Attachment E
Survey Instrument
OMB No. 0920-XXXX
Exp. Date:
Childhood Experiences Survey
On this survey, we will ask you some questions about your health, relationships, and behaviors. We will ask about these during 3 different time periods: now (as an adult), and thinking back to when you were a teenager and when you were a child.
You will also be asked to compare some different health experiences and to choose which you would prefer. Finally, we will ask some questions about your childhood experiences.
Your responses are very important to public health. Your answers will help us to improve the health of others in the future.
There are no right or wrong answers. We are only interested your experiences and opinions.
[bottom of 1st screen]
Public reporting burden of this collection of information is estimated to average 25 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
Health, Relationships, and Behavior in the Past 30 Days
In the past 30 days how often did the following things happen…
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Always |
Often |
Sometimes |
Rarely |
Never |
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Poor |
Fair |
Good |
Very good |
Excellent |
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Health, Relationships, and Behavior during a Typical Month as an Adult
Now, please think about the same items during a typical month as an adult (since you turned age 18).
During a typical month as an adult how often did the following things happen…
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Always |
Often |
Sometimes |
Rarely |
Never |
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Poor |
Fair |
Good |
Very good |
Excellent |
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Health, Relationships, and Behavior as a Teenager (Ages 12-17)
Though it may feel like a long time ago, please think about the same items experienced during a typical month as a teenager (ages 12-17). This is about grades 7 and up in school.
During a typical month as a teenager how often did the following things happen…
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Always |
Often |
Sometimes |
Rarely |
Never |
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Poor |
Fair |
Good |
Very good |
Excellent |
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Health, Relationships, and Behavior as a Child (Ages 5-11)
Last, please think about the same items experienced during a typical month as a child (ages 5-11). This is about grades K-6 in school.
During a typical month as a child how often did the following things happen…
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Always |
Often |
Sometimes |
Rarely |
Never |
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Poor |
Fair |
Good |
Very good |
Excellent |
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Comparing Quality of Life as an Adult
Now we will ask you to compare different possible adult lives that you could experience today and into the future. These include the same aspects of health, relationships and behaviors that we just asked you about.
For each pair of lives A and B, we will ask which you would prefer. For example:
In Adult Life A:
You would sometimes feel depressed, afraid or worthless
You would have fair overall health
Or, in Adult Life B:
You would never feel depressed, afraid, or worthless
You would have excellent overall health
We will show these using dots, and displayed side-by-side in a table like this:
Aspects |
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Adult Life A |
Adult Life B |
Depressed, afraid, or worthless |
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Sometimes depressed
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Never depressed
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Overall health |
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Fair
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Excellent
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Would you prefer A or B?
Adult Life A
Adult Life B
There is one additional aspect: You would live in each life for the number of years shown from today, and then die.
Years you live from today, followed by death |
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Live for 8 years |
Live for 7 years |
Would you prefer A or B?
Adult Life A
Adult Life B
Next, we will add the other aspects of health and quality of life.
Note: electronic version of survey will have a “mouse over” option with fuller descriptors of each attribute (Aspect). Respondents will be reminded of this with a note on screen.
Adult Comparison #1
Imagine yourself now in Life A or Life B.
Aspects |
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Adult Life A |
Adult Life B |
Anger
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Never angry
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Never angry
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Risky behaviors
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Never risks health
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Never risks health
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Depressed, afraid, or worthless
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Sometimes depressed
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Never depressed
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Emotions out of control
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Never out of control
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Never out of control
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Relationship or trust problems
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Never has problems
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Never has problems
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Illness, injuries, accidents, interfere with daily activities |
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Never interfered
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Never interfered
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Overall health
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Fair
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Excellent
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Would you prefer A or B?
Adult Life A
Adult Life B
Now suppose you would live in each life for the number of years shown from today, then die.
Years you live from today, followed by death
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Live for 8 years |
Live for 7 years |
Would you prefer A or B?
Adult Life A
Adult Life B
[Note: Respondents will be asked to answer 12 comparison questions total: 4 child, 4 teen, and 4 adult]
Adult Comparison #2
Similar to above. Values for each cell in the table will be determined by a random draw from a statistical algorithm (near-orthogonal D-efficient design, with good level balance, no or minimal overlap, no dominated pairs, etc.), which selects many dozen health states out of the total number of possibilities.
As above.
Adult Comparison #3
As above
As above
Adult Comparison #4
As above
As above
Comparing Quality of Life as a Teenager
Now we would like you to think about different possible teenage lives that you could have had while age 12-17, instead of the life that you actually lived. For each pair, please tell us which one has a better quality of life.
Teenage Comparison #1
Imagine yourself having lived Teenage Life A and Teenage Life B.
Aspects |
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Teenage Life A |
Teenage Life B |
Anger
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Sometimes angry
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Sometimes angry
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Risky behaviors
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Always risks health
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Never risks health
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Depressed, afraid, or worthless
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Never depressed
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Never depressed
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Emotions out of control
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Sometimes out of control
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Never out of control
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Relationship or trust problems
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Never has problems
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Never has problems
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Illness, injuries, accidents, interfere with daily activities |
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Never interfered
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Sometimes interfered
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Overall health
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Very good
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Fair
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Which life would you have rather lived through?
Teenage Life A
Teenage Life B
Now suppose your current adult life would be no different except for you would live for the number of years shown from today, then die.
Years you live from today, followed by death
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Live for 6 years |
Live for 10 years |
Which life would you have rather lived through?
Teenage Life A
Teenage Life B
Teenage Comparison #2
Similar to above. Values for each cell in the table will be determined by a random draw from a statistical algorithm (near-orthogonal D-efficient design, with good level balance, no or minimal overlap, no dominated pairs, etc.), which selects many dozen health states out of the total number of possibilities.
As above
Teenage Comparison #3
As above
As above
Teenage Comparison #4
As above
As above
Comparing Quality of Life as a Child
Finally, we would like you to think about different possible childhood lives that you could have had while ages 5-11, instead of the life that you actually lived. For each pair, please tell us which one has a better quality of life.
Childhood Comparison #1
Imagine yourself having lived Child Life A and Child Life B.
Aspects |
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Child Life A |
Child Life B |
Anger
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Never angry
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Never angry
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Risky behaviors
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Never risks health
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Never risks health
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Depressed, afraid, or worthless
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Rarely depressed
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Never depressed
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Emotions out of control
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Rarely out of control
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Never out of control
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Relationship or trust problems
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Never has problems
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Never has problems
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Illness, injuries, accidents, interfere with daily activities |
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Rarely interfered
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Often interfered
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Overall health
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Good
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Fair
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Which life would you have rather lived through?
Child Life A
Child Life B
Now suppose your current adult life would be no different except for you would live for the number of years shown from today, then die.
Years you live from today, followed by death
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Live for 8 years |
Live for 6 years |
Which life would you have rather lived through?
Child Life A
Child Life B
Childhood Comparison #2
Similar to above. Values for each cell in the table will be determined by a random draw from a statistical algorithm (near-orthogonal D-efficient design, with good level balance, no or minimal overlap, no dominated pairs, etc.), which selects many dozen health states out of the total number of possibilities.
As above
Childhood Comparison #3
As above
As above
Childhood Comparison #4
As above
As above
About You
Next, we have a few simple questions about you.
What is your gender?
Female
Male
What is the highest level of education you have completed?
Less than high school
Some high school
High school degree or GED
Some college but no degree
Technical school
2-year college degree
4-year college degree
Some graduate school but no degree
Graduate or professional degree
Which of the following racial groups best describes you? Please check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Which of the following describes your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
How many children, if any, have you had? Please include all for which you are the parent or legal guardian.
None (0 children)
1 child
2 children
3 children
4 children
5 children
6 or more children
What is your current marital status?
Married
Divorced
Widowed
Separated
Never been married
What is your current employment status?
Not employed
Employed part-time
Employed full-time
Self-employed
What is your total household income before tax?
None ($0)
$1 - $12,500
$12,501 - $25,000
$25,001 - $50,000
$50,001 - $75,000
$75,001 - $100,000
$100,001 - $125,000
$125,001 - $150,000
Over $150,000
Not sure
Which of the following describes your health insurance? Please check all that apply.
Private health insurance, often provided by an employer
Medicaid or other public insurance
TRICARE (military health)
No health insurance
Not sure
Childhood Experiences
For the last few sections of this survey, we would like to ask questions about your childhood experiences. Some of the questions may make you uncomfortable. We recommend that you complete this section of the survey in a private place.
You may also take a break at any time. You may close your web browser and resume the survey later if you choose.
Remember that you can refuse to answer any question by leaving it blank.
Please click here to continue.
These questions ask about some of your experiences growing up as a child and a teenager. Although these questions are of a personal nature, please try to answer as honestly as you can. For each question, place check the response that best describes how you feel.
When I was growing up … |
Never True |
Rarely True |
Some-times True |
Often True |
Very Often True |
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[Programmer notes—not displayed on survey] Most items are scored 1-5 where “never true” is 1 and “very often true” is 5. Items 2, 5, 7, 13, 19, 26, and 28 are reverse scored where “never true” is 5 and “very often true” is 1. (Note: these numbers refer to the original CTQ, so here 2=Q47, etc.) Compute the following scores:
ea_score = Q3 + Q8 + Q14 + Q18 + Q25
pa_score = Q9 + Q11 + Q12 + Q15 + Q17
sa_score = Q20 + Q21 + Q23 + Q24 + Q27
en_score = Q5 + Q7 + Q13 + Q19 + Q28
pn_score = Q1 + Q2 + Q4 + Q6 + Q26
If ea_score>8 OR pa_score>7 OR sa_score>5 OR en_score>9 OR pn_score>7, then display the question text for all items for which the score(s) exceed the threshold and the following additional question:
Thinking about these childhood events in particular, approximately when did any of these events first begin to occur?
Before age 5
Ages 5-11
Ages 12-17, and not earlier
Don’t know or not sure
Other Experiences Before Age 18
You are now at the final section of the survey. To finish, we have a few other questions about your childhood before 18 years of age.
Were you ever put in foster care or put up for adoption?
Yes
No
When you were growing up, would you say your family was… ?
Pretty well off
About average financially
Poor
For most of the time, did your family own their home?
Yes
No
Not Sure
Did either of your parents or guardians ever receive public assistance, such as welfare, food stamps, or a food bank?
Yes
No
Not Sure
What is the highest level of education that your mother (or main female caregiver) completed?
Didn’t go to high school
Some high school
High school degree or GED
Some college or technical school
4-year college degree or higher
Not Sure
For most of the time, did your mother (or main female caregiver) work outside the home for pay?
Yes
No
Not Sure
Was there a time of several months or more when your father (or main male caregiver) had no job?
Yes
No
Not Sure
How old was your mother when you were born?
16 or younger
17-19
20-29
30-39
40 or older
Which of the following best describes your parents’ marital status before you were 18?
Always married or lived together
Married until widowed or death
Separated or divorced
Never lived together
Were you an only child?
Yes
No
Did you live with anyone who suffered from mental illness or depression?
Yes
No
Not Sure
Did you live with anyone who was a problem drinker or alcoholic?
Yes
No
Not Sure
Did you live with anyone who used illegal drugs?
Yes
No
Not Sure
Did you live with anyone who went to prison or committed a serious crime?
Yes
No
Not Sure
About how many times did you move residences, even in the same town?
0 to 2
3 to 5
6 to 9
10 or more
Not sure
Thank you for your help with this survey. We appreciate your responses.
Childhood Trauma Questionnaire™: A Retrospective Self-Report (CTQ™). Copyright © 1998 NCS Pearson, Inc. Computer adaption copyright © 2010 NCS Pearson, Inc. Adapted and reproduced with permission. All rights reserved. Childhood Trauma Questionnaire” and “CTQ” are trademarks in the US and/or other countries of Pearson Education, Inc. or its affiliates.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | There are many ways your health can affect your quality of life |
Author | sarnold |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |