Form 1 BYOMM KAB Form

OMB Control Number: 0925-0648

Expiration Date: 03/31/2018

Thank you for taking part in today’s event. Please take a few minutes to complete a brief
assessment about the impact of this Brother, You’re on My Mind activity.
1) Date _________________
2) Location (city, state) __________________________
3) Omega chapter ____________________
4) What is your age?
a. Under 18 years

e. 45 to 54 years

b. 18 to 24 years

f.

55 to 64 years

c. 25 to 34 years

g. Age 65 or older

d. 35 to 44 years
5) What is your sex?
a. Male
b. Female

6) What is your gender identity?
a. Male
b. Female
c. Male to Female Transgender

d. Female to Male Transgender
e. Other Gender Identity
f.

Refuse to Answer

7) Are you Hispanic or non-Hispanic?
a. Yes
b. No
8) What is your race? (check all that apply)
a. Black or African American
b. White (e.g., European, Middle Eastern, North African)
c. American Indian or Alaska Native
d. Asian (e.g., Indian, Chinese, Filipino, Japanese, Korean, Vietnamese)
e. Native Hawaiian or other Pacific Islander
f.

Other ___________________________

Measuring knowledge
Please evaluate each statement per the following scale:
Strongly Agree = 1
Agree = 2
Neutral = 3
Disagree = 4
Strongly Disagree = 5
BEFORE today’s event,
Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

1

2

3

4

5

10. I believed mental illness was caused by something biological.

1

2

3

4

5

11. I believed most people with depression could get better with
treatment.

1

2

3

4

5

12. I believed men displayed signs of depression more often
through anger and irritation.

1

2

3

4

5

13. If any of my relatives or friends had a mental illness, I would
have told them not to tell anyone.

1

2

3

4

5

14. I believed only people who were weak or overly sensitive let
mental illness affect them.

1

2

3

4

5

15. I would not have told anyone if I had depression.

1

2

3

4

5

16. I believed it was a good idea to avoid any discussion of
mental illness.

1

2

3

4

5

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

17. I believe mental illness is often confused with effects of
drug abuse.

1

2

3

4

5

18. I believe mental illness is caused by something biological.

1

2

3

4

5

19. I believe most people with depression can get better
with treatment.

1

2

3

4

5

20. I believe men display signs of depression more often through
anger and irritation.

1

2

3

4

5

21. If any of my relatives or friends had a mental illness, I would
tell them not to tell anyone.

1

2

3

4

5

22. I believe only people who are weak or overly sensitive let
mental illness affect them.

1

2

3

4

5

23. I would not tell anyone if I had depression.

1

2

3

4

5

24. I believe it is a good idea to avoid any discussion of
mental illness.

1

2

3

4

5

9.

I believed mental illness was often confused with effects of
drug abuse.

AFTER today’s event,