Community Survey

OWH Survey
Survey Instrument

Assessment of the Behavioral Health of Women in Western North Dakota and Eastern Montana
Note: the survey instrument is designed for electronic administration via email, but it can also be
converted to paper format. The survey can be self-administered or with the assistance of an
interviewer/administrator in person.
Form Approved
OMB No. 0990Exp. Date XX/XX/20XX
WELCOME AND INFORMED CONSENT
Thank you for taking this confidential survey to evaluate women’s physical and behavioral health in
your community. Before we begin, we ask that you read our informed consent form.
Background
The 2006 discovery and subsequent development of the Parshall Oil Field has led to significant
economic opportunities and population growth in in western North Dakota and eastern Montana.
Rapid population growth has many intended and unintended consequences, both positive and
negative, on the social and economic environment of the region and the population’s health and
well-being.
Purpose
The purpose of this survey is to understand the perceptions and experiences of health and
behavioral health of women in western North Dakota and eastern Montana. Behavioral health is a
term that covers the full range of mental and emotional well-being – from the basics of how we cope
with day-to-day challenges of life, to the treatment of mental illnesses, such as depression or
personality disorder, as well as substance use disorders and other addictive behaviors.
Our study includes interviews with key stakeholders, focus groups and surveys with community
members. Throughout the project, our assessment is emphasizing community engagement. Our
work is guided by community organizations, tribes, and state partners to ensure the assessment
produces evidence that will benefit women living in “boomtown” and surrounding communities.
What Happens In This Research Study
If you are a woman residing in North Dakota or Montana, you are eligible to take this survey. The
survey will ask you questions about your health, about changes happening in your community
related to the energy industry, and what you think about the role of energy development on
women’s behavioral health. This survey contains 51 questions and will take 10 minutes. There are
no “right” or “wrong” answers. Once you complete the survey, your participation in the study will
be completed. There will be no further invitations, activities or contact with study personnel.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information
collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W.,
Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Confidentiality
Your responses will be kept private to the extent allowed by law. Information from this survey will
be used for community improvement and may be published; however, your name will not be used
in any publications. Responses will be summarized in a report across all survey participants.

* If you accept these terms and wish to take the survey, please click the button below:
I Accept/Understand

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OWH Survey
DEMOGRAPHICS

1. What is your age? [BRFSS 2017]

2. Are you Hispanic or Latina/o? [BRFSS 2017]
Yes
No

3. What is your race? (check all that apply) [US Census/BRFSS 2017]
White
Black or African American
Alaska Native or American Indian
Asian
Pacific Islander

4. Do you currently live on an American Indian reservation?
Yes
No

5. What is your zip code?

6. Where were you born?
United States (please specify state)

Outside the United States (please specify country)
please leave blank if born in United States

_

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7. What is the highest grade or level of school you have finished? [BRFSS 2017/US Census]
I didn’t go to school
8th grade or less
Some high school but did not graduate
High School graduate or GED
Some college / vocational or technical school
Graduated from college, graduate school

8. How would you describe your relationship status?
Married
Divorced
Widowed
Separated
Never married
Member of an unmarried couple

9. Do you have any children?
Yes, residing with me
Yes, not residing with me
No

10. What language do you speak most at home? (select one option)
English
Spanish
Other (please specify)

11. What best describes your employment status? Please select one. [BRFSS 2017]
Employed for wages

A Homemaker

Self-employed

A Student

Out of work for 1 year or more

Retired

Out of work for less than 1 year

I am unable to work

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12. What is your annual household income? [Adapted from BRFSS 2017]
Less than $25,000
$25,000 to less than $35,000
$35,000 to less than $50,000
$50,000 to less than $75,000
$75,000 or more

13. What category best describes yourprimary source of health care coverage? Please select one.
[BRFSS 2017]
I don’t have health insurance coverage
A plan provided through an employer or union (includes plans purchased through another person's employer)
A plan that you or another family member buys on your/their own
Medicare
Medicaid
TRICARE (formerly CHAMPUS), VA, or Military
Alaska Native, Indian Health Service, Tribal Health Services
Some other source

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OWH Survey
COMMUNITY CONTEXT

14. How long have you lived in your current community?
Less than a year
One to two years
Three to four years
More than five years
Five to ten years

15. Do you or a member of your household work in the energy industry (e.g. oil drilling, fracking, etc.)? This
could include support roles, e.g. clerical work, driving a delivery truck, …)
Yes, I work in the energy industry
Yes, another member of my household works in the energy industry but I don’t
Yes, myself and another member of my household works in the energy industry
No

16. From the following list, what do you think are the three most important concerns in your community?
Please select 3.
Access to health care

Jobs and economy

Access to healthy food

Roads/infrastructure

Access to transportation

Schools/education

Affordable housing

Healthy behaviors/lifestyles

Arts and cultural events

Parks and recreation

Child abuse/neglect

Community leadership

Clean environment

Community cohesion

Disease/death rates

Child Care

Other (please specify)

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OWH Survey
HEALTH MEDIATORS AND OUTCOMES

17. Would you say your general health is____? [BRFSS 2017]
Excellent
Very good
Good
Fair
Poor

18. Now thinking about your physical health, which includes physical illness and injury, for how many days
during the past 30 days was your physical health not good? [BRFSS 2017]

19. Now thinking about your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not good? [BRFSS 2017]

20. During the past 30 days, for about how many days did poor physical or mental health keep you from
doing your usual activities, such as self-care, work, or recreation? [BRFSS 2014]

21. A routine checkup is a general physical exam, not an exam for a specific injury, illness or condition.
About how long has it been since you last visited a doctor for a routine checkup? [BRFSS 2017]
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 5 years (2 years but less than 5 years ago)
5 or more years ago
NEVER

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22. Please indicate if you have experienced the following issues as barriers to receivingmedical care.
Please check all that apply.
Cost of Care
Transportation to/from care
Distance to care provider
Unsure where to go for care
Lack of providers
Lack of time due to work or family obligations
Lack of insurance

23. Please indicate if you have experienced the following issues as barriers to receivingmental health care.
Please check all that apply.
Cost of Care
Transportation to/from care
Distance to care provider
Unsure where to go for care
Lack of providers
Lack of time due to work or family obligations
Lack of insurance

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OWH Survey
BEHAVIORAL HEALTH

24. During the past 30 days, how many days per week or per month did you have at least one drink of any
alcoholic beverage such as beer, wine, a malt beverage, or liquor? [BRFSS 2017]
Days per week

Days in past 30 days

Number of drinks

25. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5
(FOR MEN) / 4 (FOR WOMEN) or more drinks on an occasion? [BRFSS 2014]

26. During the past 30 days, how many times have you driven when you’ve had perhaps too much to
drink? [BRFSS 2014]

27. During the past 30 days, which of the following substances have you used? Please check all that
apply. [NSDUH 2014]
Marijuana

Hallucinogens (e.g. LSD, ecstasy)

Pain relievers (non-medical use) (e.g. Oxycodone)

Inhalants (e.g. markers, air duster)

Tranquilizers (non-medical use) (e.g. Xanax)

Heroin

Stimulants (e.g. meth)

Sedatives (non-medical use) (e.g. Ambien, Lunesta)

Cocaine / Crack

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About how often (all of the time, most of the time, some of the time, a little of the time, or none of the time)
during the past 30 days did you feel… [BRFSS 2014]
ALL OF THE TIME

MOST OF THE
TIME

SOME OF THE
TIME

A LITTLE OF THE
TIME

NONE OF THE
TIME

28. Nervous?
29. Hopeless?
30. Restless or fidgety?
31. So depressed that
nothing could cheer you
up?
32. That everything was
an effort?
33. Worthless?

34. Have you thought seriously about killing yourself at any time during the past year? [NSDUH 2014]
Yes
No

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OWH Survey
SAFETY

35. In your community, which factors contribute to your feelings of feeling unsafe? Please check all that
apply.
Signage or information on streets

Visible police or civil guards

Maintenance of public open spaces

Strangers

Bus stops or stations

Homeless individuals

Gambling establishments

Drug dealing

Public restrooms

I feel safe

Other (please specify)

36. Which of the following factors affect your personal safety in your community? Please check all that
apply.
Being a woman

Being from another geographic area – region/state/country

Being of a certain religion

Having a certain sexual orientation

Being of a certain race and/or ethnicity

None

37. Which personal safety issues concern you the most in your community? Please check all that apply.
Sexual harassment

Public drunkenness

Verbal hassling

Robbery or having money or other possessions stolen

Stalking

Kidnapping

Staring

Forced labor

Whistling

Forced prostitution

Sexual assault or rape

Drug trafficking and dealing

Public disorderly conduct

Murder

Other (please specify)

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38. Have you ever been the victim of violence in your household?
Yes
No

39. Have you ever been the victim of violence in the community where you currently live?
Yes
No

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