Attachment C Attachment C

Form Approved

OMB#

Exp. Date 2021

Social and Health Experiences

Your opinion matters!

Your health is affected by many social, environmental and behavioral influences. This survey focuses on your well-being, ability to meet basic needs, and your social and family experiences. This information will help better understand how these external influences affect health. Your participation is important for increasing this understanding.

Survey Instructions

• Please answer every question by marking one box “.” If you are unsure about how to answer a question, please give the best answer you can.

• Your participation is voluntary and all of your answers will be kept confidential to the extent permitted by law. If you have any questions about this booklet, please call Alex Scott at
  1-800-945-MEPS (6377).

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 7 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

T he Agency for Healthcare Research and Quality and
The Centers for Disease Control and Prevention of the
U.S. Department of Health and Human Services

Social and Health Experiences

1. How satisfied are you with your life as a whole these days?

• Completely satisfied

• Very satisfied

• Somewhat satisfied

• A little satisfied

• Not at all satisfied

2. How satisfied are you with the house or apartment where you live?

• Completely satisfied

• Very satisfied

• Somewhat satisfied

• A little satisfied

• Not at all satisfied

3. How would you rate the following characteristics of your neighborhood?

   	Excellent	Very Good	Good	Fair	Poor
   a. Availability of places to get medical care.					
   b. Availability of parks and playgrounds.					
   c. Availability of places to buy healthy food.					
   d. Safety from crime and violence.					
   e. Access to public transportation.					
   f. Availability of affordable housing.					

4. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?

• Yes

• No

5. Was there any time in the past 12 months when your household did not pay the full amount of the rent or mortgage or was late with a payment because your household could not afford to pay?

• Yes

• No

• Don’t Know

6. Was there any time in the past 12 months when your household was not able to pay the full amount of electric, gas, oil, or water bills on time?

• Yes

• No

• Don’t Know

7. Was there any time in the past 12 months when the electric, gas, oil, or water company threatened to shut off services in your home?

• Yes

• No

• Already shut off

• Don’t Know

8. Think about the place you live. Do you have problems with any of the following?
   MARK “” ALL THAT APPLY

• Pests such as bugs, ants, or mice

• Mold

• Lead paint or pipes

• Lack of heat

• Oven or stove not working

• Smoke detectors missing or not working

• Water leaks

• None of the above

9. Some people have made the following statements about their food situation. Please answer whether the statements were often, sometimes, or never true for you in the last 12 months.

	Often True	Sometimes True	Never True
a. Within the past 12 months, you worried that your food would run out before you got money to buy more.			
b. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.			

10. How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is…?

• Very hard

• Somewhat hard

• Not hard at all

11. How confident are you that you could come up with $400 if an unexpected expense arose within the next month?

• Not at all confident

• Not too confident

• Somewhat confident

• Very confident

12. In the past 12 months, have you missed a payment on a credit card or a loan (do not include missed payments on a mortgage)?

• Yes

• No

13. In the past 12 months, have you been contacted by a debt collection agency?

• Yes

• No

Behavior and Community

14. In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?

• 0

• 1

• 2

• 3

• 4

• 5

• 6

• 7

15. On average, how many minutes did you usually spend exercising at this level on one of those days?

• 0

• 10

• 20

• 30

• 40

• 50

• 60

16. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days?

• Not at all

• A little bit

• Somewhat

• Quite a bit

• Very much

17. If you had a problem with which you needed help (for example, sickness or moving), how much help would you expect to get…

	All of the help needed	Most of the help needed	Very little of the help needed	No help
a. From family? (Including any of your relatives or your spouse/partner's relatives if applicable, whether or not they are living with you.).				
b. From friends?				
c. From other people in the community besides friends and family, such as a social agency or church?				

18. In a typical week, how many times do you talk on the telephone (or by video) with family, friends, or neighbors?

• Never

• 1 time

• 2 times

• 3 times

• 4 times

• 5 times

• 6 or more times

19. In a typical week, how often do you get together with friends or relatives (for example, going out together or visiting in each other’s homes)?

• Never

• 1 time

• 2 times

• 3 times

• 4 times

• 5 times

• 6 or more times

20. How often do you attend church or religious services (in-person or online)?

• Never

• 1-3 times per year

• 4-6 times per year

• 7-9 times per year

• 10-12 times per year

• 13-15 times per year

• 16 or more times per year

21. How often do you attend meetings of the clubs or organizations you belong to (in-person or online)?

• Never

• 1-3 times per year

• 4-6 times per year

• 7-9 times per year

• 10-12 times per year

• 13-15 times per year

• 16 or more times per year

22. The next questions are about how you feel about different aspects of your life. For each one, mark how often you feel that way.

    1. First, how often do you feel that you lack companionship?

• Never

• Rarely

• Sometimes

• Often

2. How often do you feel left out?

• Never

• Rarely

• Sometimes

• Often

3. How often do you feel isolated from others?

• Never

• Rarely

• Sometimes

• Often

23. Have you ever used an electronic nicotine product, even one or two times? (Electronic nicotine products include e-cigarettes, vape pens, personal vaporizers and mods, e-cigars, e-pipes, e-hookahs and hookah pens.)

• Yes

• No

24. Have you ever personally experienced discrimination in any of the following situations?

    1. At a doctor's office, clinic, or hospital?

• Yes

• No

2. At work?

• Yes

• No

3. When applying for jobs?

• Yes

• No

4. When trying to rent a room or apartment or buy a house?

• Yes

• No

5. When interacting with police or law enforcement?

• Yes

• No

6. When applying for social services or public assistance?

• Yes

• No

7. At a restaurant or store?

• Yes

• No

Physical and Social Violence

25. Violence and abuse happens to many people, which can affect their health. The following questions ask about your experiences with physical violence and abuse to help us better understand how this affects health.

    1. How often does anyone, including family and friends, physically hurt you?

• Never

• Rarely

• Sometimes

• Fairly often

• Frequently

2. How often does anyone, including family and friends, insult or talk down to you?

• Never

• Rarely

• Sometimes

• Fairly often

• Frequently

3. How often does anyone, including family and friends, threaten you with harm?

• Never

• Rarely

• Sometimes

• Fairly often

• Frequently

4. How often does anyone, including family and friends, scream or curse at you?

• Never

• Rarely

• Sometimes

• Fairly often

• Frequently

Childhood Experiences

The following questions are about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. Page 14 includes phone numbers for organizations that can provide information and referrals for these issues. Please keep in mind that you can skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age.

26. Now, looking back before you were 18 years of age, did you live with anyone who was depressed, mentally ill, or suicidal?

• Yes

• No

27. Did you live with anyone who was a problem drinker or alcoholic?

• Yes

• No

28. Did you live with anyone who used illegal street drugs or who abused prescription medications?

• Yes

• No

29. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

• Yes

• No

30. Were your parents separated or divorced?

• Yes

• No

• Parents not married

31. How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? Was it…

• Never

• Once

• More than once

32. Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it…

• Never

• Once

• More than once

33. How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…

• Never

• Once

• More than once

34. How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…

• Never

• Once

• More than once

35. How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…

• Never

• Once

• More than once

36. How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…

• Never

• Once

• More than once

 Please go to the "Date Completed" box on the back cover.

The following are phone numbers for organizations that can provide additional information and referrals, if needed.

• The National Domestic Violence Hotline at 1-800-799-SAFE (7233).

• The National Sexual Assault Hotline at 1-800-656-HOPE (4673).

• The National Child Abuse Hotline at 1-800-4-A-Child (1-800-422-4453).

• The National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Date completed:

Who completed this form?

• Person named on front of this form

  

• Someone else

If Someone Else, what is person’s relationship to the person named on the front of this form?

• Person named on front of this form

• Husband or wife

• Unmarried partner

• Mother, father, or guardian

• Son or daughter

• Other relative

• Not related

Thank you for taking the time to complete this survey.

• Please place this survey in the envelope provided to you and give it to the MEPS interviewer.

• If the interviewer is no longer available, place the survey in the return envelope provided to you by the interviewer. If the envelope is missing, mail this survey to:

MEPS

c/o Westat

1600 Research Blvd, Room GA51

Rockville, MD 20850

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