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Mental Health Survey Instrument

Demographics

I would just like to ask some general background information – first about you and then about your household.

What year were you born? 
YEAR OF BIRTH19__
DON'T KNOW8
REFUSE9
Have you had your birthday already this calendar year? 
YES1
NO2
DON'T KNOW8
REFUSE9
DM1. What is the highest grade or year of school you have completed? [Read choices 1 – 7 if necessary.] 
Eighth grade or less1
Some high school2
High school graduate or GED certificate3
Some post high school4
College graduate (Associate or Bachelor's)5
Post graduate education or degree6
Other (Specify)7
DON'T KNOW98
REFUSE99
DM2. What is the highest grade or year of school that anyone else in your household has completed? [Read choices 1 – 7 if necessary.] 
Eighth grade or less1
Some high school2
High school graduate or GED certificate3
Some post high school4
College graduate (Associate or Bachelor's)5
Post graduate education or degree6
Other (Specify)7
DON'T KNOW98
REFUSE99
DM3. Are you currently: [Read answers 1-8.] 
Employed or self-employed full-time1
Employed or self-employed part-time2
Homemaker or caregiver3
Out of work or unable to work4
Student5
Student and employed6
Retired7
Something else (Specify)8
DON'T KNOW98
REFUSE99
DM4. Are you currently: [Read answers 1-7.] [Prompt if necessary, “Pick the one that you feel best describes your current status.”] 
Married1
Partnered2
Divorced3
Widowed4
Separated5
Never married6
Other (Specify)7
DON'T KNOW98
REFUSE99
DM5. Do you consider yourself of Hispanic or Latino origin, including Mexican, Latin American, Puerto Rican, or Cuban descent? 
YES1
NO2
DON'T KNOW8
REFUSE9
DM6. What is your race? Please select one or more of the following. [Read answers 1 – 6 and code all that apply.] 
Native American or Alaskan Native1
Asian2
African American or Black3
Native Hawaiian or Other Pacific Islander4
Caucasian or White5
Other (Specify)6
DON'T KNOW98
REFUSE99
DM7. Would you tell me what category best represents the total gross income (income brought in before taxes) during the past 12 months by all members of your household? Please stop me when I read the right category. [Read answers 1-5.] 
Less than $20,0001
$20,000 - <$35,0002
$35,000 - <$50,0003
N$50,000 - <$100,0004
$100,000 or more5
DON'T KNOW8
REFUSE9

Exposure to Event

The following questions are about the [TRAUMATIC EVENT].

The next two questions [P1-P2] assess personal exposure to traumatic event.
P1. Which best describes your personal exposure to [TRAUMATIC EVENT]? Would you say (READ ANSWERS)? 
You were in or around [TRAUMATIC EVENT] and you saw at least some of this happen1
You were in or around the [TRAUMATIC EVENT] but did not see any of it happen2
You were not in or around any of the [TRAUMATIC EVENT]3
DON'T KNOW8
REFUSE9
P2. As a result of your exposure to the [TRAUMATIC EVENT] did you feel that you were at risk of being injured or killed? 
YES1
NO2
DON'T KNOW8
REFUSE9
The next six questions [P3-P8] assess known others' exposure to traumatic event.
P3. When you first heard about the [TRAUMATIC EVENT], did you fear that a family member or close friend who was in or around the site of the [TRAUMATIC EVENT] might be killed, injured, or missing? 
YES1
NO2
DON'T KNOW8
REFUSE9
P4. As a result of the [TRAUMATIC EVENT], did you actually have a family member or close friend who was killed, injured, or missing? 
YES1
NO (skip to P6)2
DON'T KNOW (skip to P6)8
REFUSE (skip to P6)9
P5. What was this person's relationship to you? 
CURRENT OR FORMER SPOUSE1
CURRENT OR FORMER BOYFRIEND/GIRLFRIEND)2
PARENT OR STEP PARENT3
SIBLING OR STEP-SIBLING4
CHILD OR STEP CHILD5
GRANDPARENT6
GRANDCHILD7
OTHER FAMILY MEMBER (AUNT/UNCLE, COUSIN, NEPHEW/NIECE ETC.)8
CLOSE FRIEND9
OTHER (SPECIFY)10
MULTIPLE PEOPLE (SPECIFY)95
DON'T KNOW98
REFUSE99
N/A (SKIP)97
P6. Was anyone else you personally know killed, injured, or missing, as a result of the [TRAUMATIC EVENT]? 
YES1
NO (skip to P8)2
DON'T KNOW (skip to P8)8
REFUSE (skip to P8)9
P7. What was this person's relationship to you? 
FRIEND1
NEIGHBOR2
CO-WORKER3
OTHER (SPECIFY)4
MULTIPLE PEOPLE (SPECIFY)95
DON'T KNOW98
REFUSE99
N/A (SKIP)97
P8. Do you know someone who had a family member or close friend who was killed, injured, or missing as a result of the [TRAUMATIC EVENT]? 
YES1
NO2
DON'T KNOW8
REFUSE9

Assessment of Symptoms

 
The next seven questions [P9-P15] assess PTSD symptoms.
 
The next questions are about the time after the [TRAUMATIC EVENT]. Please answer yes or no for each question. After the [TRAUMATIC EVENT]…
P9. Did you avoid being reminded of this experience by staying away from certain places, people, or activities? 
YES1
NO2
DON'T KNOW8
REFUSE9
P10. Did you lose interest in activities that were once important or enjoyable? 
YES1
NO2
DON'T KNOW8
REFUSE9
P11. Did you begin to feel more isolated or distant from other people? (PROMPT: Other people with whom you normally interact.) 
YES1
NO2
DON'T KNOW8
REFUSE9
P12. Did you find it hard to have love or affection for other people? 
YES1
NO2
DON'T KNOW8
REFUSE9
P13. Did you begin to feel that there was no point in planning for the future? (PROMPT: I mean long-term future, such as planning for a career, children, or retirement.) 
YES1
NO2
DON'T KNOW8
REFUSE9
P14. After this experience, were you having more trouble than usual falling asleep or staying asleep? (PROMPT: By this experience I mean the [TRAUMATIC EVENT].) 
YES1
NO2
DON'T KNOW8
REFUSE9
P15. Did you become jumpy or get easily startled by ordinary noises or movements? 
YES1
NO2
DON'T KNOW8
REFUSE9
The next six questions [P16-P21] assess anxiety symptoms.
Since [TRAUMATIC EVENT] have you been distressed or bothered by…
P16. Feelings of nervousness or shakiness inside? 
YES1
NO2
DON'T KNOW8
REFUSE9
P17. Suddenly scared for no good reason? 
YES1
NO2
DON'T KNOW8
REFUSE9
P18. Feeling fearful? 
YES1
NO2
DON'T KNOW8
REFUSE9
P19. Feeling tense or keyed up? 
YES1
NO2
DON'T KNOW8
REFUSE9
P20. Spells of terror or panic? 
YES1
NO2
DON'T KNOW8
REFUSE9
P21. Feeling so restless you couldn't sit still? 
YES1
NO2
DON'T KNOW8
REFUSE9
The next six questions [P22-P27] assess anxiety symptoms.
P22. Thoughts of taking your life? 
YES1
NO2
DON'T KNOW8
REFUSE9
P23. Feeling lonely? 
YES1
NO2
DON'T KNOW8
REFUSE9
P24. Feeling blue? 
YES1
NO2
DON'T KNOW8
REFUSE9
P25. Difficulty making decisions? 
YES1
NO2
DON'T KNOW8
REFUSE9
P26. Feeling hopeless about the future? 
YES1
NO2
DON'T KNOW8
REFUSE9
P27. Feelings of worthlessness? 
YES1
NO2
DON'T KNOW8
REFUSE9
The next question [P28] assesses frequency of symptoms.
P.28 Are you currently having these reactions at least a few times a week? 
YES (skip to P29)1
NO2
DON'T KNOW8
REFUSE9
N/A (SKIP)7
The next question [P29] assesses professional help-seeking.
P29. Have you discussed these reactions with a doctor, nurse, psychologist, or other health professional? 
YES (skip to P29)1
NO2
DON'T KNOW8
REFUSE9
N/A (SKIP)7
The next two questions [P30-P31] assess heavy drinking.
P30. How many drinks did you have on a typical day since the [TRAUMATIC EVENT]? 
None0
1 to 2 drinks0
3 to 4 drinks1
7 to 9 drinks2
10 or more drinks4
DON'T KNOW8
REFUSE9
N/A (SKIP)7
P31. How often did you have 6 or more drinks on one occasion since the [TRAUMATIC EVENT]? 
Never0
Once1
2 to 3 times2
4 to 5 times3
6 or more times4
DON'T KNOW8
REFUSE9
N/A (SKIP)7
 
Contact Us:

  • Page last reviewed: July 26, 2005
  • Page last updated: March 27, 2003
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