Form 1 BYOMM KAB

OMB Control Number: 0925-0648

Expiration Date: 05/31/2021

Thank you for taking part in today’s event. Please take a few minutes to complete a brief
assessment about the impact of this Brother, You’re on My Mind activity.
1) Date _________________
2) Location (city, state) __________________________
3) Omega chapter ____________________
4) What is your age?
 Under 18 years
 18 to 24 years
 25 to 34 years
 35 to 44 years

 45 to 54 years
 55 to 64 years
 Age 65 or older

5) What is your sex?
 Male
 Female
6) Are you Hispanic, Latino, or of Spanish origin?
 Yes
 No
7) What is your race? (check all that apply)
 Black or African American
 White (e.g., European, Middle Eastern, North African)
 American Indian or Alaska Native
 Asian (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese)
 Native Hawaiian or Other Pacific Islander

Measuring knowledge
Please evaluate each statement per the following scale:
Strongly Agree = 1
Neutral = 3
Agree = 2
Disagree = 4
Strongly Disagree = 5
BEFORE today’s event,

9.

I believed mental illness was often confused with effects of
drug abuse.

10. I believed mental illness was caused by something biological.
11. I believed most people with depression could get better with
treatment.
12. I believed men displayed signs of depression more often
through anger and irritation.
13. If any of my relatives or friends had a mental illness, I would
have told them not to tell anyone.
14. I believed only people who were weak or overly sensitive let
mental illness affect them.
15. I would not have told anyone if I had depression.
16. I believed it was a good idea to avoid any discussion of
mental illness.

Strongly
Agree
1

Agree
2

Neutral
3

Disagree
4

Strongly
Disagree
5

Strongly
Agree
1

Agree
2

Neutral
3

Disagree
4

Strongly
Disagree
5

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AFTER today’s event,

17. I believe mental illness is often confused with effects of
drug abuse.
18. I believe mental illness is caused by something biological.
19. I believe most people with depression can get better
with treatment.
20. I believe men display signs of depression more often through
anger and irritation.
21. If any of my relatives or friends had a mental illness, I would
tell them not to tell anyone.
22. I believe only people who are weak or overly sensitive let
mental illness affect them.
23. I would not tell anyone if I had depression.
24. I believe it is a good idea to avoid any discussion of
mental illness.

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