Baseline Survey

OMB No. 0990-

Exp Date

XX/XX/20XX

Baseline Survey (DIFO) Doing It For Ourselves

Program

Doing It For Ourselves (DIFO) Survey

Thank you for participating in this important survey! This information will help us understand how to best serve all types of women enrolled in the DIFO health program. Some survey questions may be difficult to answer, but please respond to the items as best you can.

Section I - Demographic information

We want to understand the different types of women that our program serves. This section includes items asking about some of your background characteristics.

Name:

Date:

1. What is your date of birth?

   Month:

   Day:

   Year:

2. Are you of Hispanic or Latino/a origin?
   
   

	Yes
	No
	Don’t know/Not Sure

3. Which one or more of the following would you say is your race? (Check all that apply)

	Black or African American
	Asian
	White
	American Indian or Alaska Native
	Native Hawaiian or Other Pacific Islander

4. What is the highest level of education you have completed?

	Less than high school
	High school
	GED
	Technical school -- no degree
	Some college -- no degree
	2-year college degree/technical school degree
	4-year college degree
	Post-graduate work or degree

5. How long have you lived in the U.S.?

	I was born here
	Less than 10 years
	More than 10 years

6. What was your household income before taxes last year?
   
   

   $

7. How many people relied on that income (including yourself)?

people

8. What is your current employment status?

	Working part-time
	Working full-time
	Unemployed, laid off, on strike
	Retired
	Disabled or unable to work
	In school full-time and not working
	Full-time homemaker

9. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

	Yes
	No
	Don’t know/Not sure

10. If Yes, do you currently have

	Private health insurance under your own plan
	Private insurance under your partner’s plan
	Public coverage such as Medicare or MediCal
	No health insurance
	Don’t know/not sure

11. Which of the following best describes your present relationship?
    
    

	In a committed relationship with a woman (for example,
	cohabiting, domestic partnership, or legally married)
	In a committed relationship with a man (for example,
	cohabiting, domestic partnership, or legally married)
	Single, but somewhat involved with a woman, man, or both
	Single, and not involved with anyone

12. If in a committed relationship, do you currently live with your partner
    
    

	All or most of the time
	Some of the time
	None of the time
	I do not have a partner (skip to question 15)

13. If partnered, is your current partner

	Male
	Female
	Transgender
	Other (Explain):
	I do not have a partner

14. If partnered, for how long?

year(s)

month(s)

Section II - Sexual and gender identity

Since this program is designed for lesbian and bisexual women, we are interested in understanding a little bit about how you identify yourself.

15. Which of the following best represents how you think of yourself?
    
    

	Lesbian or gay
	Straight, that is, not lesbian or gay
	Bisexual
	Something else
	Don’t know the answer

16. If answered “something else” in the previous question: What do you mean by something else?
    
    

	You are not straight, but identify with another label such as
	queer, trisexual, omnisexual or pansexual
	You are transgender, transsexual or gender variant
	You have not figured out or are in the process of figuring out
	your sexuality
	You do not think of yourself as having sexuality
	You do not use labels to identify yourself
	You mean something else

On a scale of 0 to 10, how would you rate yourself?

0	1		2		3		4		5	6	7		8		9			10
Very Butch or Masculine								Androgynous									Very Femme or Feminine

At what age did you first admit to yourself that you had same-sex attractions?

At what age did you acknowledge that you were lesbian/bisexual or a
similar identity?

At what age did you have your first same-sex relationship?

How “out” are you about your sexuality in the following contexts?
	Out to All	Out to Some	Out to a Few	Out to None	N/A
With immediate family
With extended family
With coworkers, bosses, supervisors

	Out to All	Out to Some	Out to a Few	Out to None	N/A
With health care providers (doctors, nurses, nutritionists, mental health professionals, personal trainers, etc.)

For questions 25-63, please indicate your agreement or disagreement with each of the following statements. Please do your best to complete each item. Some statements may depict situations that you have not experienced; please imagine yourself in those situations when answering those statements.

1	2	3	4	5	6	7
Strongly	Moderately	Slightly		Slightly	Moderately	Strongly
Disagree	Disagree	Disagree	Neutral	Agree	Agree	Agree
I try not to give signs that I am a lesbian/bisexual woman. I am careful about the way I dress, the jewelry I wear, the places, people and events I talk about.
I can’t stand lesbians who are too “butch”. They make lesbians as a group look bad.
Attending lesbian/gay/bisexual events and organizations is important to me.
I hate myself for being attracted to other women.
I believe female homosexuality is a sin.
I am comfortable being an “out” lesbian/bisexual woman. I want others to know and see me as a lesbian/bisexual woman.
I have respect and admiration for other lesbians/bisexual women
I wouldn’t mind if my boss knew that I was a lesbian/bisexual woman.
If some lesbians would change and be more acceptable to the larger society, lesbians as a group would not have to deal with so much negativity and discrimination.
I am proud to be a lesbian/bisexual woman.
I am not worried about anyone finding out that I am a lesbian/bisexual woman.
When interacting with members of the lesbian/gay/bisexual community, I often feel different and alone, like I don’t fit in.
I feel bad for acting on my lesbian desires.
I feel comfortable talking to my heterosexual friends about my everyday home life with my female partner/lover or my everyday activities with my lesbian/bisexual friends.
Having lesbian/bisexual friends is important to me.
I am familiar with lesbian/gay/bisexual books and/or magazines.
Being a part of the lesbian/gay/bisexual community is important to me.
It is important for me to conceal the fact that I am a lesbian/bisexual from my family.
I feel comfortable talking about homosexuality in public.
I live in fear that someone will find out I am a lesbian/bisexual woman.
If I could change my sexual orientation and become heterosexual, I would.
I do not feel the need to be on guard, lie, or hide my lesbianism/ bisexuality to others.
I feel comfortable joining a lesbian/gay/bisexual social group, sports team, or organization.
When speaking of my female lover/partner to a straight person I change pronouns so that others will think I’m involved with a man rather than a woman.
Being a lesbian/bisexual woman makes my future look bleak and hopeless.
If my peers knew of my lesbianism/bisexuality, I am afraid that many would not want to be friends with me.
Social situations with other lesbians/bisexual women make me feel uncomfortable.
I wish some lesbians wouldn’t “flaunt” their lesbianism. They only do it for shock value and it doesn’t accomplish anything positive.
I don’t feel disappointment in myself for being a lesbian/bisexual woman.
I am familiar with lesbian/gay/lesbian movies and/or music.
I am aware of the history concerning the development of lesbian/gay/bisexual communities and/or the lesbian/gay/bisexual rights movement.
I act as if my female lovers are merely friends.
I feel comfortable discussing my lesbianism/bisexuality with my family.
I could not confront a straight friend or acquaintance if she or he made a homophobic or heterosexist statement to me.
I am familiar with lesbian music festivals and conferences.
When speaking of my female lover/partner to a straight person, I often use neutral pronouns so the sex of the person is vague.
Lesbians are too aggressive.
I frequently make negative comments about other lesbians/bisexual women.
I am familiar with community resources for lesbians/bisexual woman (i.e., bookstores, support groups, bars, etc).

Section III - Partner and social network status

The following set of questions asks about your relationships and your social network, both in general and regarding your connection to the LGBT community.

64. How satisfied are you with your current relationship status?

	Very satisfied
	Somewhat satisfied
	Somewhat dissatisfied
	Very dissatisfied

65. How would you rate the health of your current partner?

	Excellent
	Very good
	Good
	Fair
	Poor
	I do not have a partner (skip to question 67)

66. Circle the number of the diagram that best depicts the approximate outline of your partner

___	Don’t know
___	Do not have a partner

67. How satisfied are you with the support you receive from your current social network of friends?

	Very satisfied
	Somewhat satisfied
	Not satisfied nor unsatisfied
	Somewhat dissatisfied
	Very dissatisfied

68. How closely connected do you feel to your local lesbian and/or bisexual women’s community?

	Very closely connected
	Closely connected
	Somewhat connected
	Not very connected
	Not at all connected

69. How closely connected do you feel to your local LGBT community?

	Very closely connected
	Closely connected
	Somewhat connected
	Not very connected
	Not at all connected

Section IV –Life experiences

In your lifetime, how often have you had the following experiences?
Experience	Often	Some-times	Rarely	Never
Been treated with less courtesy than others
Been treated with less respect than others
Received poorer services than others in restaurants or stores
Experienced people treating you as if you’re not smart
Experienced people acting as if they were better than you
Experienced people acting as if they were afraid of you
Experienced people acting as if you were dishonest
Been called names or insulted

How much do you think the following factors have led people to treat you differently in your lifetime?
Factor	Very much	Somewhat	Not at all	Don’t know
My sexuality
My race/ethnicity
My sex/gender
My religion
My weight
My social class standing
My educational level
Other
If you selected ‘Other’, please explain:

Section V. Health

The following set of questions asks about your physical and mental health, including your health history.

86. Have you had at least one menstrual period in the past 12 months? (Please do not include bleedings caused by medical conditions, hormone therapy, or surgeries.)

	Yes
	No

In your lifetime, have you ever been diagnosed and/or treated for:
Depression	Yes:		No:
Bi-polar disorder	Yes:		No:
Post-traumatic stress disorder	Yes:		No:
Other anxiety disorders	Yes:		No:
Alcohol dependence	Yes:		No:
Drug dependence	Yes:		No:
Arthritis of any type	Yes:		No:
Asthma	Yes:		No:
Chronic Obstructive Pulmonary Disease, emphysema, or other serious lung disease	Yes:		No:

Diabetes			Yes:		No:
(if Yes, at what age were you diagnosed with diabetes)
Heart disease of any type			Yes:		No:
HIV/AIDS			Yes:		No:
Cancer of any type			Yes:		No:
High blood pressure			Yes:		No:
High cholesterol			Yes:		No:

103. About how many times in your adulthood have you tried to lose weight?

	Never
	1-4 times
	5-10 times
	More than 10 times

Please rate which of the weight loss methods you have tried, if any, and how effective you thought it was:

	Did not try	Not effective	Some-what effective	Very effective
Ate less food
Ate foods with lower calories
Ate less fat
Exercised
Attended weight loss program
Drank extra water
Followed a weight loss plan
Ate diet foods
Skipped meals
Liquid diets
Used prescription drugs to enhance weight loss
Used herbal products to enhance weight loss
Used over-the-counter diet pills
Used laxatives or vomiting
Had weight loss surgery

119. Do you have a long-term physical or mental impairment that substantially limits one or more major life activities?
     
     

	Yes
	No

120. If yes, in which activities are you limited? [Check all that apply]:

	Caring for myself
	Performing manual tasks
	Walking or standing
	Lifting or reaching
	Seeing
	Hearing, speaking or communicating
	Learning, thinking or concentrating
	Working

In the past week	Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or a moderate amount (3-4 days)	Most or all of the time (5-7 days)
I felt depressed
I felt lonely
I had crying spells
I felt sad

125. Do you NOW smoke every day, some days or not at all?

	Every day
	Some days
	Not at all

126. If you have quit smoking, how long has it been since you quit smoking cigarettes?

	Less than one year ago
	One year or longer
	Not Applicable

127. Have you smoked at least 100 cigarettes in your lifetime?

	Yes
	No

For 128- 130: By a drink we mean half an ounce of absolute alcohol (e.g., a 12 ounce can or glass of beer or cooler, a 5 ounce glass of wine, or a drink containing 1 shot of liquor).

128. During the last 30 days, how often did you usually have any kind of drink containing alcohol? Choose only one.

	Every day
	5 to 6 times a week
	3 to 4 times a week
	Twice a week
	Once a week
	2 to 3 times a month
	Once a month
	I did not drink any alcohol in the past month, but I did drink
	in the past (skip to question 131)
	I never drank any alcohol in my life (skip to question 131)

129. During the last 30 days, how many alcoholic drinks did you have on a typical day when you drank alcohol?

	25 or more drinks		7 to 8 drinks
	19 to 24 drinks		5 to 6 drinks
	16 to 18 drinks		3 to 4 drinks
	12 to 15 drinks		2 drinks
	9 to 11 drinks		1 drink

130. During the last 30 days, how often did you have 4 or more drinks containing any kind of alcohol in within a two-hour period? Choose only one.

	Every day		One day a week
	5 to 6 days a week		2 to 3 days a month
	3 to 4 days a week		One day a month
	Two days a week		Never

131. Do you consider yourself in recovery from alcohol or drug use?

	Yes
	No

The following questions ask for your views about your health—how you feel and how well you are able to do your usual activities. There are no right or wrong answers; please choose the answer that best fits your life right now.

132. In general, would you say your health is:

	Excellent
	Very good
	Good
	Fair
	Poor

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

133. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?

	Yes, limited a lot
	Yes, limited a little
	No, not limited at all

134. Climbing several flights of stairs

	Yes, limited a lot
	Yes, limited a little
	No, not limited at all

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

135. Accomplished less than you would like.

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time
	Yes, all of the time

136. Were limited in the kind of work or other activities.

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time
	Yes, all of the time

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

137. Accomplished less than you would like.
     
     

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time
	Yes, all of the time

138. Didn’t do work or other activities as carefully as usual.

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time

139. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

	Not at all
	A little bit
	Moderately
	Quite a bit
	Extremely

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

140. How much of the time during the past 4 weeks have you felt calm and peaceful?

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time

How much of the time during the past 4 weeks did you have a lot of energy?

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time

141. How much of the time during the past 4 weeks have you felt downhearted and blue?

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time

142. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
     
     

	All of the time
	Most of the time
	Some of the time
	A little of the time
	None of the time

143. Compared to one year ago, how would you rate your physical health in general now?

	Much better
	Slightly better
	About the same
	Slightly worse
	Much worse

Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?

	Much better
	Slightly better
	About the same
	Slightly worse
	Much worse

Section VI. Nutrition

We are now interested in understanding a little bit about your eating and drinking habits.

Please select one option for each of the following items:

	Never/ Rarely	Some -times	Often	Usually/ Always	N/A
I notice when there are subtle flavors in the foods I eat
When eating a pleasant meal, I notice if makes me feel relaxed
I snack without noticing that I am eating
I appreciate the way my food looks on my plate
When I’m feeling stressed at work, I’ll go find something to eat
When I’m sad, I eat to feel better
I notice when foods and drinks are too sweet
Before I eat I take a moment to appreciate the colors and smells of my food
I taste every bite of food that I eat
I notice when the food I eat affects my emotional state
I have trouble not eating ice cream, cookies, or chips if they’re around the house

The next section is about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks. Remember to include any sweetened beverages used as a mixer.

155. During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.

Times per (circle one):

Day

Week

Month

Don’t know

156. During the past month, not counting juice, how many times per day, week or month did you eat fruit? Count fresh, frozen or canned fruit.

Times per (circle one):

Day

Week

Month

Don’t know

157. During the past month, how many times per day, week or month did you eat cooked or canned beans, such as refried, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.

Times per (circle one):

Day

Week

Month

Don’t know

158. During the past month, how many times per day, week or month did you eat dark green vegetables, for example, broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

Times per (circle one):

Day

Week

Month

Don’t know

159. During the past month, how many times per day, week or month did you eat orange colored vegetables such as sweet potatoes, pumpkin, winter squash or carrots?

Times per (circle one):

Day

Week

Month

Don’t know

160. Not counting questions 159-161, during the past month, about how many times per day, week or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, lettuce, cabbage and white potatoes that are not fried such as baked or mashed potatoes.

Times per (circle one):

Day

Week

Month

Don’t know

161. How many servings of fruits and vegetables do you usually have per day? (1 serving = 1 medium piece of fruit; ½ cup fresh, frozen or canned fruits/ vegetables; ¾ cup fruit/vegetable juice; 1 cup salad greens; or ¼ cup dried fruit)

	0 servings per day
	1-2 servings per day
	3-4 servings per day
	5 or more servings per day

162. During the past month, how often did you drink regular soda or pop that contains sugar? Do not include diet soda.

Times per (circle one):

Day

Week

Month

Don’t know

163. During the past month, how often did you drink diet soda?

Times per (circle one):

Day

Week

Month

Don’t know

164. During the past month, how often did you drink sports or energy drinks such as Gatorade, Red Bull and Vitamin Water? Remember to include sports or energy drinks used as a mixer. Do not include diet or sugar-free kinds.

Times per (circle one):

Day

Week

Month

Don’t know

165. During the past month, how often did you drink sweetened fruit drinks such as Kool-aid, cranberry drink and lemonade? Include fruit drinks you made at home and added sugar to. Do not include 100% fruit juices and drinks with things like Splenda or Equal.

Times per (circle one):

Day

Week

Month

Don’t know

166. During the past month, how often did you drink coffee or tea with sugar or honey added? Do not include drinks with things like Splenda or Equal. Include pre-sweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino.

Times per (circle one):

Day

Week

Month

Don’t know

167. During the past month, how often did you drink water (including tap, bottled, and carbonated water)?

	Never or Less than 1 time per week (skip to question 171)
	1 – 2 times per week
	3 – 4 times per week
	5 - 6 times per week
	1 time per day
	2 to 3 times per day
	4 – 5 times per day
	6 or more times per day

168. Each time you drank water, how much did you usually drink?

	Less than 6 fl oz (3/4 oz)
	8 fl oz (1 cup)
	12 fl oz (1-1/2 cups)
	16 fl oz (2 cups)
	More than 20 fl oz (2-1/2 cups)

Section VII: Physical activity

Physical activities are activities where you move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or transportation.

The following questions ask about the amount and intensity of physical activity you usually do. The intensity of the activity is related to the amount of energy you use to do these activities.

Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

169. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?

	days per week
	No vigorous physical activities (skip to Question 173)

170. How much time did you usually spend doing vigorous physical activities on one of those days?

	hours per day
	minutes per day
	Don’t know/Not sure

Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

171. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.

	days per week
	No moderate physical activities (skip to question 175)

172. How much time did you usually spend doing moderate physical activities on one of those days?

	hours per day
	minutes per day
	Don’t know/Not sure

Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

173. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

	days per week
	None (skip to question 177)

174. How much time did you usually spend walking on one of those days?

	hours per day
	minutes per day
	Don’t know/Not sure

The last question is about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

175. During the last 7 days, how much time did you spend sitting on a week day?

	hours per day
	minutes per day
	Don’t know/Not sure

Thank you so much for your participation! Your input is critical to this study.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,   Attention: PRA Reports Clearance Officer