Attach 6

OMB #: 0925-NEW
Expiration Date: xx/xxxx
This survey should take approximately 35 minutes to complete
Network Enumeration Module Part 1 (Family)
We'd like learn about people that are important to you. First, please list all members of your family of origin (parents and
siblings) and your nuclear family (spouse/partner and children). We'll ask about other important people later. This list of
people will help us map your personal network. You may name anyone you know, no matter who they are or where they
live, using any name that’s identifiable to you, such as initials or a nickname (we won't save this information, so feel free
to use last names if it helps you). Please also indicate their relationship to you, their age, gender, where they live, and
how often you have had contact with them during the past 3 months. If you don't know an answer, just leave that space
blank.
Name*

Relationship

Age

Gender

In the last 3 months, about how often did
you have contact with this person, either
face-to-face, by email, or by phone?

Where does this person live?

□ Male
□ Female

□ Everyday
□ More than once a week
□ A couple of times a month
□ Once
□ I did not have contact with this person in
the last 3 months.

□ This person lives with me.
□ Within an hour drive.
□ Within a two hour drive.
□ Within a three hour drive.
□ More than a three hour drive.
□ This person is deceased

A

B

.

.

.

.

.

.

…

...

...

...

...

...

...

Z

□ Male
□ Female

□ This person lives with me.
□ Within an hour drive.
□ Within a two hour drive.
□ Within a three hour drive.
□ More than a three hour drive.
□ This person is deceased

*Note for OMB: This survey does not collect PII. In the network enumeration modules, respondents are prompted that they may list their contacts

(e.g., relatives and friends) in any manner that is helpful to them. This information is not collected by us, rather it is temporarily stored in memory
cache that can only be read by the survey instrument on respondents' computers. When respondents complete, or otherwise exit, the survey, these
data are completely lost. Full disclosure to the respondent that we are not collecting PII is made both at the time of consent and in the
network enumeration question prompt.

Network Enumeration Module Part 2 (Other Important People)
Now we'd like you to think about other people that are important to you that are not members of your family of origin or
nuclear family. Please list other people that are important to you, such as extended family members (your grandmother,
grandchildren, cousins, etc.), family through marriage (mother-in-law, brother-in-law), friends, and coworkers. This list of
people will help us map your personal network. You may name anyone you know, no matter who they are or where they
live, using any name that’s identifiable to you, such as initials or a nickname (we won't save this information, so feel free
to use last names if it helps you). Please also indicate their relationship to you, their age, gender, where they live, and
how often you have had contact with them during the past 3 months. If you don't know an answer, just leave that space
blank.
Name

Relationship

Age

Gender

In the last 3 months, about how often did
you have contact with this person, either
face-to-face, by email, or by phone?

Where does this person live?

□ Male
□ Female

□ Everyday
□ More than once a week
□ A couple of times a month
□ Once
□ I did not have contact with this person in
the last 3 months.

□ This person lives with me.
□ Within an hour drive.
□ Within a two hour drive.
□ Within a three hour drive.
□ More than a three hour drive.
□ This person is deceased

.

.

...

...

A

B

.

.

.

.

…

...

...

...

...

Z

□ Male
□ Female

□ This person lives with me.
□ Within an hour drive.
□ Within a two hour drive.
□ Within a three hour drive.
□ More than a three hour drive.
□ This person is deceased

Relational Assessment Module Part 1
Consider your list of family and other important people in your personal network. We'd like to know more about how
you feel about your relationships with these people. Please indicate all of the people who you can count on for help or
support in the manner described. You can select more than one person in response to each question.
FCM1.Q3
AQ3
N
FCM1.Q4
AQ4
N
FCM1.Q5
FCM1.Q6.
FCM1.Q7.
FCM1.Q8

On scale of 1 to 7, where 1 is “not very
close” and 7 is “very close”, how close
would you rate your relationship with
“PERSON A”?
On scale of 1 to 7, where 1 is “never in
conflict at all” and 7 is “always in conflict”,
how often are you in conflict with “PERSON
A”?
With whom do you feel comfortable sharing
your feelings?
With whom do you discuss your health?
Who can you count on to console you when
you are upset?
Who do you go to for advice?

Who feels comfortable sharing their feelings
with you?
FCM1.Q10 Who discusses their health with you?
FCM1.Q11 Who do you console when they are upset?
FCM1.Q12 Who comes to you for advice?
FCM1.Q9

Roster of Folks from Enumeration
Roster of Folks from Enumeration

Roster of Folks from Enumeration
Roster of Folks from Enumeration
Roster of Folks from Enumeration
Roster of Folks from Enumeration
Roster of Folks from Enumeration
Roster of Folks from Enumeration
Roster of Folks from Enumeration
Roster of Folks from Enumeration

Relational Assessment Module Part 2
Now we're going to ask you some questions about the relationships between members of your personal network. Here,
we want you to think about how people in your network get along and interact with each other. Please think carefully
about each question and answer to the best of your ability.
FCM2.Q1PX Does “PERSON A” know “PERSON B”? □ Yes □ No
[[CONDITIONAL ASK NEXT 7 Questions iff FCM2.Q1PX==YES]]
FCM2.Q2PX [undirected] How often, to the best of your knowledge, did “PERSON A” and “PERSON B” have contact
during the past 3 months or so, either face-to-face, by phone, mail, or e-mail?
0=Never 1=Rarely 2=Sometimes 3=Often 4=I Don't Know
FCM2.Q3PX [undirected] On a scale of 1 to 7, where 1 is “not close at all” and 7 is “very close”, how close do you feel
“PERSON A” and “PERSON B” are to each other?
1----2----3----4----5----6----7
FCM2.Q4PX [undirected] On a scale of 1 to 7, where 1 is “Never in conflict” and 7 is “Always in conflict”, how often do
you feel “PERSON A” and “PERSON B” are in conflict with each other?
1----2----3----4----5----6----7
FCM2.Q5PX [directed] Does “PERSON A” feel comfortable sharing his/her feelings with “PERSON B”?
□ Yes □ No
□ Don’t Know
FCM2.Q6PX [directed] Does “PERSON A” discuss his/her health with “PERSON B”?
□ Yes
□ No
□ Don’t Know
FCM2.Q7PX [directed] Does “PERSON A” console “PERSON B” when he/she is upset?
□ Yes
□ No
□ Don’t Know

FCM2.Q8PX [directed] Does “PERSON A” go to “PERSON B” for advice?
□ Yes
□ No
□ Don’t Know

FCM2.Q9PX [directed] Does “PERSON B” feel comfortable sharing his/her feelings with “PERSON A”?
□ Yes
□ No
□ Don’t Know
FCM2.Q10PX [directed] Does “PERSON B” discuss his/her health with “PERSON A”?
□ Yes
□ No
□ Don’t Know
FCM2.Q11PX [directed] Does “PERSON B” console “PERSON A” when he/she is upset?
□ Yes
□ No
□ Don’t Know
FCM2.Q12PX [directed] Does “PERSON B” go to “PERSON A” for advice?
□ Yes
□ No
□ Don’t Know

Thank you for your participation in this project. Click here

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NOTE TO OMB: This survey does not collect PII. In the
network enumeration modules, respondents are prompted
that they may list their contacts (e.g., relatives and friends) in
any manner that is helpful to them. This information is not
collected by us, rather it is temporarily stored in memory
cache that can only be read by the survey instrument and
network mapping applet on respondents' computers. When
respondents exit the survey, these data are completely lost.
Full disclosure to the respondent that we are not collecting PII
is made both at the time of consent and in the network
enumeration question prompt. Further, no identifying
information regarding social media accounts will be extracted
and collected by us.

www.genome.gov/SocialNetworkMap