Form 1 Supplemental Mental Health Questionnaire

OMB#0925-XXXX
EXP. XX/XXXX

Supplemental Mental Health Questionnaire
(Estimated Burden: 15 minutes per administration)

Public reporting burden for this collection of information is estimated to average 15 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 (0925-0626). Do not return the completed form to this address.

Table of Contents
Section Q: General Health Scale ................................................................................................................... 2
Section R: Resilience Scale ............................................................................................................................ 4
Section S: Anxiety Scale ............................................................................................................................... 9
Section T: PTSD Scale ................................................................................................................................. 10
Section U: Traumatic Events Scale .............................................................................................................. 11
Section V: Financial Events Scale ................................................................................................................ 16
Section W: Social Support Scale ................................................................................................................ 20

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Section Q: General Health Scale
I would like to begin the survey by asking you some questions about your general health.
Q1. 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?
Q1a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or
playing golf?
YES, LIMITED A LOT...................... 1
YES, LIMITED A LITTLE ................. 2
NO, NOT LIMITED AT ALL ............. 3
DON’T KNOW ................................. 8
REFUSED ....................................... 9
Q1b. Climbing several flights of stairs?
YES, LIMITED A LOT...................... 1
YES, LIMITED A LITTLE ................. 2
NO, NOT LIMITED AT ALL ............. 3
DON’T KNOW ................................. 8
REFUSED ....................................... 9
Q2. 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?
Q2a.

Accomplished less than you would like?
YES ............................................ 1
NO .............................................. 2
DON’T KNOW ............................ 8
REFUSED .................................. 9

Q2b.

Were limited in the kind of work or other activities?
YES ............................................ 1
NO .............................................. 2
DON’T KNOW ............................ 8
REFUSED .................................. 9

Q3. 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?
Q3a.

Accomplished less than you would like?
YES ............................................ 1
NO .............................................. 2
DON’T KNOW ............................ 8
REFUSED .................................. 9

Q3b.

Did work or other activities less carefully than usual?
YES ........................................... 1
NO .............................................. 2
DON’T KNOW ............................ 8
REFUSED .................................. 9

Q4. 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 ........................ 1

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A little bit ........................ 2
Moderately .................... 3
Quite a bit ...................... 4
Extremely ...................... 5
DON’T KNOW ............... 8
REFUSED ..................... 9
Q5. 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.
The choices are: All of the time, Most of the time, A good bit of the time, Some of the time, A little of
the time, and None of the time. How much of the time during the past 4 weeks...
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

Q5a. Have
you felt calm
and
peaceful?
Q5b. Did you
have a lot of
energy?
Q5c. Have
you felt
downhearted
and blue?
Q6. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities, such as visiting friends, relatives, etcetera?
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9

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Section R: Resilience Scale
Please tell me how much you agree with the following statements as they apply to you over the last
month. If a particular situation has not occurred recently, answer according to how you think you would
have felt. Respond to each statement with one of the following choices: Not true at all, Rarely true,
Sometimes true, Often true, or True nearly all the time. [INTERVIEWER NOTE: THE FIRST TIME AND
AFTER EVERY 5 QUESTIONS, REPEAT RESPONSE OPTIONS.]

R1. I am able to adapt when changes occur.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R2. I have at least one close and secure relationship that helps me when I am stressed.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R3. When there are no clear solutions to my problems, sometimes fate or God can help.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R4. I can deal with whatever comes my way.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R5. Past successes give me confidence in dealing with new challenges and difficulties.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8

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REFUSED ..................... 9
R6. I try to see the humorous side of things when I am faced with problems.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R7. Having to cope with stress can make me stronger.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R8. I tend to bounce back after illness, injury, or other hardships.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R9. Good or bad, I believe that most things happen for a reason.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R10.

I give my best effort no matter what the outcome may be.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R11.

I believe I can achieve my goals, even if there are obstacles.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

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R12.

Even when things look hopeless, I don’t give up.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R13.

During times of stress/crisis, I know where to turn for help.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R14.

Under pressure, I stay focused and think clearly.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R15.

I prefer to take the lead in solving problems rather than letting others make all the decisions.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R16.

I am not easily discouraged by failure.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R17.

I think of myself as a strong person when dealing with life’s challenges and difficulties.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R18.

I can make unpopular or difficult decisions that affect other people, if it is necessary.
Not true at all ................. 1

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Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R19.

I am able to handle unpleasant or painful feelings like sadness, fear, and anger.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R20.

In dealing with life’s problems, sometimes you have to act on a hunch without knowing why.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R21.

I have a strong sense of purpose in life.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R22.

I feel in control of my life.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R23.

I like challenges.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

R24.

I work to attain my goals no matter what roadblocks I encounter along the way.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3

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Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9
R25.

I take pride in my achievements.
Not true at all ................. 1
Rarely true ..................... 2
Sometimes true ............. 3
Often true ...................... 4
True nearly all the time.. 5
DON’T KNOW ............... 8
REFUSED ..................... 9

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Section S: Anxiety Scale
Now I am going to ask you some questions about your mood. When answering these questions, please
think about how many days each of the following has occurred in the last two weeks.
S1. Over the last 2 weeks, how many days have you been nervous, anxious, or on edge?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9
S2. Over the last 2 weeks, how many days have you not been able to stop or control worrying?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9
S3. Over the last 2 weeks, how many days have you worried too much about different things?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9
S4. Over the last 2 weeks, how many days have you had trouble relaxing?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9
S5. Over the last 2 weeks, how many days have you been so restless that it was hard to sit still?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9
S6. Over the last 2 weeks, how many days have you been easily annoyed or irritable?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9
S7. Over the last 2 weeks, how many days have you felt afraid as if something awful might happen?
01-14 DAYS ....................... 1
NONE ................................ 0
DON’T KNOW .................... 8
REFUSED .......................... 9

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Section T: PTSD Scale
The following questions are about any traumatic experiences.
During the past 30 days , have you …
T1. Had nightmares about the oil spill or any clean-up efforts you engaged in or thought about it when
you did not want to?
YES .................................... 1
NO ..................................... 2
DON’T KNOW .................... 8
REFUSED .......................... 9
T2. Tried hard not to think about the oil spill or any clean-up efforts you engaged in or went out of your
way to avoid situations that remind you of it?
YES .................................... 1
NO ..................................... 2
DON’T KNOW ................... .8
REFUSED .......................... 9
T3. Been constantly on guard, watchful, or easily startled?
YES .................................... 1
NO ..................................... 2
DON’T KNOW .................... 8
REFUSED .......................... 9
T4. Felt numb or detached from others, activities, or your surroundings?
YES .................................... 1
NO ..................................... 2
DON’T KNOW .................... 8
REFUSED .......................... 9

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Section U: Traumatic Events Scale
Now I would like to ask you some questions about traumatic events you may have experienced in your
lifetime. Please tell me if you have experienced them and how many times they have occurred.
U1. Have you ever served in a war-zone or in a noncombat job that exposed you to war-related
casualties, such as working as a medic or on graves registration duty?
NEVER ............................... 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ..................... 8
REFUSED ........................... 9
U1a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U2. Have you ever been in a serious car accident, or serious accident at work or somewhere else?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U2a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U3. Have you ever been in a major natural disaster, such as a fire, tornado, hurricane, flood, or
earthquake?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9

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U3a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U4. Have you ever been in a major man-made disaster other than the Deepwater Horizon oil spill, such
as another oil spill, a chemical spill, terrorist event, or airplane or railroad accident?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U4a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U5. Have you ever had a life-threatening illness, such as cancer, a heart attack, leukemia, AIDS, multiple
sclerosis, and so forth?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U5a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U6. Have you ever been attacked, beaten up, or mugged by anyone, including friends, family members,
or strangers?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7

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DON’T KNOW ...................... 8
REFUSED ............................ 9
U6a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U7. As a child, 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?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U7a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U8. Have you ever been in a situation in which someone made or pressured you into having some type of
unwanted sexual contact?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U8a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U9. Have you ever been in any other situation in which you were seriously injured or in which you feared
you might be seriously injured or killed?
YES ...................................... 1
NO ....................................... 2
DON’T KNOW ...................... 8
REFUSED ............................ 9

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U9a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U10.
Have you ever witnessed a situation in which someone with whom you were very close was
seriously injured or killed, or in which you feared someone would be seriously injured or killed?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U10a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U11.
Have you ever witnessed a situation in which someone with whom you were not so close was
seriously injured or killed or in which you feared someone would be seriously injured or killed?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U11a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U12.
Have any close family members or friends died violently, for example, in a serious car crash,
mugging, or attack?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7

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DON’T KNOW ...................... 8
REFUSED ............................ 9
U12a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
U13.
Have you experienced the death of any of your children?
NEVER ................................ 1
ONCE .................................. 2
TWICE ................................. 3
3 TIMES ............................... 4
4 TIMES ............................... 5
5 TIMES ............................... 6
MORE THAN 5 TIMES ........ 7
DON’T KNOW ...................... 8
REFUSED ............................ 9
U14.
Have you experienced a seriously traumatic event not already covered in any of these questions?
YES ...................................... 1
NO ...................................... 2 [GO TO NEXT SECTION]
DON’T KNOW ..................... 8 [GO TO NEXT SECTION]
REFUSED ........................... 9 [GO TO NEXT SECTION]
U14a. Please describe your experience.
[FREE TEXT FIELD]
U14b. How old were you when this happened?
I__II__II AGE
DON’T KNOW......... 8
REFUSED............... 9

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Section V: Financial Events Scale
Now I would like to ask you some questions regarding your finances.
During the past 12 months have you…
[INTERVIEWER NOTE: AFTER EVERY 5 QUESTIONS, REPEAT “During the past 12 months
have you…”.]

V1. Been evicted due to not paying rent?
YES ............................... 1
NO ................................ 2
DON’T KNOW............... 8
REFUSED..................... 9

V2.

R
eceived assistance from non-government organizations such as church or community groups?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V3. Applied for federal government disability benefits?
YES, AND RECEIVED IT .............
YES, BUT WAS DENIED IT .........
NO .............................................
DON’T KNOW .............................
REFUSED ...................................

1
2
3
8
9

V4. Borrowed money from friends or family to help pay bills?
YES...................................................................... 1
NO, I ASKED BUT WAS TURNED DOWN ........ 2
NO, I DIDN’T ASK ............................................... 3
DON’T KNOW ..................................................... 8
REFUSED ........................................................... 9

V5. Sold possessions or property to raise money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V6. Spouse or partner began to work outside of the home?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V7. Spouse or partner stopped working outside of the home?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V8. Cashed in life insurance?
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YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V9. Changed residence to save money, for example, moving somewhere with lower rent, sleeping
on a couch with friends or family, living on a boat, etcetera?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V10.

T

ook in a housemate to increase income?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V11.

R

educed medical insurance?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V12.

Eliminated medical insurance?

YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V13.

C

hanged food shopping habits to save money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V14.

C

hanged eating habits to save money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V15.

P

ostponed paying property tax?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V16.

P

ostponed paying rent?

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YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V17.

Received shut-off warning(s) regarding utilities such as electricity, gas, water, phone,
o r cable due to late payment?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V18.

U

tilities were actually shut-off due to late payment or non-payment?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V19.

C

ut back on social activities and entertainment expenses?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V20.

P

ostponed major household purchases?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V21.

P

ostponed clothing purchases?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V22.

C

hanged transportation patterns to save money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V23.

C

ut back on charitable donations and/or tithing?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

V24.
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educed household utility use?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
During the past 12 months…

V25.

H

ave you taken on additional employment to help meet expenses?
YES .......................................................................................................................... 1
NO, I SOUGHT ADDITIONAL EMPLOYMENT, BUT DIDN’T FIND ANY ............... 2
NO, I DIDN’T TRY TO FIND ANY ........................................................................... 3
DON’T KNOW.......................................................................................................... 8
REFUSED................................................................................................................ 9

V26.

H

as your s pous e taken on additional employment to help meet expenses?
YES .......................................................................................................................... 1
NO, HE/SHE SOUGHT ADDITIONAL EMPLOYMENT, BUT DIDN’T FIND ANY .. 2
NO, HE/SHE DIDN’T TRY TO FIND ANY ............................................................... 3
N/A ........................................................................................................................... 4
DON’T KNOW.......................................................................................................... 8
REFUSED................................................................................................................ 9

V27.

Has your c hil d taken on additional employment to help meet expenses?
YES .......................................................................................................................... 1
NO, HE/SHE SOUGHT ADDITIONAL EMPLOYMENT, BUT DIDN’T FIND ANY .. 2
NO, HE/SHE DIDN’T TRY TO FIND ANY ............................................................... 3
N/A ........................................................................................................................... 4
DON’T KNOW.......................................................................................................... 8
REFUSED................................................................................................................ 9

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Section W: Social Support Scale
Now I would like to ask a few questions about your friends and family.
W1.
Can you count on anyone to provide you with emotional support such as talking over
problems or helping you make a difficult decision?
YES ..................................... 1
NO ....................................... 2
I DON’T NEED HELP ......... 3
DON’T KNOW .................... 8
REFUSED........................... 9
W2.
In the last 12 months, who has been helpful in providing you with emotional support?
[CHECK ALL THAT APPLY]
SPOUSE ....................................................... 10
DAUGHTER .................................................. 11
SON............................................................... 12
SISTER/BROTHER ....................................... 13
PARENT ........................................................ 14
OTHER RELATIVE........................................ 15
NEIGHBORS ................................................. 16
CO-WORKERS ............................................. 17
CHURCH MEMBERS .................................... 18
CLUB MEMBERS .......................................... 19
PROFESSIONALS ........................................ 20
FRIENDS....................................................... 21
OTHER .......................................................... 22
NO ONE ........................................................ 23
DON'T KNOW ............................................... 8
REFUSED ..................................................... 9
W3.In the last 12 months, could you have used more emotional support than you received?
YES ..................................... 1
NO ....................................... 2
DON’T KNOW ..................... 8
REFUSED ........................... 9
W3a. Concerning emotional support, would you say that you could have used…?
A lot more ............... 1
Some more............. 2
A little more ............ 3
DON’T KNOW ....... 8
REFUSED.............. 9
W4.
How often do you attend church or religious services?
I__II__II__I NUMBER OF TIMES
UNITS ................................. 1
DAY ..................................... 2
WEEK ................................. 3
MONTH ............................... 4
YEAR .................................. 5
DON’T KNOW .................... 8
REFUSED........................... 9

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W5.
Is there someone you could count on to help you if you were sick, for example, to take
you to the doctor or help you with daily chores?
YES ..................................... 1
NO ....................................... 2
YES, BUT I WOULDN’T ACCEPT IT
3
DON’T KNOW .................... 8
REFUSED........................... 9
W6.
If you need some extra help financially, could you count on anyone to help you, for
example, by paying any bills, housing costs, medical expenses, or providing you with food
or clothes?
YES ............................................................... 1
NO ................................................................. 2
YES, BUT I WOULDN’T ACCEPT IT .......... 3
DON’T KNOW .............................................. 8
REFUSED..................................................... 9
W7.
In general how many close friends do you have?
[INTERVIEWER PROBE: By “close friends” I mean relatives or non-relatives that you feel
at ease with, can talk to about private matters, and can call on for help]
I__II__I NUMBER OF CLOSE FRIENDS
DON’T KNOW .................... 8
REFUSED........................... 9

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