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pdfTHE LONGITUDINAL INVESTIGATION OF GENDER,
HEALTH, AND TRAUMA SURVEY (LIGHT Survey)
Time 3
Welcome to the third survey! Thank you in advance
for completing this survey.
Q2a Would you consider yourself the or one of the
primary caregivers for your child/children?
Yes
If you have any questions, you may contact our
helpdesk at 1-855-462-7577.
INSTRUCTIONS
Choose one answer for each question unless the
instructions say otherwise.
Read each question carefully. Different questions
ask about different timeframes.
No
Q3
What is your current living situation?
Rent an apartment, house, or room
Own my house or apartment
Live with a relative or friend and not paying
rent
Live in a car, on the street, or in a homeless
shelter
Other (Please describe)
300001
This number preserves your confidentiality and allows us to mail you
the incentive as a thank you for your time.
*300001*
Q1
Q4
What is the highest degree or level of
education you have completed?
Have you been homeless in the
past 4 months?
Yes
No
Some high school but no diploma or GED
High school diploma / GED
Post-high school vocational or technical
training
Some college credit, no degree
Associate’s degree (for example, AA, AS)
Bachelor’s degree (for example, BA, BS)
Master’s, Doctorate or professional degree (for
example, MA, MSW, MBA, PhD, MD, JD)
Q2
How many children do you have (both your
biological children and other children for whom
you have parenting responsibilities)?
Number of children:
I do not have any children → Go to question 3
Light Survey - Time 3 (F)
Time 3 (F)
301
Q5
What is your current employment status?
Select all that apply.
Working for pay full-time (≥30 hours/week)
Working for pay part-time (<30 hours/week)
Not working for pay but actively looking for
paid work
Full-time care of children under the age of 18
or adult (for example, disabled adult
child/parent/spouse)
Full-time homemaker without full-time child or
elder care responsibilities
Retired
Disabled
1
Q6
Please provide an estimate of your
HOUSEHOLD’S yearly income before taxes
are taken out. Include all sources of income
from all earners in your household. If you do
not know the answer, please make your best
guess.
No income
Less than $15,000 per year
$15,000 – $24,999
$25,000 – $34,999
$35,000 – $44,999
$45,000 - $54,999
$55,000 – $74,999
$75,000 – $99,999
$100,000 - $149,999
$150,000 or more per year
Q7
How many people are supported by this
HOUSEHOLD income, including yourself, your
significant other (if you have one), and anyone
else partially or fully supported by this income
whether or not they live with you?
Q9
In the past 4 months...
Not
at all
Once or Several
twice
times
Many
times
a. Serious accident (for
example, car / boat
accident, accident at
work)
b. Exposure to toxic
substance (for example,
dangerous chemicals,
radiation)
c. Witnessed sudden,
violent death or
aftermath (for example,
homicide, suicide)
d. Sudden, unexpected
death of someone close
to you
e. Serious injury, harm,
or death you caused to
someone else
f. Captivity (for example,
being kidnappde, held
hostage, prisoner of
war)
g. Community violence
(for example, terrorist
attack, bombing, riots)
h. Natural disaster (for
example, flood,
hurricane, tornado,
earthquake
This section is about violent attacks against
you by someone who is NOT a romantic
partner or spouse.
Q8
Have you been incarcerated for longer than 24
hours within the past 4 months?
Yes
No
In past surveys you told us about exposures
to traumatic events across your lifespan. The
next set of questions ask about experiences
you may have had in the last 4 months (since
the last survey). If the event does not apply
to you, mark “Not at all.”
Light Survey - Time 3 (F)
In the past 4 months...
Not
at all
Once or Several
twice
times
Many
times
i. Sexual assault by
anyone who is NOT an
intimate partner (rape,
attempted rape, made to
perform any sexual act
through force or threat of
harm)
j. Serious physical
assault by anyone who
is NOT an intimate
partner (attacked with or
without a weapon,
threatened with a
weapon)
2
This section is about violence against you by
someone who WAS/IS a romantic partner or
spouse.
In the past 4 months...
Not at all
Once or Several
twice
times
Many
times
k. Physical assault
(pushed, grabbed, shaken,
hit, beat up by a significant
other/spouse)
l. Unwanted sexual
experience by a significant
other/spouse (pressured
or forced to do sexual
things you didn’t want to
do)
m. Emotional mistreatment
by significant other/spouse
(name-calling, criticized,
not allowed to see
friends/family, humiliated,
or denied money)
n. Other traumatic event:
please specify. Please
describe the event below.
Combat/ exposure to warzone
Physical assault
Sexual assault
Accident
Natural disaster
Seen someone killed or seriously injured
Death of loved one through homicide or suicide
I did not have an experience like this → Go to
question 15
Other: (Please describe)
Q9o We are interested in other natural disasters
you have experienced in your life. Please tell
us the number of times you’ve experienced
a natural disaster across each time in your
life.
Not at all
Childhood (birth – age
17)
Age 18 to enlistment (if
applicable)
During military service
After military service until
January 2019
Light Survey - Time 3 (F)
Q10 Of all the traumatic events that you have ever
experienced across your life, please select the
ONE experience that causes you the MOST
distress. If you have never had an experience
like these, please select “I did not have an
experience like this” and proceed to question
15. Check one only.
Once or
twice
Several
times
Q11 How old were you when this most distressing
trauma (the trauma selected from Q10)
occurred?
Many
times
Q12 How long ago did this trauma (from Q10)
occur?
Within the past month
Within the past 4 months
Over 4 months ago
3
Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then choose one of the responses
below to indicate how much you have been bothered by that problem in the past month.
Please base your answers on problems related to the experience you named as the worst in
question 10.
Q13 Thinking about the experience you named in question 10, in the past month, how much were you
bothered by:
Not at all
A little bit
Moderately
Quite a bit
Extremely
a. Repeated, disturbing, and unwanted memories of the
stressful experience?
b. Repeated, disturbing dreams of the stressful
experience?
c. Suddenly feeling or acting as if the stressful
experience were actually happening again (as if you
were actually back there reliving it)?
d. Feeling very upset when something reminded you of
the stressful experience?
e. Having strong physical reactions when something
reminded you of the stressful experience (for example,
heart pounding, trouble breathing, sweating)?
f. Avoiding memories, thoughts, or feelings related to the
stressful experience?
g. Avoiding external reminders of the stressful
experience (for example, people, places, conversations,
activities, objects, or situations)?
h. Trouble remembering important parts of the stressful
experience?
i. Having strong negative beliefs about yourself, other
people, or the world (for example, having thoughts such
as: I am bad, there is something seriously wrong with
me, no one can be trusted, the world is completely
dangerous)?
j. Blaming yourself or someone else for the stressful
experience or what happened after it?
k. Having strong negative feelings such as fear, horror,
anger, guilt, or shame?
l. Loss of interest in activities that you used to enjoy?
m. Feeling distant or cut off from other people?
n. Trouble experiencing positive feelings (for example,
being unable to feel happiness or have loving feelings for
people close to you)?
o. Irritable behavior, angry outbursts, or acting
aggressively?
p. Taking too many risks or doing things that could cause
you harm?
q. Being “superalert” or watchful or on guard?
r. Feeling jumpy or easily startled?
s. Having difficulty concentrating?
t. Trouble falling or staying asleep?
Light Survey - Time 3 (F)
4
Q14 For these questions, please continue to think of the traumatic event that bothers you most (from
Q10). What do you do when memories of the traumatic event pop into your mind? Please mark
the answer that applied best to you during the past week.
Never
Sometimes
Often
Always
a. I think about how life would have been different if the
event had not occurred.
b. I dwell on how the event could have been prevented.
c. I think about why the event happened to me.
d. I dwell on how I used to be before the event.
e. I dwell on what other people have done to me.
f. I dwell on what I should have done differently.
g. I go over what happened again and again.
h. I worry that something similar will happen to me or my
family.
Q15 The next set of items ask about potentially stressful situations you may be currently
experiencing. Think about whether or not the stressful situation described happened within the
past 4 months. If the situation IS NOT occurring for you, choose "N/A" and go to the next item. If
the situation IS occurring, please rate the extent to which it is NOW stressful/distressing to you
on a scale from 1-10.
N/A
Not at all
distressing
1
2
3
4
Somewhat
distressing
5
6
7
8
9
Extremely
distressing
10
a. Laid off or fired from work
b. At risk for losing your
home/lost your home
c. Caring of seriously ill
and/or disabled dependents
(e.g., children, elders)
d. Divorce or separation
from romantic partner
e. Legal problems, court
proceedings, ongoing
litigation
f. Major negative change in
financial status
g. Major problems at
school/At risk of losing spot
at school or Veteran
subsidies
h. Major health problem
i. Major problem with your
significant other or child(ren)
j. Moved to a new home
Light Survey - Time 3 (F)
5
Q16 Over the past two weeks how often have you been bothered by any of the following problems?
Not at all
Several days
More than half Nearly every
the days
day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much.
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself – or that you are a failure or
have let yourself or your family down
g. Trouble concentrating on things, such as reading the
newspaper or watching television
h. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless that
you have been moving around a lot more than usual
i. Thoughts that you would be better off dead, or of hurting
yourself
j. Feeling nervous, anxious, or on edge
k. Not being able to stop or control worrying
l. Worrying too much about different things
m. Trouble relaxing
n. Being so restless that it's hard to sit still
o. Becoming easily annoyed or irritable
p. Feeling afraid as if something awful might happen
Light Survey - Time 3 (F)
6
Q17 People think and do many different things when they feel depressed. Please read each of the
items below and indicate whether you almost never, sometimes, often or always think or do each
one when you feel down, sad, or depressed. Please indicate what you generally do, not what you
think you should do.
Almost
never
Sometimes
Often
Almost
always
a. Think about how alone you feel.
b. Think “I won’t be able to do my job if I don’t snap out of this.”
c. Think about your feelings of fatigue and achiness.
d. Think about how hard it is to concentrate.
e. Think “What am I doing to deserve this?”
f. Think about how passive and unmotivated you feel.
g. Analyze recent events to try to understand why you are depressed.
h. Think about how you don’t seem to feel anything anymore.
i. Think “Why can’t I get going?”
j. Think “Why do I always react this way?”
k. Go away by yourself and think about why you feel this way.
l. Write down what you are thinking and analyze it.
m. Think about a recent situation, wishing it had gone better.
n. Think “I won’t be able to concentrate if I keep feeling this way.”
o. Think “Why do I have problems other people don’t have?”
p. Think “Why can’t I handle things better?”
q. Think about how sad you feel.
r. Think about all your shortcomings, failings, faults, mistakes.
s. Think about how you don’t feel up to doing anything.
t. Analyze your personality to try to understand why you are depressed.
u. Go someplace alone to think about your feelings.
v. Think about how angry you are with yourself.
Q18 Have you been diagnosed with any of the following emotional/mental health conditions within the past 4
months? Select all that apply.
Post-traumatic Stress Disorder (PTSD)
Depression
Anxiety Disorder (for example, panic disorder, generalized anxiety disorder)
None
Other mental health problem (please specify):
Light Survey - Time 3 (F)
7
Please check the one box beside the statement or phrase that best applies to you.
Q19a Have you thought about or attempted to kill yourself in the past 4 months? Check one only.
Never
It was just a brief passing thought
I have had a plan at least once to kill myself but did not try to do it
I have had a plan at least once to kill myself and really wanted to die
I have attempted to kill myself, but did not want to die
I have attempted to kill myself, and really hoped to die
Q19b How often have you thought about killing yourself in the past 4 months? Check one only.
Never
Rarely (1 time)
Sometimes (2 times)
Often (3-4 times)
Very often (5 or more times)
Q19c Have you ever told someone in the past 4 months that you were going to commit suicide, or that you
might do it? Check one only.
No
Yes, at one time, but did not really want to die
Yes, at one time, and really wanted to die
Yes, more than once, but did not want to do it
Yes, more than once, and really wanted to do it
Q19d How likely is it that you will attempt suicide someday? Check one only.
Never
No chance at all
Rather unlikely
Unlikely
Likely
Rather likely
Very likely
Having thoughts of hurting yourself can be a common response to feeling distressed. We
want you to know that help is available. We recommend that you contact your primary care
provider or call the Veterans Crisis Hotline (1-800-273-8255) if you are experiencing suicidal
thoughts.
Light Survey - Time 3 (F)
8
Q20 Thinking over the past month, check the option that best describes the amount of time you felt
that way.
None or
All or almost
almost none A little of the Some of the Most of the all of the
of the time
time
time
time
time
a. I found myself getting angry at people or situations.
b. When I got angry, I got really angry.
c. When I got angry, I stayed mad.
d. When I got angry at someone I wanted to hit them.
e. My anger prevented me from getting along with people
as well as I'd have liked to.
Q21 What is your current marital status?
Never married
Married - first and only marriage → Go to question 23
Married - second or later marriage → Go to question 23
Separated
Divorced
Widowed
Q22 Are you currently in a romantic relationship?
Currently in a relationship and living as a couple
Currently in a relationship but not living as a couple
Not currently in a relationship → Go to question 24
If you are married or currently in a romantic relationship, please answer the following
questions. If you are not married or in a romantic relationship, please skip to question 24:
Q23 Over the past month, how often have you done the following in your romantic relationship:
Never
Rarely
Sometimes
Often
Most or all of
the time
a. Provided your significant other with the emotional
support they sought.
b. Shared your intimate thoughts and feelings.
c. Done your fair share of day-to-day tasks (for example,
grocery shopping, errands, planning activities).
d. Initiated leisure time activities that both you and your
significant other enjoy.
e. Made effort to work through disagreements
respectfully.
f. Expressed interest and/or willingness to engage in
regular sexual or physical intimacy.
Light Survey - Time 3 (F)
9
If you currently have parenting responsibilities for any children 18 or under please answer
the following questions. If not, please skip to question 25.
Q24 All parents have strengths and weaknesses. Over the past month, how often have you:
Never
Rarely
Sometimes
Often
Most or all
of the time
a. Provided a healthy environment for your children (for
example, preparing healthy meals, caring for their health,
keeping them safe).
b. Been a good example for your children (for example,
being respectful during disagreements with others,
taking good care of your own health).
c. Been actively involved in your child(ren)’s activities (for
example, regularly attending sporting and school events,
giving your full attention during time together).
d. Met your children’s needs for physical affection and
emotional support (for example, giving them hugs, being
sympathetic to their problems).
e. Been able to successfully manage your child(ren)’s
unique challenges (for example, effectively disciplining
children).
Q25 How dissatisfied or satisfied are you with…
Extremely
dissatisfied
0
Extremely
satisfied
Neither
1
2
3
4
5
6
7
8
9
10
a. Your physical health (the health of
your body)?
b. How well you care for yourself, for
example, preparing meals, bathing, or
shopping?
c. How well you think and remember?
d. The amount of walking you do?
e. How often you get outside the house,
for example, going into town, using
public transportation, or driving?
f. How well you carry on a conversation,
for example, speaking clearly, hearing
others, or being understood?
g. The kind and amount of food you eat?
h. How often you see or talk to your
family and friends?
Light Survey - Time 3 (F)
10
(continued)
Extremely
dissatisfied
0
Extremely
satisfied
Neither
1
2
3
4
5
6
7
8
9
10
i. The help you get from your family and
friends, for example, helping in an
emergency, fixing your house, or doing
errands?
j. The help you give to your family and
friends?
k. Your contributions to your community,
for example, a neighborhood, religious,
political or other group?
l. Your work situation, for example, your
current job, retirement for any reason, or
never having worked?
m. The kind and amount of recreation or
leisure you have?
n. Your level of sexual activity or lack of
sexual activity?
o. The way your income meets your
needs?
p. How respected you are by others?
q. The meaning and purpose of your
life?
r. The amount of variety in your life?
s. The amount and kind of sleep you
get?
Q26 How happy are you?
Extremely
unhappy
0
Extremely
happy
Neither
1
2
3
4
5
6
7
8
9
Neither
Likely or
Unlikely
Likely
10
The following questions ask about your neighborhood and community.
Q27 How likely are these things to happen in your neighborhood…
Very Unlikely
Unlikely
Very likely
a. People around here are willing to help their neighbors.
b. This is a close-knit neighborhood.
c. People in this neighborhood can be trusted.
d. People in this neighborhood generally don’t get along
with each other.
e. People in this neighborhood do not share the same
values.
Light Survey - Time 3 (F)
11
Q28 On the whole, how much do you like this neighborhood as a place to live?
Not at all
A little
Somewhat
A great deal
Q29 We are interested in how you feel about the following statements. Read each statement carefully.
Indicate how you feel about each statement.
Strongly
disagree
Disagree
Agree
Strongly
agree
a. There is a lot of graffiti in my neighborhood.
b. My neighborhood is noisy.
c. Vandalism is common in my neighborhood.
d. There are a lot of abandoned buildings in
my neighborhood.
e. My neighborhood is clean.
f. People in my neighborhood take good care of their
houses and apartments.
g. There are too many people hanging around on
the streets near my home.
h. There is a lot of crime in my neighborhood.
i. There is too much drug use in my neighborhood.
j. There is too much alcohol use in my neighborhood.
k. I’m always having trouble with my neighbors.
l. In my neighborhood, people watch out for each other.
m. My neighborhood is safe.
Q30 In the past 4 months, how often have you
heard gunshots associated with crime or
violence in your neighborhood?
Q32 How common do you think it is for people to
carry guns in the neighborhood?
Very common
Never
Somewhat common
Once or twice
Somewhat uncommon
Three to five times
Very uncommon
More than five times
Q31 How common would you say it is for people to
belong to street gangs in your neighborhood?
Very common
Somewhat common
Q33 Have you ever seen someone threatened with
a gun in the neighborhood within the last 4
months?
Yes
No
Q34 Have you ever seen someone shot with a gun
in the neighborhood within the last 4 months?
Somewhat uncommon
Yes
Very uncommon
No
Light Survey - Time 3 (F)
12
Q35 If a fight were to break out near your home,
how likely is it that your neighbors would
attempt to break it up?
The following questions ask about your
health.
Q40
Very likely
During the past month, what time have you
usually gone to bed at night (hh:mm)?
Somewhat likely
:
Somewhat unlikely
Very unlikely
Q36
AM
If a fight were to break out near your home,
how likely is it that the police would be called?
PM
Q41
Very likely
During the past month, how long, has it
usually taken you to fall asleep each night?
Somewhat likely
Number of Hours:
Somewhat unlikely
Very unlikely
Number of minutes:
Q37 How safe do you feel…
Very safe
SomewhatSomewhat Very
at safe
unsafe
unsafe
a. Alone inside
your house?
b. Outside in your
neighborhood
during the day?
c. Outside in your
neighborhood at
night?
d. Walking alone
toward a group of
people that you
don’t know?
Q38
Q39
Q42
In your neighborhood, it is sometimes
necessary for people to carry guns to protect
themselves or their family.
During the past month, what time have you
usually gotten up in the morning (hh:mm)?
:
AM
PM
Q43
During the past month, how many hours of
actual sleep did you get on average each
night? (This may be different from the number
of hours you spent in bed.)
Hours of sleep per night:
Q44
How often do you exercise for 30 minutes or
more?
Daily or almost daily
Strongly agree
3 to 4 times per week
Agree
2 to 3 times per week
Disagree
1 to 2 times per week
Strongly Disagree
Fewer than once per week
In this neighborhood, it is sometimes
necessary for people to join a gang to protect
themselves or their family.
Strongly agree
Agree
Please answer the following questions
related to your current substance use. Skip
any questions that are irrelevant to you.
Q45
How many cigarettes did you smoke on an
average day in the last month (if you do not
smoke write 0)?
Disagree
Strongly disagree
Light Survey - Time 3 (F)
13
For alcohol, one drink equals:
· 4 oz. wine
· 1 wine cooler
· 12 oz. beer
· 1 cocktail with 1 oz. hard liquor
Q50a Does your marijuana use cause any
problems?
Q46
Q50b Did anyone else think your marijuana use
caused a problem?
How often do you currently have a drink
containing alcohol?
No
N/A, I do not use marijuana
Never → Go to question 50
Yes
Monthly or less
No
2-4 times a month
N/A, I do not use marijuana
2-3 times a week
4 or more times a week
Q47
Yes
How many standard drinks containing alcohol
do you have on a typical day?
1 or 2
Q51 In the past month, did you use other drugs,
other than alcohol or marijuana? If YES, how
many times in a typical week did you use, if at
all? This includes cocaine, crack, heroin, acid,
speed, ecstasy, methamphetamines, steroids,
and medicines prescribed for someone else.
3 or 4
No → Go to question 52
5 or 6
Yes
7 to 9
Times in a week:
10 or more
Q48
On average, how often do you have 5 or more
drinks on one occasion?
Q51a Does your use of drugs other than alcohol or
marijuana cause any problems?
Yes
Never
No
Less than monthly
N/A, I do not use drugs, not including alcohol
or marijuana
Monthly
Weekly
Daily or almost daily
Q51b Did anyone else think your use of drugs other
than alcohol or marijuana cause a problem?
Yes
Q49
Have you been diagnosed with alcohol abuse
or dependence in the past 4 months?
No
N/A, I do not use drugs, not including alcohol
or marijuana
No
Yes
Q50
In the past month, did you use marijuana? If
YES, how many times in a typical week?
No → Go to question 51
Yes
Times in a week:
Light Survey - Time 3 (F)
Q52
Have you been diagnosed with drug
(including prescription drugs) abuse or
dependence in the past 4 months?
No
Yes
If you are prescribed pain medication please
answer the following questions, otherwise
skip to item 54.
14
Q53 In the past 4 months…
Never
Rarely
Sometimes
Often
Almost
Always
Not at all
A little bit
Somewhat
Quite a bit
Very much
a. I abused prescription pain medication.
b. I ran out of my prescription pain medication early.
c. I got prescription pain medication from someone other
than my healthcare provider.
d. I used more of my prescription pain medication than I
was supposed to.
e. I experienced cravings for pain medication.
f. I used more pain medication before the effects wore
off.
Q53a In the past 4 months…
When my prescription for pain medication ran out, I felt
anxious
The following questions are about food and eating behavior.
Q54
Please answer yes or no to the following questions:
No
Yes
a. Do you make yourself sick because you feel uncomfortably full?
b. Do you worry that you have lost control over how much you eat?
c. Have you recently lost more than 14 lbs in a 3-month period?
d. Do you believe yourself to be fat when others say you are too thin?
e. Would you say that food dominates your life?
Q55
What is your current weight (if you are currently pregnant please put your pre-pregnancy weight)?
lbs
Q56
Have you ever experienced any of the
following events in the past 4 months?
Select all that apply.
Blast or explosion (IED, RPG, Landmine,
Grenade, etc)
Vehicular accident/crash (any vehicle
including aircraft)
Fragment wound or bullet wound above the
shoulders
Fall
Blow to the head (head hit by falling/flying
object, head hit by another person, head hit
against something, etc)
Strangulation
Q56a Did you have any of these immediately after
any of the events in Q56? Select all that
apply.
Losing consciousness/”knocked out”
Being dazed, confused, or “seeing stars”
Not remembering the event
Concussion
Head injury that resulted in broken bones in
head, neck, face, damaged teeth, or ruptured
eardrum
None of the above
Shaken violently
None of the above → Go to question 57
Light Survey - Time 3 (F)
15
Q56b Did any of the following problems begin or get
worse afterwards? Select all that apply.
Q58b How many live or stillborn births have you had
in the past 4 months?
Memory problems or lapses
Balance problems or dizziness
Sensitivity to bright light
Irritability
Headaches
Q58c Did you have any pregnancies that did NOT
lead to a birth, either live or stillborn, such as
an abortion or miscarriage in the past 4
months? If YES, how many?
Sleep problems
No
None of the above
Yes
Q56c In the past week, have you had any of the
symptoms from question 56? Select all that
apply.
Memory problems or lapses
Balance problems or dizziness
Number of abortions:
Number of miscarriages:
Q58d Did you have an ectopic/tubal pregnancy in
the past 4 months?
Sensitivity to bright light
No
Irritability
Yes
Headaches
Sleep problems
None of the above
Q57
Have you been diagnosed with any new
medical conditions in the past 4 months?
If you gave birth (live or stillborn) in the past 4
months, please answer the following questions.
If you are currently pregnant, please skip to Q61a
If you are not currently pregnant, and did not
give birth in the past 4 months, please skip to
Q60
Yes
No
If yes, please specify the condition(s):
Q59a What month and year did you become
pregnant?
Month
Q58
Were you pregnant at any point in the past 4
months or are you currently pregnant?
Please include live births, stillbirths,
miscarriages, induced abortions, and tubal
and other ectopic pregnancies.
No à
Skip to question 60
Yes, I was pregnant but am not currently
Yes, I am currently pregnant
Q58a How many times have you been pregnant in
the past 4 months? Please include live
births, stillbirths, miscarriages, induced
abortions, and tubal and other ectopic
pregnancies.
Year
Q59b Did your pregnancy lead to (Select all that
apply). Do not include current pregnancies.
Live birth
Stillborn
Twins/Triplets
Other
Q59c Was this pregnancy planned? Do not include
current pregnancies.
Yes
No
Do not remember
Light Survey - Time 3 (F)
16
Q59d If planned, how long did it take you to get
pregnant? Do not include current
pregnancies.
Q59h What kind of delivery did you have? Do not
include current pregnancies.
Vaginal (spontaneous)
Vaginal (induced)
Months
Planned c-section
Emergency c-section
Q59e Did you see a doctor regularly during your
pregnancy? Do not include current
pregnancies.
Non-emergency c-section
NA
Yes
No
Q59f Did you have any of the following medical
conditions during your pregnancy? Select all
that apply. Do not include current
pregnancies.
No conditions
High blood pressure
Q59i How many weeks did the pregnancy last? Do
not include current pregnancies.
Weeks
Q59j What was the birth weight of the baby? Do
not include current pregnancies.
Gestational diabetes
Lbs
Sexually transmitted disease
Oz
/
Depression and/or anxiety
Other
Q59g Did you use any of the following substances
and/or medications during this pregnancy?
Select all that apply. Do not include current
pregnancies.
Q59k Were you prescribed pain medication after
this pregnancy? Do not include current
pregnancies.
Yes
No
None
Prenatal Vitamins
Cigarettes
Alcohol
Opioid pain medication
Q59l Did you suffer from postpartum depression
and/or anxiety after this pregnancy? Do not
include current pregnancies.
Other non-prescribed substance(s)
Yes
Other prescribed substance(s)
No
The following questions are about family planning.
Q60
Are you currently trying to get pregnant?
No, I’m not trying and I’m not pregnant à skip to question 62
No, I’m already pregnant à skip to question 61a
Yes à continue with 60a and 60b on next page
Light Survey - Time 3 (F)
17
Q60a If YES, how many months have you been trying to become pregnant?
Q60b If you have been trying for 12 months or longer, has a doctor identified any of the following reasons for
your difficulties in becoming pregnant? Select all that apply.
I have been trying for less than 12 months
I did not see a doctor for this problem
No reason identified
Cervical factor
Tubal factor
Ovulation factor
Semen or sperm factor
Hormonal factor
Other
Please answer the following questions about your current pregnancy. If you are not pregnant,
please skip to question 62.
Q61a How many weeks pregnant are you?
Q61d Are you using any of the following substances
and/or medications during this pregnancy?
None
Prenatal Vitamins
Q61b Was this pregnancy planned?
Cigarettes
No
Alcohol
Yes
Opioid pain medication
Other non-prescribed substance(s)
If planned, how many months have you
been trying to become pregnant?
Q61c Do you have any of the following medical
conditions during this pregnancy? Select all
that apply.
No Conditions
High blood pressure
Other prescribed substance(s)
Q61e Are you seeing a doctor regularly during your
pregnancy?
Yes
No
Gestational diabetes
Sexually transmitted disease
Depression and/or Anxiety
Other
Light Survey - Time 3 (F)
18
Q62 Within the past 4 months, have you ever
been diagnosed or do you suffer with (Select all
that apply):
Q63b If YES, did you have a colposcopy with
cervical biopsies or a procedure to remove
cervical tissue known as LEEP?
Fibroids in womb
Yes
Chronic pelvic pain
No
Polycystic Ovary Syndrome or PCO/PCOS
Not sure
Pelvic Inflammatory Disease
None
Q63 During the past four months, have you had a
Pap smear?
Yes
Q64
Did you see an OB/GYN or gynecologist
during the past 4 months?
Yes
No
No
Q63a If YES, were you told you that you had an
abnormal Pap smear?
Q64a If YES, did you use a VA provider for this
care?
Yes
Yes
No
No
The following questions ask about your use of healthcare and thoughts about mental health
treatment.
Q65
Do you get any healthcare (physical and/or
mental health) at Veterans’ Administration
(VA) hospitals or clinics within the past 4
months?
Yes → Go to question 66
No
Q65a If NO, why not?
Not eligible
Distance to VA facilities/transportation
concerns
My VA does not provide the services I need.
I don’t feel comfortable seeking services at
the VA.
Preference for my current healthcare
providers
Other (please specify):
Q67 I think that I might benefit from mental health
treatment.
True
False
Q68 Are you currently receiving mental health
services (for example, seeing a therapist,
counselor, or medications) to help with
distress?
Yes → Go to question 69
No
Q68a If NO, what prevents you from seeking mental
health treatment? Select all that apply.
Concern for job security
Judgment from others
Distance/transportation to mental healthcare
providers
Don’t think it will help me
Q66 I think that I am suffering from mental health
problems (for example, feeling anxious
depressed, or too angry).
True
No insurance coverage
I don't need mental health treatment
Other (please specify):
False
Light Survey - Time 3 (F)
19
Q69
If I thought that I were suffering from serious depression, anxiety, anger, or fear, I would seek
assistance from (Select all that apply):
Good female friends
Good male friends
Spouse or intimate partner
Family member (brother, sister, mother, father, etc.)
Coworker
Religious leader (e.g. pastor, priest, rabbi)
Medical doctor (primary care doctor)
Therapist or counselor
Information on the internet
Self-help books or magazine articles
Other (please specify):
Q70 We are interested in your use of mental health services in the past 4 months. If you received any
help (even if it was only once or for a little while), please mark where you received this help. Mark
the no column only if you did not receive any of that type of help in the past 4 months.
No, I did not
get this kind
of help
Yes, from
a VA provider
Yes, from a
community
(non-VA)
provider
Yes, from both
a VA and a
community
provider
a. Medication for a mental health problem (e.g., an
antidepressant)
b. Individual counseling or therapy for a mental health
program
c. Group counseling or therapy for a mental health
problem
d. Family therapy
e. Inpatient or partial hospitalization program for a mental
health problem
f. Another type of mental health treatment (please
specify):
Q71
If you felt as though you needed mental health treatment, do you feel your health care provider could
get it for you?
Yes
No
N/A
Light Survey - Time 3 (F)
20
Q72
If you have received any mental health treatments within the past 4 months, how satisfied were you
with the care you received?
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
N/A
Q73
If you have received any mental health treatments within the past 4 months, how helpful was this
care in reducing your distress?
Not at all helpful
Slightly helpful
Moderately helpful
Very helpful
Extremely helpful
N/A
Q74
If you have received any mental health treatments within the past 4 months, how difficult was it to find
a therapist and schedule your mental health appointments?
Very difficult
Difficult
Moderately difficult
Neutral
Easy
Very easy
N/A
Q75
Please indicate how many times you have done each of these things to someone else in the past
4 months.
Once
Twice
Not in the
past 4
months,
but it did This has
More than happen
never
3-5 times 6-10 times 11-20 times 20 times
before
happened
a. I insulted, swore, shouted
or yelled at someone.
b. I pushed, shoved, or
slapped someone.
c. I punched, kicked, or beatup someone.
d. I destroyed something
belonging to someone else or
threatened to hit someone.
Light Survey - Time 3 (F)
21
Q76
You will be asked to describe how you typically think about negative experiences or problems.
Please read the following statements and rate the extent to which they apply to you when you
think about negative experiences or problems.
Never
Rarely
Sometimes
Often
Almost
Always
a. The same thoughts keep going through my mind again and
again.
b. Thoughts intrude into my mind.
c. I can’t stop dwelling on them.
d. I think about many problems without solving any of them.
e. I can’t do anything else while thinking about my problems.
f. My thoughts repeat themselves.
g. Thoughts come to my mind without me wanting them to.
h. I get stuck on certain issues and can’t move on.
i. I keep asking myself questions without finding an answer.
j. My thoughts prevent me from focusing on other things.
k. I keep thinking about the same issue all the time.
l. Thoughts just pop into my mind.
m. I feel driven to continue dwelling on the same issue.
n. My thoughts are not much help to me.
o. My thoughts take up all my attention.
Q77
Below are ten statements about yourself which may or may not be true. Please mark one answer
for each item.
Not at all True
Barely True
Moderately True Exactly True
a. I can always manage to solve difficult problems if I
try hard enough.
b. If someone opposes me, I can find means and ways
to get what I want.
c. It is easy for me to stick to my aims and accomplish
my goals.
d. I am confident that I could deal efficiently with
unexpected events.
e. Thanks to my resourcefulness, I know how to handle
unforeseen situations.
f. I can solve most problems if I invest the necessary
effort.
g. I can remain calm when facing difficulties because I
can rely on my coping abilities.
h. When I am confronted with a problem, I can usually
find several solutions.
i. If I am in a bind, I can usually think of something to
do.
j. No matter what comes my way, I’m usually able to
handle it.
Light Survey - Time 3 (F)
22
The next set of questions asks you about your current support system and coping
strategies.
Q78
We are interested in how you feel about the following statements. Read each statement
carefully. Indicate how you feel about each statement.
Very
strongly
disagree
Strongly
disagree
Mildly
disagree
Neutral
Mildly
agree
Strongly
agree
Very
strongly
agree
a. There is a special person who is around
when I am in need.
b. There is a special person with whom I can
share my joys and sorrows.
c. My family really tries to help me.
d. I get the emotional help and support I
need from my family.
e. I have a special person who is a real
source of comfort to me.
f. My friends really try to help me.
g. I can count on my friends when things go
wrong.
h. I can talk about my problems with my
family.
i. I have friends with whom I can share my
joys and sorrows.
j. There is a special person in my life who
cares about my feelings.
k. My family is willing to help me make
decisions.
l. I can talk about my problems with my
friends.
Q79 In your day-to-day life, how often are you treated unfairly because of such things as your race, ethnicity,
gender, age, religion, physical appearance, sexual orientation, or other characteristics?
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
Q80
In dealing with these day-to-day experiences, how often do you...
Almost
every day
At least
once a
week
A few
times a
month
A few
times a
year
Less than
once a
year
Never
a. Try to prepare for possible insults from other
people before leaving home.
b.Feel that you always have to be very careful about
your appearance (to get good service or avoid being
harassed).
c. Carefully watch what you say and how you say it.
d. Try to avoid certain social situations and places.
Light Survey - Time 3 (F)
23
Q81
How did you respond to this/these experience(s)?
No
Yes
a. Tried to do something about it.
b. Accepted it as a fact of life.
c. Worked harder to prove them wrong.
d. Realized that you brought it on yourself.
e. Talked to someone about how you were feeling.
f. Expressed anger or got mad.
g. Prayed about the situation.
Q82
Overall, how much have these experiences interfered with you having a full and productive life?
A lot
Some
A little
Not at all
Q83
Overall, how much harder has your life been because of these experiences?
A lot
Some
A little
Not at all
Q84
Overall, how stressful are these experiences for you?
A lot
Some
A little
Not at all
THANK YOU FOR YOUR CONTINUED PARTICIPATION IN THIS SURVEY.
PLEASE RETURN YOUR SURVEY IN THE ENCLOSED ENVELOPE.
ONCE WE RECEIVE THE SURVEY, $20 WILL BE MAILED TO YOU.
Light Survey - Time 3 (F)
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| File Type | application/pdf |
| File Modified | 2019-06-28 |
| File Created | 2019-06-14 |