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Mass Trauma > Response Tools > Mental Health Survey > Instrument 

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Mental Health Survey Instrument

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Demographics

I would just like to ask some general background information Ė first about you and then about your household. 

 

What year were you born?

YEAR OF BIRTH  19__
DONíT KNOW 8
REFUSE  9
Have you had your birthday already this calendar year?   
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
DM1. What is the highest grade or year of school you have completed? [Read choices 1 Ė 7 if necessary.] 

   

Eighth grade or less  1
Some high school  2
High school graduate or GED certificate 3
Some post high school  4
College graduate (Associate or Bachelorís) 5
Post graduate education or degree  6
Other (Specify) 7
DONíT KNOW  98
REFUSE  99
DM2. What is the highest grade or year of school that anyone else in your household has completed? [Read choices 1 Ė 7 if necessary.] 
Eighth grade or less  1
Some high school  2
High school graduate or GED certificate 3
Some post high school  4
College graduate (Associate or Bachelorís) 5
Post graduate education or degree  6
Other (Specify) 7
DONíT KNOW  98
REFUSE  99
DM3. Are you currently: [Read answers 1-8.]
Employed or self-employed full-time 1
Employed or self-employed part-time 2
Homemaker or caregiver 3
Out of work or unable to work 4
Student 5
Student and employed 6
Retired  7
Something else (Specify)  8
DONíT KNOW  98
REFUSE  99
DM4. Are you currently: [Read answers 1-7.] [Prompt if necessary, ďPick the one that you feel best describes your current status.Ē] 
Married 1
Partnered  2
Divorced 3
Widowed 4
Separated 5
Never married 6
Other (Specify)   7
DONíT KNOW  98
REFUSE  99
DM5. Do you consider yourself of Hispanic or Latino origin, including Mexican, Latin American, Puerto Rican, or Cuban descent?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
DM6.  What is your race?  Please select one or more of the following.  [Read answers 1 Ė 6 and code all that apply.]
Native American or Alaskan Native  1
Asian  2
African American or Black 3
Native Hawaiian or Other Pacific Islander 4
Caucasian or White  5
Other (Specify)   6
DONíT KNOW  98
REFUSE  99
DM7. Would you tell me what category best represents the total gross income (income brought in before taxes) during the past 12 months by all members of your household? Please stop me when I read the right category. [Read answers 1-5.]
Less than $20,000  1
$20,000 - <$35,000  2
$35,000 - <$50,000 3
N$50,000 - <$100,000 4
$100,000 or more  5
DONíT KNOW  8
REFUSE  9

Exposure to Event

The following questions are about the [TRAUMATIC EVENT].

The next two questions [P1-P2] assess personal exposure to traumatic event.
P1. Which best describes your personal exposure to [TRAUMATIC EVENT]? Would you say (READ ANSWERS)?
You were in or around [TRAUMATIC EVENT] and you saw at least some of this happen  1
You were in or around the [TRAUMATIC EVENT] but did not see any of it happen  2
You were not in or around any of the [TRAUMATIC EVENT] 3
DONíT KNOW  8
REFUSE  9

 

P2. As a result of your exposure to the [TRAUMATIC EVENT] did you feel that you were at risk of being injured or killed?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
The next six questions [P3-P8] assess known othersí exposure to traumatic event.
P3. When you first heard about the [TRAUMATIC EVENT], did you fear that a family member or close friend who was in or around the site of the [TRAUMATIC EVENT] might be killed, injured, or missing?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P4. As a result of the [TRAUMATIC EVENT], did you actually have a family member or close friend who was killed, injured, or missing?
YES 1
NO (skip to P6) 2
DONíT KNOW (skip to P6) 8
REFUSE (skip to P6) 9
P5. What was this personís relationship to you? 
CURRENT OR FORMER SPOUSE 1
CURRENT OR FORMER BOYFRIEND/GIRLFRIEND) 2
PARENT OR STEP PARENT 3
SIBLING OR STEP-SIBLING 4
CHILD OR STEP CHILD 5
GRANDPARENT  6
GRANDCHILD  7
OTHER FAMILY MEMBER (AUNT/UNCLE, COUSIN, NEPHEW/NIECE ETC.) 8
CLOSE FRIEND  9
OTHER (SPECIFY) 10
MULTIPLE PEOPLE (SPECIFY) 95
DONíT KNOW 98
REFUSE  99
N/A (SKIP) 97
P6. Was anyone else you personally know killed, injured, or missing, as a result of the [TRAUMATIC EVENT]?
YES 1
NO (skip to P8) 2
DONíT KNOW (skip to P8) 8
REFUSE (skip to P8) 9
P7. What was this personís relationship to you? 
FRIEND 1
NEIGHBOR 2
CO-WORKER 3
OTHER (SPECIFY)  4
MULTIPLE PEOPLE (SPECIFY) 95
DONíT KNOW 98
REFUSE  99
N/A (SKIP) 97
P8. Do you know someone who had a family member or close friend who was killed, injured, or missing as a result of the [TRAUMATIC EVENT]?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9

Assessment of Symptoms
 

The next seven questions [P9-P15] assess PTSD symptoms.
 
The next questions are about the time after the [TRAUMATIC EVENT]. Please answer yes or no for each question. After the [TRAUMATIC EVENT]Ö
P9. Did you avoid being reminded of this experience by staying away from certain places, people, or activities?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P10. Did you lose interest in activities that were once important or enjoyable?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P11. Did you begin to feel more isolated or distant from other people? (PROMPT: Other people with whom you normally interact.)
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P12. Did you find it hard to have love or affection for other people?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P13. Did you begin to feel that there was no point in planning for the future? (PROMPT: I mean long-term future, such as planning for a career, children, or retirement.)
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P14. After this experience, were you having more trouble than usual falling asleep or staying asleep? (PROMPT: By this experience I mean the [TRAUMATIC EVENT].)
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P15. Did you become jumpy or get easily startled by ordinary noises or movements?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
The next six questions [P16-P21] assess anxiety symptoms.
Since [TRAUMATIC EVENT] have you been distressed or bothered byÖ 
P16. Feelings of nervousness or shakiness inside?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P17. Suddenly scared for no good reason?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P18. Feeling fearful?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P19. Feeling tense or keyed up?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P20. Spells of terror or panic?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P21. Feeling so restless you couldnít sit still?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
The next six questions [P22-P27] assess anxiety symptoms.
P22. Thoughts of taking your life?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P23. Feeling lonely?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P24. Feeling blue?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P25. Difficulty making decisions? 
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P26. Feeling hopeless about the future?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
P27. Feelings of worthlessness?
YES 1
NO  2
DONíT KNOW 8
REFUSE 9
The next question [P28] assesses frequency of symptoms.
P.28 Are you currently having these reactions at least a few times a week?
YES (skip to P29) 1
NO  2
DONíT KNOW 8
REFUSE 9
N/A (SKIP) 7
The next question [P29] assesses professional help-seeking.
P29. Have you discussed these reactions with a doctor, nurse, psychologist, or other health professional?
YES (skip to P29) 1
NO  2
DONíT KNOW 8
REFUSE 9
N/A (SKIP) 7
The next two questions [P30-P31] assess heavy drinking.
P30. How many drinks did you have on a typical day since the [TRAUMATIC EVENT]?
None 0
1 to 2 drinks 0
3 to 4 drinks 1
7 to 9 drinks  2
10 or more drinks  4
DONíT KNOW 8
REFUSE 9
N/A (SKIP) 7
P31. How often did you have 6 or more drinks on one occasion since the [TRAUMATIC EVENT]? 
Never 0
Once  1
2 to 3 times  2
4 to 5 times 3
6 or more times  4
DONíT KNOW 8
REFUSE 9
N/A (SKIP) 7

Content last revised 3/26/03.
 


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