27.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Brief Symptom Inventory (BSI®) SAQ, Phase 2g

OMB Specification

Clone of Brief Symptom Inventory (BSI®) SAQ

Event Category:	Time-Based
Event:	30M
Administration:	N/A
Instrument Target:	Primary Caregiver
Instrument Respondent:	Primary Caregiver
Domain:	Neuro-Psychosocial
Document Category:	Scored Assessment
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI
Estimated Administration Time:	9 minutes
Multiple Child/Sibling Consideration:	Per child
Special Considerations:	N/A
Version:	1.1
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

Copyright © 1975, 2004 Leonard R. Derogatis, PhD.  All rights reserved.  Published and distributed exclusively by NCS Pearson, Inc.

This page intentionally left blank.

Clone of Brief Symptom Inventory (BSI®) SAQ

TABLE OF CONTENTS

No table of contents entries found.

This page intentionally left blank.

Clone of Brief Symptom Inventory (BSI®) SAQ

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

BRIEF SYMPTOM INVENTORY (BSI®) SAQ

BSI00100. Your Name: ___________________________________

 

Your Gender: __________________________________

BSI00200/(BSI_DATE_COMP). Date Completed: |___|___|/|___|___|/|___|___|___|___|

BSI01000. The BSI test consists of a list of problems people sometimes have. Read each one carefully and circle the number of the response that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Circle only one number for each problem. Do not skip any items. If you change your mind, draw an X through your original answer and then circle your new answer. Read the example before you begin. If you have any questions, please ask them now.

Label	Code	Go To
New Response Option	0

SOURCE

Brief Symptom Inventory (BSI^®), Leonard R. Derogatis, Pearson Education, Inc.

BSI01100. HOW MUCH WERE YOU DISTRESSED BY: 

BSI02000/(BSI_NERVOUS). Nervousness or shakiness inside

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI03000/(BSI_FAINTNESS). Faintness or dizziness

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI04000/(BSI_CONTROL_THOUGHTS). The idea that someone else can control your thoughts

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI05000/(BSI_BLAME_OTHERS). Feeling others are to blame for most of your troubles

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI06000/(BSI_MEMORY_TROUBLE). Trouble remembering things

Label	Code	Go To
Not all all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI07000/(BSI_ANNOY_EASY). Feeling easily annoyed or irritated

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI08000/(BSI_CHEST_PAIN). Pains in heart or chest

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI09000/(BSI_AFRAID_STREETS). Feeling afraid in open spaces or on the streets

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI10000/(BSI_SUICIDE_THOUGHTS). Thoughts of ending your life

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI11000/(BSI_NO_TRUST). Feeling that most people cannot be trusted

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI12000/(BSI_NO_APPETITE). Poor appetite

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI13000/(BSI_SCARED). Suddenly scared for no reason

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI14000/(BSI_TEMPER_OUTBURST). Temper outbursts that you could not control

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI15000/(BSI_LONELY_PEOPLE). Feeling lonely even when you are with people

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI16000/(BSI_BLOCKED). Feeling blocked in getting things done

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI17000/(BSI_LONELY). Feeling lonely

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI18000/(BSI_BLUE). Feeling blue

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI19000/(BSI_NO_INTEREST). Feeling no interest in things

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI20000/(BSI_FEARFUL). Feeling fearful

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI21000/(BSI_EASILY_HURT). Your feelings being easily hurt

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI22000/(BSI_PEOPLE_UNFRIENDLY). Feeling that people are unfriendly or dislike you

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI23000/(BSI_INFERIOR). Feeling inferior to others

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI24000/(BSI_NAUSEA). Nausea or upset stomach

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI25000/(BSI_WATCHED). Feeling that you are watched or talked about by others

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI26000/(BSI_TROUBLE_SLEEP). Trouble falling asleep

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI27000/(BSI_DOUBLECHECK). Having to check and double-check what you do

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI28000/(BSI_DIFFICULT_DECISION). Difficulty making decisions

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI29000/(BSI_FEAR_TRAVEL). Feeling afraid to travel on buses, subways, or trains

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI30000/(BSI_TROUBLE_BREATHE). Trouble getting your breath

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI31000/(BSI_HOT_COLD). Hot or cold spells

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI32000/(BSI_AVOID). Having to avoid certain things, places, or activities because they frighten you

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI33000/(BSI_MIND_BLANK). Your mind going blank

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI34000/(BSI_BODY_NUMB). Numbness or tingling in parts of your body

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI35000/(BSI_PUNISH_SINS). The idea that you should be punished for your sins

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI36000/(BSI_HOPELESS_FUTURE). Feeling hopeless about the future

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI37000/(BSI_TROUBLE_ CONCENTRATE). Trouble concentrating

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI38000/(BSI_WEAK_BODY). Feeling weak in parts of your body

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI39000/(BSI_TENSE). Feeling tense or keyed up

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI40000/(BSI_DEATH_THOUGHTS). Thoughts of death or dying

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI41000/(BSI_URGE_HARM). Having urges to beat, injure, or harm someone

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI42000/(BSI_URGE_BREAK). Having urges to break or smash things

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI43000/(BSI_SELF_CONSCIOUS). Feeling very self-conscious with others

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI44000/(BSI_UNEASY_CROWDS). Feeling uneasy in crowds, such as shopping or at a movie

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI45000/(BSI_NEVER_CLOSE). Never feeling close to another person

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI46000/(BSI_TERROR_SPELLS). Spells of terror or panic

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI47000/(BSI_ARGUE). Getting into frequent arguments

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI48000/(BSI_NERVOUS_ALONE). Feeling nervous when you are left alone

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI49000/(BSI_NO_CREDIT). Others not giving you proper credit for your achievements

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI50000/(BSI_RESTLESS). Feeling so restless you couldn't sit still

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI51000/(BSI_WORTHLESS). Feelings of worthlessness

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI52000/(BSI_ADVANTAGE). Feeling that people will take advantage of you if you left them

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI53000/(BSI_GUILT). Feelings of guilt

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

BSI54000/(BSI_MIND_WRONG). The idea that something is wrong with your mind

Label	Code	Go To
Not at all	0
A little bit	1
Moderately	2
Quite a bit	3
Extremely	4

SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.

FOR OFFICE USE ONLY:

FOU01000/(P_ID). ID Number - Participant ___________________________________

FOU02000/(R_P_ID). ID Number - Respondent: ________________________________

Public reporting burden for this collection of information is estimated to average 9 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.