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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 (0925-0584). Do not return the completed form to this address.
OMB#: 0925-0584
Exp. xx/xx/xxxx
HCHS/SOL Visit 2 Chronic Stress
FORM CODE: STE
VERSION: 1, 12/10/13
ID NUMBER:
Contact
Occasion
0
2
SEQ #
Administrative Information
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.
A. Chronic Stress
Many people experience ongoing problems with their everyday lives. Please tell us whether any of the
following has been a problem for you.
1. Have you had a serious ongoing health problem?
No
Yes
GO TO QUESTION 2
0
1
1a. Has this been a problem for six months or more?
No
Yes
0
1
1b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
2. Has someone close to you had a serious ongoing health problem?
No
Yes
GO TO QUESTION 3
0
1
2a. Has this been a problem for six months or more?
No
Yes
0
1
2b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
STE-Stress-12-10-2013.docx
Page 1 of 3
FORM CODE: STE
VERSION: 1, 12/10/13
ID NUMBER:
Contact
Occasion
0
2
SEQ #
3. Have you had ongoing difficulties with your job or ability to work?
No
Yes
GO TO QUESTION 4
0
1
3a. Has this been a problem for six months or more?
No
Yes
0
1
3b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
4. Have you experienced ongoing financial strain?
No
Yes
GO TO QUESTION 5
0
1
4a. Has this been a problem for six months or more?
No
Yes
0
1
4b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
5. Have you had ongoing difficulties in a relationship with someone close to you?
No
Yes
GO TO QUESTION 6
0
1
5a. Has this been a problem for six months or more?
No
Yes
0
1
5b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
6. Has someone close to you had an ongoing problem with alcohol or drug use?
No
Yes
0
1
STE-Stress-12-10-2013.docx
GO TO QUESTION 7
Page 2 of 3
FORM CODE: STE
VERSION: 1, 12/10/13
ID NUMBER:
Contact
Occasion
0
2
SEQ #
6a. Has this been a problem for six months or more?
No
Yes
0
1
6b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
7. Have you been helping someone close to you, who is sick, limited or frail?
No
Yes
GO TO QUESTION 8
0
1
7a. Has this been a problem for six months or more?
No
Yes
0
1
7b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
8. Have you had another ongoing problem not listed here?
No
0
GO TO QUESTION 9
Yes
1
If yes, please describe:
8a. Has this been a problem for six months or more?
No
Yes
0
1
8b. Would you say this problem has been
Not very stressful
1
Moderately Stressful 2
Very Stressful
3
STE-Stress-12-10-2013.docx
Page 3 of 3
File Type | application/pdf |
File Modified | 2014-05-30 |
File Created | 2014-05-30 |