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Attachment
Page
Attachment A – Household Roster .....................................................................................4
Attachment B – Household Roster PAPI Instrument ..........................................................19
Attachment C – Household Screening Instrument .............................................................24
Attachment D – Household Screening PAPI Instrument ....................................................91
Attachment E – Clinical Interview .......................................................................................104
MDPS Clinical Interview (non-SCID) ........................................................................105
Medication Showcard for use with the MDPS Clinical Interview ...........................186
Income Showcard for use with the MDPS Clinical Interview .................................187
Structured Clinical Interview for DSM-IV (SCID) .....................................................188
SCID for Prison Inmates ..........................................................................................257
Short Blessed Test ...................................................................................................309
Attachment G – Informed Consent Forms..........................................................................311
Screening Survey Informed Consent.......................................................................312
Household Consent to Participate ..........................................................................315
Hospital Volunteers Consent to Participate ...........................................................319
Jail Volunteers .........................................................................................................323
Prisoner Volunteers Consent to Participate ...........................................................326
Shelter Volunteers Consent to Participate .............................................................330
Proxy Consent to Participate ..................................................................................334
Attachment H – Household Respondent Materials ............................................................338
Roster Mailing 1 Lead Letter ...................................................................................339
Roster Mailing 2 Pressure Seal Self-Mailer .............................................................340
Roster Mailing 3 Postcard 1 ....................................................................................342
Roster Mailing 4 Reminder Letter...........................................................................343
i
Roster Mailing 5 Paper Reminder Letter ................................................................344
Roster Mailing 6 Postcard 2 ....................................................................................345
Roster Mailing 7 Final Pressure Seal Self-Mailer ....................................................346
Screener Mailing 1 Lead Letter ...............................................................................348
Screener Mailing 2 Pressure Seal Self-Mailer .........................................................349
Screener Mailing 3 Reminder Letter .......................................................................351
Screener Mailing 4 Follow-up Reminder Letter ......................................................352
Screener Mailing 5 Final Postcard...........................................................................353
Screener Mailing 6 Final Pressure Seal Self-Mailer ................................................354
Screener Reminder Emails ......................................................................................355
Screener Notification Card......................................................................................360
Clinical Interview Scheduling Script ........................................................................361
Clinical Interview Appointment Emails & Letters ...................................................365
Clinical Interview Follow-Up Letter ........................................................................372
Clinical Interview Recontact Letter (Screener CI Reluctance) ................................373
Letters (Unable to Contact, Controlled Access, Call Me, Reluctance) ....................374
Automated Emails: New, Rescheduled, Canceled, Missed Appointments ............383
Texts ........................................................................................................................385
Unable to Contact Text ...........................................................................................386
Website Content .....................................................................................................387
COVID Risk Form Vaccinated Protocol A ................................................................393
COVID Risk Form Unvaccinated Protocol B ............................................................395
Incentive/Thank You E-mail (Roster, Screener, CI) .................................................397
Incentive Receipt In-person ....................................................................................398
Brochure Text..........................................................................................................399
FAQs ........................................................................................................................401
Field and Clinical Interviewer Authorization Letter ................................................405
ii
Attachment I – Nonhousehold Facility Materials ...............................................................406
Recruitment Commencement Letter State DOCs...................................................407
Recruitment Commencement Letter Combined ....................................................408
National Organizations Letter of Support Combined .............................................410
SAMHSA NSMH Letter of Support ..........................................................................411
NSMH 1-page study description .............................................................................412
Recruitment Commencement Letter Follow-up Email ...........................................413
Letter to Facility POC ..............................................................................................414
NSMH FAQs Facility Staff ........................................................................................416
Summary of Clinical Interview Questionnaire Nonhousehold ...............................419
SAMHSA NSMH Thank You Letter...........................................................................421
Attachment J – Nonhousehold Respondent Materials.......................................................422
NSMH FAQs Respondents .......................................................................................423
Contact Cards ..........................................................................................................424
Shelter Flyer ............................................................................................................425
Shelter Flyer No Incentive .......................................................................................426
Jail Flyer...................................................................................................................428
Jail Contact Card......................................................................................................429
COVID Risk Form Nonhousehold ............................................................................430
iii
Attachment A
Household Roster
1) Household Roster Specifications
NSMH Roster Specifications
MODE = WEB, PHONE, OR IN-PERSON
PROGRAMMER NOTE: FOR WEB, INCLUDE “Not sure” AND “Prefer not to answer” AS RESPONSE
OPTIONS IF A RESPONDENT MOVES FORWARD WITHOUT SELECTING AN ANSWER. FOR PHONE AND
IN-PERSON, INCLUDE DK AND REF ON ALL QUESTIONS.
** INDICATES THAT RESPONSE OPTIONS SHOULD BE IN ALL CAPS FOR INTERVIEWER ADMINISTERED
MODES.
*** INDICATES THAT TEXT SHOULD BE IN ALL CAPS FOR INBOUND CATI ONLY
STUDY INTRO [IF WEB] RTI International, an independent nonprofit research institute, is conducting a
nationwide study sponsored by the Substance Abuse and Mental Health Services
Administration. You should have received a letter explaining the study.
***[IF PHONE] Hello, my name is [FI NAME], and I’m calling from RTI International, an
independent nonprofit research institute. We are conducting a nationwide study
sponsored by the Substance Abuse and Mental Health Services Administration. You
should have received a letter explaining the study.
[IF IN-PERSON] Hello, my name is [FI NAME] with RTI International in North Carolina.
We are conducting a nationwide study sponsored by the Substance Abuse and Mental
Health Services Administration. You should have received a letter explaining the study.
R1
[IF WEB] Would you prefer to respond in English or Spanish?
English
Spanish [SWITCH TO SPANISH TRANSLATION IF SELECTED]
**R2
First, to verify, do you receive mail at [ADDRESS FILL]?
1
YES
2
NO
R2a
[IF R2 = NO] We need to speak to a resident of this address. Thank you for your time.
END ROSTER
EDITAD [IF CITY_STYLE_ADDRESS = 0] What is the physical address, including zip code, for this property?
STREET: (NUMBER AND STREET NAME)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
1
PROGRAMMER NOTE: EDITAD REPLACES ADDRESSFILL IF EDITAD IS NOT BLANK OR DK OR REF;
IF ANY FIELD IN EDITAD = DK/REF, ADDRESSFILL = “this address”;
ADDRESSFILL1 STORES THE ORIGINAL MAILING ADDRESS.
PROGRAMMER NOTE: ALLOW FOR FOR D.C.
R3
[IF R2 = YES OR CITY_STYLE_ADDRESS = 0] How old are you?
_______ Years old (RANGE 1-110)
POP UP: [IF WEB AND R3 < 18] These questions must be answered by someone aged 18 or older. Please
ask an adult to complete these questions. CLOSE [BACK TO R3]
[IF (PHONE OR IN-PERSON) AND R3 < 18] These questions must be answered by someone aged
18 or older. Is there someone who lives here and is over 18 years old available? CLOSE [BACK TO STUDY
INTRO]
**CARI [IF PHONE] This call may be recorded for quality assurance purposes.
[IF IN-PERSON] I am recording part of this interview so my supervisor can make sure I am
following the correct procedures. The recording will be kept private and will be deleted after my
work has been reviewed. If you don’t want me to record the interview I will stop the recording.
We can still do the interview even if you don’t want it to be recorded.
May we record part of the interview?
1
2
**R4
YES
NO
[IF (WEB OR PHONE) AND R3 ≥ 18] Your address is one of 60,000 in the United States randomly
chosen for the National Study of Mental Health. This study, sponsored by the Substance Abuse
and Mental Health Services Administration, collects information for research and program
planning by asking about:
•
Mental health;
•
health behaviors;
•
access to, and use of, medical care or treatment; and
•
tobacco, alcohol, and drug use or non-use.
If you answer a brief set of questions about the people who live here, you will receive a $10
electronic pre-paid Visa or check. And, if there are people in the household who are eligible,
they will be paid $20 to complete a 15-minute screening survey. Your answers will be used for
statistical purposes only and your participation is voluntary.
[IF IN-PERSON AND R3 ≥ 18] Your address is one of 60,000 in the United States randomly chosen
for the National Study of Mental Health. This study, sponsored by the Substance Abuse and
Mental Health Services Administration, collects information for research and program planning
by asking about:
•
Mental health;
2
•
•
•
health behaviors;
access to, and use of, medical care or treatment; and
tobacco, alcohol, and drug use or non-use.
If you answer a brief set of questions about the people who live here, you will receive $10 in
cash. And, if there are people in the household who are eligible, they will be paid $20 to
complete a 15-minute screening survey. Your answers will be used for statistical purposes only
and your participation is voluntary.
**GQU Does anyone not related to you live at [ADDRESS FILL OR] to receive help or support for:
•
•
•
•
•
Developmental disabilities
Physical disabilities
Mental health issues
Substance use issues
Elder care
1
2
YES
NO
**R5
[IF R4 = NEXT] To begin, do you or anyone else in this household consider this to be your or their
primary residence? In other words, is this the address where you or they receive mail?
1
YES
2
NO
R5a
[IF R5 = NO] This needs to be a primary residence to participate. Thank you for your time.
END ROSTER
R6
[IF R3 ≥ 18] Including yourself, how many people consider [ADDRESS FILL] their primary
residence?
• Do include students who live in on-campus housing while at school.
• Do not include anyone who lives most of their time somewhere else even if they are
currently staying here.
_______ # of people, including yourself (RANGE 1-20)
R6a
[IF WEB AND GQU = 0 AND R6 > 8] Thank you for answering these questions. We are unable to
complete this portion of the survey online. Please call 877-267-2910 to complete these
questions or an interviewer will follow up with your household in person.
[EXIT]
PROGRAMMER NOTE: IF WEB AND isGQU = 1 AND R6 > 8, CONTINUE WITH ROSTER. ALLOW UP TO 20
HH MEMBERS TO BE ROSTERED.
R6b
[IF R6 = DK OR REF] We need to know how many people consider this their primary residence to
continue. Thank you for your time.
3
END ROSTER
PROGRAMMER: IF RECORDING CONSENT = YES, STOP RECORDING
R7
[IF R6 > 1]
Of these [R6 FILL] people, how many are now ages 18 and older?
_______ # of adults, including yourself (RANGE 0-R6 FILL)
R7a
[IF R6 > R7]
Of these [R6 – R7] people, how many are ages 12 to 17 years old?
_______ # of children 12 to 17 years old (RANGE 0-(R6-R7))
R7b
[IF R7 = DK OR REF] We need to know how many people at this residence are ages 18 and older
to continue. Thank you for your time.
END ROSTER
R17
[IF R7 ≥ 1]
Is [ADDRESS FILL] …
Owned by you or someone else in this household?
Rented by you or someone else in this household?
Owned or managed by a third party, such as a college dorm or nursing home?
Occupied without payment of rent?
PROGRAMMER NOTE: IF WEB AND R17 = BLANK, SHOW ERROR MESSAGE: This question is important
for classification purposes. Please try to answer if you can. Otherwise select 'Not sure' or 'Prefer
not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND R17 = BLANK, SHOW ERROR MESSAGE: This
question is important for classification purposes. Please try to answer if you can.
R8
[IF R7 > 1]
Next are a few questions about the people who live here. Let’s start with you.
[IF R7 ≥ 1]
What is your first name?
OPEN ENDED RESPONSE
NEXT
DEFINE RRNAMEFILL
RRNAMEFILL = R8
IF R8 = DK/REF, NAMEFILL = you
**R9
[IF R7 ≥ 1]
What is your sex?
Male
Female
4
R11
[IF R7 = 2]
Now we need some general information about the other person in this
household who is age 18 or older.
What is the first name of the other person in this household who is age 18 or older? This
information will only be used to contact this person if they are selected for a screening survey.
OPEN ENDED RESPONSE
[IF R7 > 2]
Now we need some general information about all of the other people in this
household who are ages 18 and older. Let's start with the oldest and work down to the
youngest, not including yourself.
What is the first name of the [oldest/next oldest] person in this household who is age 18 or
older, not including yourself? This information will only be used to contact this person if they are
selected for a screening survey.
OPEN ENDED RESPONSE
DEFINE NAMEFILL
NAMEFILL = R11
IF R11 = DK/REF, NAMEFILL = person # [FILL ROSTER NUMBER]
R11a
[IF R11 NE BLANK] How old is [NAMEFILL]?
______ Years old
**R12 [IF R7 > 1]
What is [NAMEFILL]’s sex?
Male
Female
PROGRAMMER NOTE: [IF WEB] REPEAT R11 THROUGH R12 FOR ALL ROSTER MEMBERS. ONLY INCLUDE
INTRO STATEMENT IN R11 FOR FIRST ROSTER MEMBER.
**R14 [IF WEB AND R7 > 0 AND NO ONE ELSE TO ROSTER] These are the people listed as ages 18 and
older living at [ADDRESS FILL]. Please review this information.
[IF (PHONE OR IN-PERSON) AND R7 > 1 AND NO ONE ELSE TO ROSTER: REVIEW INFORMATION
WITH RESPONDENT AND DETERMINE IF CORRECTIONS NEED TO BE MADE.]
Is this correct?
YES
NO
LIST NAMEFILL, AGE, AND SEX FOR EACH ROSTER MEMBER
5
R14a
[IF WEB AND R14 = NO] Please make any corrections below. To remove a person, delete their
first name. To add a new person, enter the new information in the bottom row.
[IF (PHONE OR IN-PERSON) AND R14=NO] (What needs to be corrected?)
INTERVIEWER: MAKE APPROPRIATE CHANGES
LIST NAMEFILL, AGE, AND SEX FOR EACH ROSTER MEMBER IN EDITABLE TABLE
R15
[IF WEB AND R7 = 1]
Below is a list of health conditions. Have you ever been told by a doctor
or other health care professional that you had any of these conditions?
[IF WEB AND R7 > 1] Below is a list of health conditions. Have any of these household
members ever been told by a doctor or other health care professional that they had any of
these conditions?
[IF (PHONE OR IN-PERSON) AND R7 = 1] Have you ever been told by a doctor or other health
care professional that you had any of the following conditions?
[IF (PHONE OR IN-PERSON) AND R7 > 1] Have any of these household members ever been told
by a doctor or other health care professional that they had any of the following conditions?
Condition
Diabetes?
Heart problems?
Cancer?
Schizophrenia or schizoaffective disorder?
Other problems with emotions, nerves or mental
health?
Problems with alcohol or drugs?
YES
NO
Not
Sure
1
1
1
1
1
2
2
2
2
2
8
8
8
8
8
Prefer
Not to
Answer
9
9
9
9
9
1
2
8
9
Next [START SELECTION]
R18
[IF ONE SELECTED] Thank you for your help. The following household member is eligible to
participate in a short screening survey.
Each person who participates will receive $20 at the end of their screening survey.
RRNAMEFILL (You) OR NAMEFILL
SELECTIONS
AGE
SEX
[IF TWO SELECTED] Thank you for your help. The following household members are eligible to
participate in a short screening survey.
6
Each person who participates will receive $20 at the end of their screening survey.
RRNAMEFILL (You) OR NAMEFILL
SELECTIONS
AGE
SEX
[IF NO ONE SELECTED] Thank you for providing your household listing. No one in your
household was selected to complete a screening survey.
R19a
[IF IN-PERSON] Now we need some contact information so we can complete the screening
survey.
R19
[IF (WEB OR IN-PERSON) AND ((ONE SELECTED BUT NOT RR) OR TWO SELECTED)] Please enter
[NAMEFILL]’s phone number and email address so that we can contact [him/her] about this
upcoming screening survey.
[IF PHONE AND ((ONE SELECTED BUT NOT RR) OR TWO SELECTED)] What is [NAMEFILL]’s phone
number and email address so that we can contact [him/her] about this upcoming screening
survey.
Phone Number:
OPEN ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO PROMPT
USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:
OPEN ENDED RESPONSE OPTION
Confirm Email Address:
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF TWO SELECTED INCLUDING RR USE NON-RR FILLS FOR R19
PROGRAMMER NOTE: IF WEB AND R19 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please enter their
contact information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R19 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please try to
answer if you can.
**R20 [IF (ONE SELECTED BUT NOT RR) OR TWO SELECTED] Generally, what are good days and times in
the next few weeks for an interviewer to contact [NAMEFILL] to conduct the screening survey?
CHECK ALL THAT APPLY
Day:
Time of Day:
7
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No Preference
Other times
Morning
Afternoon
Evening
No Preference
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
**R20b [IF (ONE SELECTED BUT NOT RR) OR TWO SELECTED] In which time zone does [NAMEFILL] live?
1
2
3
4
5
6
Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii-Aleutian Time
DK/REF
**R21 [IF (ONE SELECTED BUT NOT RR) OR TWO SELECTED] Does [NAMEFILL] currently stay at
[ADDRESS FILL] or is [he/she] staying somewhere else, like in a college dorm or other temporary
housing?
Staying at [ADDRESS FILL]
Staying somewhere else
R22
[IF (WEB OR IN-PERSON) AND TWO SELECTED BUT NOT RR] Please enter [NAMEFILL]’s phone
number and email address so that we can contact [him/her] about this screening survey.
[IF PHONE AND TWO SELECTED BUT NOT RR] What is [NAMEFILL]’s phone number and email
address so that we can contact [him/her] about this upcoming screening survey.
Phone Number:
OPEN ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO PROMPT
USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:
OPEN ENDED RESPONSE OPTION
Confirm Email Address:
OPEN ENDED RESPONSE OPTION
8
PROGRAMMER NOTE: IF WEB AND R22 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please enter their
contact information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R22 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please try to
answer if you can.
PROGRAMMER NOTE: IF WEB and EMAIL IN R22 IS THE SAME AS EMAIL IN R19, SHOW ERROR
MESSAGE: This information is important so we can contact you about the next survey in this
study. Please enter your own, unique email address. If you do not have your own email address,
please be sure to enter an accurate phone number.
IF (PHONE OR IN-PERSON) AND EMAIL IN R22 IS THE SAME AS EMAIL IN R19, SHOW ERROR
MESSAGE: This information is important so we can contact you about the next survey in this
study. Please provide your own, unique email address if you can.
**R23 [IF TWO SELECTED BUT NOT RR] Generally, what are good days and times in the next few weeks
for an interviewer to contact [NAMEFILL] to conduct the screening survey?
CHECK ALL THAT APPLY
Day:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No Preference
Other times
Time of Day:
Morning
Afternoon
Evening
No Preference
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
**R23b [IF TWO SELECTED BUT NOT RR] In which time zone does [NAMEFILL] live?
1
2
3
4
5
6
Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii-Aleutian Time
DK/REF
9
**R24
[IF TWO SELECTED BUT NOT RR] Does [NAMEFILL] currently stay at [ADDRESS] or is
[he/she] staying somewhere else, like in a college dorm or other temporary housing?
Staying at [ADDRESS FILL]
Staying somewhere else
R25
[IF (WEB OR IN-PERSON) AND RR SELECTED] Please enter your first name, phone number, and
email address so that we can contact you about this upcoming screening survey.
[IF PHONE AND RR SELECTED] What is your first name, phone number, and email address so that
we can contact you about this screening survey.
First Name:
OPEN ENDED RESPONSE OPTION
Phone Number:
OPEN ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO PROMPT
USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:
OPEN ENDED RESPONSE OPTION
Confirm Email Address:
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF WEB AND R25 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact you about the next survey in this study. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND R25 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact you about the next survey in this study. Please try to answer if you
can.
PROGRAMMER NOTE: IF WEB and EMAIL IN R25 IS THE SAME AS EMAIL IN R19 OR R22, SHOW
ERROR MESSAGE: This information is important so we can contact you about the next survey in
this study. Please enter your own, unique email address. If you do not have your own email
address, please be sure to enter an accurate phone number.
IF (PHONE OR IN-PERSON) AND EMAIL IN R25 IS THE SAME AS EMAIL IN R19 OR R22, SHOW
ERROR MESSAGE: This information is important so we can contact you about the next survey in
this study. Please provide your own, unique email address if you can.
**R25a [IF RR SELECTED AND R25 PHONE NUMBER NE BLANK] Is [FILL R25 PHONE NUMBER] your
personal cell phone?
1
2
YES
NO
10
**R25b [IF R25a = YES] May we send text messages to your personal cell phone to contact you about the
upcoming screening survey?
1
YES
2
NO
**RR VERIFICATION
[IF IN-PERSON AND RR SELECTED AND R25 PHONE NUMBER NE BLANK] We may
contact you to verify the information you have given us. May we call you at
[PHONE NUMBER FILL] for that verification?
1
2
**RRSTART
YES
NO
[IF IN-PERSON AND RR SELECTED] Would you like to begin your screening survey now?
1
YES
2
NO
INTERVIEWER NOTE: CLICK NEXT TO CLOSE OUT THE CASE, THEN RETURN TO LAUNCH THE SCREENER
**R26 [IF ((WEB OR PHONE) AND RR SELECTED) OR (IN-PERSON AND RRSTART = NO)] Generally, what
are good days and times in the next few weeks for an interviewer to contact you to conduct the
screening survey?
CHECK ALL THAT APPLY
Day:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No Preference
Other times
Time of Day:
Morning
Afternoon
Evening
No Preference
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
**R26b [IF ((WEB OR PHONE) AND RR SELECTED) OR (IN-PERSON AND RRSTART = NO)] In which time
zone do you live?
1
2
3
4
5
6
Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii-Aleutian Time
DK/REF
11
VERIFICATION
[IF IN-PERSON AND RR NOT SELECTED] We may contact you to verify the
information you have given us. Please enter your first name and telephone
number so that we can contact you for this verification.
FIRST NAME:
PHONE: (Area code and phone number)
PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
PROGRAMMER: IF RECORDING CONSENT = YES, RESUME RECORDING
**R30 You can receive your payment either as an electronic pre-paid Visa or as a check . You should allow 1 to
2 weeks to receive the electronic pre-paid Visa and about 4 weeks to receive the check.
[IF WEB] How would you like to receive your incentive payment?
[IF PHONE] Would you like to receive your payment as an electronic prepaid Visa or as a check?
[IF IN-PERSON] Would you like to receive your payment as an electronic prepaid Visa, a check or
in cash?
1
2
4
Electronic pre-paid Visa. Please allow 1 to 2 weeks for processing.
Check. Please allow up to 4 weeks for processing and delivery.
3
NO, THANKS. DECLINE THE INCENTIVE.
PROGRAMMER: IF RECORDING CONSENT = YES, STOP RECORDING
R31
[IF IN-PERSON & R30 == 4] IF NOT DONE EARLIER HAND RESPONDENT $10 CASH.
1 CASH ACCEPTED
2 CASH REFUSED
I have checked a box to indicate that [you accepted/you refused] the $10 in cash for
completing this screening.
R30b [IF R30 = 1] Please provide your email address to receive the electronic pre-paid Visa.
________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
PROGRAMMER NOTE: IF WEB AND R30b = BLANK, SHOW ERROR MESSAGE: This
information is important so we can send you your incentive. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
12
IF (PHONE OR IN-PERSON) AND R30b = BLANK OR DK OR REF, SHOW ERROR MESSAGE:
THIS INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY
TO ANSWER IF YOU CAN.
R30c [IF R30 = 2] Please provide your first and last name to receive your check.
First Name:**
OPEN-ENDED RESPONSE OPTION
Last Name:**
OPEN-ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF WEB AND R30c = BLANK, SHOW ERROR MESSAGE: This
information is important so we can send you your incentive. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R30c = BLANK OR DK OR REF, SHOW ERROR MESSAGE:
THIS INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY
TO ANSWER IF YOU CAN.
**R30d
[IF R30 = 2] Would you like us to mail your check to [ADDRESS FILL] or to another
address?
1
2
Yes, mail to [ADDRESS FILL]
No, mail to another address
DK/REF
R30e
[IF R30= 2 AND R30d = 2] What address do you want us to mail the check to?
STREET: (NUMBER AND STREET NAME)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
PROGRAMMER NOTE: IF WEB AND R30e = BLANK, SHOW ERROR MESSAGE: This
information is important so we can send you your incentive. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R30e = BLANK OR DK OR REF, SHOW ERROR MESSAGE:
THIS INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY
TO ANSWER IF YOU CAN.
PROGRAMMER NOTE: ALLOW FOR FOR D.C.
**R28 [IF (WEB OR PHONE) AND RR SELECTED] Would you like to begin your screening survey now?
[IF (PHONE OR IN-PERSON) AND ONE SELECTED BUT NOT RR] Is [NAMEFILL] available for me to
speak with now?
13
YES
NO
PROGRAMMER NOTE: IF YES, BEGIN INTERVIEW.
**R29 [IF (PHONE OR IN-PERSON) AND TWO SELECTED BUT NOT RR]
available for me to speak with now?
Is [NAMEFILL] or [NAMEFILL]
[IF (PHONE AND (TWO SELECTED INCLUDING RR AND R28 = NO)) OR (IN-PERSON AND (TWO
SELECTED INCLUDING RR AND RRSTART = NO))] Is [NAMEFILL] available for me to speak with
now?
YES FOR [NAMEFILL]
YES FOR [NAMEFILL]
NO
PROGRAMMER NOTE: ALLOW ONLY ONE YES RESPONSE IN R29.
IF YES FOR EITHER, BEGIN INTERVIEW.
R30a
[IF RRSTART = NO OR R28 = NO OR R29 = NO] We will contact you soon to complete the
interview. Thank you for your time.
[IF (R28 = NO OR R29 = NO) AND ONE SELECTED BUT NOT RR] We will contact [NAMEFILL] soon
to complete the interview. Thank you for your time.
[IF (R28 = NO OR R29 = NO) AND TWO SELECTED BUT NOT RR] We will contact [NAMEFILL] and
[NAMEFILL] soon to complete the interview. Thank you for your time.
PROGRAMMER NOTE: Incentive Flags for Screener
DEFINE ROSTERINCAMOUNT
IF WEB OR PHONE, ROSTERINCAMOUNT = $10
IF IN-PERSON, ROSTERINCAMOUNT = $10
DEFINE ROSTERPAYMENTINFO
IF IN-PERSON, ROSTERPAYMENTINFO = 1
IF (WEB OR PHONE) AND R28 = YES, ROSTERPAYMENTINFO = 2
IF (WEB OR PHONE) AND R29 = ANY YES, ROSTERPAYMENTINFO = 2
IF (WEB OR PHONE) AND R30 = 3, ROSTERPAYMENTINFO = 2
IF (WEB OR PHONE) AND (R30b OR R30c OR R30d OR R30e = DK OR REF), ROSTERPAYMENTINFO = 2
ELSE, ROSTERPAYMENTINFO = 1
14
Attachment B
Household Roster PAPI Instrument
1) Paper and Pencil Household Roster
Household Membership Listing
Your address is one of 60,000 in the United States randomly chosen for the National Study of
Mental Health. This study, sponsored by Substance Abuse and Mental Health Services
Administration, collects information for research and program planning by asking about:
•
•
•
•
Mental health;
health behaviors;
access to, and use of, medical care or treatment; and
tobacco, alcohol, and drug use or non-use.
If you answer this brief set of questions about the people who live here, we would like to send
you a $10 check. And, if there are people in the household who are eligible, they will be paid $20
to complete a 15-minute screening survey. Your answers will be used for statistical purposes
only and your participation is voluntary.
Please answer this survey for the address listed below.
CITY RESIDENT
ADDRESS1
ADDRESS2
CITY, STATE ZIP
1
1
6412107753
1. Does anyone not related to you live at the
address on the cover of the survey receive
help or support for:
•
•
•
•
•
7. Next are a few questions about the people
who live here. Let’s start with you.
What is your first name?
Developmental disabilities
Physical disabilities
Mental health issues
Substance use issues
Elder care
This information will only be used if you are
selected to participate in the next survey in this
study.
First Name:
Yes
No
8. How old are you?
years old
2. Do you or anyone else in this household
consider this to be your or their primary
residence? In other words, is this the
address where you or they receive mail?
Yes
No Skip to question 17
9. What is your sex?
Male
Female
10. Do you currently stay at the address on the
cover of the survey or are you staying
somewhere else, like in a college dorm or
other temporary housing?
Staying at this address
Staying somewhere else
3. Including yourself, how many people
consider the address on the cover of the
survey their primary residence?
•
Do include students who live in oncampus housing while at school.
•
Do not include anyone who lives most of
their time somewhere else even if they are
currently staying here.
11. Please enter your phone number so that we
can contact you if you are selected for the
next survey in this study.
# of people, including yourself
−
If you entered 0, skip to question 17
-
−
-
12. Is the phone number you provided in Q11
your personal cell phone?
Yes
No Skip to question 14
4. Of the people who live here, how many are
now ages 18 and older?
# of people now age 18 and older,
including yourself
5. Of the people who live here, how many are
ages 12 to 17 years old?
13. If you are selected, may we send text
messages to your personal cell phone
to contact you about the survey?
Yes
No
# of people now age 12 to 17 years old
6. Is the address on the cover of the survey …
Owned by you or someone else in this
household?
Rented by you or someone else in this
household?
Owned or managed by a third party, such as
a college dorm or nursing home?
Occupied without payment of rent?
14. Please enter your email address so that we
can contact you if you are selected for the
next survey in this study.
2
8670107751
15. Now we need some general information about all of the other people in this household who are
ages 18 and older. Not including you, please start with the oldest and work down to the youngest.
This information will only be used to contact this person if they are selected for the next survey in this study.
First Name
Household
member 1 Phone Number:
Age
Sex
Male
Female
-
Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)
-
Email Address:
First Name
Household
member 2 Phone Number:
Age
Sex
Male
Female
-
Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)
-
Email Address:
First Name
Household
member 3 Phone Number:
Age
Sex
Male
Female
-
Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)
-
Email Address:
First Name
Household
member 4 Phone Number:
Age
Sex
Male
Female
-
Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)
-
Email Address:
First Name
Household
member 5 Phone Number:
Age
Sex
Male
Female
-
Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)
-
Email Address:
3
0788107753
16. Below is a list of health conditions. Have any of the household members you listed on the
previous page ever been told by a doctor or other health care professional that they had any of
these conditions?
Select one response per row.
Don’t
Rather
Yes
No
Know
Not Say
Diabetes?
Heart problems?
Cancer?
Schizophrenia or schizoaffective disorder?
Other problems with emotions, nerves or mental
health?
Problems with alcohol or drugs?
17. To show our appreciation for completing this short survey today, we would like to send you a $10
check. Please enter your first and last name to receive this check. Print in all CAPS.
Please allow up to 4 weeks for processing and delivery.
First Name:
Last Name:
Please return your questionnaire in the enclosed return envelope or mail it to:
NSMH
RTI International
ATTN: Data Capture
5265 Capital Boulevard
Raleigh, NC 27690
Thank you for participating in the NSMH
Household Membership Listing.
4
4
1825107756
Attachment C
Household Screening Instrument
1) MDPS Screener Specifications for Household and Jail Populations
2) CAT-MH™ Item Bank
MDPS Screening Survey Instrument
MDPS Screening Specifications
Acronyms used:
• HH = household population
• GQU = group quarters
• NHH = non-household population
• JA = jail population
• PR = prison population
• SH = state psychiatric hospital population
• HL = homeless population
Symbols used
• [] skips
• <> fills
• != = not equal
• | = OR
• ** = indicates that we need two versions of response options, i.e., one for selfadministration in “Sentence case” and one for interviewer administration in “ALL CAPS”.
GENERIC ERROR MESSAGE FOR BLANK: “If you are not sure or prefer not to answer, simply select 'Not
sure' or 'Prefer not to answer' and then click 'Next' to continue.” **
PROGRAMMER: FOR DK PLEASE DISPLAY “Not sure”** and for REF “Prefer not to answer’**; FOR PHONE
AND IN-PERSON (NOT IN-PERSON SELF-ADMINISTERED), WHERE APPLICABLE, PLEASE DISPLAY ON
SCREEN IMMEDIATELY.
Populations:
• The routing through the instruments for the different populations will be based on a
preloaded case ID which differentiates the populations.
• HH/GQU:
• Up to two randomly selected individuals in separate sessions.
• Self-completion via web, (inbound) phone with TI, or self-completion in-person with FI
(note April 2021: due to COVID, in-person will always be CASI).
• Pilot sample of 200-250 cases will only be administered the CIDI screener
• Replicate 2: Randomly assign individuals who complete on the web or in-person selfadministered (CASI) to either non-adaptive CIDI screener or to CAT-MH screener. Switch
CAT-MH to CIDI only if in-person interviewer is offline.
• JA
• JA are exempted from the screener randomization to non-adaptive CIDI screener or
CAT-MH. They will only receive the non-adaptive CIDI screener.
• Everyone in the JA population completing the screener will be invited to complete the
NetSCID – no subsampling.
• JA will not be asked for consent to the clinical interview at the end of the screener.
• Note April 2021: currently FI administration is not planned, possibly later. Older
comment: The JA where FI administered will not be via self-completion section.
1
Line #
Pop.
1. Introduction and consent
1
Variable
Name
Variable Description / Original
Variable Name
Spre
Programmer preload
instructions
CIDI or CAT-MH random
assignment
Study introduction
Screener overview
Confirmation of correct
respondent
Interview language selection
(if known: from roster)
Age
Source
2
HH, CAT-MH
Sscreen
3
4
5
HH, JA, CAT-MH
HH, CAT-MH
HH, JA, CAT-MH
Sintro
Sopen
Sconf
6
HH, CAT-MH
S1
7
HH, JA, CAT-MH
SSD1
8
9
10
11
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SSD1a
SSD1b
S3a
S3
12
HH, JA, CAT-MH
S3_int
Age verification
Age verification
Recording allowance / start
Informed consent and indepth study introduction
Interview consent
13
JA
S3_rec
Recording consent
New
14
15
16
17
HH, JA, CAT-MH
JA
JA
JA
S3b
S3c
SOL1
SOL2
New
New
NIS
NIS
18
19
30
HH, JA, CAT-MH
CAT-MH
HH, JA, CAT-MH
SFIID3
SFIID3a
SSD2
Non-consent interview end
Programmer note recording
Date admitted to this facility
Estimate when admitted to
facility
Interview administration mode
Interviewer online/offline
Sex
31
CAT-MH
SCAT1
Pregnancy / post-partum
status
32
HH, JA, CAT-MH
SSF1
General health
33
CAT-MH
CATMHIntro CAT_MH transition
2. Depression – reference period: past 12 months
34
HH, JA
SMDD1a
Dysphoria
35
HH, JA
SMDD1b
Discouragement
36
HH, JA
SMDD1c
Anhedonia
37
HH, JA
SMDD1d
Worthlessness
Note(s)
New
New
New
NSDUH
NSDUH
Redesign
NIS
NIS
New
New
New
New
New
Modified
ACS
Modified
NSDUH
SF12
In consent
document
In consent
document
Adapted to
“you”
instead of
this person
Added postpartum
CIDI
2
3. Anxiety – GAD; reference period: past 12 months
38
HH, JA
SGAD1a
39
HH, JA
SGAD1b
40
HH, JA
SGAD1c
41
HH, JA
SGAD1d
4. Mania/Hypomania – reference period: lifetime
42
HH, JA
SCI1
43
HH, JA
SCI2
5. PTSD – reference period: past 12 months
CIDI
Feeling worried/anxious
Worried about a number of
different things
Feeling more worried than
other people
Trouble controlling worry
CIDI
Episode mood higher or more
irritable y/n
Duration of longest episode
PTSD
checklist
(PCL-5)
44
HH, JA
SPC1a
45
HH, JA
SPC1b
46
HH, JA
SPC1c
47
HH, JA
SPC1d
6. Substance Abuse – reference period: past 12 months
48
HH
SAU1
Reexperiencing
Avoiding external reminders
Felt distant
Irritable behavior
How often drink/alcohol
Modified
AUDIT-C
49
HH
SAU2
How many drinks typical day
Modified
AUDIT-C
50
HH
SDA1
Definition of drug use
51
HH
SDU1
How often drugs
Modified
DAST
DUDIT
52
HH
SDU2
How often heavily influenced
by drugs
SCI3a
SCI3b
SCI3c
SCI3d
SCI3e
SCI3f
SCI3g
Seeing visions
Hearing voices
Thought insertion
Thoughts stolen
Mind control
Force communication
Conspiracy
7. Psychosis – lifetime reference period
53
HH, JA
54
HH, JA
55
HH, JA
56
HH, JA
57
HH, JA
58
HH, JA
59
HH, JA
8. Health and Health Care
DUDIT
Added
reference
period.
Added
reference
period.
Deleted
‘standard’
drinks
Added
reference
period.
Added
reference
period.
CIDI
3
60
HH, JA, CAT-MH
SH1
Health insurance
Modified
NSDUH
New
New
61
62
HH, JA, CAT-MH
HH, JA, CAT-MH
SH2
SH3
63
HH, JA, CAT-MH
SH4
64
65
HH, JA, CAT-MH
HH, JA, CAT-MH
SH5
SH6
Disability benefits
Reasons for disability mental
or physical health
Reasons for disability mental
health follow-up
Ever diagnosed with …
Height
66
HH, JA, CAT-MH
SH7
Weight
67
68
69
70
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SH8a
SH8b
SH8c
SH8d
71
HH, JA, CAT-MH
SH8e
72
HH, JA, CAT-MH
SH9
73
74
75
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
SH10
SH11
S4
COVID-19 self-diagnosed
COVID-19 tested positive
COVID-19 self-hospitalization
COVID-19 hospitalization of
someone close
COVID-19 death of someone
close
COVID-19 mental health
change
COVID-19 alcohol use change
COVID-19 drug use change
Selection mechanism
9. Socio-demographics
76
HH, JA, CAT-MH
SSD3
Marital status
Modified
ACS
77
78
79
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SSD3a
SSD4
S2
Living with partner
Ethnicity
Speaking English/Spanish
NSDUH 2025
NSDUH
NLAAS
80
81
HH, JA, CAT-MH
HH, JA, CAT-MH
SSD5
SSD6
Race
Highest educational degree
NSDUH
Modified
ACS
82
HH, JA, CAT-MH
SSD7
Student status
Modified
B&B:08/18
Simplified to
y/n
New
CIDI
Modified
NSDUH
Modified
NSDUH
New
New
New
New
Only asked in
feet
Only asked in
pounds
New
New
New
New
New
Everyone in
jail is invited
to clinical
interview
Adapted to
“you”
instead of
this person
asked in
English
Adapted to
“you”
instead of
this person
and
aggregated
categories
Wording
adjusted to
current,
4
83
HH, JA, CAT-MH
SSD7a
First enrollment (in months)
New
84
HH, JA, CAT-MH
SSD7b
New
85
HH, JA, CAT-MH
SSD7e
86
HH, JA, CAT-MH
SSD7c
87
HH, JA, CAT-MH
SSD7d
88
89
HH, JA, CAT-MH
HH, JA, CAT-MH
SSD8
SSD9
On campus housing current
y/n
On campus housing any time
past 12 months y/n
On campus housing mostly
past 12 months y/n
Off campus housing type past
12 months
Veteran status
Active duty
90
HH, JA, CAT-MH
SSD10
Paid work
Modified
ACS
91
92
93
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SSD10a
SSD10b
SSD10c
Paid work any
Layoff
Temporary absence
94
95
96
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SSD10d
SSD10e
SSD10f
Recalled to work
Actively looking for work
Could have started work
ACS
ACS
Modified
ACS
ACS
ACS
Modified
ACS
10. Overlap with (non-)HH population – reference period: past 12 months
97
JA
SOL3
Sentenced
98
JA
SOL4
County & state lived in most
prior to incarceration
99
JA
SOL5a
State lived in most prior to
incarceration
New
New
New
NIS
Modified
ACS
irrespective
of degree
seeking or
not, full time
or part time
or not.
Added
instruction to
answer yes if
on break.
Maps to
NPSAS
Maps to
NPSAS
Maps to
NPSAS
Maps to
NPSAS
Maps to
NPSAS
Simplified to
current in
U.S. armed
forces
Added
introduction,
exact
reference
period, and
unpaid
instructions
NIS
New
New
5
100
JA
SOL5b
101
102
103
JA
HH, CAT-MH
HH, JA, CAT-MH
SOL6
SOL7
SOL8
104
105
106
107
108
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
JA
JA
SOL8N
SOL8W
SOL8M
SOL9
SOL10
109
JA
SOL10N
110
JA
SOL10W
111
JA
SOL10M
112
113
HH, JA, CAT-MH
HH, JA, CAT-MH
SOL11
SOL12
114
115
116
117
118
119
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SOL12N
SOL12W
SOL12M
SOL13
SOL13a
SOL14
120
HH, JA, CAT-MH
SOL14N
121
HH, JA, CAT-MH
SOL14W
122
HH, JA, CAT-MH
SOL14M
123
124
125
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
SOL15
SOL15a
SOL16
126
127
HH, JA, CAT-MH
HH, JA, CAT-MH
SOL16N
SOL16W
128
HH, JA, CAT-MH
SOL16M
11. Scheduling CI and Incentives
129
HH, JA, CAT-MH
S6a
County lived in most prior to
incarceration
Jail more than once
Jail stay
Jail length of stay reporting
unit
Jail stay in nights
Jail stay in weeks
Jail stay in months
House/apartment lived
House/apartment length of
stay reporting unit
House/apartment stay in
nights
House/apartment stay in
weeks
House/apartment stay in
months
Prison stay
Prison length of stay reporting
unit
Prison stay in nights
Prison stay in weeks
Prison stay in months
Psychiatric hospital stay
State psychiatric hospital stay
State psychiatric hospital
length of stay reporting unit
State psychiatric hospital stay
in nights
State psychiatric hospital stay
in weeks
State psychiatric hospital stay
in months
Homeless stay
Homeless shelter stay
Homeless shelter length of
stay reporting unit
Homeless shelter stay in nights
Homeless shelter stay in
weeks
Homeless shelter stay in
months
New
Respondent hands tablet back
to interviewer
New
New
New
New
New
New
New
New
New
If multiple:
overall
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
6
130
131
132
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, CAT-MH
133
134
135
136
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
S6b
S5a
S5b_1,
S5b_2,
S5b_3
S5c
S5d
S5e
S5f
137
138
HH, CAT-MH
HH, CAT-MH
S6c
S6
139
140
141
142
143
HH, CAT-MH
HH, JA, CAT-MH
JA
JA
JA
144
Interviewer passcode
Selection and transition
Selection and transition
New
New
Email incentive payment
Name incentive payment
Address incentive payment
Address new incentive
payment
Recording start
Informed consent for clinical
interview
New
New
New
New
S6_int
S3d
S7
S8
S9
Main interviewing consent
Programmer note recording
Release date y/n
Expected release date
Type of residence post-release
New
New
NIS
NIS
Modified
NSHAPC
HH, JA, CAT-MH
S10
Video call
New
145
HH, JA, CAT-MH
S11
Contacting information for
selected RR (post-release)
New
146
147
148
149
150
151
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
S11a
S11b
S11c
S11d
S12
S13
New
New
New
New
New
New
152
HH, JA, CAT-MH
S14
153
HH, JA, CAT-MH
S14a
Landline y/n
Landline #
Text message consent
Mode preference
Additional contact y/n
Contacting information for
additional contact (postrelease)
Best days and times for
selected RR
Time zone for selected RR
New
New
Administered
for jail
population
as part of
clinical
interview
and not
here.
Adjusted
question
wording and
response
categories.
Make smartphone more
explicit
First name,
email, and
phone
number.
New
New
7
154
HH, JA, CAT-MH
155
156
157
158
159
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
S15_1,
S15_2,
S15_3,
S15_4
S15b1
S15b2
S15c
S15d
S15e
Incentive information
New
New
New
New
New
New
New
Modified
NSFG
Modified
NSFG
NSDUH
NSDUH
NSDUH
NSDUH
NSFG
NSFG
NSFG
160
HH, JA, CAT-MH
161
HH, CAT-MH
162
HH, CAT-MH
12. INTERVIEWR DEBRIEFING
163
164
S16
S17
S17_a
Email incentive payment
Email incentive payment
Name incentive payment
Address incentive payment
Address new incentive
payment
END
Screener transition
Screener transition
IDB0
IDB1
Complete or breakoff
Mode of completion
165
IDB2
Assistance during completion?
166
167
168
169
170
171
172
IDB3
IDB4
IDB5
IDB6
IDB6a
IDB7
IDB8
173
174
175
IDB9
IDB10
IDB11
176
IDB13
At home?
Where
Privacy
Who observed
Type of influence
Interview atmosphere
Type of
distractions/interruptions
Attentiveness of respondent
Upset respondent
Trouble completing the
interview and which
See respondent’s screen
177
178
179
IDB14
IDB15
IDBBR1
Comments interview length
Anything else
Breakoff codes
New
New
New
NSFG
NSFG
Modified
NBS
Modified
NSFG
NSDUH
NSDUH
Modified
NBS
8
SECTION 1: INTRODUCTION AND CONSENT
Spre PROGRAMMER, PLEASE PRELOAD
- WEB = YES/NO FROM SYSTEMS
- JA = YES/NO FROM SAMPLING
- HH = YES/NO FROM SAMPLING
- SAMPLINGFRACTION = # FROM SAMPLING
- STATE = FROM SAMPLING FOR JA ONLY
- COUNTY = FROM SAMPLING FOR JA ONLY
- TARGET RESPONDENT = FROM ROSTER (1st SELECTED PERSON WITHIN THE HOUSEHOLD)
- SELECTED2 = FROM ROSTER (2ND SELECTED PERSON WITHIN THE HOUSEHOLD)
- AGE FROM ROSTER: FOR TARGET RESPONDENT AND SELECTED2
- NAME FROM ROSTER: FOR TARGET RESPONDENT AND SELECTED2
- SEX FROM ROSTER: FOR TARGET RESPONDENT AND SELECTED2
- # OF INDIVIDUALS SELECTED FOR SCREENING FROM ROSTER
- EMAIL FROM ROSTER IF ROSTER R = SCREENING R
- TELEPHONE FROM ROSTER IF ROSTER R = SCREENING R
- LANGUAGE FROM ROSTER IF ROSTER R = SCREENING R
- ROSTER INCENTIVE PAID Y/N IF ROSTER R = SCREENING R
- ROSTERINCAMOUNT FROM ROSTER
- MODE IN WHICH ROSTER WAS COMPLETED IF ROSTER R = SCREENING R. WEB, TELEPHONE,
MAIL, IN-PERSON
- ADDRESS FILL FROM SYSTEMS/ROSTER
- ROSTERPAYMENTINFO Y/N FROM ROSTER
- R30 FROM ROSTER
- INCENTIVES:
o ROSTERINCF2F = $10
o ROSTERINC = $10
o SCREENERINC = $20
o CLINICALINC = $30
o JASCREENERINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [JAIL]”
- SCREENERRANDOMIZATION:
o PILOT: 100% CIDI;
o REPLICATE 2: 50:50
o REMAINDER: 100% CIDI
PROGRAMMER: SPANISH SCREENER IS HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20201012_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20201123_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20201209_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
9
AND MOST RECENT VERSION
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20210119_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
Sscreen [IF MAIN SAMPLE RELEASE 2 & HH = YES] PROGRAMMER, PLEASE RANDOMLY ASSIGN
INDIVIDUAL TO CIDI OR CAT-MH SCREENER WITH THE FOLLOWING RATIO:
PROGRAMMER BASED ON RANDOMIZATION GENERATE SCR = CIDI OR SCR = CAT-MH
INTERVIEWER: THIS RESPONDENT HAS BEEN ASSIGNED TO COMPLETE THE SCREENING INTERVIEW.
PROGRAMMER TIME STAMP SET: START
Sintro [IF (S17 = 1) | (TI ADMINISTERED & SCREENER RESPONDENT != ROSTER RESPONDENT) | (FI
ADMINISTERED & (SCREENER RESPONDENT!= ROSTER RESPONDENT) | (SCREENER RESPONDENT
= ROSTER RESPONDENT & COMPLETE IN SEPARATE SESSION)))] FOR YOUR TIME.>
: IF INCENTIVES ARE ALLOWED IN THIS FACILITY
READ: AND YOU WILL RECEIVE “FILL INCENTIVE” FOR YOUR TIME>.>
[IF WEB & HH = YES| (TI ADMINISTERED & SCREENER RESPONDENT = ROSTER RESPONDENT)]
Thank you for agreeing to participate in the National Study of Mental Health screening survey.
The screening survey will take about 15 minutes to complete and you will receive a
electronic pre-paid Visa or check for your time. Please click next to start the
screening survey.**
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
Sopen [IF HH = YES & FI | TI ADMINISTERED & # OF INDIVIDUALS SELECTED FOR SCREENING = 2 &
BOTH INTERVIEWS ARE YET TO BE COMPLETED] INTERVIEWER: YOU WILL NEED TO SCREEN 2
INDIVIDUALS IN THIS HOUSEHOLD.
[IF TARGET RESPONDENT = YES & SELECTED2 != SCREENER COMPLETE] THE TARGET
RESPONDENT FOR THE SCREENING SURVEY YOU ARE ABOUT TO START IS: NAME: , AGE: , SEX:
[IF TARGET RESPONDENT = YES & SELECTED2 != SCREENER COMPLETE] AFTER COMPLETING THIS
SCREENING SURVEY, YOU SHOULD COMPLETE THE NEXT SCREENING SURVEY IN THIS
HOUSEHOLD WITH: NAME: , AGE: , SEX:
[IF TARGET RESPONDENT = NO & TARGET RESPONDENT != SCREENER COMPLETE] THE TARGET
RESPONDENT FOR THE SCREENING SURVEY YOU ARE ABOUT TO START IS: NAME: , AGE: , SEX:
[IF TARGET RESPONDENT = NO & TARGET RESPONDENT != SCREENER COMPLETE] AFTER
COMPLETING THIS SCREENING SURVEY, YOU SHOULD COMPLETE THE NEXT SCREENING SURVEY
IN THIS HOUSEHOLD WITH: NAME: , AGE: , SEX:
Sconf [IF FI|TI ADMINISTERED]
, AGE: , SEX: ) IS COMPLETING THE SCREENER.>
1
YES – CORRECT RESPONDENT, CONTINUE
2
NO
PROGRAMMER IF Sconf = YES CONTINUE;
ELSE DISPLAY “INTERVIEWER, PLEASE IDENTIFY THE CORRECT RESPONDENT , AGE: , SEX: )>. IF THAT IS NOT
POSSIBLE END THE INTERVIEW AND ASSIGN THE CORRESPONDING STATUS CODE.”
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
S1
[IF FI|TI ADMINISTERED AND ROSTER RESPONDENT = SCREENING RESPONDENT] INTERVIEWER:
CONFIRM/SELECT THE LANGUAGE TO BE USED FOR THIS INTERVIEW. THE ROSTER WAS
COMPLETED IN .
[IF FI|TI-ADMINISTERED AND ROSTER RESPONDENT != SCREENING RESPONDENT] INTERVIEWER:
SELECT THE LANGUAGE TO BE USED FOR THIS INTERVIEW ESTABLISHED DURING THE INITIAL
CONTACT.
11
1
2
ENGLISH
SPANISH
[IF WEB ADMINISTERED & HH = YES] If you need to change the language of the survey between
Spanish and English, please use the dropdown menu in the top right of the survey or press F3.
PROGRAMMER: IF WEB ADMINISTERED & ROSTER RESPONDENT = SCREENING RESPONDENT &
LANGUAGE = ENGLISH, DISPLAY IN ENGLISH. IF WEB ADMINISTERED & ROSTER RESPONDENT =
SCREENING RESPONDENT & LANGUAGE = SPANISH, DISPLAY IN SPANISH. IF WEB ADMINISTERED
& ROSTER RESPONDENT != SCREENING RESPONDENT, DISPLAY IN QUESTION TEXT IN ENGLISH
FOLLOWED BY SPANISH.
SSD1
[IF ROSTER RESPONDENT != SCREENING RESPONDENT | JA = YES | (AGE = MISSING)] We will
start by asking you some background questions. How old are you?
_______ years old (RANGE 1-110) **
DK/REF
SSD1a [IF SSD1 < 18 | SSD1 > 65] Thank you for your willingness to participate, but we cannot interview
anyone who is 65: older than 65> for this study.
[PROGRAMMER: ROUTE THESE CASES TO S16]
SSD1b [IF SSD1 = DK/REF] Thank you for your willingness to participate, but we cannot interview you if
we don’t know how old you are.
[PROGRAMMER: ROUTE THESE CASES TO S16]
S3a
PROGRAMMER: PLEASE START RECORDING THE CONSENT PROCESS AND, TURN RECORDINGS
OFF AFTER
S3
[IF HH = YES] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED CONSENT TEXT FROM “1
Household Screening Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
12
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLD POPULATION:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Screener ICF Pro00042170
Aug1320_approved_toProgrammingTranslation_Jan 0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Screener ICF Pro00042170
Aug1320_approved_toProgrammingTranslation_SPA_Jan 0721_clean.pdf
[IF SCR = CIDI & JA = YES] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED CONSENT
TEXT FROM “2 Jail Screening Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE JAIL
POPULATION:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\Ringeisen Jail ICF Pro00042170
Aug1320_approved_toProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\Ringeisen Jail ICF Pro00042170
Aug1320_approved_toProgrammingTranslation_SPA.docx
PROGRAMMER USE S3_int FOR INTERVIEW CONSENT FOR BOTH POPULATIONS AS APPLICABLE.
DO NOT DISPLAY S3_rec IF FI ADMINISTERED AND END CONSENT RECORDING AFTER CONSENT
QUESTION.
S3b
[IF S3_int = NO] Thank you for your willingness to participate, but we cannot interview you
without your consent.
PROGRAMMER: THIS CONCLUDES THE INTERVIEW
S3c
[IF FI ADMINISTERED & JA = YES & S3_rec = NO] PROGRAMMER, THE RESPONDENT DOES NOT
WISH TO BE RECORDED; PLEASE TURN OFF THE RECORDING NOW
SOL1
[IF JA = YES] When were you admitted to this facility?
SOL1a. 2-DIGIT Month**: _________ [RANGE: 1 – 12] DK/REF
SOL1b. 2-DIGIT Day**: ____________ [RANGE: 1 – 31] DK/REF
SOL1c. 4-DIGIT Year**: ___________ [RANGE: 1915 – CURRENT YEAR]
DK/REF
[PROGRAMMER: CALCULATE LENGTH OF STAY; USE THE 15TH IF SOL1b = DK/REF]
SOL2
[IF SOL1a = DK/REF AND SOL1c != DK/REF] What time of year was it? Was it winter, spring,
summer, or fall when you were admitted to this facility?
1
Winter**
2
Spring**
3
Summer**
4
Fall**
13
DK/REF
PROGRAMMER: CALCULATE LENGTH OF STAY. FOR WINTER USE JANUARY AS THE
MONTH; FOR SPRING APRIL, FOR SUMMER JULY, FOR FALL OCTOBER
PROGRAMMER: IF SOL2 = DK/REF & (SOL1c = CURRENT YEAR OR CURRENT YEAR – 1)
then “LENGTH OF STAY IN MONTHS” = 11 (Less than 12 months)
IF SOL2 = DK/REF & (SOL1c >= CURRENT YEAR -2) then “LENGTH OF STAY IN MONTHS” =
12* (CURRENT YEAR – SOL1c) (More than 12 months)
SFIID3 [IF FI|TI ADMINISTERED] PROGRAMMER PLEASE ASSIGN THE INTERVIEW ADMINSTRATION
MODE
1
TELEPHONE
2
IN-PERSON AND SELF ADMINISTERED
[IF JA = YES] INTERVIEWER: IF JA = YES IN-PERSON AND INTERVIEWER ADMINISTERED ONLY
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
PROGRAMMER: REASSIGN SCR = CIDI IF SFIID3 = 1 & HH = YES
NOTE: OPTION 3 (IN-PERSON AND INTERVIEWER ADMINISTERED) WAS REMOVED ON 4/26 AND
WAS NEVER IN EFFECT. SIMILAR TO THE SELF-ADMINISTRATION TUTORIAL WHICH WAS
REMOVED ON 4/26.
SFIID3a [IF FI-ADMINISTERED SCR = CAT-MH] PROGRAMMER INSTRUCTION – AUTOMATICALLY ASSIGN 1
ONLINE / 2 OFFLINE STATUS BASED ON INTERVIEWER TABLET CONNECTIVITY
PROGRAMMER: IF SFIID3a = 1 & SCR = CAT-MH & CAPI APP = NO CONTINUE WITH SCR = CATMH; ELSE REASSIGN CASE TO SCR = CIDI
SI1
[IF SFIID3 = 2] You will complete the rest of this interview on your own using this tablet.
INTERVIEWER: PLEASE HAND THE TABLET TO THE RESPONDENT. PROGRAMMER TIME STAMP SET:
INTRO
SSD2
[IF (ROSTER RESPONDENT != SCREENING RESPONDENT) | (SEX = MISSING)] What is your sex?
1
Male**
2
Female**
DK/REF
SCAT1 [IF (ROSTER RESPONDENT != SCREENING RESPONDENT & SCR = CAT-MH & SSD2 = FEMALE &
SSD1 = 18 – 44) | (ROSTER RESPONDENT = SCREENING RESPONDENT & SCR = CAT-MH & SEX =
FEMALE AND AGE = 18-44)] Are you currently pregnant or did you give birth in
the past 6 weeks, that is since ?
1
Yes**
2
No**
14
DK/REF
SSF1
This question is about your overall health. Would you say your health in general is:
1
Excellent
2
Very Good
3
Good
4
Fair
5
Poor
DK/REF
CATMHIntro [IF SCR = CAT-MH & (WEB = YES | SFIID3 = 2 )] When you click Next you will be
redirected to the “Computerized Adaptive Testing Mental Health” (CAT-MH) website to
complete the next part of the screening survey. The CAT-MH website is hosted by Adaptive
Testing Technologies and use of the CAT-MH website is governed by the terms of service that
you can access here.
By clicking on “Next” you agree to the terms of service.
After you complete the CAT-MH you will be automatically redirected back to this site to
complete the rest of the screening survey and receive your .
Please click “Next” to begin the CAT-MH.
PROGRAMMER: IF SCR = CIDI OR JA = YES CONTINUE; IF SCR = CAT-MH SWITCH TO CAT-MH;
SPECIFICALLY, SWITCH TO CAT-MH PREGNANCY IF SCAT1 = 1; ELSE SWITCH TO NORMAL CAT-MH
MODULE
CATMHfinish1 [IF CAT-MH Sign off] Please select “Continue” and click “Next” to finish the survey.
1
Continue
CATMHfinish2 [IF CATMHfinish1 = NEXT] It looks like you have not yet completed all of the questions at
the CAT-MH website. What would you like to do …
1
Go to the CAT-MH website and finish those questions, or
2
Continue without answering the remaining CAT-MH questions?
DK/REF
CATMHfinish3 [IF CATMHfinish2 = 1] When you click “Next” you will be redirected to the CAT-MH
website.
PROGRAMMER: PLEASE LAUNCH CAT-MH IF CATMHfinish2 = 1; ELSE RETURN TO BLAISE PORTION
15
SECTION 2: DEPRESSION
PROGRAMMER TIME STAMP SET: DEPRESSION
SMDD1 The next questions are about emotional difficulties you might have experienced at some time in
the past year.
Almost everyone has times when they feel sad, depressed, or discouraged about how things are
going in their life. Think about a time in the past 12 months lasting 2 weeks or longer when you
had the strongest feelings of this sort. During those 2 weeks, how often did you have each of
the following feelings?
If you are one of the few people that never had such times, “none of the time” to all the following questions.
a.
b.
Felt sad or depressed
Felt discouraged about how things
were going in your life
c. Took little or no interest or pleasure in
things
d. Felt down on yourself, no good, or
worthless
DK/REF
All or
almost
all the
time
4
Most of
the time
3
Some of
the time
2
A little of
the time
1
None of
the time
0
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: During
those 2 weeks, how often did you have each of the following feelings?]
DEFINE DEPCIDI
IF (SMDD1a OR SMDD1c = 3 OR 4) AND (AT LEAST THREE OF SMDD1a OR SMDD1b OR SMDD1c OR
SMDD1d = 3 OR 4), THEN DEPCIDI = 2
ALL ELSE, DEPCIDI = 3
16
SECTION 3: GAD
PROGRAMMER TIME STAMP SET: GAD
SGAD1 Think about a time lasting 6 months or longer in the past 12 months when you had the
strongest feelings of worry and anxiety. During those 6 months, how often did you have each of
the following feelings?
a.
b.
c.
d.
You felt worried or anxious
You worried about a number of different
things in your life, such as your work,
family, health, or finances
You felt more worried than other people
in your same situation
You had trouble controlling your worry
DK/REF
Just
about
every
day
4
More
days
than not
3
1-3 days
a week
2
Less
than 1
day a
week
1
Never
0
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: During
those 6 months, how often did you have each of the following feelings?]
DEFINE GADCIDI
IF (SGAD1a OR SGAD1b OR SGAD1c OR SGAD1d = 4) AND (SGAD1a AND SGAD1b AND SGAD1c AND
SGAD1d = 3 OR 4), THEN GADCIDI = 2
ALL ELSE, GADCIDI = 3
17
SECTION 4: MANIA/HYPOMANIA
PROGRAMMER TIME STAMP SET: MANIA
SCI1
The next question is about whether you ever in your life had an episode lasting 4 days or
longer when your mood was either much higher than usual most of the day, much more
irritable than usual most of the day, or a mix of these things.
During these episodes, people are often much more excitable than usual or are extremely selfconfident or optimistic. They often do things they would normally not do. And this sometimes
gets them into trouble or puts them at risk of trouble.
With this definition in mind, did you ever in your life have an episode of this sort lasting 4 days
or longer?
1
Yes**
2
No**
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SCI2
[IF SCI1 = YES] What is the longest episode of this sort you ever had in your life?
1
4 to 7 days
2
8 to 14 days
3
More than 14 days
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
DEFINE MANCIDI
IF SCI2 = 2 OR 3, THEN MANCIDI = 2
IF SCI2 = 1, THEN MANCIDI = 2
ALL ELSE, MANCIDI = 3
18
SECTION 5: PTSD
PROGRAMMER TIME STAMP SET: PTSD
SPC1
Many people have extremely stressful experiences that affect them psychologically for many
years. Think of a time lasting 1 month or longer in the past 12 months when you had the most
severe reactions to such an extremely stressful experience. During that month, how much were
you bothered by each of the following problems:
Extremely
a.
b.
c.
d.
Suddenly feeling or acting as if the
stressful experience were actually
happening again – as if you were
actually back there reliving it?
Avoiding external reminders of the
stressful experience, for example,
people, places, conversations,
activities, objects, or situations?
Feeling emotionally distant or
depressed?
Irritable behavior, angry outbursts, or
acting aggressively?
DK/REF
4
Quite
a bit
3
Moderately
2
A little
bit
1
Not at all
0
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: During that
month, how much were you bothered by each of the following problems?]
DEFINE PTSDCIDI
IF THE SUM OF SPC1a AND SPC1b AND SPC1c AND SPC1d ≥ 6, THEN PTSDCIDI = 2
ALL ELSE, PTSDCIDI = 3
19
SECTION 6: SUBSTANCE ABUSE
PROGRAMMER TIME STAMP SET: SUBSTANCE
SAU1
[IF HH = YES] The following questions are about drinking alcohol. During the past 12 months,
how often did you have a drink containing alcohol?
1
Never
2
Once a month or less often
3
2 to 4 times a month
4
2 to 3 times a week
5
4 times a week or more
DK/REF
SAU2
[IF HH = YES & SAU1 != NEVER] During the past 12 months, how many drinks containing alcohol
did you have on a typical day when you drank?
1
1 or 2
2
3 or 4
3
5 or 6
4
7 to 9
5
10 or more
DK/REF
SDA1
[IF HH = YES] These next questions are about drug use. "Drug use" refers to:
• Use of marijuana or cannabis,
• illegal drug use,
• use of prescribed drugs without your own prescription, and
• use of prescribed drugs in greater amounts, more often, or longer than you were told
to take them.
[IF (SFIID3 = 2 | WEB = YES) & HH = YES] The various classes of drugs include cannabis
(marijuana, hashish), cocaine, methamphetamine, heroin, fentanyl, hallucinogens (such as LSD),
and prescription medications such as benzodiazepines (such as Xanax, Ativan), stimulants (such
as Ritalin, Adderall) and opioids (such as hydrocodone, oxycodone).
[IF SFIID3 = 1 | 3 & HH = YES] The various classes of drugs include cannabis, which includes
marijuana and hashish, cocaine, methamphetamine, heroin, fentanyl, hallucinogens, such as
LSD, and prescription medications such as benzodiazepines – such as Xanax or Ativan –
stimulants – such as Ritalin or Adderall – and opioids – such as hydrocodone or oxycodone.
SDU1
[IF HH = YES] During the past 12 months, how often did you use drugs other than alcohol?
1
Never
2
Once a month or less often
3
2 to 4 times a month
4
2 to 3 times a week
5
4 times a week or more
DK/REF
20
SDU2
[IF HH = YES & SDU1 != NEVER] During the past 12 months, how often were you influenced
heavily by drugs other than alcohol?
1
Never
2
Less often than once a month
3
Every month
4
Every week
5
Daily or almost daily
DK/REF
DEFINE ALCCIDI
IF SAU1 = 5 AND (SAU2= 3 OR 4 OR 5), THEN ALCCIDI = 2
ALL ELSE, ALCCIDI = 3
DEFINE DRUGCIDI
IF SDU1 = 5 AND (SDU2 = 4 OR 5), THEN DRUGCIDI = 2
ALL ELSE, DRUGCIDI = 3
21
SECTION 7: PSYCHOSIS
PROGRAMMER TIME STAMP SET: PSYCHOSIS
SCI3
The next questions are about unusual experiences, like seeing visions or hearing voices. Recent
research suggests that they are common and may be normal, but we do not know exactly how
common because this is the first large-scale survey to ask about them comprehensively. So
please take your time and think carefully before answering the following questions.
Please do not count times you had these experiences when you were having a fever, dreaming,
half-asleep, or under the influence of alcohol or drugs.
Not counting those things, did you ever in your life have any of the following experiences?
Yes**
a.
The first one is seeing a vision that other people said was not there
like a face, an animal, a figure, or colors. Remember not to count
times when you were having a fever, dreaming, half-asleep or under
the influence of alcohol or drugs. Did you ever see a vision at any
other time?
b.
Did you ever hear voices that other people did not hear like voices
coming from inside your head talking to you or about you, or voices
coming out of the air when there was no one around?
c.
Did you ever believe that some mysterious force was inserting
thoughts that were definitely not your own thoughts, directly into
your head by means of x-rays, laser beams, or other methods?
d.
Did you ever believe your thoughts were being stolen out of your
mind by some force?
e.
Did you ever think your mind was being taken over by forces with
laser beams or other methods that were making you do things you
did not choose to do?
f.
Did you ever think some force was trying to communicate directly
with you by sending special signs or signals, like through the radio or
television, that you could understand but that no one else could
understand?
g.
Did you ever believe there was a plot to harm you or to have people
follow you, but your friends or family did not think this was true?
No**
DK/REF
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: Not
counting times when you were having a fever, dreaming, half-asleep, or under the influence of alcohol
or drugs, did you ever in your life have any of the following experiences?]
DEFINE PSYCIDI
22
IF SCI3b OR SCI3c OR SCI3d OR SCI3e OR SCI3f OR SCI3g = YES, THEN PSYCIDI = 1
IF ( SCI3b AND SCI3c AND SCI3d AND SCI3e AND SCI3f AND SCI3g != YES) AND SCI3a = YES, THEN PSYCIDI
=2
ALL ELSE, PSYCIDI = 3
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
23
SECTION 8: HEALTH AND HEALTH CARE
PROGRAMMER: IF SCR = CIDI | JA = YES CONTINUE; IF SCR = CAT-MH SWITCH BACK AT THE END OF THE
CAT-MH TO BLAISE AND CONTINUE HERE
PROGRAMMER: PLEASE USE THE FOLLOWING FOR THE CAT-MH
DEPRESSION:
ANXIETY:
MANIA/HYPOMANIA:
PTSD:
SUD:
PSYCHOSIS:
TEST-TYPE = p-dep OR dep
TEST-TYPE = p-anx OR anx
TEST-TYPE = p-m/mh OR m/mh
TEST-TYPE = ptsd
TEST-TYPE = sud
TEST-TYPE = psy-s
PROGRAMMER: IF SCR = CAT-MH DEFINE RISK VARIABLES AS FOLLOWS:
DEFINE DEPCATMH
IF DEPRESSION = SEVERE OR MODERATE, THEN DEPCATMH = 2
ALL ELSE, DEPCATMH = 3
DEFINE GADCATMH
IF ANXIETY = SEVERE OR MODERATE, THEN GADCATMH = 2
ALL ELSE, GADCATMH = 3
DEFINE MANCATMH
IF MANIA/HYPOMANIA = SEVERE, THEN MANCATMH = 2
IF MANIA/HYPOMANIA = MODERATE, THEN MANCATMH = 2
ALL ELSE MANCATMH = 3
DEFINE PTSDCATMH
IF PTSD = DEFINITE OR HIGHLY LIKELY, THEN PTSDCATMH = 2
ALL ELSE PTSDCATMH = 3
DEFINE SUDCATMH
IF SUD = HIGH RISK OR INTERMEDIATE RISK, THEN SUDCATMH = 2
ALL ELSE SUDCATMH = 3
DEFINE PSYCATMH
IF PSYCHOSIS = SEVERE, THEN PSYCATMH = 1
IF PSYCHOSIS = MODERATE, THEN PSYCATMH = 2
ALL ELSE PSYCATMH = 3
PROGRAMMER TIME STAMP SET: HEALTH
The next few questions are about your health and health care.
SH1
Are you currently covered by any kind of health insurance, that is, any policy or program that
provides or pays for medical care?
1
Yes**
24
2
No**
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SH2
[IF SFIID3 = 2 | (WEB = YES & HH = YES)] Are you currently receiving disability benefits such as
SSI (Supplemental Security Income), SSDI (Social Security Disability Insurance), or disability
benefits from the VA (U.S. Department of Veterans Affairs)?
[IF SFIID3 = 1 | 3] Are you currently receiving disability benefits such as Supplemental Security
Income or SSI, Social Security Disability Insurance or SSDI, or disability benefits from the U.S.
Department of Veterans Affairs or VA?
1
Yes**
2
No**
DK/REF
SH3
[IF SH2 = 1] Are you currently receiving disability benefits for:
Yes**
a.
Problems with emotions, nerves, or mental health?
b.
Problems with your physical health?
No**
DK/REF
SH4
[IF SH3a = 1] Which of the following mental health problems are reasons for your disability:
Yes**
a.
Depression
b.
Bipolar disorder
c.
Post-traumatic stress disorder
d.
Schizophrenia or schizoaffective disorder
e.
Any other mental health problem
No**
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
25
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
26
SH5
Below is a list of health conditions. Have you ever been told by a doctor or other health care
professional that you had any of these conditions?
Yes**
a.
Diabetes
b.
Heart problems
c.
Cancer
d.
e.
Any other life-threatening or seriously impairing physical health
problem
Depression
f.
Mania, manic-depression, or bipolar disorder
g.
Schizophrenia or schizoaffective disorder
h.
Any other seriously impairing emotional health problem
No**
DK/REF
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: Have you
ever been told by a doctor or other health care professional that you had any of these conditions?]
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SH6
The next question asks about your height. About how tall are you, without shoes? Please your height in feet and
inches.
______feet** [RANGE: 2-8]
______inch(es)** [RANGE: 0-11]
DK/REF
PROGRAMMER IF OUTSIDE OF FEET RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your response for height in feet is out
of range. Please enter your height in feet using a number between 2 and 8.
PROGRAMMER IF OUTSIDE OF INCHES RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your response for height in inches is
out of range. Please use a number between 0 and 11 to specify inches.
SH7
And, about how much do you weigh in pounds?
________pounds** [RANGE: 40-999]
DK/REF
27
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your response is out of range. Please
enter a number between 40 and 999.
PROGRAMMER: CALCULATE BMI = 703*(weight (lbs)/(height (in))2)
SH8a
Now I have a few questions about your personal experiences with the Coronavirus Disease
2019 pandemic, also referred to as COVID-19. Since the beginning of the COVID-19 pandemic,
… did you think or know that you had COVID-19?
1
Yes**
2
No**
DK/REF
SH8b
[IF SH8a = YES] Since the beginning of the COVID-19 pandemic,**
… at any time, did you test positive for the COVID-19 virus or for COVID-19 antibodies?
1
Yes**
2
No**
DK/REF
SH8c
[IF SH8b = YES] Since the beginning of the COVID-19 pandemic, **
… were you yourself hospitalized due to COVID-19?
1
Yes**
2
No**
DK/REF
SH8d
Since the beginning of the COVID-19 pandemic, **
… was someone in your immediate family or close friend(s) hospitalized due to COVID-19?
1
Yes**
2
No**
DK/REF
PROGRAMMER: PLEASE INSERT A CHECK BOX FOR ‘Does not apply’**
SH8e
Since the beginning of the COVID-19 pandemic, **
… did someone in your immediate family or close friend(s) die due to COVID-19?
1
Yes**
2
No**
DK/REF
28
PROGRAMMER: PLEASE INSERT A CHECK BOX FOR ‘Does not apply’**
SH9
How much, if at all, has the coronavirus pandemic negatively affected your emotional or mental
health?
1
Not at all
2
A little
3
Some
4
Quite a bit
5
A lot
DK/REF
SH10
[IF HH = YES & ((SCR = CIDI & SAU1 != NEVER) | (SCR = CAT – MH & ALCOHOL != 0))] How much,
if at all, has the coronavirus pandemic affected the amount of alcohol you drink?
1
I drink much less than I did before the coronavirus pandemic began
2
I drink a little less than I did before the coronavirus pandemic began
3
I drink about the same amount as I did before the coronavirus pandemic began
4
I drink a little more than I did before the coronavirus pandemic began
5
I drink much more than I did before the coronavirus pandemic began
DK/REF
SH11
[IF HH = YES & ((SCR = CIDI & SDU1!= NEVER) | (SCR = CAT – MH & SEDATIVES/HYPNOTICS != 0 |
OPIOIDS/ANALGESICS != 0 | HEROIN/METHADONE != 0 | COCAINE/AMPHETAMINES != 0 |
MARIJUANA != 0))] How much, if at all, has the coronavirus pandemic affected your use of drugs
other than alcohol?
[IF (SFIID3 = 2 | WEB = YES) & HH = YES] By drugs we mean various classes of drugs including
cannabis (marijuana, hashish), cocaine, methamphetamine, heroin, fentanyl, hallucinogens
(such as LSD), and use of prescription medications that you took without your own prescription
or in greater amounts, more often or for longer than you were told to take them. These
prescription medications include benzodiazepines (such as Xanax, Ativan), stimulants (such as
Ritalin, Adderall) and opioids (such as hydrocodone, oxycodone).
[IF SFIID3 = 1 | 3 & HH = YES] By drugs we mean various classes of drugs including cannabis,
which includes marijuana and hashish, cocaine, methamphetamine, heroin, fentanyl,
hallucinogens, such as LSD, and use of prescription medications that you took without your own
prescription or in greater amounts, more often or for longer than you were told to take them.
These prescription medications include benzodiazepines – such as Xanax or Ativan – stimulants
– such as Ritalin or Adderall – and opioids – such as hydrocodone or oxycodone.
1
I use much less than I did before the coronavirus pandemic began
2
I use a little less than I did before the coronavirus pandemic began
3
I use about the same amount as I did before the coronavirus pandemic began
4
I use a little more than I did before the coronavirus pandemic began
5
I use much more than I did before the coronavirus pandemic began
DK/REF
DEFINE HLTHCIDI
IF SH4d OR SH5g = YES, THEN HLTHCIDI = 1
29
IF (SH4a OR SH4b OR SH4c OR SH4e = YES) OR (SH5e OR SH5f OR SH5h = YES) OR (AGE < 40 AND BMI <
17 AND SH5c = NO AND (SMDD1a ≥ 2 OR SMDD1b ≥ 2 OR SMDD1c ≥ 2 OR SMDD1d ≥ 2 OR SGAD1a ≥
3 OR SGAD1b ≥ 3 OR SGAD1c ≥ 3 OR SGAD1d ≥ 3)), THEN HLTHCIDI = 2
ALL ELSE, HLTHCIDI = 3
NOTE: IF BMI IS MISSING ASSIGN TO TIER 3. BMI WAS ACCIDENTALLY CODED AS “0” IF ONLY SH6 WAS
DK/REF AND AS SUCH INDIVIDUALS WERE ERRONEOUSLY CODED TO TIER 2 (IF ALL OTHER ANOREXIA
CONDITIONS WERE MET AND NOTHING ELSE APPLIED; IF SH7 WAS DK/REF BMI WAS CORRECTLY SET TO
MISSING). THIS WAS CORRECTED AS OF 5/3/2021 AT 4:11 EDT AND IS NO ISSUE FOR HLTHCATMH.
DEFINE HLTHCATMH
IF SH4d OR SH5g = YES, THEN HLTHCATMH = 1
IF (SH4a OR SH4b OR SH4c OR SH4e = YES) OR (SH5e OR SH5f OR SH5h = YES) OR (AGE < 40 AND BMI <
17 AND SH5c = NO AND ((ANXIETY = MODERATE OR SEVERE) OR (DEPRESSION MODERATE OR
SEVERE))), THEN HLTHCATMH = 2
ALL ELSE, HLTHCATMH = 3
DEFINE PARTIALCOMPLETE
IF HEALTH AND HEALTH CARE SECTION = COMPLETE, THEN PARTIALCOMPLETE = YES
ALL ELSE, PARTIALCOMPLETE = NO
S4
NOTE: THE DIAGNOSIS AND STRATA DEFINITIONS ENCOMPASS ALL POSSIBLE DISORDERS AT ALL
LEVELS EVEN IF THEY HAVE NOT BEEN DEFINED ABOVE (E.G., DEPCIDI = 1). THIS GIVES US
MAXIMUM FLEXIBILITY SHOULD WE NEED TO ADJUST ANYTHING IN THE GENERATION OF THE
DISORDERS ABOVE. AT THIS POINT THEY JUST EVALUATE AS FALSE AND ARE ULTIMATELY
IGNORED IN THE BELOW.
DEFINE CIDIDIAGNOSIS
IF (DEPCIDI = 1 OR 2) OR (GADCIDI = 1 OR 2) OR (MANCIDI = 1 OR 2) OR (PTSDCIDI = 1 OR 2) OR
(ALCCIDI = 1 OR 2) OR (DRUGCIDI = 1 OR 2) OR (PSYCIDI = 1 OR 2) OR (HLTHCIDI = 1 OR 2), THEN
CIDIDIAGNOSIS = YES
ALL ELSE, CIDIDIAGNOSIS = NO
DEFINE CATMHDIAGNOSIS
IF (DEPCATMH = 1 OR 2) OR (GADCATMH = 1 OR 2) OR (MANCATMH = 1 OR 2) OR (PTSDCATMH
= 1 OR 2) OR (SUDCATMH = 1 OR 2) OR (PSYCATMH = 1 OR 2) OR (HLTHCATMH = 1 OR 2), THEN
CATMHDIAGNOSIS = YES
ALL ELSE, CATMHDIAGNOSIS = NO
DEFINE STRATA
IF DEPCIDI = 1 OR GADCIDI = 1 OR MANCIDI = 1 OR PTSDCIDI = 1 OR ALCCIDI = 1 OR DRUGCIDI =
1 OR PSYCIDI = 1 OR HLTHCIDI = 1, THEN STRATA = 1
IF DEPCATMH = 1 OR GADCATMH = 1 OR MANCATMH = 1 OR PTSDCATMH = 1 OR SUDCATMH =
1 OR PSYCATMH = 1 OR PSYCATMH = 2 OR HLTHCATMH = 1, THEN STRATA = 1
IF DEPCIDI = 2 OR GADCIDI = 2 OR MANCIDI = 2 OR PTSDCIDI = 2 OR ALCCIDI = 2 OR DRUGCIDI =
2 OR PSYCIDI = 2 OR HLTHCIDI = 2, REPLACE STRATA = 2 IF STRATA != 1
30
IF DEPCATMH = 2 OR GADCATMH = 2 OR MANCATMH = 2 OR PTSDCATMH = 2 OR SUDCATMH =
2 OR HLTHCATMH = 2, REPLACE STRATA = 2 IF STRATA != 1
IF DEPCIDI = 3 OR GADCIDI = 3 OR MANCIDI = 3 OR PTSDCIDI = 3 OR ALCCIDI = 3 OR DRUGCIDI =
3 OR PSYCIDI = 3 OR HLTHCIDI = 3, REPLACE STRATA = 3 IF STRATA != (1 | 2)
IF DEPCATMH = 3 OR GADCATMH = 3 OR MANCATMH = 3 OR PTSDCATMH = 3 OR SUDCATMH =
3 OR PSYCATMH = 3 OR HLTHCATMH = 3, REPLACE STRATA = 3 IF STRATA != (1 | 2)
IF (STRATA = 1 & HH = YES) | (JA = YES) THEN SELECT 100% SAMPLINGFRACTION
IF STRATA = 2 & HH = YES THEN SELECT 80% SAMPLINGFRACTION
IF STRATA = 3 & HH = YES THEN SELECT 20% SAMPLINGFRACTION
DEFINE UNBLINDMDE
IF (SCR = CIDI AND (SMDD1a OR SMDD1c = 3 OR 4)) OR (SCR = CAT-MH AND (DEPRESSION =
MODERATE OR SEVERE)), THEN UNBLINDMDE = YES; ELSE UNBLINDMDE = NO
DEFINE UNBLINDMANIA
IF (SCR = CIDI AND SCI1 = 1) OR (SCR = CAT-MH AND (MANIA/HYPOMANIA = MODERATE OR
SEVERE)), THEN UNBLINDMANIA = YES; ELSE UNBLINDMANIA = NO
DEFINE UNBLINDPSYCHOS1
IF (SH5g = 1), THEN UNBLINDPSYCHOS1 = YES; ELSE UNBLINDPSYCHOS1 = NO
DEFINE UNBLINDPSYCHOS2
IF (SH5g != 1 AND SH4d = 1), THEN UNBLINDPSYCHOS2 = YES; ELSE UNBLINDPSYCHOS2 = NO
DEFINE UNBLINDPSYCHOS3
IF (SCR = CIDI AND SH5g != 1 AND SH4d != 1 AND (SCI3a OR SCI3b OR SCI3c OR SCI3d OR SCI3e
OR SCI3f = 1)) OR (SCR = CAT-MH AND SH5g != 1 AND SH4d != 1 AND (PSYCHOSIS = MILD TO
MODERATE OR SEVERE)), THEN UNBLINDPSYCHOS3 = YES; ELSE UNBLINDPSYCHOS3 = NO
DEFINE UNBLINDGAD
IF (SCR = CIDI AND (SGAD1= 3 OR 4)) OR (SCR = CAT-MH (ANXIETY = MODERATE OR SEVERE)),
THEN UNBLINDGAD = YES; ELSE UNBLINDGAD = NO
DEFINE UNBLINDPTSD
IF (SCR = CIDI AND (SPC1a OR SPC1b OR SPC1c OR SPC1d = 2 OR 3 OR 4)) OR (SCR = CAT-MH AND
(PTSD = POSSIBLE OR DEFINITE OR HIGHLY LIKELY)), THEN UNBLINDPTSD = YES; ELSE
UNBLINDPTSD = NO
PROGRAMMER INTERNAL NOTE ONLY REGARDING THE TIERS [IF SCR = CIDI]
TIER 1 (HIGH PRIORITY DISORDER):
Psychosis: SCI3 Yes to at least 1 item in B thru G
Health: SH4 – Yes to d; SH5 – Yes to g
31
TIER 2 (ANY DISORDER):
Depression: 3 of the 4 items must be at least most of the time and the three items must
include one or both of items A and C
GAD: Must have at least 1 item at the “just about every day” level and the other 3
items at least at the “more days than not” level
Mania/Hypomania: If SCI2 = 4 days or longer
PTSD: SPC1, a score of 6 or more summed across all items (where not at all = 0; a little
bit = 1; moderately = 2; quite a bit = 3; and extremely = 4)
Alcohol: SAU1 = category 5 (4 or more times a week) and SAU2 = category 3 or higher
(5 drinks or more)
Drugs: SDU1 = category 5 (4 times a week or more) and SDU2 = category 4 or 5 (every
week or more)
Psychosis: SCI3 Yes to only item A
Health:
•
•
•
SH4 Any other item(s) = yes except d;
SH5 Yes to e, f or h;
SH6/SH7 – If respondent is younger than 40 and BMI is less than 17 and
SH5c = NO and at least (“some of the time” in one of the questions on the
GAD scale or the MDE scale). Update from Mark, go with 3 “3. More days
than not” for GAD.
And not already in tier 1.
TIER 3 (NO DISORDER):
Everyone who does not meet Tier 1 or Tier 2 requirements.
PROGRAMMER INTERNAL NOTE ONLY REGARDING THE TIERS [IF SCR = CAT-MH]
TIER 1 (HIGH PRIORITY DISORDER):
Psychosis: Severe or moderate
Health: SH4 – Yes to d; SH5 – Yes to g
TIER 2 (ANY DISORDER):
Depression: moderate or severe
Anxiety: moderate or severe
Mania/hypomania: moderate or severe
PTSD: definite or highly likely
SUD: intermediate or high risk
32
Psychosis: There will be no CAT-MH Psychosis cases assigned to Tier 2
Health:
• SH4 Any other item(s) = yes except d;
• SH5 Yes to e, f or h [diagnosed depression, mania, other seriously impairing
emotional health problem];
• SH6/SH7 – If respondent is younger than 40 and BMI is less than 17 and ((anxiety
moderate or severe) or (depression moderate or severe))
TIER 3 (NO DISORDER):
Everyone who does not meet Tier 1 or Tier 2 requirements.
33
SECTION 9: SOCIO-DEMOGRAPHICS
PROGRAMMER TIME STAMP SET: DEMOGRAPHICS
SSD3
We now have a few more background questions about yourself.
Are you now married, widowed, divorced, separated, or have you never married?
1
Now married**
2
Widowed**
3
Divorced**
4
Separated**
5
Never married**
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SSD3a [IF SSD3 != 1] Are you now living with a partner?
1
Yes**
2
No**
DK/REF
SSD4
Are you of Hispanic, Latino or Spanish origin?
That is, do any of these groups describe your national origin or ancestry—Puerto Rican, Cuban,
Cuban-American, Mexican, Mexican-American, Chicano, Central or South American, or origin in
some other Spanish-speaking country?
1
Yes**
2
No**
DK/REF
S2
[IF SSD4 = 1] Do you speak Spanish only, mostly Spanish with some English, Spanish and English
about the same, mostly English with some Spanish, or English only?
1
Spanish only**
2
Mostly Spanish, but some English **
3
Spanish and English about the same**
4
Mostly English, but some Spanish **
5
English only**
DK/REF
SSD5
Are you White, Black or African American, American Indian or Alaska Native, Native Hawaiian or
other Pacific Islander, or Asian? Please mark all that apply.
34
□
White**
□
Black or African American**
□
American Indian or Alaska Native**
□
Native Hawaiian or Other Pacific Islander**
□
Asian**
DK/REF
SSD6
What is the highest grade or level of school you have completed?
If currently enrolled, previous grade or highest degree received.
1
Less than a high school diploma
2
High school degree or equivalent (for example: GED)
3
Some college, no degree
4
Associate degree (for example: AA, AS)
5
Bachelor’s degree (for example: BA, BS)
6
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
7
Professional degree (for example: MD, DDS, DVM, LLB, JD)
8
Doctorate degree (for example: PhD, EdD)
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SSD7
Are you currently attending a college, university, or trade school either full-time or part-time?
If you are on a holiday or break from school, such as spring break or summer vacation, but plan
to return when the break is over, please answer yes.
1
Yes**
2
No**
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
35
SSD7a [IF SSD7 = YES] How long ago did you first enroll at this college, university, or trade school? If
you transferred to your current institution directly from another college or university, please
include that time. Was that …
1
Within the past 12 months, or
2
More than 12 months ago
DK/REF
SSD7b [IF SSD7 = YES] Do you currently live in college-owned housing on campus, such as a dorm or a
residence hall?
1
Yes**
2
No**
DK/REF
SSD7e [IF SSD7b = NO] At any time did you live in college-owned housing on campus, such as a dorm or
a residence hall?
1
Yes**
2
No**
DK/REF
SSD7c [IF SSD7b = YES | SSD7e = YES] did you mostly live in college-owned housing on campus, such as a
dorm or a residence hall?
1
Yes**
2
No**
DK/REF
SSD7d [IF SSD7c = NO | SSD7e = NO] You said you did not live on campus . In what type of off-campus housing did you mostly live in during that time? Is
that …
1
Off-campus housing, owned or managed by the school,
2
Off campus with relatives, such as parents or guardians, or
3
Other off-campus housing?
DK/REF
SSD8
Have you ever served in the United States Armed Forces?
1
Yes**
2
No**
DK/REF
SSD9
[IF SSD8 = YES] Are you currently serving on active duty in the United States Armed Forces?
1
Yes**
2
No**
36
DK/REF
SSD10 The next question is about working. Last week, did you work for pay at a job or business? By last
week, I mean the week beginning on Sunday, and ending on Saturday,
.
To view information about unpaid work please click on the question mark or press F2.**
1
Yes**
2
No – Did not work or are retired**
DK/REF
HELPTEXT**:
• Please include
- unpaid work in a family farm or business if you usually work more than
15 hours each week, or
- personal labor you provide in exchange for work done for you, rather
than for pay.
•
Please do not include
- work done as part of a student stipend, or
- volunteer work.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SSD10a [IF SSD10 = NO] Last week, did you do any work for pay, even for as little as one hour?
1
Yes**
2
No**
DK/REF
SSD10b [IF SSD10a = NO] Last week, were you on layoff from a job?
1
Yes**
2
No**
DK/REF
SSD10c [IF SSD10b = NO] Last week, were you temporarily absent from a job or business, for example,
because of vacation, temporary illness, maternity leave, other family or personal reasons, or
bad weather?
1
Yes**
2
No**
DK/REF
37
SSD10d [IF SSD10b = YES] Have you been informed that you will be recalled to work within the next 6
months or been given a date to return to work?
1
Yes**
2
No**
DK/REF
SSD10e [IF SSD10c = NO | SSD10d = NO] During the last 4 weeks, have you been actively looking for
work?
1
Yes**
2
No**
DK/REF
SSD10f [IF SSD10d = YES | SSD10e = YES] Last week, could you have started a job if you had been
offered one, or returned to work if you had been recalled?
1
Yes, you could have gone to work,
2
No, you could not have gone to work because of your own temporary illness,
3
No, you could not have gone to work for some other reason, such as, being in
school or taking care of house or family
38
SECTION 10: OVERLAP WITH (NON-)HH POPULATION
PROGRAMMER TIME STAMP SET: OVERLAP
SOL3
[IF JA = YES] The next few questions are about your stay at this and other facilities. Are you
currently in this facility because you have been sentenced to serve time for an offense?
1
Yes**
2
No**
DK/REF
SOL4
[IF JA = YES] During the 12 months before your incarceration, did you live in in
for most of the time?
1
Yes**
2
No**
DK/REF
SOL5a [IF SOL4 = NO] During the 12 months before your current incarceration, in which state did you
live in for most of the time?
__________ [State**]
PROGRAMMER: ALLOW FOR OUT OF COUNTRY CODE AND FOR D.C.
DK/REF
SOL5b [IF SOL4 = NO & SOL5a != OUTSIDE OF US | DK | REF] And what county was that in?
__________ [County**]
DK/REF
SOL6
[IF JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] Other than your current incarceration,
have you stayed overnight or longer in a jail at any time during the past 12 months?
1
Yes**
2
No**
DK/REF
SOL7
[IF HH = YES] During the past 12 months, have you stayed overnight or longer in a jail? Please do
not count any time spent in prison.
1
Yes**
2
No**
DK/REF
SOL8
[IF (SOL7 = YES) | (SOL6 = YES/DK/REF)] During the past 12 months, how much time have you spent in a jail? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
39
SOL8N
[IF SOL8 = 1 OR DK/REF] During the past 12 months, how many nights have you spent in a jail? Again, if you are not sure, just make
your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
SOL8W
[IF SOL8 = 2] During the past 12 months, how many weeks have you spent in a jail? Again, if you are not sure, just make your best
guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
SOL8M
[IF SOL8 = 3] During the past 12 months, how many months have you spent in a jail? Again, if you are not sure, just make your best
guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.
SOL9
[IF JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] During the past 12 months, have you
lived in a house, an apartment, or a mobile home, even if just for a short period of time?
1
Yes**
2
No**
DK/REF
SOL10 [IF SOL9 = YES] During the past 12 months, how much time have you spent in a house, an
apartment, or a mobile home? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL10N
[IF SOL10 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a house, an apartment, or a mobile home? Again, if you are not sure, just make your
best guess.
40
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
SOL10W
[IF SOL10 = 2] During the past 12 months, how many weeks have you spent in a house,
an apartment, or a mobile home? Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
SOL10M
[IF SOL10 = 3] During the past 12 months, how many months have you spent in a house,
an apartment, or a mobile home? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.
SOL11 [IF (JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HH = YES] During the past 12
months, have you stayed overnight or longer in a prison?
1
Yes**
2
No**
DK/REF
SOL12 [IF SOL11 = YES] During the past 12 months, how much time have you spent in a prison? If you
are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL12N
[IF SOL12 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a prison? Again, if you are not sure, just make your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
41
SOL12W
[IF SOL12 = 2] During the past 12 months, how many weeks have you spent in a prison?
Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
SOL12M
[IF SOL12 = 3] During the past 12 months, how many months have you spent in a
prison? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.
SOL13 During the past 12 months, have you stayed overnight or longer in a psychiatric hospital?
1
Yes**
2
No**
DK/REF
SOL13a [IF SOL13 = YES/DK/REF] During the past 12 months, have you stayed overnight or longer in a
state psychiatric hospital? State psychiatric hospitals are public psychiatric hospitals operated by
a state for treatment of serious mental disorders.
1
Yes**
2
No**
DK/REF
SOL14 [IF SOL13a = YES] During the past 12 months, how much time have you spent in a state
psychiatric hospital? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL14N
[IF SOL14 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a state psychiatric hospital? Again, if you are not sure, just make your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
42
SOL14W
[IF SOL14 = 2] During the past 12 months, how many weeks have you spent in a state
psychiatric hospital? Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
SOL14M
[IF SOL14 = 3] During the past 12 months, how many months have you spent in a state
psychiatric hospital? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.
SOL15 [IF (JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HH = YES] During the past 12
months, have you been homeless, even if just for a short period of time?
1
Yes**
2
No**
DK/REF
SOL15a [IF SOL15 = YES/DK/REF] The next question is about shelters that provide a place for people who
are homeless to stay. These shelters may also serve meals. Not counting living on the street, in a
vehicle, or in some type of makeshift housing like a tent or empty building, during the past 12
months, have you stayed overnight or longer in a homeless shelter?
1
Yes**
2
No**
DK/REF
SOL16 [IF SOL15a = YES] During the past 12 months, how much time have you spent in a homeless
shelter? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL16N
[IF SOL16 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a homeless shelter? Again, if you are not sure, just make your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
43
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
SOL16W
[IF SOL16 = 2] During the past 12 months, how many weeks have you spent in a
homeless shelter? Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
SOL16M
[IF SOL16 = 3] During the past 12 months, how many months have you spent in a
homeless shelter? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.
44
SECTION 11: SCHEDULING CLINICAL INTERVIEW AND INCENTIVES
PROGRAMMER TIME STAMP SET: SELECTION
S6a
Thank you for completing this portion of the interview. We are almost done.
S6b
[IF SFIID3 = 2] INTERVIEWER: ENTER PASSCODE TO CONTINUE: _____
PROGRAMMER: PLEASE DISPLAY AN ERROR MESSAGE IF THE INTERVIEWER ENTERS THE WRONG
CODE.
S5a
[IF SELECT = YES] You are eligible to participate in the main interview. If you agree to take part,
you will receive < CLINICALINC>
S5b_1 [IF SELECT = NO] Based on your responses, you are not eligible to participate in the main
interview.
[IF SELECT = NO & ((SFIID3 = 1 | WEB = YES) & HH = YES)) & (ROSTER = SCREENER RESPONDENT
& ROSTERPAYMENTINFO = YES & R30 = 1 | 2)] To show our appreciation for completing this
short screening survey today, we would like to send you the additional .
S5b_2 [IF SELECT = NO & ((SFIID3 = 1 | 2 | 3 | WEB = YES) & HH = YES)) & (ROSTER != SCREENER
RESPONDENT | ROSTERPAYMENTINFO = NO | ((SFIID = 1 | WEB = YES) & R30 = 3 | 4 | DK | REF)
| ((SFIID = 2 | 3)))] To show our appreciation for completing this short screening survey today,
we would like to send you the
by either electronic pre-paid Visa or check .
1
2
4
Electronic pre-paid Visa. Please allow 1 to 2 weeks for processing.**
Check. Please allow up to 4 weeks for processing and delivery.**
45
3
NO, THANKS. DECLINE THE INCENTIVE.
DK/REF
HELPTEXT: The electronic pre-paid Visa card can be used for online shopping only.
S5b_3 [IF SELECT = NO & HH = YES & S5b_2 = 4] PLEASE HAND RESPONDENT THE CASH INCENTIVE.
IF THEY COMPLETED THIS SCREENING SURVEY.>
IF THEY COMPLETED THE HOUSEHOLD MEMBERSHIP LISTING WITH YOU AND
AN ADDITIONAL FOR COMPLETING THIS SCREENING SURVEY.>
I have checked a box to indicate that you the payment for
completing this short survey.
S5c
[IF SELECT = NO & HH = YES & S5b_2 = 1] Please provide your email address to receive the
electronic pre-paid Visa.
________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER NOTE: IF WEB AND S5c = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S5c = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
S5d
[IF SELECT = NO & HH = YES & S5b_2 = 2] Please provide your first and last name to receive your
check.
First Name:**
OPEN-ENDED RESPONSE OPTION
Last Name:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER NOTE: IF WEB AND S5d = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S5d = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
46
S5e
[IF SELECT = NO & HH = YES & S5b_2 = 2] Would you like us to mail your check to [ADDRESS FILL]
or to another address?
1
Yes, mail to [ADDRESS FILL]**
2
No, mail to another address**
DK/REF
S5f
[IF S5e = 2] What address do you want us to mail the check to?
Street**: (NUMBER AND STREET NAME)
City**: (CITY)
State**: (STATE)
ZIP: (ZIP)
DK/REF
PROGRAMMER NOTE: IF WEB AND S5f = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S5f = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
PROGRAMMER: GO TO S16_TRANS IF SELECT = NO
PROGRAMMER TIME STAMP SET: SCONSENT
S6c
[IF FI ADMINISTERED & HH = YES] PROGRAMMER PLEASE START RECORDING OF THE CLINICAL
CONSENT QUESTION S6_int AND END RECORDING AFTER CONSENT QUESTION S6_int.
S6
[IF SELECT = YES & HH = YES] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED
CONSENT TEXT FROM “3 Household Clinical Interview Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLD POPULATION:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170 Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf
PROGRAMMER USE S6_int FOR CLINICAL INTERVIEW CONSENT AND GENERATE CONSENT Y/N
S3d
[IF FI ADMINISTERED & HH = YES] PROGRAMMER, PLEASE TURN OFF THE RECORDING.
Sknow1 [IF SELECT = YES & HH = YES & CONSENT = YES] To ensure you understand your rights as a
NSMH respondent, need to ask you
47
a few questions about the information You are being asked to participate in the National Study of
Mental Health – the NSMH. Would you say the NSMH is about:
a. How pets improve our mental health
b. Mental health and other health issues
c. The health of kids in schools
d. Public transportation
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: MM/DD/2021)
Sknow2 [IF SELECT = YES & HH = YES & CONSENT = YES] Your participation in the NSMH interview will
take about:
a. 15 minutes
b. 6 hours
c. 80 minutes
d. 3 days
PROGRAMMER NOTE: AS OF MARCH, 1, 2021 PLEASE DEACTIVATE THE FIRST RESPONSE OPTION
(15 minutes)
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
Sknow3 [IF SELECT = YES & HH = YES & CONSENT = YES] You have been asked to:
a. Take part in a group discussion with 10 to 12 other people
b. Call your local health department to participate
c. Participate in an interview with an interviewer
d. Send a letter with information about your health
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
Sknow4a [IF SELECT = YES & HH = YES & CONSENT = YES] True or False: Your participation is voluntary.
1
True**
2
False**
DK/REF
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
Sknow4b [IF SELECT = YES & HH = YES & CONSENT = YES] True or False: You can refuse to answer any
questions.
1
True**
2
False**
DK/REF
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
PROGRAMMER NOTE PRIOR TO MM/DD/2021: GENERATE SKNOWLEDGEPASS IF HH = YES
REPLACE SKNOWLEDGEPASS = 1 IF Sknow1 = b & Sknow2 = c & Sknow3 = c & Sknow4a = 1 &
Sknow4b = 1 & HH = YES
ELSE SKNOWLEDGEPASS = 0 IF HH = YES
48
PROGRAMMER NOTE: PLEASE GENERATE SKNOWLEDGEPASS = 1 FOR ALL RESPONDENTS, I.E.,
HH|JA = YES (DATE: 06/15/2021)
PROGRAMMER TIME STAMP SET: SCHEDULING
S7
[IF JA = YES] Do you have a definite date on which you expect to be released from jail?
1
Yes**
2
No**
DK/REF
S8
[IF JA = YES & S7 = YES] Do you expect to be released...
1
Within the next 7 days,
2
More than 7 days but within the next 30 days, or
3
More than 30 days from now.
DK/REF
S9
[IF JA = YES] Where are you planning to live once you are released from your incarceration …
1
In your own house or apartment, meaning your name is on the deed, mortgage,
or lease
2
In someone else’s house or apartment, including your parents’ home
3
In a residential treatment facility
4
In a transitional housing facility or halfway house
5
In a group home
6
In a state psychiatric hospital
7
In a homeless shelter
8
On the street
9
In no set place
10
In some other place or situation
DK/REF
S10
[IF SELECT = YES & HH = YES & CONSENT = YES] Can you participate in a private video call, for
example using a smartphone, tablet, or a computer?
1
Yes**
2
No**
DK/REF
[IF JA = YES] Do you think you will be able to participate in a video call, for example using a
smartphone, tablet or computer, once you are released from your incarceration?
1
Yes**
2
No**
DK/REF
S11
[IF (SELECT = YES & HH = YES & CONSENT = YES & ROSTER RESPONDENT != SCREENING
RESPONDENT) OR (ROSTER RESPONDENT = SCREENING RESPONDENT & (NAME | PHONE |
EMAIL FROM ROSTER = MISSING)) OR (JA = YES)] Please your first name, cell phone number, and email address so that we can
contact you to schedule
this upcoming interview.
49
First Name:**
OPEN-ENDED RESPONSE OPTION
Cell Phone Number:**
OPEN-ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
I don’t have a cell phone PROGRAMMER PLEASE INCLUDE CHECK BOX
Email Address:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER GENERATE EMAIL AND CELL PHONE TO DIFFERENTIATE IF EITHER ARE
MISSING
PROGRAMMER NOTE: IF WEB AND S11 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact you about the next survey in this study. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S11 = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN CONTACT YOU ABOUT THE NEXT SURVEY IN THIS
STUDY. PLEASE TRY TO ANSWER IF YOU CAN.
S11a
[IF S11 CELL PHONE = MISSING OR ‘I DON’T HAVE A CELL PHONE’] You indicated that you don’t
have a cell phone. Do you have a landline number so that we can contact you to schedule the
upcoming interview?
1
Yes**
2
No**
DK/REF
S11b
[IF S11a = YES] And what is that number?
Landline Phone Number:**
OPEN-ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
DK/REF
S11c
[IF S11 CELL PHONE != MISSING] May we send text messages to your personal cell phone to
contact you about the upcoming interview?
1
Yes**
2
No**
DK/REF
S11d
[IF (S11 CELL PHONE != MISSING & S11 EMAIL != MISSING) | (S11 EMAIL != MISSING & S11b !=
MISSING) | (ROSTER RESPONDENT = SCREENING RESPONDENT & (PHONE & EMAIL FROM
ROSTER != MISSING)] And how would you prefer that we reach out to you?
1
Via telephone, or
50
2
Via email
DK/REF
S12
[IF (SELECT = YES & CONSENT = YES) | JA = YES] And, is there another person who would know
how to get in touch with you if we cannot reach you?
1
Yes**
2
No**
DK/REF
S13
[IF S12= YES] Please their first name,
their phone number, and their email address.
First Name:**
OPEN-ENDED RESPONSE OPTION
Phone Number:**
OPEN-ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
S14
[(IF SELECT = YES & HH = YES & CONSENT = YES & (ROSTER RESPONDENT != SCREENING
RESPONDENT | ROSTER COMPLETED IN SEPARATE SITTING)) OR ( JA = YES)] Please a specific date and time when you can be available
for the upcoming 80-minute main interview. Please note that the earliest we can schedule you
for this interview is and no later than .
PROGRAMMER: ROUTE TO SCHEDULING CALENDAR TO SELECT MAIN INTERVIEW DATE AND
TIME.
PROGRAMMER NOTE: CALENDAR VIEW FOR POSSIBLE DATES (CURRENT DATE +7 TO +60) AND
DROPDOWN WITH ONE HOUR TIME SLOTS FROM 9AM TO 7PM.
Please use the calendar to select a convenient date and time for your clinical interview. Note
that the interview takes 80 minutes on average and the appointments are usually set up for two
hours. Please specify your time zone from the dropdown list so that we can adjust the calendar
accordingly. Also, specify your language from the dropdown list so that we can adjust available
appointments. If you modify time zone or language, click the refresh scheduler button.
51
S15_2 [IF ((SFIID3 = 1 | WEB = YES) & HH = YES & SELECT = YES) & (ROSTER = SCREENER RESPONDENT
& ROSTERPAYMENTINFO = YES & R30 = 1 | 2)] Thank you for your time. To show our
appreciation for completing this short survey today, we would like to send you the additional
.
, by either electronic pre-paid Visa or check .
incentive
payment, electronic pre-paid Visa, or check?>
1
2
4
Electronic pre-paid Visa. Please allow 1 to 2 weeks for processing.**
Check. Please allow up to 4 weeks for processing and delivery.**
3
NO, THANKS. DECLINE THE INCENTIVE.
DK/REF
HELPTEXT: The electronic pre-paid Visa card can be used for online shopping only.
S15_1 [IF S15_3 = 4 & HH = YES & SELECT = YES] Thank you for your time .
PLEASE HAND RESPONDENT THE CASH INCENTIVE.
IF THEY COMPLETED THIS SCREENING SURVEY.>
IF THEY COMPLETED THE HOUSEHOLD MEMBERSHIP
LISTING IN THIS SESSION WITH YOU AND AN ADDITIONAL FOR COMPLETING
THIS SCREENING SURVEY. IF THEY ONLY COMPLETE THE SCREENING SURVEY THEY SHOULD
ONLY RECEIVE .>
52
IF THEY COMPLETED THIS SCREENING SURVEY.
IF THEY COMPLETED THE HOUSEHOLD MEMBERSHIP
LISTING WITH YOU, AN ADDITIONAL FOR COMPLETING THIS SCREENING
SURVEY. IF THEY ONLY COMPLETE THE SCREENING SURVEY THEY SHOULD ONLY RECEIVE
the incentive as a thank you for completing this short interview.
S15_4 [IF JA = YES] Thank you for your time.
INTERVIEWER: PLEASE COLLECT FIRST AND LAST NAME OF THE RESPONDENT
FIRST NAME:
OPEN-ENDED RESPONSE OPTION
LAST NAME:
OPEN-ENDED RESPONSE OPTION
DK/REF
AND THEN SELECT IF INCENTIVES ARE ALLOWED FOR THIS RESPONDENT
1 INCENTIVES ALLOWED
2 INCENTIVES NOT ALLOWED
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE NONELECTRONIC PAYMENTS PLEASE
PROCEED HERE: PLEASE HAND RESPONDENT INCENTIVE OR TELL THE RESPONDENT
THAT THE FACILITY WILL HAND OUT THE INCENTIVE ().
1 INCENTIVE ACCEPTED / WILL ACCEPT INCENTIVE
2 INCENTIVE REFUSED
I HAVE CHECKED A BOX TO INDICATE THAT YOU THE INCENTIVE FOR COMPLETING THIS SCREENING SURVEY.
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE ELECTRONIC PAYMENTS PLEASE PROCEED
HERE: PLEASE COLLECT NECESSARY INFORMATION TO MAKE INCENTIVE PAYMENTS, E.G., TO
COMMISSARY OR JPAY. PLEASE DOUBLE-KEY ALL PAYMENT-RELATED INFORMATION.
______________________________(Allow 500 characters)
S15b1 [IF HH = YES & S15_3 = 1 & S11 EMAIL = BLANK] Please provide your email address to receive
the electronic pre-paid Visa.
53
________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER NOTE: IF WEB AND S15b1 = BLANK, SHOW ERROR MESSAGE: This information
is important so we can send you your incentive. Please enter your contact information.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S15b1 = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
S15b2 [IF HH = YES & S15_3 = 1 & S11 EMAIL != BLANK] We will send your electronic pre-paid Visa to
the email address you provided earlier.
S15c
[IF HH = YES & S15_3 = 2] Please provide your first and last name to receive your check.
First Name:**
OPEN-ENDED RESPONSE OPTION
Last Name:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER NOTE: IF WEB AND S15c = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S15c = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
S15d
[IF HH = YES & S15_3 = 2] Would you like us to mail your check to [ADDRESS FILL] or to another
address?
1
Yes, mail to [ADDRESS FILL]**
2
No, mail to another address**
DK/REF
S15e
[IF S15d = 2] What address do you want us to mail the check to?
Street**: (NUMBER AND STREET NAME)
City**: (CITY)
State**: (STATE)
ZIP: (ZIP)
DK/REF
PROGRAMMER NOTE: IF WEB AND S15e = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S15e = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
54
S16_trans
S16
[IF FI | TI ADMINISTERED] INTERVIEWER, PLEASE CLICK “NEXT” TO FINALIZE THIS CASE,
OTHERWISE CLICK BACK BUTTON TO MODIFY PREVIOUSLY ENTERED ANSWERS
This concludes our screening survey. Thank you for your participation.
S17
[IF HH = YES & FI | TI ADMINISTERED & # OF INDIVIDUALS SELECTED FOR SCREENING = 2] Is available for me to speak with now?
1
Yes**
2
No**
DK/REF
INTERVIEWER: IF ON THE PHONE: THE NEW INTERVIEW WILL OPEN IN A NEW WINDOW. PLEASE
COMPLETE THE DEBRIEFING ITEMS FOR THE FIRST INTERVIEW ONLY IF YOU HAVE TO WAIT FOR
THE SECOND PERSON TO COME TO THE PHONE. OTHERWISE, COMPLETE BOTH DEBRIEFINGS
AFTER THE INTERVIEWS.
PROGRAMMER NOTE: IF YES, BEGIN SECOND SCREENING SURVEY BY OPENING THAT CASE IN A
SEPARATE TAB/WINDOW.
S17_a Thank you.
PROGRAMMER TIME STAMP SET: END
55
SECTION 12: INTERVIEWER DEBRIEFING QUESTIONS
PROGRAMMER TIME STAMP SET: DEBRIEF
[IF SFIID3 = 1 | 2 | 3] THESE QUESTIONS ARE FOR THE INTERVIEWER TO ANSWER. DO NOT READ TO THE
R.
INTERVIEWER: ENTER PASSCODE TO CONTINUE:_____
IDB0
Did the respondent complete the entire screening survey or is this an incomplete
interview/breakoff?
1. RESPONDENT COMPLETE INTERVIEW
2. INCOMPLETE INTERVIEW/BREAKOFF
PROGRAMMER: GO TO IDBBR1 IF IDB0 = INCOMPLETE INTERVIEW/BREAKOFF
ELSE CONTINUE
IDB1
[IF SFIID3 = 2] How did the respondent complete the screening survey?
1. THE RESPONDENT COMPLETED THE SCREENING SURVEY WITH NO ASSISTANCE
FROM ME
2. THE RESPONDENT COMPLETED THE SCREENING SURVEY, BUT NEEDED
ASSISTANCE ON A FEW SCREENS
3. THE RESPONDENT COMPLETED THE SCREENING SURVEY, BUT NEEDED
ASSISTANCE ON MANY SCREENS
4. I ADMINISTERED THE ENTIRE INTERVIEW
IDB2
[IF IDB1 != 1|4] What type of assistance did you provide to R?
Check all that apply.
1. READ ONE OR MORE QUESTIONS TO R
2. HELPED R ENTER ONE OR MORE ANSWERS
3. HELPED R MOVE TO NEXT SCREEN
4. HELPED R BACK UP TO PREVIOUS SCREEN
5. HELPED R HIDE QUESTION TEXT
6. ANSWERED QUESTIONS ABOUT WHAT A QUESTION MEANT
7. OTHER (SPECIFY:_______________)
IDB3
[IF HH = YES & SFIID3 = 2 | 3] Did you conduct this interview at the respondent’s home,
either inside or outside?
1. YES
2. NO
IDB4
[IF IDB3 = NO | JA = YES] Where did you conduct this interview?
1.
2.
3.
4.
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5.
6.
7.
8.
9.
10. SOME OTHER PLACE (SPECIFY: _______________)
IDB5
[IF SFIID3 = 2 | 3] Please indicate how private the interview was. Do not count yourself
or a project observer as another person in the .
1. COMPLETELY PRIVATE – NO ONE WAS IN THE OR LISTENING
2. MOSTLY PRIVATE – PERSON(S) IN THE OR LISTENING LESS THAN HALF OF THE TIME
3. SOMEWHAT PRIVATE – PERSON(S) IN THE OR LISTENING ABOUT HALF OF THE TIME
4. NOT VERY PRIVATE – PERSON(S) IN THE OR LISTENING MORE THAN HALF OF THE TIME
5. NOT AT ALL PRIVATE – CONSTANT PRESENCE OF OTHER PERSON(S) IN THE OR LISTENING
IDB6
[IF IDB5 !=1] Not including yourself or project observers, who were the other people
present or listening to the interview?
Check all that apply.
1. PARENT(S)
2. SPOUSE
3. LIVE-IN PARTNER/BOYFRIEND/GIRLFRIEND
4. OTHER ADULT RELATIVE(S)
5.
6.
7. CHILD(REN) UNDER 18
8. OTHER
IDB6a
[IF IDB5 !=1] In what ways did the other people’s presence influence the interview?
Check all that apply.
1. PERSON(S) CAME INTO THE AND
YOU PAUSED THE INTERVIEW UNTIL THEY LEFT
2. PERSON(S) CAME INTO THE ,
YOU OR R ANSWERED THEIR QUESTION OR EXPLAINED THAT PRIVACY WAS
NEEDED, AND THEY LEFT
3. PERSON(S) STAYED IN THE BUT
DID NOT PARTICIPATE IN INTERVIEW
4. PERSON(S) STAYED IN THE AND
OFFERED R HELP WITH ANSWERS
5. PERSON(S) STAYED BUT WAS TOO YOUNG TO UNDERSTAND THE INTERVIEW
6. OTHER (SPECIFY: ___________________)
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IDB7
During the interview, was the atmosphere at the interview site:
1. EXTREMELY CHAOTIC AND NOISY; DISRUPTIVE TO INTERVIEW
2. SOME NOISE OR INTERRUPTIONS BUT INTERVIEW WENT REASONABLY
SMOOTHLY
3. VERY QUIET AND CALM, IDEAL FOR INTERVIEW
IDB8
What types of distractions or interruptions were present during the interview?
Check all that apply.
□ TELEVISION ON DURING INTERVIEW BUT R NOT WATCHING
□ TELEVISION ON DURING INTERVIEW WITH R WATCHING AT LEAST SOME OF THE
TIME
□ R RECEIVED 1 OR 2 PHONE CALLS
□ R RECEIVED 3 OR MORE PHONE CALLS
□ CHILDREN PRESENT NEEDED ATTENTION
□ OTHER (SPECIFY: ___________________)
□ NO DISTRACTIONS OR INTERRUPTIONS PRESENT
IDB9
How attentive was the respondent to the questions during the interview?
1. NOT AT ALL ATTENTIVE
2. SOMEWHAT ATTENTIVE
3. VERY ATTENTIVE
IDB10
Was the respondent upset during the interview?
1. YES, UPSET BECAUSE OF INTERVIEW CONTENT
2. YES UPSET, BUT NOT RELATED TO INTERVIEW CONTENT
3. NO, NOT UPSET
IDB11
While completing the interview, did the respondent experience any of the following
difficulties?
a.
b.
c.
d.
LANGUAGE/TRANSLATION PROBLEMS
READING OR VISION PROBLEMS
COMPREHENSION PROBLEMS
SUBSTANCE OF THE INTERVIEW (I.E., TOPICS WE
WERE ASKING ABOUT)
e. OTHER (SPECIFY: ___________________)
IDB13
Yes
No
[IF IDB1 = 1 | 2 | 3] Were you able to see the computer screen < IF IDB1 = 2 | 3: during
the parts of the interview that the respondent self-completed?>
1. I COULD SEE THE SCREEN THE ENTIRE TIME
2. I COULD SEE THE SCREEN ON MOST, BUT NOT ALL OF THE SELF-ADMINISTERED
QUESTIONS
3. I COULD SEE THE SCREEN ON A FEW SELF-ADMINISTERED QUESTIONS
4. I COULD NEVER SEE THE SCREEN DURING THE SELF-ADMINISTRATION
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IDB14
Did the respondent make any comments about the interview being too long?
1. YES
2. NO
IDB15
Please note anything else you think would be helpful for the interpretation and
understanding of this interview.
___________ALLOW 250 CHARACTERS
PROGRAMMER ALLOW FOR BLANK SUBMISSIONS
PROGRAMMER TIME STAMP SET: ENDDB
PROGRAMMER TIME STAMP SET: BEGINDBBR
IDBBR1
[IF BREAKOFF = YES] Please indicate if any of the following contributed to the interview
termination.
Yes
a. DISTRESSED RESPONDENT PROTOCOL INITIATED
b. RESPONDENT IS PHYSICALLY OR MENTALLY
INCABPABLE OF COMPLETING THE INTERVIEW
c. RESPONDENT NOTED THE INTERVIEW WAS TOO
LONG AND DID NOT WISH TO CONTINUE
d. RESPONDENT DID NOT HAVE TIME TO COMPLETE
THE INTERVIEW BUT IS WILLING TO COMPLETE AT
A LATER TIME
e. RESPONDENT DOES NOT WISH TO CONTINUE THE
INTERVIEW ALONE
f. RESPONDENT WAS STRESSED ABOUT THE
CONTENT OF THE INTERVIEW
g. EQUIPMENT PROBLEM
h. ABRUPT END, RESPONDENT DIDN’T GIVE A
REASON
i. OTHER (SPECIFY: ___________________)
PROGRAMMER CHECKBOX: NA (INTERVIEW WAS COMPLETED)
No
PROGRAMMER: IF IDBBR1 = NA GO TO IDB1
PROGRAMMER TIME STAMP SET: ENDDBBR
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Were you serious, introverted, or gloomy?
The littlest thing could make you sad.
Did you feel persistently sad or empty, blue, or down in the dumps?
Did your mood change rapidly from happy to sad and back again?
I felt sad.
Did you generally feel content?
How much did you experience positive feelings in your life?
How often did you have negative feelings, such as blue mood, despair, anxiety, depression?
How much did any feelings of depression bother you?
I felt gloomy.
Have you been depressed or sad?
Has there been a time when you have been seriously depressed?
I had a sense of harmony with myself.
How much of the time did you feel depressed?
I felt depressed.
How much of the time have you felt downhearted and blue?
How much have you felt really lively?
How much have you felt cheerful?
How much have you felt really happy?
How much have you felt sad?
How much have you felt dissatisfied with things?
How much have you been troubled or bothered by psychological or emotional problems?
How much of the time have you been in low or very low spirits?
I felt sad.
Were you in good spirits most of the time?
Did you feel happy most of the time?
How much were you distressed by feeling blue?
I have been feeling bad lately.
Did you experience long periods of sadness?
Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have experienced serious depression?
Have you felt emotionally exhausted?
I was happy.
I was unhappy.
Did you receive care for feeling depressed or blue?
How sad did you feel?
How happy did you feel?
Did you feel unhappy?
How often did you feel content with your life?
How often did you feel happy?
How often did you feel sad?
Have you been in low or very low spirits?
How depressed (at its worst) have you felt?
I was bothered by things that usually don''t bother me.
Did you often feel upset for no obvious reason?
Did you find yourself crying very easily?
Did you feel like crying and laughing at the same time?
Did you ever become very distressed or did you avoid things that evoked episodes of crying and/or intense emotions?
Have you cried?
Have you felt like crying even though you did not?
I had crying spells.
How often have you felt like crying?
I cry more than I used to.
I had crying spells or felt like it.
How much were you distressed by crying easily?
Did you find yourself needing to cry?
I felt weepy or tearful.
Were you deeply annoyed with everything?
Were you constantly complaining?
Did you tend to do the opposite of what people wanted you to do or to play the devil''s advocate?
Were you very irritable (for example, even the smallest thing could make you very irritable)?
Were you very irritable (for example, you found that you were particularly critical or sarcastic)?
Were you very irritable (for example, you had great difficulty seeing others'' points of view)?
Were you very irritable (for example, you were unusually argumentative or showed unusual hostility)?
Have you had trouble controlling your temper (for example, you felt that you really needed to even the score)?
Have you had trouble controlling your temper (for example, you found yourself shouting at people or starting arguments or fights, even over minor matters)?
Were you very impatient?
Did you ever feel irritable, have outbursts of anger or rage, or lose your temper over minor things?
How much of the time have you been in firm control of your behavior, thoughts, emotions, or feelings?
How much of the time have you felt emotionally stable?
How much of the time have you been moody or brooded about things?
How much difficulty have you been having in the area of mood swings or unstable moods?
Were you an excessively emotional person?
How often have you felt emotionally stable?
How often have you been moody or brooded about things?
My mood has been sad, but this sadness is like the sad mood I would feel if someone close to me died or left.
You completely lost your capacity to laugh, have fun, or enjoy your life.
How much did you enjoy life?
Were you bothered by any difficulties in your sex life?
How much were you able to relax and enjoy yourself?
How much did you enjoy your free time?
How much has pain interfered with your enjoyment of life?
I enjoyed life.
How much have you been able to laugh easily?
How much have you felt that nothing was enjoyable?
How much have you felt like you were having a lot of fun?
How much of the time has living been a wonderful adventure for you?
How much difficulty have you been having in the area of feeling satisfaction with your life?
I didn''t enjoy things the way I used to.
Have you been basically satisfied with your life?
Have you been able to enjoy your normal day-to-day activities?
I felt satisfied.
Did you have difficulty in becoming sexually aroused?
How happy, satisfied or pleased have you been with your personal life?
How much of the time have you generally enjoyed the things you do?
I could laugh and see the funny side of things.
I looked forward with enjoyment to things.
I could enjoy a good book, radio or tv program.
I still enjoyed sex.
My life was pretty full.
Have you had decreased libido?
Did you actually receive care for sexual problems or concerns?
I enjoyed sex as much as ever.
Did you enjoy the things you usually do for fun?
Was your sense of humor reduced?
You lost interest in how you looked.
Did your mood become depressed as a result of using alcohol, sleeping pills, anti-anxiety drugs, nicotine, caffeine, stimulants or similar substances even though you took them in order to feel better?
Did you lose interest and pleasure in your social life and did you prefer spending most of your time alone, withdrawing from your family and friends?
Did you lose interest in making new friends or find it difficult to make new friends?
Did you lose interest in your romantic life?
Did you lose interest in your hobbies or in playing games or sports?
Did you feel indifferent about everything (either positive or negative) that happened to you or your family?
Did you lose interest or pleasure in all or almost all the things you usually enjoyed?
Did you find that activities or things that used to be interesting or important to you became pointless, meaningless, or insignificant?
I was not interested in having sex.
How much of the time has your daily life been full of things that were interesting to you?
How much have you felt bored?
How much have you felt nothing was interesting or fun?
How much have you felt there were many interesting things to do?
I noticed that I was less interested in people or activities.
I was less interested in sex than I used to be.
How much of a problem was lack of sexual interest?
How much were you distressed by feeling no interest in things?
I did not feel like embracing, kissing, or caressing my partner.
Did you feel interest in anything?
Have you lost interest in the things you used to do?
Has your daily life been full of things that were interesting to you?
Did you feel frustrated and defeated although you couldn''t think of any reason for this?
Did you feel that you no longer had emotions you used to have or that your feelings were dulled?
I felt that I could not shake off the blues even with help from my family or friends.
How much of the time have you felt so down in the dumps that nothing could cheer you up?
My mood brightened when good events occurred, but I did not feel like my normal self.
My thinking was clear.
Did you drift in and out of conversations?
I had difficulty concentrating.
How much of the time did you have difficulty doing activities involving concentration and thinking?
I had trouble keeping my mind on what I was doing.
How much have you had trouble paying attention?
How much difficulty have you been having in the area of confusion, concentration, or memory?
How much were you distressed by trouble concentrating?
How much of the time did you have trouble keeping your attention on any activity for long?
My mind was as clear as it used to be.
Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
You had difficulty making even minor decisions (such as what shirt to wear, what household task to do first).
Did you have a lot of trouble thinking or concentrating, such as trouble taking part in a discussion, reading, writing, doing math, or following a television program?
How much of the time did you have difficulty reasoning and solving problems; for example, making plans, making decisions, learning new things?
How much have you had trouble making decisions?
I put off making decisions more than I used to.
I occasionally felt indecisive.
I found that my attention wandered.
I felt indecisive.
I found it easy to make decisions.
You couldn''t make decisions easily?
Did you have problems with your memory, such as finding the right word or remembering things that should have been easy to remember?
I had trouble remembering things.
How much of the time did you forget things that happened recently, where you put things, or appointments?
How much have you had trouble remembering things?
Did you feel you had more problems with memory than most?
How much were you distressed by trouble remembering things?
How much have you been bothered by poor memory for recent events?
Did you feel you had become forgetful?
Did you feel that your memory was failing?
Did your speech or thinking seem slowed down?
Did you experience time as passing very slowly?
Did you feel mentally dull or confused?
How much of the time did you react slowly to things that were said or done?
I found that my thinking was slowed down.
My voice sounded dull or flat.
Could you think as quickly as you used to?
How much have you been bothered by thoughts that are slow?
How much have you been bothered by not being able to find the right words?
Did you find that silly or unreasonable thoughts kept recurring in your mind?
Did you think there was nothing you could do to change the way things were going?
Did you see the future as very bleak?
How positive did you feel about the future?
How much have you been pessimistic about the future?
I felt discouraged about the future.
How often did you feel your life was moving in a positive direction?
Were you hypercritical or skeptical about all the things that people ordinarily value in life?
You felt very vulnerable.
You felt constantly afraid of doing something wrong.
Were you disappointed in yourself?
Did you feel useless, as if you were without any talent and you couldn''t do anything right?
How much have you been proud of yourself?
How much have you been disappointed in yourself?
How much have you felt good about yourself?
How much have you blamed yourself for things?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
I felt I have failed more than the average person.
I was disappointed in myself.
I was critical of myself for my weaknesses or mistakes.
I was more self-blaming than usual.
How much were you distressed by blaming yourself for things?
I sometimes had bad thoughts that made me feel ashamed of myself.
How often did you feel good about yourself?
You felt you had no purpose, as if everything had lost its significance?
Did you feel unappreciated because others did not understand or share your optimistic or imaginative ideas?
Did you feel happy about yourself as a person?
My life has been productive.
I felt that I was just as good as other people.
How much have you felt like a failure?
How much have you felt inferior to others?
How much have you felt successful?
How much have you felt confident?
How much have you felt worthless?
Did you think that most people were better off than you?
How much were you distressed by feelings of worthlessness?
I felt that I was useful and needed.
How often have you felt worthless?
Nothing you put on looked or felt right.
Was there any part of your appearance which made you feel uncomfortable?
I was self-conscious about my appearance.
I was self-conscious about how my face and neck looked.
How much have you felt unattractive?
I was worried that I was looking old or unattractive.
I lost interest in my appearance.
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Did you avoid activities that evoked feelings of loneliness or other distressing emotions?
Have you felt lonely?
How much of the time have you felt loved and wanted?
How much difficulty have you been having in the area of isolation or feelings of loneliness?
How much difficulty have you been having in the area of being able to feel close to others?
How much were you distressed by feeling lonely?
Did you feel isolated from others?
Did you find it unusually hard to take rejections, particularly those involving friendships or romantic relationships?
You felt as if others were causing all of your problems.
I felt that people disliked me.
How much of the time did you feel left out?
I occasionally felt rejected, slighted, criticized, or hurt by others.
How much were you distressed by feeling others were to blame for most of your troubles?
How much were you distressed by feeling others did not understand you or were unsympathetic?
How often did you feel disappointed and resentful?
How often did you feel rejected?
I was more sensitive than usual.
How often have you felt ignored by people?
How often did you feel left out?
I felt a sense of purpose in my life.
My life lacked meaning and purpose.
How much have you felt discouraged?
How much difficulty have you been having in the area of goals or direction in life?
Did you feel that your life was empty?
How much were you distressed by feeling hopeless about the future?
How much of the time did you feel that you had nothing to look forward to?
How often did you feel hopeless?
Did you believe that you had come to a "dead end"?
How much control did you feel you have had over your life?
How much difficulty have you been having in the area of developing independence?
Did you often feel helpless?
How often have you felt that you can''t take it anymore?
Did you feel you wanted to give up trying?
Did you have the feeling that you just didn''t have what it takes anymore?
Did you feel defeated?
I felt like I was at the end of my rope.
How often did you feel that the changes in your life were overwhelming?
I felt I should be punished.
I cheated at something and suffered unbearable feelings of remorse.
It depressed me that I did not do more for my parents.
I was concerned about being forgiven for my sins.
I did many things that made me feel remorseful afterward.
Failure gave me a feeling of remorse.
When I did wrong my conscience punished me quickly.
I often felt that I have not lived the right kind of life.
How much were you distressed by the idea that you should be punished for your sins?
How much were you distressed by feelings of guilt?
Did you regret much of your past behavior?
Did you feel guilty?
Have you had problems accomplishing less than you would like with your work or other regular daily activities as a result of emotional problems (such as feeling depressed or anxious)?
How often has feeling depressed interfered with what you usually do?
I found that the frequency of sexual intercourse had decreased for me.
I found it easy to do the things I used to do.
Have you cut down the amount of time you spent on work or other activities as a result of any emotional problems (such as feeling depressed or anxious)?
Did you have difficulty starting to do anything?
You felt passive, sluggish, and failed to take care of your usual commitments and responsibilities?
Have you had difficulty taking care of yourself (for example, you showered less, wore the same clothes, did not put on make-up or shave)?
Did your housework, child care or your performance at school, work, sports, or hobbies deteriorate?
How much did feelings of sadness or depression interfere with your everyday functioning?
Did you stop taking care of yourself (for example, not getting enough rest, not eating right)?
I felt motivated to do things.
How much emotional strain, stress, or pressure was associated with your usual daily activity (job, schoolwork, housework, or whatever you usually do)?
How much difficulty have you been having in the area of school (for example, academic performance, completing assignments, attendance)?
How often has feeling depressed interfered with what you usually do?
I felt emotionally drained from my work.
I felt burned out from my work.
Has feeling depressed interfered with what you usually do?
Have you accomplished less than you would like?
You didn''t do work or other activities as carefully as usual as a result of any emotional problems (such as feeling depressed or anxious)?
Did you have a lot of trouble getting out of bed in the morning?
Have you felt fatigued, weak, or tired as though the smallest task was an effort and required a great deal of energy?
I felt that everything I did was an effort.
I could not get "going".
How much have you needed to give extra effort to get started?
It took an extra effort to get started at doing something.
Did you have to make a special effort to face up to a crisis or difficulty?
How much were you distressed by feeling everything was an effort?
Did you feel that life was too much effort?
Did you shrink from your regular work as if it were a mountain to climb?
How easily did you get tired?
How much were you bothered by fatigue?
Have you felt as if you did not have enough energy?
Have you actually been sitting around a lot because of lack of energy?
How much have you gotten fatigued easily?
How much have you felt tired or sluggish?
I got tired more easily than I used to.
Have you been feeling run down?
Have you been feeling out of sorts?
Did you feel overly tired and exhausted?
I got tired for no reason.
Did fatigue interfere with your mood?
I felt guilty that I was too tired to do the things that I normally do.
When you felt sad, empty or depressed did you feel tired?
My fatigue-related limitations made me feel guilty.
To what degree has fatigue caused you distress?
Tiredness often made me irritable and I wanted to be left alone.
Did you feel physically slowed down, as if every movement was in slow motion?
Have you been feeling sluggish?
Did you feel that you had become slowed down in your physical movements?
How much have you felt slowed down?
I experienced periods of feeling physically weighted down and without physical energy but without a negative effect on my work, my school or my activity level.
Have you been taking longer with the things you do?
How much were you distressed by feeling low in energy or slowed down?
How much were you distressed by feeling blocked in getting things done?
How much were you distressed by having to do things very slowly to ensure correctness?
I felt as if I was slowed down.
Did you feel cut-off or detached, like you couldn''t connect with people or enjoy their company?
How much have you felt like being alone?
How much have you felt withdrawn from others?
How much have you felt like being with others?
Did you prefer to stay at home rather than going out and doing new things?
How often did you withdraw from other people?
Did you find it difficult to sit still or to lie down, or you needed to pace the room or to be constantly in motion?
Did you find your interests shifting frequently from one thing to another and were easily distracted?
I felt restless as if I had to always be on the move.
Did you repeatedly wake up in the middle of the night and have difficulty falling asleep again?
Did you repeatedly wake up much earlier than you wanted to, and were unable to go back to sleep?
I slept well.
Did you have more difficulty falling asleep or staying asleep than you did before?
I had difficulty sleeping.
Did you wake very early in the morning?
My sleep was restless.
More than half the time I awakened more than thirty minutes before I needed to get up.
Have you had difficulty staying asleep?
I had a restless, light sleep with a few brief awakenings each night.
How much were you distressed by trouble falling asleep?
How much were you distressed by awakening in the early morning?
How much were you distressed by sleep that was restless or disturbed?
Did you feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while sleeping)?
Have you had trouble falling asleep?
Did you awaken from sleep and have trouble falling asleep again?
Did you wake unusually early in the morning?
I used sleep as an escape.
I felt sleepy all the time.
I needed much more sleep than usual either at night or during the day.
Did you have bad dreams which upset you when you woke up?
I did not feel like eating; my appetite was poor.
How much have you had a loss of appetite?
My appetite was not as good as it used to be.
Has your appetite decreased?
I found food unappealing.
Have you lacked an appetite?
Have you been eating well?
I ate somewhat less often or lesser amounts of food than usual.
I felt the need to eat more frequently than usual.
How much were you distressed by overeating?
I was bothered by a change in weight.
I gained too much weight.
I lost more than five pounds.
I noticed that I was losing weight.
Did you repeatedly have distressing physical symptoms, for instance you were constipated?
Did you repeatedly have distressing physical symptoms, for instance you had nausea or other stomach or bowel problems?
Did you repeatedly have distressing physical symptoms, for instance frequent headaches?
Did you repeatedly have distressing physical symptoms, for instance your mouth felt dry?
Were you more sensitive or less sensitive than usual to heat, cold or pain?
Did your mood become depressed when you had some sort of medical problem such as the flu or a cold?
Did your mood become more depressed when you took medications, such as antibiotics, contraceptives, or steroids?
Did you feel as if your body were diseased or somehow transformed?
Have you felt that you were ill?
It was difficult (that is, more difficult than is common for your friends or acquaintances) for you to work or be productive in the early morning.
It was difficult (that is, more difficult than is common for your friends or acquaintances) for you to work or be productive in the evening or night.
Did you become irritable or have difficulty functioning if your daily routine was disrupted (for instance, you had to get up, eat or work at a time that wasn''t usual for you)?
Has there been any time of day when you felt slower and less energetic?
Did you think that life was not worth living?
Have you felt that life was not worth living?
I had a reason for living.
How often did you feel that others would be better off if you were dead?
I felt that life was empty or wondered if it was worth living.
Have you felt that life wasn''t worth living?
Did you think it was wonderful to be alive?
I felt that others would be better off if I were dead.
Have you found yourself wishing you were dead and away from it all?
Did you want to be dead at times?
Did you think about taking your own life?
Did you ever feel like you just couldn''t relax or let your guard down?
How much of the time have you been anxious or worried?
I felt anxious or tense.
How much of the time have you been anxious or worried?
I felt secure.
Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have experienced serious anxiety or tension?
I felt anxious.
I felt fearful.
How much have you felt afraid?
How much difficulty have you been having in the area of fear, anxiety or panic?
I felt frightened.
How much were you distressed by feeling fearful?
I got a sort of frightened feeling like "butterflies" in my stomach.
How much have you been bothered by feeling terrified?
How much have you been bothered by feeling scared?
Did you feel fearful?
Did you ever startle easily at the sound of sudden noises, when someone touched you, spoke to you, or approached you unexpectedly?
How much difficulty have you been having in the area of recognizing and expressing emotions appropriately?
How often have you experienced psychological or emotional problems?
How much have you been troubled or bothered by psychological or emotional problems?
I felt upset.
I felt comfortable.
I felt content.
I felt pleasant.
How much of the time have you felt emotionally stable?
Were you an excessively emotional person?
How often did you feel emotionally exhausted?
How often did you experience being troubled?
I felt upset because I didn''t get enough accomplished.
I was distressed.
Have you felt emotionally stable?
Did you have difficulty calming down?
Did you get rattled, upset, or flustered?
Have you ever suddenly and unexpectedly experienced the feeling that things around you were no longer familiar, but were unreal and strange?
Did you awaken in a panic for no reason?
I had mild panic episodes that did not change my behavior or stop me from functioning.
Have you recently been getting scared or panicky for no good reason?
How much were you distressed by suddenly feeling scared for no reason?
Did you feel panicky in crowds?
How much were you distressed by spells of terror or panic?
I had sudden feelings of panic.
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Did you sometimes feel really panicky?
Have you ever worried about hurting people''s feelings because of something you said or did?
Have you ever worried about disapproval or hostility from others?
How much did you worry about your safety and security?
How much did you worry about money?
Did you worry about almost everything?
Have you worried a lot about things?
I wished I could get over worrying about the things I have said that may have injured other people''s feelings.
Have you lost much sleep over worry?
I was worrying over possible misfortunes.
I worried about being fired.
How much were you distressed by worrying too much about things?
Did you find yourself worrying unreasonably about things that did not really matter?
My worries overwhelmed me.
Many situations made me worry.
I could not help myself from worrying about things.
I worried a lot when I was under pressure.
I was always worrying about something.
I found it easy to dismiss worrisome thoughts.
As soon as I finished one task, I started to worry about everything else I had to do.
Once I started worrying I couldn''t stop.
I worried about projects until they were all done.
Worrying thoughts went through my mind.
Would you say you were a worrying person?
I think that my fatigue came from worries, or stress.
Did you feel worried about your future?
Did you worry?
Did you experience a lot of distress because of thoughts that you might lose someone close to you or some harm might come to them?
Did you worry a lot that something bad would happen to you and lead to separation from someone close to you?
Have you worried that there might be something terribly wrong that you cannot define?
I felt uneasy.
How much have you felt something awful would happen?
I felt at ease.
Were you afraid that something bad was going to happen to you?
How much were you distressed by the feeling that something bad was going to happen to you?
How much have you been bothered by fear of the worst happening?
Did you stay in a relationship even when it was not in your best interest, rather than risk being alone?
Did you feel that you got involved in things when you didn''t want to because you couldn''t say no?
Did you feel particularly uncomfortable working or playing as part of a team?
Did you feel particularly embarrassed or uncomfortable meeting a new person?
Because of fear or unpleasant feelings, how much did you avoid worrying about projects until they were all done?
Because of fear or unpleasant feelings, how much would you avoid injections or minor surgery?
Because of fear or unpleasant feelings, how much would you avoid eating or drinking with other people?
Because of fear or unpleasant feelings, how much would you avoid hospitals?
Because of fear or unpleasant feelings, how much would you avoid traveling alone by bus?
Because of fear or unpleasant feelings, how much would you avoid walking alone in busy streets?
Because of fear or unpleasant feelings, how much would you avoid being watched or stared at?
How much were you distressed by having to avoid certain things, places or activities because they frightened you?
Because of fear or unpleasant feelings, how much would you avoid going into crowded shops?
Because of fear or unpleasant feelings, how much would you avoid talking to people in authority?
Because of fear or unpleasant feelings, how much would you avoid the sight of blood?
Because of fear or unpleasant feelings, how much would you avoid being criticized?
How much would you avoid going far from home alone because of fear or unpleasant feelings?
Because of fear or unpleasant feelings, how much would you avoid thoughts of injury or illness?
Because of fear or unpleasant feelings, how much would you avoid speaking or acting to an audience?
Because of fear or unpleasant feelings, how much would you avoid large open spaces?
Because of fear or unpleasant feelings, how much would you avoid going to the dentist?
Have you had distressing thoughts, feelings, or images that came into your head out of the blue?
How much difficulty have you been having with disturbing or unreal thoughts or beliefs?
How much difficulty have you had in the area of uncontrollable or compulsive behavior (for example, eating disorder, hand-washing, hurting yourself)?
How much were you distressed by repeated unpleasant thoughts?
How much were you distressed by worries of sloppiness or carelessness?
How much were you distressed by having to check and double check what you do?
Did you have to check things you do to an unnecessary extent?
Did it irritate you if your normal routine was disturbed?
How much were you distressed by having to repeat the same actions such as touching, counting, or washing?
How much were you distressed by having thoughts about sex?
How much were you distressed by thoughts and images of a frightening nature?
Did people ever say you were too conscientious?
I felt emotionally drained from my work.
I felt burned out from my work.
Have you cut down the amount of time you spent on work or other activities as a result of emotional problems?
Have you accomplished less than you would like as a result of emotional problems?
Did you often or were you told that you used very short phrases?
Did you often or were you told that you lowered your body and your head?
Did you often or were you told that you found it difficult to look others straight in the eye?
Did you often feel afraid that someone might misinterpret your glance?
Did you often feel afraid to look someone in the eyes because you felt that they could tell what you were thinking or feeling?
Did you often or were you told that you apologized frequently even when it was not necessary?
Did you often or were you told that you carefully controlled your movements?
Did you often or were you told that you fidgeted to reduce your anxiety?
Did you often or were you told that you clowned around to reduce your anxiety?
Did you often or were you told that you found it difficult to know where to look when talking to someone?
Did you often or were you told that you found it difficult to know what to do with your hands in social situations?
Did you often or were you told that you found you lost your breath when you talked to others?
Did you often or were you told that you played a role (not being yourself), in order to be more comfortable?
Did you often or were you told that you lied in order to be more comfortable?
Did you feel put upon or resentful because you couldn''t say no to a request?
How much of the time did you have difficulty reasoning and solving problems; for example, making plans, making decisions, learning new things?
How much have you had trouble making decisions?
I had a change of heart about my life''s work.
How much were you distressed by difficulty making decisions?
I found it easy to make decisions.
How much have you been bothered by not being able to make decisions?
My thinking was clear.
I had difficulty concentrating.
Were you bewildered or confused?
I did not do work or other activities as carefully as usual.
How much of the time did you have difficulty doing activities involving concentration and thinking?
How much have you felt confused?
How much of the time did you forget things (for example, things that happened recently, where you put things or appointments)?
How much were you distressed by your mind going blank?
Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
Have you ever suddenly and unexpectedly experienced feeling afraid that you might lose control or go crazy?
Have you ever suddenly and unexpectedly experienced feeling afraid that you might die?
Did you feel that you were about to lose control of your behavior?
Have you been afraid of or did you avoid taking prescribed medication because it might cause you to lose control or might change your personality?
Have you worried a lot that there might be something terribly wrong with you mentally, like losing your mind or losing control?
Have you had any reason to wonder if you were losing your mind?
How much have you felt afraid of losing control?
How much have you felt like you were going crazy?
How much have you felt afraid of dying?
When I noticed my heart was beating rapidly, I worried that I might have a heart attack.
How much were you distressed by feeling afraid you will faint in public?
How much have you been bothered by a fear of dying?
How much were you distressed by the idea that something serious was wrong with your body?
How much were you distressed by the idea that something was wrong with your mind?
Have you felt frightened or worried about falling in public?
Did you experience a lot of distress if you were separated or anticipated separation from home or loved ones?
Did you have trouble going to school or work because of fear of separation?
Has it been very difficult for you to be alone or with a loved one, either at home or in other places?
Did you have repeated nightmares about being separated from your family?
Did you feel nervous or uncomfortable when you were alone outside your home or somewhere far from home?
Did you feel nervous or uncomfortable when home alone?
Did you feel nervous or uncomfortable when you were in a crowded place?
Did you feel nervous or uncomfortable when you were in closed places?
Did you feel nervous or uncomfortable being in an open place like a town square or a wide street?
Did you ever feel afraid to go to bed or to go to sleep?
I became nervous when I was waiting to see the doctor.
I became nervous when I got my blood drawn.
How much were you distressed by feeling afraid in open spaces or on the streets?
How much were you distressed by feelings of being trapped or caught?
How much were you distressed by feeling afraid to go out of your house alone?
How much were you distressed by feeling afraid to travel on buses, subways or trains?
Did you worry excessively when relatives were late coming home?
Were you scared of heights?
How much were you distressed by feeling uneasy in crowds such as shopping or at a movie?
How much were you distressed by feeling nervous when you were left alone?
Did you have an unreasonable fear of being in enclosed spaces such as stores, elevators, etc.?
Did you feel uneasy traveling on buses or the subway even if they were not crowded?
Did you dislike going out alone?
How often did you feel trapped?
When my stomach was upset, I worried that I might be seriously ill.
It scared me when I was unable to keep my mind on a task.
Other people noticed when I felt shaky.
Unusual body sensations scared me.
It scared me when I was nervous.
It was important to me not to appear nervous.
When I couldn''t keep my mind on task, I worried that I might be going crazy.
It scared me when I felt shaky.
It scared me when I felt faint.
It scared me when my heart beat rapidly.
It embarrassed me when my stomach growled.
It scared me when I was nauseous or sick to my stomach.
It scared me when I became short of breath.
I had difficulty asking doctors questions.
Have you ever been very worried that people might be critical of you?
Have you ever felt that the fear of being judged by others affected your relationships?
Have you ever worried that you might be unappealing to others?
Have you ever worried that others considered you stupid, clumsy or ridiculous?
Did you feel you were physically unattractive?
Did you feel you needed to dress in a manner that didn''t call any attention to yourself?
Did you feel particularly embarrassed or uncomfortable when you had to undress in front of another person?
When talking on the phone did you sometimes become self-conscious of the sound of your voice?
When talking on the phone did you sometimes find it difficult to understand or remember what the other person said?
When talking on the phone did you sometimes feel embarrassed to talk when other people were present?
When talking on the phone did you sometimes find it difficult to think of what to say?
When attending or giving a party or meeting your friends, did you feel embarrassed or uncomfortable?
When attending or giving a party or meeting your friends, did you feel afraid of meeting people?
When attending or giving a party or meeting your friends, did you feel afraid of not being able to make conversation?
When at a party or meeting with your friends, did you feel afraid that you were not interesting?
When attending or giving a party or meeting your friends, did you feel afraid of being judged?
When attending or giving a party or meeting your friends, did you feel afraid that your guests might criticize your home or hospitality?
Did you feel embarrassed or uncomfortable when you had to ask someone you liked to get together, work on a project, play a sport or join you in some other activity?
Did you feel embarrassed or uncomfortable when you had to express romantic feelings to someone you liked?
Did you feel embarrassed or uncomfortable when you had to think about getting undressed in front of someone you liked?
I was self-conscious about my appearance.
I felt that people disliked me.
At parties I was more likely to sit by myself or with just one other person than to join in with the crowd.
I did not want to be a member of a crowd or gang.
How much were you distressed by feeling shy or uneasy with the opposite sex?
How much were you distressed by your feelings being easily hurt?
How much were you distressed by feeling that people were unfriendly or disliked you?
How much were you distressed by feeling inferior to others?
How much were you distressed by feeling that you were watched or talked about by others?
Did you sometimes find yourself posing or pretending?
How much were you distressed by feeling uneasy when people were watching or talking about you?
How much were you distressed by feeling very self-conscious with others?
How much were you distressed by feeling uncomfortable about eating or drinking in public?
How much were you distressed by feeling lonely even when you are with people?
I had difficulty initiating contact with potential dates.
How much have you been bothered by not being able to take things in when speaking to people?
I was more sensitive than usual.
I felt embarrassed in public.
I felt worried about other people''s reaction to me.
Did you feel particularly embarrassed or uncomfortable meeting a person of the opposite sex?
Did you feel that no one could be interested in you romantically?
Did you feel that it was difficult to reject the advances of someone out of fear of hurting them?
Did you feel that it was difficult to accept the advances of someone because you couldn''t believe that he or she was really interested in you?
Did you feel that your partner was judging your performance during sexual activities?
Did you feel inadequate in everyday relationships, even with people like co-workers, sales people, or peers?
Did you feel unable to criticize your partner''s behavior even if you thought you should?
Did you feel extremely uncomfortable or wounded when others did not approve of your ideas or what you do?
Did you feel unable to state your opinions during a discussion?
Did you feel unable to disagree during a discussion?
Did you avoid, if possible, disagreeing with or expressing disapproval to others?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
Did you avoid going to bed because you might become ill or die while asleep?
Did you feel as though you were about to suffocate because of hot, stale or humid air, or because of perfume, or other smells?
Did you feel nervous or uncomfortable because of the dark?
Did you feel nervous or uncomfortable because of noises, even when the noise was not loud?
Did you feel nervous or uncomfortable because of a blurred view such as fog, open sea, or snowy landscape?
Did you read the package inserts more carefully than most other people because of feeling nervous or uncomfortable about taking medication?
I had trouble feeling peace of mind.
How much of the time have you been a very nervous person?
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How much have you felt nervous?
I believed I was more nervous than other people.
I have been made especially nervous over trouble with members of my family.
Have you recently been feeling nervous and uptight all the time?
Have you found you couldn''t do anything because your nerves were too bad?
How much were you distressed by nervousness or shakiness inside?
How much have you been bothered by nervousness or your nerves?
I felt calm.
How much have you been able to relax and enjoy yourself?
Did you feel tense?
How tense or anxious have you been?
I felt irritable.
Have you felt constantly under strain?
Have you felt overwhelmed and found everything getting on top of you?
I was relaxed.
Did you often feel tense or strung up inside?
How much were you distressed by feeling tense or keyed up?
How much have you been bothered by being unable to relax?
How tense did you feel?
How often did you feel that the changes in your life were overwhelming?
How much have you been restless?
How much have you felt "on edge" or keyed up?
How much were you distressed by feeling so restless you couldn''t sit still?
Did you feel uneasy and restless?
I have been restless and couldn''t keep still.
Have you felt restless, fidgety, or impatient?
How much have you been easily startled?
Did you often complain of physical symptoms when separated from someone close to you, or when you thought you might be separated from someone close to you?
Have you ever suddenly and unexpectedly experienced feeling cut-off from yourself or from parts of your body?
Did you feel as if something had broken in your brain or body?
Have you noticed that any of the above symptoms come on very easily when you''re in a stressful situation, even when it was not that severe?
Have you noticed that any of the above symptoms come on right after a stressful situation is over?
Did you experience any of the above symptoms when you used coffee, tea or other caffeinated beverages?
Did you experience any of the above symptoms when you used cold medicine, nasal sprays, thyroid, sleep, or antidepressant medications?
Did you experience any of the above symptoms when you used cocaine, amphetamines, or other uppers?
Did you avoid taking prescribed medications because you thought they might hurt you?
Have you been afraid of or did you avoid taking a prescribed medication because you thought it might cause you permanent brain damage?
Have you worried a lot that there might be something terribly wrong with you physically, as if, for instance, you were about to have a heart attack, stroke, suffocate, or die?
Did you worry about having a serious physical illness, when you heard about someone else who had it?
Did you worry about reading medical articles or hearing someone talk about medical topics?
Did you worry about getting results of lab tests or having your pulse or blood pressure checked?
Did you worry about seeing medical tools or being in medical settings?
Did you feel that you needed to be comforted and reassured by your friends and family?
Did you seek help from your parents, spouse, friends or neighbors because of these symptoms?
Did you use emergency services or call a doctor at home because you needed reassurance?
Did you request admission to a hospital in order to be protected or reassured even though your doctor felt this was unnecessary?
Did you have your pulse or blood pressure checked repeatedly, even though your doctor didn''t recommend it?
Did you make repeated requests for special diagnostic procedures even though your doctor didn''t recommend it?
Did you ask for medical lab tests even when your doctor didn''t recommend them?
Did you need to check whether there was a doctor or emergency service nearby when you were going someplace new?
In order to cope with the above symptoms did you need to have someone with you most of the time?
In order to cope with the above symptoms did you need to sit near the exit at the movies, theater, church or similar places?
In order to cope with the above symptoms did you need to take a cellular phone with you or check for the availability of a public telephone in the place where you were going?
In order to cope with the above symptoms, did you need to be sure you had tranquilizers in your pocket or purse, although your doctor hadn''t prescribed them, or prescribed them in the past but thought they weren''t necessary anymore?
In order to cope with the above symptoms did you need to take a bottle of water or another beverage with you when you went somewhere?
In order to cope with the above symptoms did you need to take your dog with you?
In order to cope with the above symptoms did you need to wear a hat when you went out?
In order to cope with the above symptoms did you need to take candy or gum with you when you went out?
In order to cope with the above symptoms did you need to take a good luck charm with you?
In order to cope with the above symptoms did you need to wear sunglasses, even in a dark environment?
In order to cope with the above symptoms did you need to use alcohol or sedatives?
In order to cope with the above symptoms did you need to have a special relationship with doctors to be sure they would take good care of you?
In order to cope with the above symptoms did you need to keep a light on in the bedroom in order to fall asleep?
I worried about dying.
I worried that my condition will get worse.
I had a change in weight.
I worried about the effect of stress on my illness.
Did you feel weighed down by your health problems?
Were you afraid because of your health?
Did you feel despair over your health problems?
I worried about catching diseases.
I was worried about physical problems such as aches and pains, upset stomach or constipation.
I have been concerned about my health.
How much were you distressed by thoughts of death or dying?
I was so sick I thought I might die.
Did you find yourself worrying about getting some incurable illness?
I noticed that I am losing weight.
Have you ever suddenly and unexpectedly experienced your heart pounding, racing, or skipping?
Have you ever suddenly and unexpectedly experienced feeling chest pain or pressure?
How much have you had pain in your chest?
How much have you had a racing or pounding heart?
How much were you distressed by pains in your heart or chest?
How much were you distressed by your heart pounding or racing?
Did you often suffer from excessive sweating or fluttering of the heart?
How much have you been bothered by your heart pounding or racing?
My heart beat faster than usual.
I had trouble breathing.
How much have you had shortness of breath?
How much have you been bothered by difficulty breathing?
Were you troubled by dizziness or shortness of breath?
Have you ever suddenly and unexpectedly experienced feeling nauseated, having an upset stomach, or diarrhea?
Did you feel that you could not control your bladder or bowels?
Did you often have the urge to urinate?
Have you had a sinking feeling in the pit of your stomach?
How much have you had diarrhea?
How much have you felt nauseous or sick to your stomach?
How much have you had an upset stomach?
How much were you distressed by nausea or upset stomach?
Did you often feel sick or have indigestion?
I had trouble with constipation.
Have you ever suddenly and unexpectedly experienced feeling dizzy, unsteady, or faint?
Have you ever suddenly and unexpectedly experienced having flushes or chills?
Did you often tremble?
Did you often sweat?
How easily did you get tired?
Did you have headaches?
How much have you gotten fatigued easily?
How much have you felt faint?
How much have you had to frequently urinate?
How much have you had shaky hands?
How much have you had cold or sweaty hands?
How much have you felt dizzy or lightheaded?
How much have you had dry mouth?
How much have you had twitching or trembling muscles?
How much have you had tense or sore muscles?
How much have you been trembling or shaking?
How much have you felt numbness or tingling?
How much difficulty have you been having in the area of physical symptoms (for example, headaches, aches and pains, sleep disturbance, stomach aches, dizziness)?
I felt pain in the back of my neck.
Have you had hand tremors?
I felt nervous or on edge.
I felt steady.
How much were you distressed by headaches?
How much were you distressed by faintness or dizziness?
How much were you distressed by trembling?
How much were you distressed by poor appetite?
How much were you distressed by pains in your lower back?
How much were you distressed by hot or cold spells?
How much were you distressed by numbness or tingling in parts of your body?
How much were you distressed by feeling weak in parts of your body?
How much were you distressed by heavy feelings in your arms and legs?
How much have you been bothered by feeling hot?
How much have you been bothered by wobbliness in your legs?
How much have you been bothered by feeling unsteady?
How much have you been bothered by your hands trembling?
How much have you been bothered by feeling shaky?
How much have you been bothered by feeling faint?
How much have you been bothered by your face being flushed?
How much have you been bothered by sweating (not due to heat)?
Have you felt as though you might faint?
I got tired for no reason.
To what degree did fatigue cause you distress?
Did you feel as if you were walking on foam rubber or had the sensation that your legs were jelly?
Did you feel that you were walking awkwardly, or like your legs were made of wood?
How much did any sleep problems worry you?
Have you had any physical sensations, such as pain, palpitations, sweating, headache, etc.?
Have you had trouble sleeping?
Did you have trouble falling asleep?
Did tension prevent you from falling asleep?
My sleep was restless.
How much of the time have you had trouble falling asleep?
How much of the time have you had trouble staying asleep?
I have been easily awakened by noise.
I didn''t sleep as well as usual.
More than half the time I woke up more than 30 minutes before I needed to get up.
Have you had difficulty staying asleep?
I had a restless, light sleep with a few brief awakenings each night.
I had trouble sleeping at night.
How much were you distressed by trouble falling asleep?
Could you fall asleep quickly?
Did you have bad dreams which upset you when you woke up?
How much were you distressed by awakening in the early morning?
How much were you distressed by sleep that is restless or disturbed?
Did you feel overly tired and exhausted?
How often did you feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while sleeping)?
How often did you have trouble falling asleep?
How often did you awaken during your sleep time and have trouble falling asleep again?
Did you wake unusually early in the morning?
Have you slept more than usual in response to physical health or emotional problems?
Have you ever suddenly and unexpectedly experienced the feeling that you are choking?
Have you ever suddenly and unexpectedly experienced tingling or numbness in parts of your body?
Did you feel that you had lost your sight or hearing for a few seconds?
Did you often blush?
Did you have trouble going to sleep without someone nearby, or trouble sleeping away from home?
Did you avoid having anesthesia or taking sleeping pills because you might feel sick or even die while going to sleep?
Have you had periods of at least 3 days in which your mood became irritable or elevated when you had a medical problem such as the flu or a cold?
Have you had periods of at least 3 days in which your mood became irritable or elevated when you took medications, such as antibiotics, contraceptives, or steroids?
Have you had periods of at least 3 days in which your mood became irritable or elevated when you were abusing alcohol, sedatives, hypnotics, anxiolytics, other substances?
Have you had periods of at least 2 days in which your mood became irritable or elevated within a month of withdrawal from alcohol, sedatives, hypnotics, anxiolytics, or other substances?
Have you had periods of at least 3 days in which you felt persistently good or high?
Have you had periods of at least 3 days in which even the smallest thing could make you very enthusiastic?
Have you had periods of at least 3 days in which you were full of plans or got involved in many projects, jumping from one activity to another?
Have you had periods of at least 3 days in which you (or others) found that your sense of humor was very acute?
Have you had periods of at least 3 days in which you liked to make jokes, puns, or plays on words?
Have you had periods of at least 3 days in which you liked to make a lot of jokes, even ones that might have been inappropriate or out of place?
Have you had periods of at least 3 days in which you were intrusive, insulting, or tactless, or others thought that you were?
Have you had periods of at least 3 days in which you were warm, extroverted and sociable and it was very easy to introduce yourself to others or to make new friends?
Have you had periods of at least 3 days in which you were the kind of person to whom others were attracted because of your confidence, enthusiasm, and energy?
Have you had periods of at least 3 days in which you enjoyed being the center of attention or were particularly seductive or flirtatious, as if you were playing a role?
Have you had periods of at least 3 days in which you felt an irresistible urge to communicate by phone calls, letters, e-mails or faxes?
Have you had periods of at least 3 days in which you felt a strong desire to reconnect with people you hadn''t seen or spoken with for a long time?
Have you had periods of at least 3 days in which you were overly talkative, spoke rapidly and loudly, or were difficult to interrupt or had little regard for others'' wishes to speak?
Have you had periods of at least 3 days in which you were so noisy that others complained?
Have you had periods of at least 3 days in which you were overly curious and interested in everything and everybody?
Have you been the type of person or have others told you that you liked being the center of attention?
Have you had periods of at least 3 days in which you spent a lot of time on social, political or religious causes?
Have you had periods of at least 3 days in which you wore clothing or a hairstyle that was dramatic, extravagant, very high fashion or very unusual?
Have you been the type of person or have others told you that you were provocative?
Have you had periods of at least 3 days in which you were very assertive?
Have you had periods of at least 3 days in which you felt vigorous, much livelier than usual and full of energy?
Have you had periods of at least 3 days in which you were constantly active and had the pleasant sensation of never getting tired and your energy was so high that it exhausted or irritated others?
Have you had periods of at least 3 days in which your housework, child care, or your performance at school, work, sports, or hobbies improved a lot?
Have you had periods of at least 3 days in which you found it very pleasurable and easy to buy things, even things you didn''t need?
Have you had periods of at least 3 days in which you gave lots of presents, even when you really couldn''t afford them?
Have you had periods of at least 3 days in which you had difficulty saying no to business or social opportunities, even when you knew you did not have time for them?
Have you had periods of at least 3 days in which you found it very pleasurable and exciting to get involved in dangerous, risky, challenging or emotionally intense activities?
Have you had periods of at least 3 days in which you were (or other people judged you to be) irresponsible?
Have you had periods of at least 3 days in which you made a very important decision (such as selling or buying a house or car, or changing jobs) extremely rapidly?
Have you had periods of at least 3 days in which you did such things as spend too much money?
Have you had periods of at least 3 days in which you did such things as drive recklessly or speeding?
Have you had periods of at least 3 days in which you did such things as make foolish business decisions?
Have you had periods of at least 3 days in which you tended to ignore everyday rules and social etiquette or engaged in illegal activities?
Did you ever engage in risk-taking behaviors, such as driving fast, promiscuous sex, hanging out in dangerous neighborhoods?
Did you ever intentionally cut or burn yourself?
Have you been the type of person or have others told you that you usually found exciting what others would find frightening?
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Have you been the type of person or have others told you that you often engage in reckless or dangerous activities?
Have you had periods of at least 3 days in which you had a particularly intense romantic life?
Have you had periods of at least 3 days in which you felt as if you would like to run away from your current life, for example, by getting on the highway and driving away or just getting on a bus or a plane with no destination in mind?
Have you had periods of at least 3 days in which you felt surrounded by hostility, as if everybody was against you, for example, you thought that everybody accused and hated you?
Have you had periods of at least 3 days in which you felt surrounded by hostility, as if everybody was against you, for example, you felt as if everybody was looking at you?
Have you had periods of at least 3 days in which you felt surrounded by hostility, as if everybody was against you, for example, you thought you were being persecuted or that you were wanted by the police?
Have you had periods of at least 3 days in which you felt as if everyone was talking about you?
Did you ever find that you were especially watchful, on edge, or on guard, for example, checking to see who or what was around you, feeling uncomfortable with your back to the door or needing to have your bed in a protected position?
Have you had periods of at least 3 days in which you were preoccupied with yourself and your own problems, thoughts, and feelings?
Have you had periods of at least 3 days in which you were very preoccupied with money even though you didn''t have any real financial problems?
Have you had periods of at least 3 days in which you felt self-assured, charismatic or tended to assume a leadership role?
Have you had periods of at least 3 days in which you felt you were always right, incapable of making mistakes and indifferent to criticism?
Have you had periods of at least 3 days in which you thought that you could make decisions for others because you knew their thoughts, intentions, or wishes?
Have you had periods of at least 3 days in which you had unusually high self-esteem, feelings of superiority or unrealistic ideas that you had amazing abilities, talents, knowledge or powers?
Have you had periods of at least 3 days in which you felt that your ideas came and went unusually easily, as if your thoughts were racing?
Have you had periods of at least 3 days in which you had so many thoughts and ideas all at once that you found it difficult to express them?
Have you been the type of person or have others told you that you often follow your instinct without really thinking about what you are doing?
Have you had periods of at least 3 days in which you heard voices speaking against you, or voices that were hostile to you or swore at you?
Have you had periods of at least 3 days in which you heard voices clearly?
Have you had periods of at least 3 days in which you (or others) thought you were very artistic or creative?
Have you had periods of at least 3 days in which you had bursts of inspiration or creativity (for instance, rapidly and easily wrote prose or poetry or composed music, painted, sculpted, or did other crafts)?
Have you had periods of at least 3 days in which you felt you were mentally very sharp, brilliant and clever?
Have you had periods of at least 3 days in which you felt like you had ESP?
Have you had periods of at least 3 days in which you were particularly sensitive to the forms and harmony in nature?
Have you had periods of at least 3 days in which you felt a strong need to take refuge in religion or prayer?
Have you had periods of at least 3 days in which you were unusually spiritual or mystical?
Have you had periods of at least 3 days in which you felt you had direct access to the truth, could see the grand scheme of things, understand the meaning of existence?
Have you had periods of at least 3 days in which you heard voices that inspired or praised you?
Have you had periods of at least 3 days in which you had mystical experiences or visions?
Have you had periods of at least 3 days in which you felt particularly strong and invulnerable, resistant to illnesses and accidents?
Have you had periods of at least 3 days in which you found that your mood, energy, interest and efficiency improved if you were in a regular routine?
Have you had periods of at least 3 days in which you were the kind of person whose mood, energy and physical well-being changed over the course of your menstrual cycle?
Have you had periods of at least 3 days in which you were the kind of person whose mood, energy and physical well-being changed when you traveled across more than 4 time zones?
Have you had periods of at least 3 days in which the quality of your sleep or your need for sleep increased when you traveled across at least 4 time zones?
Have you had periods of at least 3 days in which the quality of your sleep or your need for sleep decreased when you traveled across at least 4 time zones?
Have you had periods of at least 3 days in which you were the kind of person whose mood, energy and physical well-being changed in a dependable way in response to the weather?
Have you had periods of at least 3 days in which you had a lot of difficulty sleeping before or after stimulating physical, social, or professional activities?
Have you had periods of at least 3 days in which if, for some reason, you got much less sleep than is normal for you, you found that you actually had more energy rather than less the next day?
Have you had periods of at least 3 days in which you went for days without sleeping or with much less sleep than usual but didn''t feel tired?
Have you had periods of at least 3 days in which you were less sexually active than is typical for you?
Have you had periods of at least 3 days in which you had difficulty becoming sexually aroused?
Have you had periods of at least 3 days in which you were more interested in sex?
Have you had periods of at least 3 days in which you frequently changed sexual partners?
Have you had periods of at least 3 days in which there was no food that appealed to you or tasted good to you?
Have you had periods of at least 3 days in which you constantly craved sweets or carbohydrates?
Have you had periods of at least 3 days in which your appetite or weight increased?
Have you had periods of at least 3 days in which your appetite or weight decreased?
How much of the time did you have difficulty doing activities involving concentration and thinking?
Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
How much were you distressed by feeling so restless you couldn''t sit still?
I have been restless and couldn''t keep still.
How much have you felt slowed down?
How much have you felt tired or sluggish?
I felt that everything I did was an effort.
How easily did you get tired?
Did you feel guilty?
How much have you blamed yourself for things?
How much were you distressed by blaming yourself for things?
I had difficulty concentrating.
How much difficulty have you been having in the area of confusion, concentration, or memory?
Did you feel persistently sad or empty, blue, or down in the dumps?
I felt sad.
How much of the time did you feel depressed?
How much of the time have you felt downhearted and blue?
How much did any feelings of depression bother you?
Did you experience long periods of sadness?
How much have you felt nothing was interesting or fun?
How much were you distressed by feeling no interest in things?
How much have you felt that nothing was enjoyable?
Did you think about taking your own life?
I felt that life was empty or wondered if it was worth living.
How often did you feel that others would be better off if you were dead?
Have you actually had any thoughts of killing yourself?
Have you had any intention of acting on these thoughts of killing yourself? As opposed to you have the thoughts, but you definitely would not act on them?
Have you started to work out, or actually worked out, the specific details of how to kill yourself and did you actually intend to carry out the details of your plan?
In the past 3 months, have you done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn''t swallow any, held a gun but changed your mind about hurting yourself or it was grabbed from your hand, went to the roof to jump but didn''t; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
Is the child participating in this assessment 12 or older?
How much have you felt afraid?
How much were you distressed by feeling fearful?
How much have you been troubled or bothered by psychological or emotional problems?
I felt upset.
I was distressed.
Did you have difficulty calming down?
How much were you distressed by spells of terror or panic?
How much have you felt something awful would happen?
Because of fear or unpleasant feelings, how much would you avoid eating or drinking with other people?
How much were you distressed by having to avoid certain things, places or activities because they frightened you?
How much would you avoid going far from home alone because of fear or unpleasant feelings?
How much difficulty have you been having with disturbing or unreal thoughts or beliefs?
How much were you distressed by repeated unpleasant thoughts?
How much of the time did you have difficulty reasoning and solving problems; for example, making plans, making decisions, learning new things?
Were you bewildered or confused?
How much have you felt confused?
Did you feel that you were about to lose control of your behavior?
Have you worried a lot that there might be something terribly wrong with you mentally, like losing your mind or losing control?
Have you had any reason to wonder if you were losing your mind?
How much have you felt afraid of losing control?
How much have you felt like you were going crazy?
How much were you distressed by the idea that something was wrong with your mind?
Did you feel uneasy traveling on buses or the subway even if they were not crowded?
It scared me when I was nervous.
When I couldn''t keep my mind on task, I worried that I might be going crazy.
I felt that people disliked me.
How much were you distressed by feeling that people were unfriendly or disliked you?
How much were you distressed by feeling lonely even when you are with people?
How much have you been bothered by not being able to take things in when speaking to people?
Did you feel inadequate in everyday relationships, even with people like co-workers, sales people, or peers?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
I worried that my condition will get worse.
How much were you distressed by thoughts of death or dying?
I felt sad.
How often did you have negative feelings, such as blue mood, despair, anxiety, depression?
I felt gloomy.
How much of the time did you feel depressed?
I felt depressed.
How much of the time have you felt downhearted and blue?
How much have you been troubled or bothered by psychological or emotional problems?
How much of the time have you been in low or very low spirits?
How much were you distressed by feeling blue?
Did you experience long periods of sadness?
I was unhappy.
How sad did you feel?
How often did you feel sad?
Have you been in low or very low spirits?
How often have you felt like crying?
You completely lost your capacity to laugh, have fun, or enjoy your life.
How much have you felt that nothing was enjoyable?
How much difficulty have you been having in the area of feeling satisfaction with your life?
Did you lose interest in making new friends or find it difficult to make new friends?
Did you find that activities or things that used to be interesting or important to you became pointless, meaningless, or insignificant?
How much have you felt nothing was interesting or fun?
How much were you distressed by feeling no interest in things?
Have you lost interest in the things you used to do?
I felt that I could not shake off the blues even with help from my family or friends.
How much of the time have you felt so down in the dumps that nothing could cheer you up?
I had trouble keeping my mind on what I was doing.
How much have you had trouble making decisions?
You couldn''t make decisions easily?
Did you see the future as very bleak?
How much have you been disappointed in yourself?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
How much were you distressed by blaming yourself for things?
You felt you had no purpose, as if everything had lost its significance?
How much have you felt like a failure?
How much have you felt inferior to others?
How much have you felt worthless?
How much were you distressed by feelings of worthlessness?
How often have you felt worthless?
How much difficulty have you been having in the area of isolation or feelings of loneliness?
How much difficulty have you been having in the area of being able to feel close to others?
Did you feel isolated from others?
I felt that people disliked me.
How much of the time did you feel left out?
How often did you feel disappointed and resentful?
How often have you felt ignored by people?
How often did you feel left out?
My life lacked meaning and purpose.
How much have you felt discouraged?
How much were you distressed by feeling hopeless about the future?
How much of the time did you feel that you had nothing to look forward to?
How often did you feel hopeless?
Did you believe that you had come to a "dead end"?
Did you often feel helpless?
How often have you felt that you can''t take it anymore?
Did you feel you wanted to give up trying?
Did you have the feeling that you just didn''t have what it takes anymore?
I felt like I was at the end of my rope.
I felt I should be punished.
How much were you distressed by feelings of guilt?
Did you feel guilty?
How much did feelings of sadness or depression interfere with your everyday functioning?
Has feeling depressed interfered with what you usually do?
Did you feel that life was too much effort?
Have you been feeling out of sorts?
How much have you felt withdrawn from others?
How often did you withdraw from other people?
Have you been feeling in need of some medicine to pick you up?
Did you think that life was not worth living?
Have you felt that life was not worth living?
I had a reason for living.
How often did you feel that others would be better off if you were dead?
I felt that life was empty or wondered if it was worth living.
Have you felt that life wasn''t worth living?
Did you think it was wonderful to be alive?
I felt that others would be better off if I were dead.
Have you found yourself wishing you were dead and away from it all?
Did you want to be dead at times?
Did you think about taking your own life?
Have you experienced any of the following: felt sadness, hopelessness, loss of interest, change of appetite or sleep pattern, difficulty going about your daily activities?
Have you experienced a period of time when your thinking speeds up and you have trouble keeping up with your thoughts, doing risky or impulsive things, such as driving very quickly or spending too much money?
Have you been preoccupied with drinking alcohol and/or using other drugs like marijuana, or with taking medications without a prescription or more than they were prescribed?
Did you, at times, drink alcohol and/or use other drugs or medication more than you intended?
Have you felt the need to drink more alcohol and/or use more drugs or medication to get the same effect you used to get with less?
Did you, at times, drink alcohol and/or use other drugs or medication to alter the way you feel?
Have you tried to stop drinking alcohol and/or using other drugs or medication, but couldn''t?
Have you experienced problems caused by drinking alcohol and/or using other drugs or prescription medications and you kept using?
Have you experienced thoughts of harming yourself or others?
Have you ever thought that life is not worth living, or planned or attempted suicide?
Have you had periods of time when you felt that you could not trust family or friends?
Have you been prescribed medication for any psychological or emotional problem?
Have you experienced hallucinations (heard or seen things others do not hear or see)?
Have you ever been hit, slapped, kicked, emotionally or sexually hurt, or threatened by someone?
Have you experienced a traumatic event and since had repeated nightmares/dreams and/or anxiety which interferes with you leading a normal life?
How soon after you wake up do you smoke your first cigarette?
Do you find it difficult to refrain from smoking in places where it is forbidden (e.g., in church, at the library, at the movies, etc.)?
Which cigarette would you hate most to give up?
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Do you smoke even if you are so ill that you are in bed most of the day?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# opiates/analgesics (including painkillers such as Morphine, Dilaudid, Demerol, Percocet, Darvon, Talwin, Codeine, Fentanyl, OxyContin)?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# sedatives, hypnotics, tranquilizers, or barbiturates (such as Valium, Xanax, Ativan, Seconal, Nembutal)?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# more than one substance/drug per day (including alcohol)?
How troubled or bothered have you been #5:in the past 30 days/in the past 12 months/during your adult lifetime# by alcohol problems?
How important to you now is treatment for alcohol problems?
How troubled or bothered have you been #5:in the past 30 days/in the past 12 months/during your adult lifetime# by drug problems?
How important to you now is treatment for drug problems?
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Have you used drugs other than those required for medical reasons?
Have you abused more than one drug at a time?
Were you always able to stop using drugs when you wanted to?
Have you had "blackouts" or "flashbacks" as a result of drug use?
Have you felt bad or guilty about your drug use?
#4:Have your parents/Has your spouse (or parents)# ever complained about your involvement with drugs?
Have you neglected #4:important relationships/your family# because of your use of drugs?
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Have you had medical problems #4:that were so bad that you had to see a doctor as a result of your drug use/as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)#?
Was there any time when you thought you had a nervous, emotional, drug (prescription or non-prescription) or alcohol problem?
Was there any other person (relative, friend, neighbor, minister, priest or other), who thought you had a nervous, emotional, drug, medication (prescription or non-prescription) or alcohol problem?
At any time in your life did you think that you should talk to a medical doctor or other health professional about problems with your emotions, nerves, mental health, or your use of alcohol or drugs or medications (prescription or non-prescription)?
At any time in your life did a family member, friend, co-worker, or any other person tell you to talk to a medical doctor or other health professional about problems with your emotions, nerves, or mental health or your use of alcohol, drugs or medications (prescription or non-prescription)?
Have you ever been admitted for an overnight stay in the hospital for problems with your emotions, nerves, mental health, alcohol, drug or medication use (prescription or non-prescription)?
Have you ever gotten a prescription or medicine for your emotions, nerves or mental health, alcohol, drug use or medication (prescription or non-prescription) from any type of professional?
Urine test results for amphetamines.
Urine test results for benzodiazepines.
Urine test results for cocaine.
Urine test results for methamphetamine.
Urine test results for opioids.
Have you ever taken benzodiazepines like xanax, diazepam, alprazolam, lorazepam, lexatin, klonopin, tranxilium, valium, noctamid or loramet?
Have you ever taken sleeping pills like lunesta, zaleplon or ambien?
Have you ever taken sedatives?
Have you ever taken hypnotics like atarax, seroquel, trazadone or zolpidem?
Have you ever taken minor tranquilizers like passiflora or valerian?
Have you ever taken muscular relaxants like flexenil or cyclobenzaprine?
Have you ever taken other sedatives, tranquilizers or sleeping pills?
Have you taken sedatives, hypnotics, benzodiazepines, minor tranquilizers, or muscular relaxants?
Have you taken sedatives, tranquilizers, sleeping pills or muscular relaxants because you like the way they make you feel?
Have you taken another sedative or tranquilizer as soon as the effects of the previous one began to wear off?
Have you tried to reduce the number of sedatives, tranquilizers, sleeping pills or muscular relaxants you take because they interfered with your life?
Have you found that you needed to take more tranquilizers, sedatives, sleeping pills or muscular relaxants to get the same effect compared to when you first took them?
Did you need to take sedatives, tranquilizers, sleeping pills or muscular relaxants to deal with the problems in your life?
Could you stop taking sedatives tranquilizers, sleeping pills or muscular relaxants tomorrow without any difficulties?
Have you felt bad or sick as the effects of sedatives, tranquilizers, sleeping pills or muscular relaxants wore off?
Have you taken a sedative, tranquilizer, sleeping pill or muscular relaxant to reduce the unpleasant after-effects of sedatives, tranquilizers, sleeping pills or muscular relaxants?
Have you taken sedatives, tranquilizers, sleeping pills or muscular relaxants against your doctor''s advice or more frequently than recommended?
Were you concerned about the number of sedatives, tranquilizers, sleeping pills or muscular relaxants you have taken?
Did a doctor ever say you were manic-depressive or had bipolar disorder?
Did a doctor ever say you have schizophrenia or a schizoaffective disorder?
How often have you been bothered by little interest or pleasure in doing things?
How often have you been bothered by feeling down, depressed, or hopeless?
How often have you been bothered by trouble falling asleep, staying asleep, or sleeping too much?
How often have you been bothered by feeling tired or having low energy?
How often have you been bothered by poor appetite or overeating?
How often have you been bothered by feeling bad about yourself? Or that you are a failure or have let yourself or your family down?
How often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
How often have you been bothered by 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?
How often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
How often have you been bothered by feeling nervous, anxious, or on edge?
How often have you been bothered by not being able to stop or control worrying?
How often have you been bothered by worrying too much about different things?
How often have you been bothered by trouble relaxing?
How often have you been bothered by being so restless that it is hard to sit still?
How often have you been bothered by becoming easily annoyed or irritable?
How often have you been bothered by feeling afraid as if something awful might happen?
Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that: you were very frightened; or you thought you would be injured; or you received bruises, cuts, welts, lumps or other injuries?
Have you ever been attacked, beaten, or mugged by anyone, including friends, family members or strangers?
Has anyone ever made or pressured you into having some type of unwanted sexual contact? By sexual contact we mean any contact between someone else and your private parts or between you and someone else''s private parts.
Have you ever been in any situation in which you were seriously injured, or feared you might be seriously injured or killed?
How much were you bothered by repeated, disturbing, and unwanted memories or images of a very stressful experience?
How much were you bothered by repeated, disturbing dreams of a very stressful experience?
How much were you bothered by suddenly feeling or acting as if a very stressful experience were actually happening again (as if you were actually back there reliving it)?
How much were you bothered by feeling very upset when something reminded you of a very stressful experience?
How much were you bothered by having strong physical reactions when something reminded you of a very stressful experience (for example, heart pounding, trouble breathing, sweating)?
How much were you bothered by avoiding memories, thoughts, or feelings related to a very stressful experience?
How much were you bothered by avoiding external reminders of a very stressful experience (for example, people, places, conversations, activities, objects, or situations)?
How much were you bothered by trouble remembering important parts of a very stressful experience?
How much were you bothered by 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)?
How much were you bothered by blaming yourself or someone else for a very stressful experience or what happened after it?
How much were you bothered by having strong negative feelings such as fear, horror, anger, guilt, or shame?
How much were you bothered by loss of interest in activities that you used to enjoy?
How much were you bothered by feeling distant or cut off from other people?
How much were you bothered by trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
How much were you bothered by irritable behavior, angry outbursts, or acting aggressively?
How much were you bothered by taking too many risks or doing things that could cause you harm?
How much were you bothered by being "super alert" or watchful or on guard?
How much were you bothered by feeling jumpy or easily startled?
How much were you bothered by having difficulty concentrating?
How much were you bothered by trouble falling or staying asleep?
Have you taken any medication due to problems with your emotions, drug and alcohol use, nerves, energy level, concentration, sleep, or ability to cope with stress?
How much were you bothered by loss of sexual interest or pleasure?
How much were you bothered by feeling low in energy or slowed down?
How much were you bothered by thoughts of ending your life?
How much were you bothered by poor appetite?
How much were you bothered by crying easily?
How much were you bothered by feelings of being trapped or caught?
How much were you bothered by blaming yourself for things?
How much were you bothered by feeling lonely?
How much were you bothered by feeling blue?
How much were you bothered by worrying too much about things?
How much were you bothered by feeling no interest in things?
How much were you bothered by trouble falling asleep?
How much were you bothered by feeling hopeless about the future?
How much were you bothered by thoughts of death or dying?
How much were you bothered by overeating?
How much were you bothered by awakening in the early morning?
How much were you bothered by restless or disturbed sleep?
How much were you bothered by feeling everything is an effort?
How much were you bothered by feelings of worthlessness?
How much were you bothered by feelings of guilt?
Do you have or have you had chronic pain?
Do you have or have you had heart problems?
In general, would you say your physical health is:
In general, would you say your mental health is:
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my ability to work is impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my home management (such as cleaning, tidying, shopping, cooking, looking after the home or children, paying bills) is impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my social leisure activities (with other people, such as parties, bars, clubs, outings, visits, dating, home entertaining) are impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my ability to form and maintain close relationships with others, including those I live with, is impaired.
How much difficulty have you had standing for long periods such as 30 minutes?
How much difficulty have you had taking care of your responsibilities?
How much difficulty have you had learning a new task, for example, learning how to get to a new place?
How much difficulty have you had joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health condition?
How much difficulty have you had concentrating on doing something for ten minutes?
How much difficulty have you had walking a long distance such as a mile?
How much difficulty have you had washing your whole body?
How much difficulty have you had getting dressed?
How much difficulty have you had dealing with people you do not know?
How much difficulty have you had maintaining a friendship?
How much difficulty have you had with your day to day work/school?
How frequently have you had the following experience: I experienced some emotion and was not conscious of it until sometime later.
How frequently have you had the following experience: I broke or spilled things because of carelessness, not paying attention, or thinking of something else.
How frequently have you had the following experience: I found it difficult to stay focused on what''s happening in the present.
How frequently have you had the following experience: I tended to not notice feelings of physical tension or discomfort until they really grabbed my attention.
How frequently have you had the following experience: It seemed as if I was "running on automatic" without much awareness of what I was doing.
How frequently have you had the following experience: I rushed through activities without being really attentive to them.
How frequently have you had the following experience: I drove places on "automatic pilot" and then wondered why I went there.
How frequently have you had the following experience: I found myself preoccupied with the future or the past.
How frequently have you had the following experience: I found myself doing things without paying attention.
How frequently have you had the following experience: I snacked without being aware that I was eating.
How much do your symptoms get in the way of you doing things that you would like to or need to do?
How well do you feel like you are coping with your mental, emotional illness or substance use from day to day?
How much did drug use get in the way of your functioning (e.g., relationships, money, housing, legal concerns, missed appointments, increased symptoms)?
Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?
In your day-to-day life, how often do people act as if they think you are not smart?
In your day-to-day life, how often do people act as if they think you are dishonest?
In your day-to-day life, how often do people act as if they''re better than you are?
In your day-to-day life, how often are you are called names or insulted?
In your day-to-day life, how often are you threatened or harassed?
#5:How many days in the past 30 days/In the past 12 months on average, how many days per month/During your adult lifetime on average, how many days per month# did you drink alcohol (including beer, wine and liquor)?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# heroin or methadone?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# cocaine (including crack and rock cocaine) or amphetamines (including Methamphetamine)?
Experienced auditory hallucinations of voices, noises, music, etc.
Auditory hallucinations in which a voice keeps up a running commentary on the subject's behaviors or thoughts as they occur.
Sees things that are not there.
Severity of hallucinations of any type. Consider conviction in reality of hallucination, preoccupation, and effects on actions.
Experience that her feelings, impulses, thoughts or actions are not her own and the belief that they are imposed on him by some external force.
Belief or experience that her thoughts, as they occur, are broadcast from her head into the external world so that others can hear them.
The experience that thoughts, which are not her own, are inserted into her mind.
Belief that thoughts have been removed from her head resulting in a diminished number of thoughts remaining.
A persistent denial of the existence of particular things or of everything, including oneself (died several years ago).
Delusional belief that her appearance, or an organ or organ system, is diseased or changed (e.g. Brain is rotting, blood turning to ice).
Extent to which the content of any of the delusional beliefs (whether suspected or definite) have a bizarre of fantastic quality (e.g. people from another world are talking about her).
Delusional belief that she has done something terrible or is responsible for some event or condition which has had disastrous consequences.
Claims power, knowledge or identity beyond the bounds of credibility.
Somatic, grandiose, religious, nihilistic, or other delusions without persecutory or jealous content lasting at least 1 week.
Severity of delusions of any type -- consider conviction in delusion, preoccupation, and effect on her actions.
Accelerated, pressured, or increased amount of speech during a period when she had at least 1 other manic-like symptom.
Visible manifestations of generalized motor hyperactivity which occurred when she had at least 1 other manic-like symptom.
Increase in goal-directed activity as compared to usual (e.g. changes in involvement or activity level associated with work, family, friends, sex drive).
Bizarre behavior not commonly seen with simple depression, mania, alcohol or drugs or some other physical impairment in brain functioning.
The patient reports voices, noises, or other sounds that no one else hears.
The patient reports a voice, which makes a running commentary on her behavior or thoughts.
The patient reports hearing two or more voices conversing.
The patient reports experiencing peculiar physical sensations in the body.
The patient sees shapes or people that are not actually present.
This rating should be based on the duration and severity of the hallucinations and their effects on the patient's life.
The patient believes she has special powers or abilities.
The patient is preoccupied with false beliefs of a religious nature.
The patient believes that somehow her body is diseased, abnormal, or changed.
The patient believes that insignificant remarks or events refer to him or have special meaning.
The patient feels that people can read her mind or know her thoughts.
The patient believes that her thoughts are broadcast so that she or others can hear them.
The patient believes that thoughts that are not her own have been inserted into her mind.
The patient believes that thoughts have been taken away from her mind.
The patient develops a set of repetitive actions or rituals that she must perform over and over.
This rating should reflect the type of behavior and the extent to which it deviates from social norms.
A pattern of speech in which ideas slip off track onto ideas obliquely related or unrelated.
Lack of spontaneous interaction, isolation deficiency in relating to others.
Peculiar, bizarre, unnatural motor behavior (not including tics).
Affect is incongruous with content of speech, for example, giggles while discussing reason for hospitalization.
The patient's affect is inappropriate or incongruous, not simply flat or blunted.
The patient's replies are adequate in amount but tend to be vague, over concrete or overgeneralized, and convey little information.
The patient indicated, either spontaneously or with prompting, that her train of thoughts was interrupted.
The patient takes a long time to reply to questions prompting indicates the patient is aware of the question.
The core features of alogia are poverty of speech and poverty of content.
The patient's clothes may be sloppy or soiled, and she may have greasy hair, body odor, etc.
The patient has difficulty seeking or maintaining employment, completing schoolwork, keeping house, etc.
Strong weight may be given to one or prominent symptoms if particularly striking.
The patient may have few or no friends and may prefer to spend all her time isolated.
The patient appears uninvolved or unengaged. She may seem "spacey".
Test of "serial 7s" (at least five subtractions) and spelling "world" backwards. Score 2 = 1 error, score 3 = 2 errors, score 3 = 2 errors, score 4 = 3 errors
This rating should assess the patient's overall concentration, clinically and on tests.
Thought processes confused, disconnected, disorganized, disrupted.
Confusion or lack of proper association for person, place or time.
Insight refers to being aware that they have a psychotic illness.
Repeatedly saying things in juxtaposition, which lack a readily understandable relationship (e.g. "I'm tired. All people have eyes.")
Speech is adequate in amount but conveys little information because of vagueness, talking past the point, empty repetitions or use of stereotyped or obscure phrases.
Impaired understandability of speech due to psycho-pathology (e.g. lack of logical or meaningful connections between words, phrases, or sentences; abrupt changes in subject matter).
A pattern of speech that is essentially incomprehensible at times.
A pattern of speech in which conclusions are reached that do not follow logically.
A pattern of speech that is very indirect and delayed in reaching its goal idea.
Extent to which the patient's ability to communicate is affected.
Heightened emotional tone, agitation, increased reactivity.
Elevated or expansive mood and/or optimistic attitude toward the future lasting at several hours and out of proportion to the circumstances.
Increased self-esteem and appraisal of her worth, contacts, power or knowledge (up to grandiose delusions) as compared with usual level.
Making future plans of a hypomanic, grandiose or manic nature
Overt expression of irritability, annoyance, and anger, when she had at least 1 other manic-like symptom.
Accelerated speech with abrupt changes from topic to topic usually based on understandable associations, distracting stimuli or play on words.
The patient may do things considered inappropriate according to usual social norms (e.g. masturbating in public).
The patient may behave in an aggressive, agitated manner, often unpredictably.
The patient replies to a question in an oblique or irrelevant manner.
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The patient's speech is rapid and difficult to interrupt; the amount of speech produced is greater than that considered normal.
The patient is distracted by nearby stimuli, which interrupts her flow of speech.
A pattern of speech in which sounds rather than meaningful relationships govern word choice.
I have experienced hearing voices, noises, music, etc.
I hear a voice commenting upon what I am doing or thinking.
I have had visions, or seen things that are invisible to other people.
I see and/or hear things that other people do not, but I know that they are real.
I have had the feeling that I was being controlled by some force or power outside of myself, as though I was a robot and without a will of my own.
I have felt that my thoughts were broadcast so that other people knew what I was thinking.
I feel that thoughts were put into my head that were not my own.
I feel that thoughts were taken away from me by some external force.
I feel that things in this world do not really exist and that I am living in a limbo world or parallel universe.
I feel that my body and organ systems are diseased.
I feel that I am living in a fantasy world, for example where people from another world are talking to me.
I feel that I have committed a crime, or have done some terrible things and deserve punishment.
I feel that I am a particularly important person or that I have special powers or abilities.
I feel that I have infinite power.
I am concerned/preoccupied about something, but other people do not believe me.
There were times that I spoke very rapidly or talked on and on and couldn't be stopped.
There were times when I was unable to sit still or I always had to be moving or pacing up and down.
There was a time when I was more active or involved in things compared to the way I usually am.
I have done things to call attention to myself (the way I dressed or acted).
I hear voices, noises, or other sounds that no one else hears.
I hear a voice which makes a running commentary on my behavior or thoughts.
I hear two or more voices conversing.
I have experienced peculiar physical sensations in my body.
I see shapes or people that are not actually present.
I see and/or hear things that others do not frequently and they affect my life.
I have special powers or abilities.
I am preoccupied with thoughts of a religious nature.
My body is diseased, abnormal, or has changed.
I believe that insignificant remarks or events refer to me or have special meaning.
People can read my mind or know my thoughts.
My thoughts are broadcast so that others or myself can hear them.
Thoughts that are not my own have been inserted into my mind.
My thoughts have been taken away from my mind.
I have a set of repetitive actions or rituals that I must perform over and over.
My behavior deviates from social norms that most other people conform to.
When I speak, my ideas slip off track into unrelated topics.
I feel emotionally withdrawn, lack spontaneity, and am isolated from others.
My movements are unusual and unnatural.
My expressions are inconsistent with what I am talking about (e.g., I giggle when talking about someone's death).
My emotions are inappropriate for the situation.
When I respond to questions, my answers are vague, very concrete, and convey little information.
My train of thought is interrupted.
I take a long time to reply to questions.
I have difficulty having normal conversations.
My clothes are sloppy or soiled, and I have greasy hair, and body odor.
I have difficulty seeking or maintaining employment, completing schoolwork, keeping up my house, etc.
I feel drained of energy and interest in normal things.
I have few or no friends and prefer to spend all my time isolated.
I am uninvolved or unengaged. I feel "spacey."
I have trouble subtracting numbers or spelling words backwards.
I am having trouble concentrating on this interview.
I am confused, disconnected, disorganized, and/or disrupted.
I feel disorientated and am often confused about whom I am talking to, where I am and what time it is.
I am aware that I have a psychotic/mental illness and am dealing with its effects.
I say things that are unrelated to each other, for example, "I'm tired. All people have eyes."
When I talk, I have trouble conveying information, because of being vague and using obscure phrases.
When I talk, I have trouble providing a logical connection between words and phrases and have abrupt changes in subject matter.
My speech is essentially incomprehensible at times.
When I talk, the conclusions I reach do not follow logically from what I am saying.
When I speak, I have trouble expressing the idea that I am trying to convey.
I have trouble communicating with others.
I feel heightened emotions, agitation, and/or increased reactivity.
There have been times when I felt very good or too cheerful or high - not just my normal self.
I have felt more self-confident than usual. I have felt that I am a particularly important person or that I had special talents or abilities.
I feel that I have big plans in store for me in the future, such as I will be president or walk on the moon.
I am very irritable, annoyed, and/or angry.
My speech is accelerated and I change topics frequently.
I do things considered inappropriate according to usual social norms (e.g. masturbating in public).
I behave in an aggressive, agitated manner, often unpredictably.
I reply to questions in with answers that do not make sense to the person I am talking to.
My speech is rapid and difficult to interrupt; the amount of my speech is greater than what is considered normal.
When I am talking, I am distracted by nearby things, which interrupt my flow of speech.
When I talk, I choose words based on how they sound rather than what they mean.
How much were you bothered by repeated, disturbing, and unwanted memories or images of a very stressful experience?
How much were you bothered by repeated, disturbing dreams of a very stressful experience?
How much were you bothered by suddenly feeling or acting as if a very stressful experience were actually happening again (as if you were actually back there reliving it)?
How much were you bothered by feeling very upset when something reminded you of a very stressful experience?
How much were you bothered by having strong physical reactions when something reminded you of a very stressful experience (for example, heart pounding, trouble breathing, sweating)?
How much were you bothered by avoiding memories, thoughts, or feelings related to a very stressful experience?
How much were you bothered by avoiding external reminders of a very stressful experience (for example, people, places, conversations, activities, objects, or situations)?
How much were you bothered by trouble remembering important parts of a very stressful experience?
How much were you bothered by 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)?
How much were you bothered by blaming yourself or someone else for a very stressful experience or what happened after it?
How much were you bothered by having strong negative feelings such as fear, horror, anger, guilt, or shame?
How much were you bothered by loss of interest in activities that you used to enjoy?
How much were you bothered by feeling distant or cut off from other people?
How much were you bothered by trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
How much were you bothered by irritable behavior, angry outbursts, or acting aggressively?
How much were you bothered by taking too many risks or doing things that could cause you harm?
How much were you bothered by being "super alert" or watchful or on guard?
How much were you bothered by feeling jumpy or easily startled?
How much were you bothered by having difficulty concentrating?
How much were you bothered by trouble falling or staying asleep?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# marijuana?
Attachment D
Household Screening PAPI Instrument
1) Paper and Pencil Household Screener
Screening Survey
Your address was randomly chosen for the National Study of Mental Health. This is a research study about
mental health and tobacco, alcohol and drug use. If you choose to take part in the study, you will be one of
about 44,500 people to do so.
We would like to conduct a short screening survey with you to determine if you are eligible to be interviewed
for the overall study.
If you decide to participate you can complete the screening survey online or by telephone, by mail, or a
professional interviewer will come to your home to complete the survey in person. For more information
please see the invitation letter you received.
The screening survey should take about 15 minutes to complete and to show our appreciation you will
receive $20. A check for $20 will be mailed to you if you complete this paper screening survey. Or, you may
receive a $20 electronic pre-paid Visa if you choose to complete the online or telephone screening survey,
or $20 in cash if you complete the screening survey with an interviewer in your home. This study is for
research purposes only. There is no direct benefit to you from your participation in the study. Information
learned from the study may help other people in the future. You might find some of the questions we ask to
be upsetting or stressful. Your participation is voluntary, and you can refuse to answer any questions.
It is up to you whether or not to be in this study. The following information is meant to help you decide.
1
1
7320503516
General Information
This study, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), collects
information for research and program planning by asking about:
•
•
•
•
Mental health;
Health behaviors;
Access to, and use of, medical care or treatment; and
Tobacco, alcohol, and drug use or non-use.
We will be asking questions about substance abuse and mental health. You cannot be identified through any
information you give us. Your name and address will never be connected to your answers. In addition, federal law
requires us to keep all your answers confidential. Any answers you give will only be used by authorized researchers for
statistical purposes. Your participation is voluntary and you can stop at any time. Your alternative is not to participate,
and there is no expected benefit to you from your participation in the study.
This screening survey will take about 15 minutes and we will send you a $20 check through the mail when you finish.
We will request your email address at the end of this survey which will only be used to contact you if you are selected
for the main interview. It will not be stored with your answers. We included a stamped business return envelope so there
will be no additional cost to you for participating in this short survey.
If you are chosen for the main interview, it will be done on a different day that we will schedule at your convenience. The
interview takes about 80 minutes, on average.
Each person who is chosen and completes the main interview will receive a $30 electronic gift card, a $30 check, or $30
cash if in person.
Protecting Your Confidentiality
To help keep information about you confidential, we have obtained a Certificate of Confidentiality from the Department of
Health and Human Services (DHHS). This adds special protection for the research information about you because it
protects the research team from being forced, even under a court order or subpoena, to release information that could
identify you. However, there are some exceptions to this privacy rule. If you tell us about the abuse of a child or that you
plan to hurt yourself or others, we may need to notify a mental health professional or other authorities.
Whom To Contact About This Study
During the study, if you have questions, concerns or complaints about the study, please contact the project at
833-947-2575.
An institutional review board (IRB) is an independent committee established to help protect the rights of research
participants. If you have any questions about your rights as a research participant, and/or concerns or complaints
regarding this research study, contact:
•
By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
•
or call toll free:
877-992-4724
•
or by email:
[email protected]
Please reference the following number when contacting the Study Subject Adviser: Pro00042170.
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BACKGROUND INFORMATION
1. How old are you?
3. This question is about your overall health.
Would you say your health in general is:
Excellent
Very Good
Good
Fair
Poor
years old
2. What is your sex?
Male
Female
EMOTIONS AND MOOD
The next questions are about emotional difficulties you might have experienced at some time in the
past year.
4. Almost everyone has times when they feel sad, depressed, or discouraged about how things are
going in their life. Think about a time in the past 12 months lasting 2 weeks or longer when you
had the strongest feelings of this sort. During those 2 weeks, how often did you have each of the
following feelings?
If you are one of the few people that never had such times, mark “None of the time” to all the following
questions.
All or
almost all Most of
Some of A little of
None of
the time
the time
the time
the time
the time
a. Felt sad or depressed
b. Felt discouraged about how things
were going in your life
c. Took little or no interest or pleasure in
things
d. Felt down on yourself, no good, or
worthless
5. Think about a time lasting 6 months or longer in the past 12 months when you had the strongest
feelings of worry and anxiety. During those 6 months, how often did you have each of the
following feelings?
Less than
Just about More days 1-3 days a 1 day a
every day than not
week
Never
week
a. You felt worried or anxious
b. You worried about a number of
different things in your life, such as
your work, family, health, or finances
c. You felt more worried than other
people in your same situation
d. You had trouble controlling your
worry
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5910503519
6. The next question is about whether you ever in your life had an episode lasting 4 days or longer
when your mood was either much higher than usual most of the day, much more irritable than
usual most of the day, or a mix of these things.
During these episodes, people are often much more excitable than usual or are extremely selfconfident or optimistic. They often do things they would normally not do. And this sometimes
gets them into trouble or puts them at risk of trouble.
With this definition in mind, did you ever in your life have an episode of this sort lasting 4 days or
longer?
Yes
No Skip to question 8
7. What is the longest episode of this sort you ever had in your life?
4 to 7 days
8 to 14 days
More than 14 days
8. Many people have extremely stressful experiences that affect them psychologically for many
years. Think of a time lasting 1 month or longer in the past 12 months when you had the most
severe reactions to such an extremely stressful experience. During that month, how much were
you bothered by each of the following problems:
Extremely Quite a bit Moderately A little bit
Not at all
a. Suddenly feeling or acting as if the
stressful experience were actually
happening again – as if you were
actually back there reliving it?
b. Avoiding external reminders of the
stressful experience, for example,
people, places, conversations,
activities, objects, or situations?
c. Feeling emotionally distant or
depressed?
d. Irritable behavior, angry outbursts, or
acting aggressively?
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8271503512
ALCOHOL AND DRUG USE
9. During the past 12 months, how often did you have a drink containing alcohol?
Never Skip to question 11
Once a month or less often
2 to 4 times a month
2 to 3 times a week
4 times a week or more
10. During the past 12 months, how many drinks containing alcohol did you have on a typical day
when you drank?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
11. These next questions are about drug use. "Drug use" refers to:
• Use of marijuana or cannabis,
• illegal drug use,
• use of prescribed drugs without your own prescription, and
• use of prescribed drugs in greater amounts, more often, or longer
than you were told to take them.
The various classes of drugs include cannabis, which includes marijuana and hashish, cocaine,
methamphetamine, heroin, fentanyl, hallucinogens (such as LSD), and prescription medications
such as benzodiazepines (such as Xanax, Ativan), stimulants (such as Ritalin, Adderall) and
opioids (such as hydrocodone, oxycodone).
During the past 12 months, how often did you use drugs other than alcohol?
Never Skip to question 13
Once a month or less often
2 to 4 times a month
2 to 3 times a week
4 times a week or more
12. During the past 12 months, how often were you influenced heavily by drugs other than
alcohol?
Never
Less often than once a month
Every month
Every week
Daily or almost daily
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8087503517
UNUSUAL EXPERIENCES
13. This question asks about unusual experiences, like seeing visions or hearing voices. Recent
research suggests that they are common and may be normal, but we do not know exactly how
common because this is the first large-scale survey to ask about them comprehensively. So
please take your time and think carefully before answering the following questions.
Please do not count times you had these experiences when you were having a fever, dreaming,
half-asleep, or under the influence of alcohol or drugs.
Not counting those things, did you ever in your life have any of the following experiences?
Yes No
a. The first one is seeing a vision that other people said was not there like a face, an
animal, a figure, or colors. Remember not to count times when you were having a
fever, dreaming, half-asleep or under the influence of alcohol or drugs. Did you ever
see a vision at any other time?
b. Did you ever hear voices that other people did not hear like voices coming from inside
your head talking to you or about you, or voices coming out of the air when there was
no one around?
c. Did you ever believe that some mysterious force was inserting thoughts that were
definitely not your own thoughts, directly into your head by means of x-rays, laser
beams, or other methods?
d. Did you ever believe your thoughts were being stolen out of your mind by some force?
e. Did you ever think your mind was being taken over by forces with laser beams or other
methods that were making you do things you did not choose to do?
f. Did you ever think some force was trying to communicate directly with you by sending
special signs or signals, like through the radio or television, that you could understand
but that no one else could understand?
g. Did you ever believe there was a plot to harm you or to have people follow you, but
your friends or family did not think this was true?
HEALTH AND HEALTH CARE
14. Are you currently covered by any kind of
health insurance, that is, any policy or
program that provides or pays for medical
care?
Yes
No
17. Are you currently receiving disability benefits
for problems with emotions nerves, or mental
health?
Yes
No
Skip to question 19
15. Are you currently receiving disability benefits
such as SSI (Supplemental Security Income),
SSDI (Social Security Disability Insurance), or
disability benefits from the VA (U.S.
Department of Veterans Affairs)?
Yes
No
Skip to question 19
18. Which of the following mental health
problems are reasons for your disability:
Yes
No
a.
Depression
b.
Bipolar disorder
Post-traumatic stress
disorder
d. Schizophrenia or
schizoaffective disorder
e. Any other mental health
problem
c.
16. Are you currently receiving disability
benefits for problems with your physical
health?
Yes
No
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9371503514
19. Below is a list of health conditions. Have you
ever been told by a doctor or other health
care professional that you had any of these
conditions?
Yes
No
a. Diabetes
b. Heart problems
c. Cancer
d. Any other life-threatening or
seriously impairing physical
health problem
e. Depression
f. Mania, manic-depression, or
bipolar disorder
g. Schizophrenia or
schizoaffective disorder
h. Any other seriously impairing
emotional health problem
23. How much, if at all, has the coronavirus
pandemic negatively affected your emotional
or mental health?
Not at all
A little
Some
Quite a bit
A lot
24. How much, if at all, has the coronavirus
pandemic affected the amount of alcohol you
drink?
I drink much less than I did before the
coronavirus pandemic began
I drink a little less than I did before the
coronavirus pandemic began
I drink about the same amount as I did
before the coronavirus pandemic began
I drink a little more than I did before the
coronavirus pandemic began
I drink much more than I did before the
coronavirus pandemic began
20. About how tall are you, without shoes?
Please enter your height in feet and inches.
feet
inch(es)
Not applicable - I do not drink alcohol
21. About how much do you weigh in pounds?
pounds
25. How much, if at all, has the coronavirus
pandemic affected your use of drugs other
than alcohol?
By drugs we mean various classes of drugs
including cannabis, which includes marijuana and
hashish, cocaine, methamphetamine, heroin,
fentanyl, hallucinogens (such as LSD), and use
of prescription medication that you took without
your own prescription or in greater amounts,
more often or for longer than you were told to
take them. These prescription medications
include benzodiazepines (such as Xanax,
Ativan), stimulants (such as Ritalin, Adderall) and
opioids (such as hydrocodone, oxycodone).
I use much less than I did before the
coronavirus pandemic began
I use a little less than I did before the
coronavirus pandemic began
I use about the same amount as I did before
the coronavirus pandemic began
I use a little more than I did before the
coronavirus pandemic began
I use much more than I did before the
coronavirus pandemic began
22. Next are a few questions about your personal
experiences with the Coronavirus Disease
2019 pandemic, also referred to as COVID-19.
Since the beginning of the COVID-19
pandemic, …
Does not
Yes No
apply
a. Did you think or know that
you had COVID-19?
b. At any time, did you test
positive for the COVID-19
virus or for COVID-19
antibodies?
c. Were you yourself
hospitalized due to
COVID-19?
d. Was someone in your
immediate family or close
friend(s) hospitalized due
to COVID-19?
e. Did someone in your
immediate family or close
friend(s) die due to
COVID-19?
Not applicable - I do not use drugs
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4688503510
31. What is the highest grade or level of school
you have completed?
YOUR BACKGROUND
26. Are you now married, widowed, divorced,
separated, or have you never married?
Now married Skip to question 28
Widowed
Divorced
Separated
Never married
If currently enrolled, mark the previous grade or
highest degree received.
Less than a high school diploma
High school degree or equivalent (for
example: GED)
Some college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
Master’s degree (for example: MA, MS,
MEng, MEd, MSW, MBA)
Professional degree (for example: MD, DDS,
DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
27. Are you now living with a partner?
Yes
No
28. Are you of Hispanic, Latino or Spanish
origin? That is, do any of these groups
describe your national origin or ancestry—
Puerto Rican, Cuban, Cuban-American,
Mexican, Mexican-American, Chicano, Central
or South American, or origin in some other
Spanish-speaking country?
Yes
No Skip to question 30
32. Are you currently attending a college,
university, or trade school either full-time or
part-time?
If you are on a holiday or break from school, such
as spring break or summer vacation, but plan to
return when the break is over, please answer
yes.
Yes
No Skip to question 39
29. Do you speak Spanish only, mostly
Spanish with some English, Spanish and
English about the same, mostly English
with some Spanish, or English only?
Spanish only
Mostly Spanish, but some English
Spanish and English about the same
Mostly English, but some Spanish
English only
33. How long ago did you first enroll at this
college, university, or trade school?
If you transferred to your current institution
directly from another college or university,
please include that time.
Within the past 12 months
More than 12 months ago
34. Do you currently live in college-owned
housing on campus, such as a dorm or a
residence hall?
Yes Skip to question 37
No
30. Are you White, Black or African American,
American Indian or Alaska Native, Native
Hawaiian or other Pacific Islander, or Asian?
Please mark all that apply.
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
35. At any time during the past 12 months (or
if you are a recently new student, since
you enrolled) did you live in collegeowned housing on campus, such as a
dorm or a residence hall?
Yes Skip to question 37
No
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1178503511
36. In what type of off-campus housing did
you mostly live in during that time?
Off-campus housing, owned or managed
by the school
Off campus with relatives, such as
parents or guardians
Other off-campus housing
42. Last week, were you on layoff from a job?
Yes Skip to question 46
No
43. Last week, were you temporarily absent
from a job or business, for example,
because of vacation, temporary illness,
maternity leave, other family or personal
reasons, or bad weather?
Yes Skip to question 49
No
Skip to question 39
37. During the past 12 months (or if you are a
recently new student, since you enrolled), did
you mostly live in college-owned housing on
campus, such as a dorm or a residence hall?
Yes Skip to question 39
No
44. During the last 4 weeks, have you been
actively looking for work?
Yes
No Skip to question 49
38. In what type of off-campus housing did
you mostly live in during that time?
Off campus housing, owned or managed
by the school
Off campus with relatives, such as
parents or guardians
Other off campus housing
45. Last week, could you have started a job if
you had been offered one, or returned to
work if you had been recalled?
Yes, you could have gone to work
No, you could not have gone to work
because of your own temporary illness
No, you could not have gone to work for
some other reason, such as being in
school or taking care of house or family
EMPLOYMENT
39. Are you currently serving on active duty in
the United States Armed Forces?
Yes
No
Skip to question 49
46. Have you been informed that you will be
recalled to work within the next 6 months or
been given a date to return to work?
Yes Skip to question 48
No
40. The next question is about working. Last
week, did you work for pay at a job or
business? By last week, this means the last full
week beginning on a Sunday and ending last
Saturday.
Please include
• unpaid work in a family farm or business if
you usually work more than 15 hours each
week, or
• personal labor you provide in exchange for
work done for you, rather than for pay.
Please do not include
• work done as part of a student stipend, or
• volunteer work.
Yes Skip to question 49
No – Did not work or am retired
47. During the last 4 weeks, have you been
actively looking for work?
Yes
No Skip to question 49
48. Last week, could you have started a job if
you had been offered one, or returned to
work if you had been recalled?
Yes, you could have gone to work
No, you could not have gone to work
because of your own temporary illness
No, you could not have gone to work for
some other reason, such as being in
school or taking care of house or family
41. Last week did you do any work for pay,
even for as little as one hour?
Yes Skip to question 49
No
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0405503513
54. During the past 12 months, have you
stayed overnight or longer in a state
psychiatric hospital?
State psychiatric hospitals are public
psychiatric hospitals operated by a state for
treatment of serious mental disorders.
Yes
No Skip to question 56
OTHER HOUSING
49. During the past 12 months, have you stayed
overnight or longer in a jail? Please do not
count any time spent in prison.
Yes
No Skip to question 51
50. During the past 12 months, how much
time have you spent in a jail? If you are not
sure, just make your best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.
55. During the past 12 months, how much
time have you spent in a state psychiatric
hospital? If you are not sure, just make your
best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.
Nights
Weeks
Months
51. During the past 12 months, have you stayed
overnight or longer in a prison?
Yes
No Skip to question 53
52. During the past 12 months, how much
time have you spent in a prison? If you are
not sure, just make your best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.
Nights
Weeks
Months
56. During the past 12 months, have you been
homeless, even if just for a short period of
time?
Yes
No Skip to question 59
57. The next question is about shelters that
provide a place for people who are homeless
to stay. These shelters may also serve meals.
Nights
Weeks
Months
Not counting living on the street, in a
vehicle, or in some type of makeshift
housing like a tent or empty building,
during the past 12 months, have you
stayed overnight or longer in a homeless
shelter?
Yes
No Skip to question 59
53. During the past 12 months, have you stayed
overnight or longer in a psychiatric hospital?
Yes
No Skip to question 56
58. During the past 12 months, how much
time have you spent in a homeless
shelter? If you are not sure, just make your
best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.
Nights
Weeks
Months
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6364503513
CONTACT INFORMATION
59. Please record your first name, cell phone number and/or landline, and email address so that we
can contact you should you be eligible for the main interview in the study.
First Name:
Cell Phone
Number:
-
-
Landline Number:
-
-
Email Address:
60. Can you participate in a private video call, for example using a smartphone, tablet, or a computer?
Yes
No
61. How would you prefer that we reach out to you?
Via telephone
Via email
62. May we send text messages to your personal cell phone to contact you about the upcoming
interview?
Yes
No
I don’t have a cell phone
63. Generally, what would be good days and times in the next few weeks for an interviewer to contact
you to conduct the main interview, should you be eligible?
Please mark all that apply.
Morning Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
64. Please specify any further notes about your availability:
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6301503514
65. Is there another person who would know how to get in touch with you if we cannot reach you?
Yes
No Skip to question 67
66. Please record their first name, their phone number, and their email address.
First Name:
Phone Number:
-
-
Email Address:
67. To show our appreciation for completing this short survey today, we would like to send you a $20
check. Please enter your first and last name to receive this check. Print in all CAPS.
Please allow up to 4 weeks for processing and delivery.
First Name:
Last Name:
68. Do you have any additional thoughts to share about this survey or the overall study?
Please return your questionnaire in the enclosed return envelope or mail it to:
NSMH
RTI International
ATTN: Data Capture
5265 Capital Boulevard
Raleigh, NC 27690
Thank you for your participation! We will reach
out to you soon to let you know whether you
are eligible for the main interview.
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Attachment E
Clinical Interview
1) MDPS Clinical Interview (non-SCID)
2) Medication Showcard for use with the MDPS Clinical Interview
3) Income Showcard for use with the MDPS Clinical Interview
4) Structured Clinical Interview for DSM-IV (SCID)
5) SCID for Prison Inmates
6) Short Blessed Test
MDPS Main Interview Instrument
MDPS Clinical Interview Specifications
Acronyms used:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
HH = household population
GQU = group quarters
NHH = non-household population (JA, PR, SH, HL unless specified otherwise)
JA = jail population
PR = prison population
SH = state psychiatric hospital population
HL = homeless population
SI = secondary interviewer (NA as of April 21; before: only in HH, JA, OR SH)
PO = proxy (only in HH, JA; NA for SH as of April 21)
GQU = group quarters
LAR = legally authorized representative
SBT = short blessed test
Symbols used:
- [] skips
- <> fills
- != not equal to
- = equal to
- | = or
PROGRAMMER: PLEASE ALWAYS DISPLAY DK/REF (WHERE APPLICABLE) IN INTERVIEWER
ADMINISTRATION
The routing through the instruments for the different populations will be based on a preloaded case ID
which differentiates the populations.
For the proxy interviews:
- Only for HH, JA (note April 2021: NA for SH) but not in PR OR HL
- The respondent interview should be reset before the proxy interview is conducted
- Those interviews will mostly be conducted by phone
- Protocol is triggered either via:
o SBT fail
o Informed Consent Knowledge quiz fail
o Respondent initiated
- The interviewer will complete a debriefing for proxy interviews
For the secondary informant interviews – note NA entirely as of April 21:
- Only for HH, JA, and SH but not in PR OR HL
- The secondary informant will answer a handful of questions regarding the relationship to the
respondent and contact information in Blaise, and add to the information in the NetSCID portion
1
-
of the interview that was provided by the respondent, not the Blaise portion of what the
respondent provided.
o As discussed, questions that should be part of the SI interview will be marked in the
Note(s) column of the overview with an SI
Triggered by Clinical interviewer as necessary at the end of the respondent interview (failed to
establish diagnosis)
In most instances this interview will be conducted AFTER completion of the respondent
interview; Sometimes a secondary informant may be present during the interview.
Those interviews will mostly be conducted by phone
There will be no separate debriefing for these interviews
Line #
Pop.
1
2
HH, JA
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH,
NHH,
PO, SI
HH,
NHH,
PO, SI
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Variabl
e
Name
Cpre
Cconf
C1
Variable Description / Original
Variable Name
Programmer preload instructions
Confirmation of correct
respondent
Confirmation of interview
language
Interview administration mode
Source
Note(s)
SI
NSDUH
SI
New
SI
Confirmation of phone # if
disconnected
Telephone number if
disconnected
Best phone number to reconnect
New
SI
New
SI
New
SI
Thank you
New
SI
Date of birth
SI
Age verification
NSDUH
Redesign
NSDUH
Redesign
NIS
CSD1b
Age verification
NIS
SI
CSD1c_
dob
CSD1c_
age
CSD1d
Date of birth proxy
Age verification proxy
NSDUH
Redesign
NSDUH
Redesign
NIS
CSD1e
Age verification proxy
NIS
C3a
Recording start
New
SI
C3
Informed consent for clinical
interview
New
SI
CFIID3
Cphon
Cphon2
Cphon
New
CphonE
nd
CSD1_d
ob
CSD1_a
ge
CSD1a
Age
Age proxy
SI
SI
2
19
C3_int
Interview consent
New
SI
C3_rec
Recording consent
New
SI
C4a
Non-consent interview end
New
SI
C4b
Interviewer note recording
New
SI
23
HH,
NHH
HH, JA,
SH, HL
HH,
NHH
HH,
NHH
NHH
Cknow1
New
SI
24
NHH
Cknow2
New
SI
25
NHH
Cknow3
New
SI
26
NHH
New
SI
27
NHH
New
SI
28
NHH
Cknow4
a
Cknow4
b
Cknow5
29
NHH
Cknow6
30
NHH
Cknow7
31
NHH
32
NHH
33
HH, JA,
SH
Cknow8
a
Cknow8
b
Consent knowledge question:
study topic
Consent knowledge question:
study duration
Consent knowledge question:
study participation
Consent knowledge question:
voluntary participation
Consent knowledge question:
refuse to answer
Repeat consent knowledge
question: study topic
Repeat consent knowledge
question: study duration
Repeat consent knowledge
question: study participation
Repeat consent knowledge
question: voluntary participation
Repeat consent knowledge
question: refuse to answer
Short Blessed Test
New
34
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
C5
PO/SI transition
New
Paper job aid
only,
administered at
any point of the
interview if
necessary
SI
C6
PO/SI/subject relationship
SI
C6a
PO/SI/subject relationship other
C6b
PO/SI/subject living together
Modified
ACS
Modified
ACS
New
C7a
PO/SI/subject frequency of inperson contact
New
SI
HH, JA,
SH
C7e
PO/SI/subject frequency of mail
contact
New
SI
HH, JA,
SH
C7f
PO/SI/subject/subject frequency
of other contact
New
SI
20
21
22
35
36
37
38
3940HH, JA, SH C7c PO/SI/subject
frequency of telephone contact
ew SI
41HH, JA, SH C7d PO/SI/subject
frequency of email contact New
SI42
43
SI
SI
3
44
HH, JA, C7f_oth PO/SI other contact
New
SH
er
45
PR, SH,
COL1
Date admitted to this facility
NIS
HL
46
PR, SH,
COL2
Estimate when admitted to
NIS
HL
facility
47
HH,
CSD2a
Sex at birth
NIS
NHH
48
HH,
CSD2b
Gender identity current
Modified
NHH
NIS
49
HH,
CSD2c
Confirm sex at birth
NIS
NHH
50
HH,
CSD2d
Sex at birth
NIS
NHH
51
HH,
CSD2e
Gender identity current
Modified
NHH
NIS
52
HH,
C18
Interviewer online/offline
New
NHH
53
HH,
C19
Prompt for paper SCID
New
NHH
SECTION 1: SCID OVERVIEW (See separate file. Adjusted based on First et al. (2016) SCID-5-CV.
STRUCTURED CLINICAL INTERVIEW FOR DSM-5® DISORDERS. CLINICIAN VERSION.)
SECTION 2: SCID DISORDERS (See separate file. Adjusted based on First et al. (2016) SCID-5-CV.
STRUCTURED CLINICAL INTERVIEW FOR DSM-5® DISORDERS. CLINICIAN VERSION.)
SI
SI
SI
SI
SI
1.
2.
3.
4.
MDD
Mania
Psychosis
Differential diagnosis (major depressive disorder, bipolar, schizophrenia or
schizoaffective disorder)
5. Alcohol use disorder
6. Non-alcohol substance use disorder
7. GAD
8. OCD
9. PTSD
10. Anorexia nervosa
SECTION 3: CIGARETTE AND E-CIGARETTE USE
54
HH,
C20,
NHH
C20SCI
D
55
HH,
CT1
NHH
56
HH,
CT2
NHH
(not in
PR)
57
HH,
CT3
NHH
(not in
PR)
Prompt for SCID complete
New
Ever smoked cigarette
Smoked cigarette past 12
months
Modified
NSDUH
Modified
NSDUH
# cigarettes per day past 12
months
Modified
NSDUH
SI
4
58
HH,
NHH
HH,
NHH
(not in
PR)
HH,
NHH
(not in
PR)
CT4
Ever vaped
CT5
Vaped past 12 months
CT6
Frequency vaped past 30 days
Modified
NSDUH
Redesign
HH,
NHH
HH,
NHH
(not in
SH)
HH,
NHH
HH,
NHH
CT7a
Intro to treatment module
New
CT7
Hospitalization inpatient past 12
months
NSDUH
CT9a
Transition mental health
New
CT9Intr
o
HH,
NHH
(not in
SH)
HH,
NHH
(not in
SH)
HH,
NHH
CT9
Counseling, medication,
treatment mental health,
emotions, behavior
Counseling, medication,
treatment mental health,
emotions, behavior ever
Modified
NSDUH
2025
Modified
NSDUH
2025
CT10
Inpatient: Counseling,
medication, treatment mental
health, emotions, behavior
Modified
NSDUH
Redesign
CT11
68
HH,
NHH
CT12
Modified
NSDUH
Redesign
Modified
NSDUH
69
HH,
NHH
CT13
70
HH,
NHH
HH,
NHH
HH,
NHH
CT14
Outpatient: Counseling,
medication, treatment mental
health, emotions, behavior
Outpatient: Counseling,
medication, treatment mental
health, emotions, behavior # of
visits all facilities
Medication mental health,
emotions, behavior past 12
months y/n
Medication mental health,
emotions, behavior current y/n
Medication ID current
CT16
Counseling, medication,
treatment alcohol/drug use ever
HH,
NHH
CT17
Inpatient: Alcohol/drugs
59
60
SECTION 4: TREATMENT MODULE
61
62
63
64
65
66
67
71
72
73
CT15
Modified
MTF
Modified
NSDUH
Redesign
NSDUH
Redesign
NSDUH
Redesign
Modified
NMHS
Modified
NSDUH
Redesign
Modified
NSDUH
Redesign
2-part translation
2-part translation
2-part translation
2-part translation
5
74
HH,
NHH
CT18
Outpatient: Alcohol/drugs
75
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
CT19
Outpatient: alcohol/drugs # of
visits all facilities
Medications used to reduce drug
use past 12 months y/n
Other medications used to
reduce drug use (specify)
Intro COVID-19
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
CT20
CT20SP
COV0
COV1a
Access to mental health
treatment
COV1c
… appointments moved to
telehealth
… delays/cancelations of
appointments
… delays in prescriptions
COV1d
… unable to access care
COV5a
Access to alcohol and drug use
treatment
COV1b
COV5c
… appointments moved to
telehealth
… delays/cancelations of
appointments
… delays in prescriptions
COV5d
… unable to access care
COV2a
Access to medical care
COV2b
COV2c
… appointments moved to
telehealth
… delays/cancelations of
appointments
… delays in prescriptions
COV2d
… unable to access care
CT21A
Medicare
CT21B
Medicaid
CT21C
Military Tricare et al.
CT21D
Private health insurance
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
COV5b
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
Modified
NSDUH
Redesign
Modified
NSDUH
Modified
NSDUH
Modified
NMHS
Modified
PhenX
Modified
PhenX
2-part translation
2-part translation
2-part translation
2-part translation
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
2-part translation
6
95
CT21E
Any health insurance
CT22
Disability benefits
CT23
New
CT8
Reasons for disability mental or
physical health
Reasons for disability mental
health follow-up
Housing assistance
SECTION 5: SOCIO-DEMOGRAPHICS
100
PR, SH,
HL
CSD4
Marital status
Modified
ACS
101
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
CSD5
Living with partner
CSD6
Ethnicity
NSDUH
2025
NSDUH
C2
Speaking English/Spanish
NLAAS
CSD7
Race
NSDUH
CSD8
Highest educational degree
Modified
ACS
106
PR, SH,
HL
CSD9
Student status
Modified
B&B:08/18
107
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL, HH
CSD9a
First enrollment (in months)
New
Adapted to “you”
instead of this
person and
aggregated
categories
Wording
adjusted to
current,
irrespective of
degree seeking or
not, full time or
part time or not.
Added
instruction to
answer yes if on
break.
Maps to NPSAS
CSD9b
On campus housing current y/n
New
Maps to NPSAS
CSD9e
On campus housing any time
past 12 months y/n
On campus housing mostly past
12 months y/n
Off campus housing type past 12
months
Veteran status
New
Maps to NPSAS
New
Maps to NPSAS
New
Maps to NPSAS
96
97
98
99
102
103
104
105
108
109
110
111
112
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
CT24
CSD9c
CSD9d
CSD10
Modified
NSDUH
New
New
New
Adapted to “you”
instead of this
person, and
adapted for
mixed-mode
asked in English
NIS
7
113
114
115
116
117
PR, SH,
HL
HH,
NHH
HH,
NHH
HH,
NHH
PR, SH,
HL
CSD11
Active duty
CSD12
Arrested
CSD13
Probation
CSD14
Parole
CSD15
Paid work
118
PR, SH,
CSD15a
HL
119
PR, SH,
CSD15b
HL
120
PR, SH,
CSD15c
HL
121
PR, SH,
CSD15d
HL
122
PR, SH,
CSD15e
HL
123
PR, SH,
CSD15f
HL
124
HH,
INTROF
NHH
I1
125
HH,
CSD16
NHH
126
HH,
CSD17a
NHH
127
HH,
CSD17b
NHH
128
HH,
COV3
NHH
129
HH,
COV4
NHH
SECTION 6: OVERLAP WITH (NON-)HH POPULATION
130
PR
COL3
131
132
133
134
PR
COL4
PR
COL5
PR, HL,
SH
COL6
PR, HL,
SH
COL7
Modified
ACS
NSDUH
NSDUH
Redesign
NSDUH
Redesign
Modified
ACS
Paid work any
ACS
Layoff
ACS
Temporary absence
Recalled to work
Modified
ACS
ACS
Actively looking for work
ACS
Could have started work
Modified
ACS
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
Modified
PhenX
New
Household income
Household income
Household income
Household income
COVID-19 financial strain
COVID-19 housing stability
State and county lived in most
prior to incarceration
State lived in most prior to
incarceration
County lived in most prior to
incarceration
Prison/homeless/state
psychiatric hospital more than
once
House/apartment lived
Added
introduction,
exact reference
period, and
unpaid
instructions
New
New
New
New
New
8
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
SECTION 7: CONCLUSION
161
162
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
HL, SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL
PR, HL
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, SH
PR, SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
SH
HH, JA
New
COL8N
House/apartment length of stay
reporting unit
House/apartment stay in nights
COL8W
House/apartment stay in weeks
New
COL8M
House/apartment stay in months
New
Jail stay
New
COL10
Jail length of stay reporting unit
New
COL10N
Jail stay in nights
New
COL10
W
COL10
M
COL11
COL12
Jail stay in weeks
New
Jail stay in months
New
Prison stay
Prison length of stay reporting
unit
Prison stay in nights
New
New
Prison stay in weeks
New
Prison stay in months
New
Psychiatric hospital stay
State psychiatric hospital stay
State psychiatric hospital length
of stay reporting unit
State psychiatric hospital stay in
nights
State psychiatric hospital stay in
weeks
State psychiatric hospital stay in
months
Homeless stay
Homeless shelter stay
Homeless shelter length of stay
reporting unit
Homeless shelter stay in nights
New
New
New
COL16
W
COL16
M
Homeless shelter stay in weeks
New
Homeless shelter stay in months
New
C8
C9
Administrative data linkage
Email confirmation
New
New
COL8
COL9
COL12N
COL12
W
COL12
M
COL13
COL13a
COL14
COL14N
COL14
W
COL14
M
COL15
COL15a
COL16
COL16N
New
New
New
If multiple:
overall
If multiple:
overall
New
New
New
New
New
New
If multiple:
overall
9
163
HH,
NHH
HH, JA,
SH
HH,
NHH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH, HL
C9a
New
C10
Contact information for possible
follow-up
Contact PO/SI
C21
Recontact consent
New
C11a
Interviewer SI necessary y/n
New
C11b
SI y/n
New
C11c
SI Name
New
C12
Relationship SI
New
C12a
SI /subject living together
New
C13
Contact SI
New
C14
New
C16
Respondent comfort with
current interview
mode/alternative preference
Respondent comfort with virtual
interviewing software
Respondent feedback general
HH, JA,
SH, HL
174
HH,
NHH
175
HH, JA,
PO, SI
176
HH, JA,
PO, SI
177
HH, JA,
PO, SI
178
HH, JA,
PO, SI
179
HH, JA,
PO, SI
180
HH, JA,
PO, SI
181
HH,
NHH
SECTION 8: INTERVIEWER DEBRIEFING
182
183
184
C15
New
SI
C17a
Incentive information
New
SI
C17b1
Email incentive payment
New
SI
C17b2
Email incentive payment
New
SI
C17c
Name incentive payment
New
SI
C17d
Address incentive payment
New
SI
C17e
Address new incentive payment
New
SI
C17
Incentive information and end
New
SI
CIDB0
GAF1
CIDB1
Complete or breakoff
Global assessment functioning
Mode of completion
185
CIDB1a
Technical difficulties
186
187
188
189
190
CIDB1b
CIDB2
CIDB3
CIDB4a
CIDB4b
Disconnected
Audio quality
See the respondent
Video quality
Respondent observation
New
DSM
Modified
NSFG
Modified
NSFG
New
New
New
New
New
164
165
166
167
168
169
170
171
172
173
New
SI
New
Virtual only
Virtual only
Virtual only
Virtual only
Virtual only
10
191
CIDB4c
192
193
194
195
196
197
198
199
CIDB5
CIDB6
CIDB7
CIDB7a
CIDB8
CIDB8a
CIDB9
CIDB10
200
201
!=PO/SI
202
PO/SI
203
204
205
206
207
208
209
210
211
212
213
CIDB11
CIDB11
a
CIDB11
b
CIDB12
CIDB13
CIDB14
CIDB15
a
CIDB15
b
CIDB16
C19n
C20n
CIDBBR
1
CIDBBR
2a
CIDBBR
2b
Usefulness of observation for
diagnosis
At home
Where
Privacy
Secondary informant presence
Who observed
Influence of observer
Interview atmosphere
Type of
distractions/interruptions
Attentiveness of respondent
Recall aids
New
Proxy/secondary informant
confidence in answers
Upset respondent
Trouble completing the interview
and which
Comments interview length
SBT administration
New
SBT pass
New
Anything else
Entering paper SCID data
Completion entering paper SCID
data
Breakoff codes
NSDUH
New
New
Virtual only
NSDUH
NSDUH
NSDUH
New
NSDUH
NSFG
NSFG
NSFG
NSFG
New
NSFG
Modified
NBS
NSDUH
New
SBT administration
Modified
NBS
New
SBT pass
New
11
Cpre PROGRAMMER, PLEASE PRELOAD
CATI = YES/NO FROM SYSTEMS
VIRTUAL = YES/NO FROM SYSTEMS
F2F = YES/NO FROM SYSTEMS
SCREENERCOMPLETE = YES/NO
SCREENER MAIL COMPLETE = YES/NO FROM SCREENER
SCREENER F2F COMPLETE = YES/NO FROM SCREENER
SCREENER CATI COMPLETE = YES/NO FROM SCREENER
JA = YES/NO FROM SAMPLING
HH = YES/NO FROM SAMPLING
SH = YES/NO FROM SAMPLING
PR = YES/NO FROM SAMPLING
HL = YES/NO FROM SAMPLING
PROXY = YES/NO FROM PROXY ASSENT
SECONDARY = YES/NO FROM SYSTEMS
LAR = YES/NO FROM SH
YOB = YEAR OF BIRTH FROM SH
HOSPITAL NAME = STATE HOSPITAL NAME FROM SH
SH_PERMISSION_REQ = YES/NO FROM SH
RESPONDENT = YES/NO FROM CLINICAL INTERVIEW
CKNOWLEDGEPASS2 FROM CLINICAL INTERVIEW
BREAKOFF = YES/NO FROM CLINICAL INTERVIEW
SBT = FAIL/PASS FROM CLINICAL INTERVIEW INTERVIEWER DEBRIEFING
NAMEFILL = RESPONDENT NAME FROM CLINICAL INTERVIEW
NAMEFILL2 = SECONDARY OR PROXY NAME
NAMEFILLLAR = LAR NAME
IF PROXY = YES NAMEFILL
PRISON = YES/NO FROM SAMPLING
STATE = FROM SAMPLING FOR PR ONLY
COUNTY = FROM SAMPLING FOR PR ONLY
AGE FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R OR LISTS FOR
PR, SH, OR HL (AS APPLICABLE)
NAME FROM ROSTER OR SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
OR IF SCREENERCOMPLETE = NO LISTS FOR PR, SH, OR HL (AS APPLICABLE)
PHONE NUMBER FROM CATI SYSTEMS
GQU FROM ROSTER
SEX FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
SH3a & b FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
R7 FROM ROSTER
SH2 FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
LANGUAGE FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
SKNOWLEDGEPASS FROM SCREENER
CIINCENTIVE = YES/NO. IF CLINICAL INTERVIEW INCENTIVE WAS ALREADY PAID AT THE SCREENER
= YES; ELSE = NO
INCENTIVE $ ALREADY PAID BY INSTRUMENT IF SCREENERCOMPLETE = YES AND SCREENER R =
CLINICAL R
SCR = CIDI FROM SCREENER
SCR = CAT-MH FROM SCREENER
12
-
-
UNBLINDMDE YES/NO FROM SCREENER
UNBLINDMANIA YES/NO FROM SCREENER
UNBLINDPSYCHOS1 YES/NO FROM SCREENER
UNBLINDPSYCHOS2 YES/NO FROM SCREENER
UNBLINDPSYCHOS3 YES/NO FROM SCREENER
UNBLINDGAD YES/NO FROM SCREENER
UNBLINDPTSD YES/NO FROM SCREENER
EMAIL1 FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R; ELSE
FROM ROSTER IF MISSING IN SCREENER INCENTIVES.
ADDRESS FILL FROM SYSTEMS/ROSTER/SCREENER
INCENTIVE PRELOADS:
o CLINICALINC = $30
o SHINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [HOSPITAL]”
o PRINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [PRISON]”
o HLINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [SHELTER]”
o PROXYINC = “$30”
o SIINC = “$10”
PROGRAMMER: SPANISH IS HERE:
\\rtpnfil02\mdps\Instrumentation\ClinicalInterview\ClinicalContent_20210310_PostAdvarra_ToProgram
mingTranslation_SPA.docx
PROGRAMMER TIME STAMP SET: START
Cconf
(AGE:
, SEX: ).>
Before I review information about the study, I need to confirm I’m talking to the right
person.
, AGE: , SEX: ) SHOULD BE COMPLETING THE CLINICAL INTERVIEW>
) SHOULD BE
COMPLETING THE CLINICAL INTERVIEW>
1
2
YES – CORRECT RESPONDENT, CONTINUE
NO
13
PROGRAMMER: IF Cconf = YES CONTINUE;
ELSE DISPLAY “INTERVIEWER, PLEASE IDENTIFY THE CORRECT RESPONDENT, AGE: , SEX: )>)>. IF THAT IS NOT
POSSIBLE END THE INTERVIEW AND ASSIGN THE CORRESPONDING STATUS CODE.”
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
C1
[IF SCREENER RESPONDENT = CLINICAL INTERVIEW RESPONDENT] INTERVIEWER:
CONFIRM/SELECT THE LANGUAGE TO BE USED FOR THIS INTERVIEW. THE SCREENER WAS
COMPLETED IN .
[IF SCREENER RESPONDENT != CLINICAL INTERVIEW RESPONDENT] INTERVIEWER: SELECT
THE LANGUAGE TO BE USED FOR THIS INTERVIEW ESTABLISHED DURING THE INITIAL
CONTACT.
1
ENGLISH
2
SPANISH
CFIID3
INTERVIEWER: PLEASE ENTER THE INTERVIEW ADMINISTRATION MODE
1
ZOOM AUDIO ONLY (TELEPHONE)
2
VIRTUAL (ZOOM VIDEO)
3
IN-PERSON
PROGRAMMER: GENERATE CATI Y/N, VIRTUAL Y/N, F2F = Y/N
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
Cphon
[IF ((CFIID3 = 1 & PHONE NUMBER = YES)) & ((HH | JA | HL = YES) | (PROXY | SECONDARY
= YES))]
Should you get disconnected please sign back into the call. Should I get disconnected
from this call, please remain on the line and I will dial back in.
Just to confirm, is a good number to reach you in case there is a
Zoom outage?
1
YES
2
NO
DK/REF
Cphon2
[IF ((CFIID3 = 1 & PHONE NUMBER = MISSING) | CFIID3 = 2) & (HH | JA | HL | SH = YES) |
(PROXY | SECONDARY = YES))]:
Should you get disconnected please sign back into the call. Should
I get disconnected from this call, please remain and I will .
14
Just in case of a ZOOM outage, is there a good phone number to reach you?
1
YES
2
NO
DK/REF
CphonNew
[IF Cphon = NO | Cphon2 = YES] Would you please give me a phone number so that I can
contact you in case there is a ZOOM outage?
______________
DK/REF
CphonEnd
[IF Cphon = YES/NO/DK/REF | Cphon2 = YES/NO/DK/REF | PR = YES]
contact the person who assisted you starting this call.>
CSD1_dob
What is your date of birth?
DOB:
_____ _____ ______
MONTH
DAY
YEAR
DK/REF
PROGRAMMER PLEASE DISPLAY ERROR MESSAGE IF THE DATE OVERALL OR THE
INDIVIDUAL FIELDS ARE OUT OF RANGE: YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A
NUMBER BETWEEN .
PROGRAMMER IF DAY = DK/REF ASSUME 28TH AS DAY.
PROGRAMMER GENERATE AGE IN YEARS
CSD1_age
[IF CSD1_dob = DK/REF MONTH AND/OR YEAR] And what is your age?
AGE: ___ ___
DK/REF
CSD1a
[IF PROXY = NO & (CSD1_dob | CSD1_age < 18 |CSD1_age > 66)] Thank you for your
willingness to participate, but we cannot interview anyone who is 66: older than 66> for this
study.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
[IF PROXY = YES & (CSD1_dob | CSD1_age < 18)] Thank you for your willingness to
participate, but we cannot interview anyone who is younger than 18 for this study.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
15
CSD1b
[IF CSD1_dob | CSD1_age = DK/REF] Thank you for your willingness to participate, but we
cannot interview you if we don’t know how old you are.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
CSD1c_dob
[IF PROXY = YES] What is ’s date of birth?
DOB:
_____ _____ ______
MONTH
DAY
YEAR
DK/REF
PROGRAMMER PLEASE DISPLAY ERROR MESSAGE IF THE DATE OVERALL OR THE
INDIVIDUAL FIELDS ARE OUT OF RANGE: YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A
NUMBER BETWEEN .
PROGRAMMER GENERATE AGE IN YEARS
CSD1c_age
[IF PROXY = YES & CSD1c_dob = DK/REF MONTH AND/OR YEAR] And what is
’s age?
AGE: ___ ___
DK/REF
CSD1d
[IF CSD1c_dob | CSD1c_age < 18 | CSD1c_dob | CSD1c_age > 66] Thank you for your
willingness to participate on ’s behalf, but we cannot interview you about
anyone who is 66: older than 66> for this study.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
CSD1e
[IF CSD1c_dob | CSD1c_age = DK/REF] Thank you for your willingness to participate on
’s behalf, but we cannot interview you about anyone if we don’t know how
old they are.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
C3a
1
CONTINUE
2
PROGRAMMER: PLEASE GENERATE RECALLOW = YES IF C3a = 1. IF RECALLOW != YES DO
NOT START RECORDING AND DO NOT ASK C3_rec.
16
C3
PROGRAMMER NOTE PLEASE INCLUDE AS FOLLOWS:
-
[IF HH = YES & SKNOWLEDGEPASS = 1 & SCREENER MAIL COMPLETE = NO & PROXY =
NO & SECONDARY = NO: RECAP HH CONSENT FORM + CONSENT FOR RECORDING]
PROGRAMMER PLEASE DISPLAY RECAP ABBREVIATED INFORMED CONSENT TEXT
FROM “3a Household Clinical Interview Informed Consent Recap” & “3b Recording
Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLDS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf
-
[IF HH = YES & SKNOWLEDGEPASS = 0 & SCREENER MAIL COMPLETE = NO & PROXY =
NO & SECONDARY = NO: INFORMED HH CONSENT FORM + CONSENT FOR
RECORDING + KNOWLEDGE TEST] PROGRAMMER PLEASE ABBREVIATED DISPLAY
INFORMED CONSENT TEXT FROM “3 Household Clinical Interview Informed Consent”
& “3b Recording Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLDS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf
-
[IF ((HH = YES & SKNOWLEDGEPASS = MISSING) | JA = YES) & PROXY = NO &
SECONDARY = NO: INFORMED HH CONSENT FORM + CONSENT FOR RECORDING +
KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED
CONSENT TEXT FROM “3 Household Clinical Interview Informed Consent” & “3b
Recording Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
17
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLDS/
JAILS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf
-
[IF PR = YES & PROXY = NO & SECONDARY = NO: FULL INFORMED PR CONSENT FORM
+ (RECORDING CONSENT +) KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “4 Prison Clinical Interview Informed
Consent” HERE: \\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH
Consent Statements 073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE
PRISONS:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Prison ICF Pro00042170 Aug1320_v4.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Prison ICF Pro00042170 Aug1320_v4_SPA.docx
-
[IF HL = YES & PROXY = NO & SECONDARY = NO: FULL INFORMED HL CONSENT FORM
+ (RECORDING CONSENT +) KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “6 Shelter Clinical Interview
Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE
SHELTERS:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Shelter ICF Pro00042170 Aug1320_ts_v4.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Shelter ICF Pro00042170 Aug1320_ts_v4_SPA.docx
-
[IF SH = YES & PROXY = NO & SECONDARY = NO: FULL INFORMED SH CONSENT FORM
+ (RECORDING CONSENT +) KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “5 Hospital Clinical Interview
Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
18
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE
HOSPITALS:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Hospital ICF Pro00042170 Aug1320_v4.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Hospital ICF Pro00042170 Aug1320_v4_SPA.docx
-
[IF PROXY = YES & SECONDARY = NO: FULL INFORMED PROXY CONSENT FORM +
RECORDING CONSENT + KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “7 Proxy Consent” & “3b Recording
Consent” HERE: \\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH
Consent Statements 073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE PROXY:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Proxy Consent_Auf1320_v5_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Proxy Consent_Aug1320_v5_SPA_Jan0721_clean.pdf
-
[IF SECONDARY = YES & PROXY = NO: FULL INFORMED SECONDARY INFORMANT
CONSENT FORM + RECORDING CONSENT]
PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED CONSENT TEXT FROM
CONSENT TEXT FROM “8 Secondary Informant Consent” & “3b Recording Consent”
HERE: \\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent
Statements 073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE SECONDARY
INFORMANTS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Secondary Informant
Consent_Aug1320_v5_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Secondary Informant Consent_Aug1320_v5_SPAJan0721_clean.pdf
PROGRAMMER: C3_rec SHOULD ONLY BE ASKED IF RESPONDENTS CONSENTED TO
PARTICIPATE IN THE INTERVIEW.
C4a
[IF C3_int = NO] Thank you for your willingness to participate ’s behalf>, but we cannot interview you without your consent.
PROGRAMMER: THIS CONCLUDES THE INTERVIEW
19
C4b
[IF C3_rec = NO] INTERVIEWER, THE RESPONDENT DOES NOT WISH TO BE RECORDED;
PLEASE TURN OFF THE ZOOM RECORDING NOW
Cknow1
[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] To ensure you understand your rights as a NSMH respondent, I
need to ask you a few questions about the information we just discussed. You are being
asked to participate in the National Study of Mental Health – the NSMH. Would you say
the NSMH is about:
a.
b.
c.
d.
a. How pets improve our mental health
b. Mental health and other health issues
c. The health of kids in schools
d. Public transportation
PROGRAMMER NOTE: IF PR | SH | HL = YES PLEASE ONLY DISPLAY THE INTRODUCTORY
SENTENCE BUT REMOVE THE “YOU ARE BEING ASKED …” AND THE RESPONSE OPTIONS
ENTIRELY; THEN SET CKnow1 = b TO ENSURE Cknow5 IS NEVER DISPLAYED (DATE:
06/15/2021).
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.
Cknow2
[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] Your participation in the NSMH interview will take about:
a.
a. 15 minutes
b.
b. 6 hours
c.
d.
c. 3 days
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.
Cknow3
[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] You have been asked to:
a.
b.
c.
d.
a. Take part in a group discussion with 10 to 12 other people
b. Call your local health department to participate
c. Participate in an interview with an interviewer
d. Send a letter with information about your health
PROGRAMMER NOTE: NEVER DISPLAY THIS QUESTION TO ANY POPULATION; SET
CKnow3 = c TO ENSURE Cknow7 IS NEVER DISPLAYED (DATE: 06/15/2021).
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.
20
Cknow4a
[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] True or False: Your participation is voluntary.
1
TRUE
2
FALSE
DK/REF
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.
Cknow4b
[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] True or False: You can refuse to answer any questions.
1
TRUE
2
FALSE
DK/REF
PROGRAMMER: GENERATE CKNOWLEDGEPASS IF (HH = NO | (HH = YES &
SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO
REPLACE CKNOWLEDGEPASS = 1 IF Cknow1 = b & Cknow2 = c & Cknow3 = c &
Cknow4a = 1 & Cknow4b = 1
ELSE CKNOWLEDGEPASS = 0 IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 |
MISSING)) & SECONDARY = NO
IF CKNOWLEDGEPASS = 0 & (PROXY = YES) SKIP TO C17a.
ELSE CONTINUE
Cknow5
[IF Cknow1 != b & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW THE
FOLLOWING STUDY INFORMATION WITH THE RESPONDENT: I may have covered the
consent to participate information too quickly. Let me reread some of the relevant
details about the study:
You are being asked to participate in the National Study of Mental Health – the NSMH.
Would you say the NSMH is about:
a.
How pets improve our mental health
21
b.
c.
d.
Mental health and other health issues
The health of kids in schools
Public transportation
PROGRAMMER GENERATE Cknow5_admin YES/NO IF ADMINISTERED
Cknow6
[IF Cknow2 != c & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW THE
FOLLOWING STUDY INFORMATION WITH THE RESPONDENT:
< IF CFIID3 = 3: $30 cash if you agree to participate.>>
for agreeing to
participate in this interview.>
: IF INCENTIVES ARE ALLOWED IN THIS FACILITY
READ: AND YOU WILL RECEIVE “FILL INCENTIVE” IF YOU AGREE TO PARTICIPATE].>
: IF INCENTIVES ARE
ALLOWED IN THIS FACILITY READ: AND YOU WILL RECEIVE “FILL INCENTIVE” IF YOU
AGREE TO PARTICIPATE].>
: IF INCENTIVES ARE ALLOWED IN
THIS FACILITY READ: AND YOU WILL RECEIVE “FILL INCENTIVE” IF YOU AGREE TO
PARTICIPATE].>
Your participation in the NSMH interview will take about:
a.
b.
c.
d.
15 minutes
6 hours
3 days
PROGRAMMER GENERATE Cknow6_admin YES/NO IF ADMINISTERED
Cknow7
[IF Cknow3 != c & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW THE
FOLLOWING STUDY INFORMATION WITH THE RESPONDENT:
22
to talk with you privately.>
You have been asked to:
a.
b.
c.
d.
Take part in a group discussion with 10 to 12 other people
Call your local health department to participate
Participate in an interview with an interviewer
Send a letter with information about your health
PROGRAMMER GENERATE Cknow7_admin YES/NO IF ADMINISTERED
Cknow8a
[IF Cknow4a != 1 & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW
THE FOLLOWING STUDY INFORMATION WITH THE RESPONDENT:
True or False: Your participation is voluntary.
1
TRUE
2
FALSE
DK/REF
PROGRAMMER GENERATE Cknow8a_admin YES/NO IF ADMINISTERED
23
Cknow8b
[IF Cknow4a != 1 & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW
THE FOLLOWING STUDY INFORMATION WITH THE RESPONDENT:
True or False: You can refuse to answer any questions.
1
TRUE
2
FALSE
DK/REF
PROGRAMMER GENERATE Cknow8b_admin YES/NO IF ADMINISTERED
PROGRAMMER: GENERATE CKNOWLEDGEPASS2 IF (HH = NO | (HH = YES &
SKNOWLEDGEPASS = 0)) & (PROXY | SECONDARY = NO)
REPLACE CKNOWLEDGEPASS2 = 1 IF
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow6_admin = YES & Cknow6 = c & Cknow5_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = NO & Cknow8b_admin = NO) |
24
(Cknow7_admin = YES & Cknow7 = c & Cknow5_admin = NO & Cknow6_admin =
NO & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow8a_admin = YES & Cknow8a = 1 & Cknow5_admin = NO & Cknow6_admin
= NO & Cknow7_admin = NO & Cknow8b_admin = NO) |
(Cknow8b_admin = YES & Cknow8b = 1 & Cknow5_admin = NO & Cknow6_admin
= NO & Cknow7_admin = NO & Cknow8a_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = NO Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
NO & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = NO & Cknow7_admin = YES & Cknow7
= c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = NO & Cknow7_admin = YES & Cknow7
= c & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = NO & Cknow7_admin = NO &
Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = YES & Cknow8b = 1)
|
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin
= NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = NO & Cknow8a_admin = YES & Cknow8a = 1 &
Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = NO & Cknow8b_admin = YES & Cknow8b = 1 &
Cknow8a_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin =
NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 &Cknow8b_admin = YES & Cknow8b
= 1) |
25
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin =
NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 &Cknow8b_admin = YES & Cknow8b
= 1) |
(Cknow5_admin = NO & Cknow6_admin = NO & & Cknow7_admin = YES &
Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = YES &
Cknow8b = 1) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 &
Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin
= YES & Cknow8b = 1) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
YES & Cknow8b = 1) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
YES & Cknow8b = 1) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 &
Cknow8b_admin = YES & Cknow8b = 1) |
ELSE CKNOWLEDGEPASS2 = 0 IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0))
& (PROXY | SECONDARY = NO)
PROGRAMMER:
- IF HH = YES & SKNOWLEDGEPASS = 1 CONTINUE
- IF HH = YES & SKNOWLEDGEPASS = 0 & (CKNOWLEDGEPASS = 1) CONTINUE
- IF HH = YES & SKNOWLEDGEPASS = 0 & (CKNOWLEDGEPASS = 0 &
CKNOWLEDGEPASS2 = 1) CONTINUE
- IF HH = YES & SKNOWLEDGEPASS = 0 & (CKNOWLEDGEPASS = 0 &
CKNOWLEDGEPASS2 = 0) TRIGGER PROXY PROTOCOL AND SKIP TO C17a:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20210201_ToProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20201214_ToProgramminTranslation_SPA.docx
-
IF SH = YES & CKNOWLEDGEPASS = 1 CONTINUE
26
-
IF SH = YES & (CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 1) CONTINUE
IF SH = YES & (CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) & (LAR = YES &
SH_PERMISSION_REQ = YES) DO NOT TRIGGER PROXY PROTOCOL AND SKIP DIRECTLY
TO C17
IF SH = YES & (CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) & (LAR = YES &
SH_PERMISSION_REQ = NO) TRIGGER PROXY PROTOCOL AND SKIP TO C17:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20210201_ToProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20201214_ToProgramminTranslation_SPA.docx
-
IF JA = YES & CKNOWLEDGEPASS = 1 CONTINUE
IF JA = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 1) CONTINUE
IF JA = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) TRIGGER PROXY
PROTOCOL AND SKIP TO C17a:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20210201_ToProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20201214_ToProgramminTranslation_SPA.docx
-
IF PR | HL = YES & CKNOWLEDGEPASS = 1 CONTINUE
IF PR | HL = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 1) CONTINUE
IF PR | HL = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) SKIP TO C17
-
IF PROXY = YES & CKNOWLEDGEPASS = 1 CONTINUE
IF SECONDARY = YES CONTINUE
PROGRAMMER NOTE: INTERVIEWER ASSESSMENT OF CAPACITY TO BE INTERVIEWED – SHORT BLESSED
TEST WILL NOT BE PART OF THE INTERVIEW BUT A JOB AID; IF FAILED & HH | JA | SH = YES PROXY
ASSENT THEN SKIP TO C17a; IF FAILED & PR | HL = YES SKIP TO C17; IF PASS CONTINUE. – REMINDER. DO
NOT PROGRAM THIS TEXT INTO THE INSTRUMENT.
C5
[IF PROXY = YES | SECONDARY = YES] Before we begin the questions about ,
we have a few questions about your relationship with .
C6
[IF PROXY = YES | SECONDARY = YES] What is your relationship to ?
□ HUSBAND/WIFE/SPOUSE
□ UNMARRIED PARTNER
□ SON OR DAUGHTER (INCL. ADOPTIVE OR
STEP)
□ PARENT-IN-LAW
□ SON-IN-LAW OR DAUGHTER-INLAW
□ OTHER RELATIVE
27
□ BROTHER OR SISTER (INCL. ADOPTIVE OR
STEP)
□ FATHER OR MOTHER (INCL. ADOPTIVE OR
STEP)
□ GRANDCHILD
DK/REF
C6a
□ ROOMMATE OR HOUSEMATE
□ OTHER NONRELATIVE, SUCH AS A
MEDICAL OR HEALTH CARE
PROVIDER
[IF C6 = OTHER (NON)RELATIVE] [INTERVIEWER PLEASE ENTER THE RELATIONSHIP]
_______________________
DK/REF
C6b
[IF PROXY = YES | SECONDARY = YES] Do you and usually live at the same
address?
1
YES
2
NO
DK/REF
C7
[(IF PROXY = YES | SECONDARY = YES) & C6b = NO] How often do you interact with
?
INTERVIEWER: READ RESPONSE OPTIONS FOR FIRST TWO CATEGORIES AND REPEAT
THEREAFTER AS NEEDED.
Daily or Every
Every
Less
UNSURE DOES
almost week
month
often
NOT
daily
than
APPLY
once a
month
a. In-person
b. Virtually
c. By telephone
d. By email
e. By mail
f. By some other mode
DK/REF
PROGRAMMER IF SECONDARY = YES & C7f = DOES NOT APPLY/DK/REF GO TO C18;
PROGRAMMER IF SECONDARY = YES & C7f != DOES NOT APPLY/DK/REF CONTINUE;
ELSE CONTINUE
C7f_other
[IF C7f != DOES NOT APPLY/DK/REF] INTERVIEWER PLEASE ENTER THE OTHER CONTACT
MODE
_______________________
DK/REF
PROGRAMMER IF SECONDARY = YES GO TO C18;
ELSE CONTINUE
28
COL1
[IF PR = YES OR SH = YES] When > admitted to this facility?
[IF HL = YES] When > enter
this shelter?
COL1a. 2-DIGIT MONTH: _________
[RANGE: 1 – 12] DK/REF
COL1b. 2-DIGIT DAY: ____________
[RANGE: 1 – 31] DK/REF
COL1c. 4-DIGIT YEAR: ___________
[RANGE: 1915 – current year]
DK/REF
[PROGRAMMER: CALCULATE LENGTH OF STAY; USE THE 15TH IF COL1b =
DK/REF]
PROGRAMMER IF (COL1c <= (CURRENT YEAR - CSD1_age)) PLEASE DISPLAY THE
FOLLOWING ERROR MESSAGE AND LEAD BACK TO QUESTION: Year cannot
be earlier than year of birth.
COL2
[IF COL1a = DK/REF AND COL1c != DK/REF] What time of year was it? Was it
winter, spring, summer, or fall when was> admitted to this facility?
1
WINTER
2
SPRING
3
SUMMER
4
FALL
DK/REF
[PROGRAMMER: CALCULATE LENGTH OF STAY IN MONTHS]
PROGRAMMER: CALCULATE LENGTH OF STAY. FOR WINTER USE JANUARY AS THE
MONTH; FOR SPRING APRIL, FOR SUMMER JULY, FOR FALL OCTOBER
PROGRAMMER: IF COL2 = DK/REF & (COL1c = CURRENT YEAR OR CURRENT YEAR – 1)
then “LENGTH OF STAY IN MONTHS” = 11 (Less than 12 months)
IF COL2 = DK/REF & (COL1c >= CURRENT YEAR -2) then “LENGTH OF STAY IN MONTHS” =
12* (CURRENT YEAR – COL1c) (More than 12 months)
CSD2a
What sex was recorded on
original birth certificate?
1
MALE
2
FEMALE
DK/REF
29
CSD2b
What is ’s> current gender identity?
Please tell me which of the following apply to >.
YES NO
Male
Female
Transgender
I am not sure of ’s> gender identity
PROGRAMMER CHECKBOX: I DO NOT KNOW WHAT THIS QUESTION IS ASKING AND SET CSD2b to
DK
REF
a.
b.
c.
d.
PROGRAMMER DEFINE PRSEX1 & PRSEX2 & PRSEX3
IF CSD2ba = 1 & (CSD2bb & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX1 = he
IF CSD2ba = 1 & (CSD2bb & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX2 = his
IF CSD2ba = 1 & (CSD2bb & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX3 = him
IF CSD2bb = 1 & (CSD2ba & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX1 = she
IF CSD2bb = 1 & (CSD2ba & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX2 = her
IF CSD2bb = 1 & (CSD2ba & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX3 = her
ELSE PRSEX1 = they
ELSE PRSEX2 = their
ELSE PRSEX3 = them
PROGRAMMER DEFINE CURRSEX FILL
IF CSD2ba = 1 THEN CURRSEX FILL = “