeric Range [1 – 366]

S1ADMT08

[IF ADMT02 = 5] During the past 12 months, how many nights did you spend in a residential treatment center for mental health care?

# OF NIGHTS:

Question Type: Numeric Range [1 – 366]

S1ADMT09

[IF ADMT02 = 6] During the past 12 months, how many nights did you spend in some other type of facility for mental health care?

# OF NIGHTS:

Question Type: Numeric Range [1 – 366]

S1ADMT25

During the past 12 months, did you take any prescription medication that was prescribed for you to treat a mental or emotional condition?

Question Type: TYESNOCAPS

S1MHSU6

[IF S1ADMT25 = 1] Are you currently taking any prescription medication that was prescribed for you to treat a mental or emotional condition?

Question Type: TYESNOCAPS

Module 16: Victimization and Violence [ITEMS FROM MACARTHUR COMMUNITY VIOLENCE INSTRUMENT] (Module Abbreviation MCV)

S1MCVINTRO

An important part of our research is to see how often people have problems with one another. We know that many of these disputes aren’t out of the ordinary for many people. These next questions ask about several types of problems that happen in some people’s lives. We would like you to tell us if they have happened to you or if you have done them to anyone else in the past 12 months.

S1MCV1a

In the past 12 months, …

has anyone thrown something at you?

Question Type: TYESNOCAPS

S1MCV1b

have you thrown something at anyone?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV1a - S1MCV1b on the same screen.

S1MCV2a

In the past 12 months, …

has anyone pushed, grabbed, or shoved you?

Question Type: TYESNOCAPS

S1MCV2b

have you pushed, grabbed, or shoved anyone?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV2a - S1MCV2b on the same screen.

S1MCV3a

In the past 12 months, …

has anyone slapped you?

Question Type: TYESNOCAPS

S1MCV3b

have you slapped anyone?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV3a - S1MCV3b on the same screen.

S1MCV4a

In the past 12 months, …

has anyone kicked, bitten, or choked you?

Question Type: TYESNOCAPS

S1MCV4b

have you kicked, bitten, or choked anyone?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV4a - S1MCV4b on the same screen.

S1MCV5a

In the past 12 months, …

has anyone hit you with a fist or object or beaten you up?

Question Type: TYESNOCAPS

S1MCV5b

have you hit anyone with a fist or object or beaten anyone up?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV5a – S1MCV5b on the same screen.

S1MCV6a

In the past 12 months, …

has anyone tried to physically force you to have sex against your will?

Question Type: TYESNOCAPS

S1MCV6b

have you tried to physically force anyone to have sex against their will?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV6a – S1MCV6b on the same screen.

S1MCV7a

In the past 12 months, …

has anyone threatened you with a knife or gun or other lethal weapon?

Question Type: TYESNOCAPS

S1MCV7b

have you threatened anyone with a knife or gun or other lethal weapon?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV7a – S1MCV7b on the same screen.

S1MCV8a

In the past 12 months, …

has anyone used a knife or fired a gun at you?

Question Type: TYESNOCAPS

S1MCV8b

have you used a knife or fired a gun at anyone?

Question Type: TYESNOCAPS

Logic After:

Display items S1MCV8a – S1MCV8b on the same screen.

Module17: Major Depressive Episode

S1ASC21

[IF S1AGE = 18 OR OLDER] Have you ever in your life had a period of time lasting several days or longer when most of the day you felt sad, empty or depressed?

Question Type: TYESNOCAPS

S1ASC22

[IF S1ASC21 = 2 OR Blank] Have you ever had a period of time lasting several days or longer when most of the day you were very discouraged about how things were going in your life?

Question Type: TYESNOCAPS

S1ASC23

[IF S1ASC22 = 2 or Blank] Have you ever had a period of time lasting several days or longer when you lost interest in most things you usually enjoy like work, hobbies, and personal relationships?

Question Type: TYESNOCAPS

S1AD01

[IF S1ASC21 =1] During times when you felt sad, empty, or depressed most of the day, did you ever feel discouraged about how things were going in your life?

Question Type: TYESNOCAPS

S1AD01a

[IF S1AD01 = 1] During the times when you felt sad, empty, or depressed, did you ever lose interest in most things like work, hobbies, and other things you usually enjoy?

Question Type: TYESNOCAPS

S1AD01b

[IF S1AD01 = 2 OR Blank] During the times when you felt sad, empty, or depressed, did you ever lose interest in most things like work, hobbies, and other things you usually enjoy?

Question Type: TYESNOCAPS

S1AD02

[IF S1ASC22 = 1] During times when you felt discouraged about how things were going in your life, did you ever lose interest in most things like work, hobbies, and other things you usually enjoy?

Question Type: TYESNOCAPS

S1AD09

[IF S1ASC23= 1] Did you ever have a period of time like this that lasted most of the day nearly every day for two weeks or longer?

Question Type: TYESNOCAPS

DEFINE FEELFILL:

IF (S1AD01a = 1), THEN FEELFILL = “were sad, discouraged, or lost interest in most things”

IF (S1AD01a = 2 OR DK/REF), THEN FEELFILL = “were sad or discouraged”

IF (S1AD01b = 1), THEN FEELFILL = “were sad or lost interest in most things”

IF (S1AD01b = 2 OR DK/REF) THEN FEELFILL = “were sad”

IF (S1AD02 = 1), THEN FEELFILL = “were discouraged or lost interest in most things”

IF (S1AD02 = 2 OR DK/REF), THEN FEELFILL = “were discouraged about the way things were going in your life”

IF (S1AD09 = 1), THEN FEELFILL = “lost interest in most things”

ELSE, FEELFILL = BLANK

DEFINE FEELNOUN:

IF (S1AD01a = 1), THEN FEELNOUN = “sadness, discouragement, or lack of interest”

IF (S1AD01a = 2 OR DK/REF), THEN FEELNOUN = “sadness or discouragement”

IF (S1AD01b = 1), THEN FEELNOUN = “sadness or lack of interest”

IF (S1AD01b = 2 OR DK/REF), THEN FEELNOUN = “sadness”

IF (S1AD02 = 1), THEN FEELNOUN = “discouragement or lack of interest”

IF (S1AD02 = 2 OR DK/REF), THEN FEELNOUN = “discouragement”

IF (S1AD09 = 1), THEN FEELNOUN = “lack of interest in most things”

ELSE FEELNOUN = BLANK

DEFINE NUMPROBS

IF S1AD01a NE BLANK OR S1AD01b = 1 OR S1AD02 = 1, THEN NUMPROBS = “these problems”

IF S1AD01b = (2 OR DK/REF) OR S1AD02 = (2 OR DK/REF) OR S1AD09 = 1, THEN

NUMPROBS = “this problem”

ELSE NUMPROBS = BLANK

DEFINE WASWERE:

IF S1AD01a NE BLANK OR S1AD01b = 1 OR S1AD02 = 1, THEN WASWERE = “were”

IF S1AD01b = (2 OR DK/REF) OR S1AD02 = (2 OR DK/REF) OR S1AD09 = 1, THEN

WASWERE = “was”

ELSE WASWERE = BLANK

S1AD12

[IF S1AD01a NE BLANK OR S1AD01b NE BLANK OR S1AD02 NE BLANK] Think about the times when you [FEELFILL]. Did you ever have a period of time like this that lasted most of the day, nearly every day, for two weeks or longer?

Question Type: TYESNOCAPS

S1AD16

[IF S1AD09 = 1 OR S1AD12 = 1] Think of times lasting two weeks or longer when [NUMPROBS] with your mood [WASWERE] most severe and frequent.

During those times, how long did your [FEELNOUN] usually last?

Question Type: Hour Range

1 Less than 1 hour

2 At least 1 hour but no more than 3 hours

3 At least 3 hours but no more than 5 hours

4 5 hours or more

S1AD17

[IF S1AD16 = 2, 3, 4, OR Blank] Still thinking of times lasting two weeks or longer when [NUMPROBS] with your mood [WASWERE] most severe and frequent, how severe was your emotional distress during those times?

Question Type: Severe Range

1 Mild

2 Moderate

3 Severe

4 Very severe

S1AD18

[IF S1AD16 = 2, 3, 4, OR Blank] Again, think of times lasting two weeks or longer when [NUMPROBS] with your mood [WASWERE] most severe and frequent.

How often, during those times, was your emotional distress so severe that nothing could cheer you up?

Question Type: Often Range 3

1 Often

2 Sometimes

3 Rarely

4 Never

S1AD19

[IF S1AD16 = 2, 3, 4, OR Blank] Once again, please think of times lasting two weeks or longer when [NUMPROBS] with your mood [WASWERE] most severe and frequent.

How often, during those times, was your emotional distress so severe that you could not carry out your daily activities?

Question Type: Often Range 3

S1AD21

[IF S1 AD16 = (2, 3, 4 OR Blank) AND NOT (S1AD17 = 1 AND S1AD18 = 4 AND S1AD19 = 4) AND (S1ASC21=1 OR S1ASC22=1 OR S1ASC23=1) AND S1AD09 NE (2 OR Blank)] People who have problems with their mood often have other problems at the same time. These problems may include things like changes in:

• sleep

• appetite

• energy

• the ability to concentrate and remember

• feelings of low self-worth

Did you ever have any of these problems during a period of time when you [FEELFILL] for two weeks or longer?

Question Type: TYESNOCAPS

S1AD22

[IF S1AD21 = 1] Think again about these other problems we just mentioned. They include things like changes in

• sleep

• appetite

• energy

• the ability to concentrate and remember

• feelings of low self-worth

Please think of a time when you [FEELFILL] for two weeks or longer and you also had the largest number of these other problems at the same time.

Is there one particular time like this that stands out in your mind as the worst one you ever had?

Question Type: TYESNOCAPS

S1AD22a

[IF S1AD22 = 1] How old were you when that worst period of time started?

AGE:

Question Type: Numeric Range [1 – 110]

[RANGE: 1-110]

S1AD22c

[IF S1AD22 = 2 OR Blank] Then think of the most recent time when you [FEELFILL] for two weeks or longer and you also had the largest number of these other problems at the same time. How old were you when that time started?

AGE:

Question Type: Numeric Range [1 – 110]

DEFINE TIMEFILL:

IF S1AD22a NE BLANK, THEN TIMEFILL = ‘worst’

IF S1AD22c NE BLANK, THEN TIMEFILL = ‘most recent’

S1AD24a

[IF S1AD22a NE BLANK] In answering the next questions, think about the period of time when your [FEELNOUN] and other problems were the worst. [IF S1AD22c NE BLANK] In answering the next questions, think about the most recent period of time when you [FEELFILL] and had other problems at the same time.

During that time, did you feel sad, empty, or depressed most of the day nearly every day?

Question Type: TYESNOCAPS

S1AD24c

[IF S1AD22a NE BLANK OR S1AD22c NE BLANK] During that [TIMEFILL] period of time, did you feel discouraged about how things were going in your life most of the day nearly every day?

Question Type: TYESNOCAPS

S1AD24e

[IF S1AD22a NE BLANK OR S1AD22c NE BLANK] During that [TIMEFILL] period of time, did you lose interest in almost all things like work and hobbies and things you like to do for fun?

Question Type: TYESNOCAPS

S1AD24f

[IF S1AD22a NE BLANK OR S1AD22c NE BLANK] During that [TIMEFILL] period of time, did you lose the ability to take pleasure in having good things happen to you, like winning something or being praised or complimented?

Question Type: TYESNOCAPS

S1AD26a

[IF ANY S1AD24a – S1AD24f = 1] The next questions are about changes in appetite and weight. [IF S1AD22a NE BLANK] In answering the next questions, think about the period of time when your [FEELNOUN] and other problems were the worst. [IF S1AD22c NE BLANK] In answering the next questions, think about the most recent period of time when you [FEELFILL] and had other problems at the same time.

Did you have a much smaller appetite than usual nearly every day during that time?

Question Type: TYESNOCAPS

S1AD26b

[IF S1AD26a = 2 OR Blank] Did you have a much larger appetite than usual nearly every day?

Question Type: TYESNOCAPS

S1AD26c

[IF S1AD26a = 2 OR Blank] Did you gain weight without trying to during that [TIMEFILL] period of time?

Question Type: TYESNOCAPS

S1AD26c1

[IF S1AD26c = 1 AND (S1AD22a ≤ 21 OR S1AD22c ≤ 21)] Did you gain weight without trying to because you were growing?

Question Type: TYESNOCAPS

S1AD26c2

[IF S1AD26c = 1 AND S1AD26c1 NE YES AND S1QD01 = 2] Did you gain weight without trying to because you were pregnant?

Question Type: TYESNOCAPS

S1AD26d

[IF S1AD26c = 1 AND S1AD26c1 NE YES AND S1AD26c2 NE YES] How many pounds did you gain? Please enter your answer as a whole number.

# OF POUNDS:

Question Type: Numeric Range [0 – 200]

__________ [RANGE: 0-200]

DK/REF

S1AD26e

[IF (S1AD26a = 1 OR S1AD26c=(2 OR Blank)] Did you lose weight without trying to?

Question Type: TYESNOCAPS

S1AD26e1

[IF S1AD26e = 1] Did you lose weight without trying to because you were sick or on a diet?

Question Type: TYESNOCAPS

S1AD26f

[IF S1AD26e1 = 2 OR Blank] How many pounds did you lose?

Please enter your answer as a whole number.

# OF POUNDS:

Question Type: Numeric Range [0 – 200]

S1AD26g

[IF S1AD26a NE BLANK] [IF S1AD22a NE BLANK] Again, please think about the period of time when your [FEELNOUN] and other problems were the worst.

[IF S1AD22c NE BLANK] Again, please think about the most recent period of time when you [FEELFILL] and had other problems at the same time.

Did you have a lot more trouble than usual falling asleep, staying asleep, or waking too early nearly every night during that [TIMEFILL] period of time?

Question Type: TYESNOCAPS

S1AD26h

[IF S1AD26g = 2 OR Blank] During that [TIMEFILL] period of time, did you sleep a lot more than usual nearly every night?

Question Type: TYESNOCAPS

S1AD26j

[IF S1AD26a NE BLANK] During that [TIMEFILL] period of time, did you feel tired or low in energy nearly every day, even when you had not been working very hard?

Question Type: TYESNOCAPS

S1AD26l

[IF S1AD26a NE BLANK] Did you talk or move more slowly than is normal for you nearly every day?

Question Type: TYESNOCAPS

S1AD26m

[IF S1AD26l = 1] Did anyone else notice that you were talking or moving slowly?

Question Type: TYESNOCAPS

S1AD26n

[IF S1AD26l = 2 OR Blank] Were you so restless or jittery nearly every day that you paced up and down or couldn't sit still?

Question Type: TYESNOCAPS

S1AD26o

[S1AD26n = 1] Did anyone else notice that you were restless?

Question Type: TYESNOCAPS

S1AD26p

[IF S1AD26a NE BLANK] The next questions are about changes in your ability to concentrate, and your feelings about yourself.

[IF S1AD22a NE BLANK] Again, in answering these questions, think about the period of time when your [FEELNOUN] and other problems were the worst.

[IF S1AD22c NE BLANK] Again, in answering these questions, think about the most recent period of time when you [FEELFILL] and had other problems at the same time.

During that [TIMEFILL] time, did your thoughts come much more slowly than usual or seem confused nearly every day?

Question Type: TYESNOCAPS

S1AD26r

[IF S1AD26a NE BLANK] Did you have a lot more trouble concentrating than usual nearly every day?

Question Type: TYESNOCAPS

S1AD26s

[IF S1AD26a NE BLANK] Were you unable to make decisions about things you ordinarily have no trouble deciding about?

Question Type: TYESNOCAPS

S1AD26u

[IF S1AD26a NE BLANK] Did you feel that you were not as good as other people nearly every day?

Question Type: TYESNOCAPS

S1AD26v

[IF S1AD26u = 1] Did you feel totally worthless nearly every day?

Question Type: TYESNOCAPS

S1AD26aa

[IF S1AD26a NE BLANK] The next questions are about thoughts of death or suicide.

[IF S1AD22a NE BLANK] Again, in answering these questions, think about the period of time when your [FEELNOUN] and other problems were the worst.

[IF S1AD22c NE BLANK] Again, in answering these questions, think about the most recent period of time when you [FEELFILL] and had other problems at the same time.

Did you often think a lot about death, either your own, someone else’s, or death in general?

Question Type: TYESNOCAPS

S1AD26bb

[IF S1AD26a NE BLANK] During that period, did you ever think that it would be better if you were dead?

Question Type: TYESNOCAPS

S1AD26cc

[IF S1AD26a NE BLANK] Did you think about committing suicide?

Question Type: TYESNOCAPS

S1AD26dd

[IF S1AD26cc = 1] Did you make a suicide plan?

Question Type: TYESNOCAPS

S1AD26ee

[IF S1AD26cc = 1] Did you make a suicide attempt?

Question Type: TYESNOCAPS

DEFINE S1D_MDEA1:

IF S1AD24A = 1 OR S1AD24C = 1, THEN S1D_MDEA1= 1

ELSE IF S1AD24A = 2 AND S1AD24C = 2, THEN S1D_MDEA1= 2

ELSE IF S1AD24A = DK OR S1AD24C = DK, THEN S1D_MDEA1= DK

ELSE IF S1AD24A = REF OR S1AD24C = REF, THEN S1D_MDEA1= REF

ELSE S1D_MDEA1= BLANK

DEFINE S1D_MDEA2:

IF S1AD24E = 1 OR S1AD24F = 1, THEN S1D_MDEA2= 1

ELSE IF S1AD24E = 2 AND S1AD24F = 2, THEN S1D_MDEA2= 2

ELSE IF S1AD24E = DK OR S1AD24F = DK, THEN S1D_MDEA2= DK

ELSE IF S1AD24E = REF OR S1AD24F = REF, THEN S1D_MDEA2= REF

ELSE S1D_MDEA2= BLANK

DEFINE S1D_MDEA3:

IF S1AD26A = 1 OR S1AD26B = 1 OR S1AD26D ≥10 OR S1AD26F ≥10, THEN S1D_MDEA3= 1

ELSE IF S1AD26A = 2 AND S1AD26B = 2 AND ((S1AD26D < 10 OR S1AD26F < 10) OR

(S1AD26C = (2 OR BLANK) AND S1AD26E = (2 OR BLANK)) OR (S1AD26C = 1 AND

(S1AD26C1 = 1 OR S1AD26C2 = 1)) OR (S1AD26E = 1 AND S1AD26E1 = 1)), THEN

S1D_MDEA3= 2

ELSE IF S1AD26A = DK OR S1AD26B = DK OR S1AD26C = DK OR S1AD26D = DK OR

S1AD26E = DK OR S1AD26F = DK, THEN S1D_MDEA3= DK

ELSE IF S1AD26A = REF OR S1AD26B = REF OR S1AD26C = REF OR S1AD26D = REF OR

S1AD26E = REF OR S1AD26F = REF, THEN S1D_MDEA3= REF

ELSE S1D_MDEA3= BLANK

DEFINE S1D_MDEA4:

IF S1AD26G = 1 OR S1AD26H = 1, THEN S1D_MDEA4= 1

ELSE IF S1AD26G = 2 AND S1AD26H = 2, THEN S1D_MDEA4= 2

ELSE IF S1AD26G = DK OR S1AD26H = DK, THEN S1D_MDEA4= DK

ELSE IF S1AD26G = REF OR S1AD26H = REF, THEN S1D_MDEA4= REF

ELSE S1D_MDEA4= BLANK

DEFINE S1D_MDEA5:

IF S1AD26M = 1 OR S1AD26O = 1, THEN S1D_MDEA5= 1

ELSE IF (S1AD26L = (2 OR DK/REF) AND (S1AD26N = (2 OR DK/REF) OR S1AD26O = 2))

OR S1AD26M = 2, THEN S1D_MDEA5= 2

ELSE IF S1AD26L = DK OR S1AD26M = DK OR S1AD26N = DK OR S1AD26O = DK, THEN

S1D_MDEA5= DK

ELSE IF S1AD26L = REF OR S1AD26M = REF OR S1AD26N = REF OR S1AD26O = REF,

THEN S1D_MDEA5= REF

ELSE S1D_MDEA5= BLANK

DEFINE S1D_MDEA6:

S1D_MDEA6= AD26J

DEFINE S1D_MDEA7:

IF S1AD26V = 1, THEN S1D_MDEA7= 1

ELSE IF S1AD26U = (2 OR DK/REF) OR S1AD26V = 2, THEN S1D_MDEA7= 2

ELSE S1D_MDEA7= S1AD26V

ELSE S1D_MDEA7= BLANK

DEFINE S1D_MDEA8:

IF S1AD26P = 1 OR S1AD26R = 1 OR S1AD26S = 1, THEN S1D_MDEA8= 1

ELSE IF S1AD26P = 2 AND S1AD26R = 2 AND S1AD26S = 2, THEN S1D_MDEA8= 2

ELSE IF S1AD26P = DK OR S1AD26R = DK OR S1AD26S = DK, THEN S1D_MDEA8= DK

ELSE IF S1AD26P = REF OR S1AD26R = REF OR S1AD26S = REF, THEN S1D_MDEA8=

REF

ELSE S1D_MDEA8= BLANK

DEFINE S1D_MDEA9:

IF S1AD26AA = 1 OR S1D26BB = 1 OR S1AD26CC = 1 OR S1AD26DD = 1 OR S1AD26EE = 1,

THEN S1D_MDEA9= 1

ELSE IF S1AD26AA = 2 AND S1AD26BB = 2 AND S1AD26CC = 2, THEN S1D_MDEA9= 2

ELSE IF S1AD26AA = DK OR S1AD26BB = DK OR S1AD26CC = DK OR S1AD26DD = DK

OR S1AD26EE = DK, THEN S1D_MDEA9= DK

ELSE IF S1AD26AA = REF OR S1AD26BB = REF OR S1AD26CC = REF OR S1AD26DD =

REF OR S1AD26EE = REF, THEN S1D_MDEA9= REF

ELSE S1D_MDEA9= BLANK

DEFINE S1DSMMDEA2:

IF SUM (S1D_MDEA1 = 1, S1D_MDEA2 = 1, S1D_MDEA3 = 1, S1D_MDEA4 = 1, S1D_MDEA5

= 1, S1D_ S1MDEA6 = 1, S1D_MDEA7 = 1, S1D_MDEA8 = 1, S1D_MDEA9 = 1) ≥ 5, THEN

S1DSMMDEA2 = 1

ELSE IF SUM (S1D_MDEA1 = (1 OR DK/REF), S1D_MDEA2 = (1 OR DK/REF),

S1D_MDEA3 = (1 OR DK/REF), S1D_MDEA4 = (1 OR DK/REF), S1D_MDEA5 = (1 OR

DK/REF), S1D_MDEA6 = (1 OR DK/REF), S1D_MDEA7 = (1 OR DK/REF), S1D_MDEA8 =

(1 OR DK/REF), S1D_MDEA9 = (1 OR DK/REF)) < 5 AND N(OF S1D_MDEA1-

S1D_MDEA9) > 0, THEN S1DSMMDEA2 = 2

ELSE IF S1D_MDEA1 = DK OR S1D_MDEA2 = DK OR S1D_MDEA3 = DK OR S1D_MDEA4

= DK OR S1D_MDEA5 = DK OR S1D_MDEA6 = DK OR S1D_MDEA7 = DK OR

S1D_MDEA8 = DK OR S1D_MDEA9 = DK, THEN S1DSMMDEA2 = DK

ELSE IF S1D_MDEA1 = REF OR S1D_MDEA2 = REF OR S1D_MDEA3 = REF OR

S1D_MDEA4 = REF OR S1D_MDEA5 = REF OR S1D_MDEA6 = REF OR S1D_MDEA7 = REF

OR S1D_MDEA8 = REF OR S1D_MDEA9 = REF, THEN S1DSMMDEA2 = REF

S1AD28

[IF S1D_MDEA9 = 1 OR S1DSMMDEA2 = 1] You mentioned having some of the problems I just asked you about.

During that [TIMEFILL] period of time, how much did your [FEELNOUN] and these other problems interfere with your work, your social life, or your personal relationships?

Question Type: Often Range 4

1 Not at all

2 A little

3 Some

4 A lot

5 Extremely

S1AD38

[IF S1AD28 NE BLANK ] In the past 12 months, did you have a period of time when you felt [FEELNOUN] for two weeks or longer while also having some of the other problems we asked about?

Question Type: TYESNOCAPS

S1SUICTHNK

At any time in the past 12 months, did you seriously think about trying to kill yourself?

Question Type: TYESNOCAPS

Module 18: Mental Health Self-Efficacy (Module Abbreviation MSE)

S1MSE1

These next questions ask about how you manage your emotions and mental health, how you manage services and supports, and how you help change or improve services systems. There are no right or wrong answers.

I focus on the good things in life, not just the problems.

Question Type: MH Often Range

1 Always or almost always

2 Mostly

3 Sometimes

4 Rarely

5 Never or almost never

S1MSE2

I make changes in my life so I can live successfully with my emotional or mental health challenges.

Question Type: MH Often Range

S1MSE3

I feel I can take steps toward the future I want.

Question Type: MH Often Range

S1MSE4

I worry that difficulties related to my mental health or emotions will keep me from having a good life.

Question Type: MH Often Range

S1MSE5

I know how to take care of my mental or emotional health.

Question Type: MH Often Range

S1MSE6

When problems arise with my mental health or emotions, I handle them pretty well.

Question Type: MH Often Range

S1MSE7

I feel my life is under control.

Question Type: MH Often Range

Module 19: Self-Efficacy (Academic, Employment, & Social) (Module Abbreviation ASE, ESE, SSE)

S1ASEINTRO

[IF S1QD17 = 1 OR S1QD17b = 1] The next questions are for understanding what is easy or difficult for you in school or job training. Please say for each statement how sure you are that you can do each of the things below, ranging from “Not at All Sure” to “Extremely Sure.”

Press “Next” to continue.

S1ASE1

[IF S1QD17 = 1 OR S1QD17b = 1] I am sure that I can use the internet or library to get information for assignments.