LIGHT Survey

THE LONGITUDINAL INVESTIGATION OF GENDER,
HEALTH, AND TRAUMA SURVEY (LIGHT Survey)
Time 2
Welcome to the first follow-up survey! Thank you in
advance for completing this survey.

Q2a

If you have children, what are their ages in
years? If you have an infant, write 00.
Child 1

If you have any questions, you may contact our
helpdesk at 1-855-462-7577.

Child 2

INSTRUCTIONS
· Choose one answer for each question unless the
instructions say otherwise.
· Read each question carefully. Different questions
ask about different timeframes.

Child 3
Child 4
Child 5
Child 6
Child 7
Child 8

This number preserves your confidentiality and allows us to mail you
the incentive as a thank you for your time

Child 9
Child 10

Q2b
Q1

What is the highest degree or level of
education you have completed?

Would you consider yourself the or one of the
primary caregivers for your child/children?
Yes
No

Some high school but no diploma or GED
High school diploma / GED

Q3

Post-high school vocational or technical
training

Rent an apartment, house, or room

Some college credit, no degree

Live with a relative or friend and not paying
rent
Live in a car, on the street, or in a homeless
shelter
Other (Please describe)

Own my house or apartment

Associate’s degree (for example, AA, AS)
Bachelor’s degree (for example, BA, BS)
Master’s, Doctorate or professional degree
(for example, MA, MSW, MBA, PhD, MD, JD)

Q2

What is your current living situation?

How many children do you have (both your
biological children and other children for whom
you have parenting responsibilities)?
Number of children:
I do not have any children → Go to question 3

Light Survey - Time 2 (M)

Q4

Have you been homeless in the
past 4 months?
Yes
No

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Q5

What is your current employment status?
Select all that apply.
Working for pay full-time (≥30 hours/week)
Working for pay part-time (<30 hours/week)
Not working for pay but actively looking for
paid work
Full-time care of children under the age of 18
or adult (for example, disabled adult
child/parent/spouse)
Full-time homemaker without full-time child or
elder care responsibilities
Retired
Disabled

Q6

Please provide an estimate of your
HOUSEHOLD’S yearly income before taxes
are taken out. Include all sources of income
from all earners in your household. If you do
not know the answer, please make your best
guess.
No income
Less than $15,000 per year
$15,000 – $24,999
$25,000 – $34,999
$35,000 – $44,999
$45,000 - $54,999
$55,000 – $74,999
$75,000 – $99,999
$100,000 - $149,999
$150,000 or more per year

Q7

Q8

How many people are supported by this
HOUSEHOLD income, including yourself,
your significant other (if you have one), and
anyone else partially or fully supported by this
income whether or not they live with you?

Have you been incarcerated for longer than
24 hours within the past 4 months?
Yes
No

Light Survey - Time 2 (M)

The following questions ask about
experiences you may have had since the
last survey 4 months ago. Please mark if
you experienced any of these events in the
past 4 months. If the event does not apply to
you, mark “Not at all."
Q9

In the past 4 months...
Once
Not at
or Several Many
all
Twice times times

a. Serious accident (for
example, car / boat
accident, accident at
work)
b. Exposure to toxic
substance (for example,
dangerous chemicals,
radiation)
c. Witnessed sudden,
violent death or aftermath
(for example, homicide,
suicide)
d. Sudden, unexpected
death of someone close
to you
e. Serious injury, harm, or
death you caused to
someone else
f. Captivity (for example,
being kidnapped, held
hostage, prisoner of war)
g. Community violence
(for example, terrorist
attack, bombing, riots)

This section is about violent attacks against
you by someone who is NOT a romantic
partner or spouse.
In the past 4 months…
Once
Not at
or Several Many
all
Twice times times

h. Sexual assault by
anyone who is NOT an
intimate partner (rape,
attempted rape, made to
perform any sexual act
through force or threat of
harm)
i. Serious physical assault
by anyone who is NOT an
intimate partner (attacked
with or without a weapon,
threatened with a
weapon)
2

This section is about violence against you by someone who WAS/IS a romantic partner or
spouse
In the last 4 months...
Not at all

Once or twice

Several times

Many times

j. Physical assault (pushed, grabbed, shaken, hit, beat
up by a significant other/spouse)
k. Unwanted sexual experience by a significant
other/spouse (pressured or forced to do sexual things
you didn’t want to do)
l. Emotional mistreatment by significant other/spouse
(name-calling, criticized, not allowed to see
friends/family, humiliated, or denied money)
m. Other traumatic event: please specify. Please
describe the event below:

Q10 Think about things that may have happened to you throughout your life that are unusually or especially
frightening, horrible, or traumatic. If you have had one of these experiences, which experience causes
you the most distress? If you have not had an experience like this, please select “I did not have an
experience like this” and proceed to question 14. Check one only.
Combat/ exposure to warzone
Physical assault
Sexual assault
Accident
Natural disaster
Seen someone killed or seriously injured
Death of loved one through homicide or suicide
I did not have an experience like this

→ Go to question 14

Other: (Please describe)

Q11 How old were you when this most distressing trauma occurred?

Q12 How long ago did this trauma occur?
Within the past month
Within the past 4 months
Over 4 months ago

Light Survey - Time 2 (M)

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Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and and then choose one of the responses
below to indicate how much you have been bothered by that problem in the past month.
Please base your answers on problems related to the experience you named as the worst in
question 10.
Q13 Thinking about the experience you named in question 10, in the past month, how much were you
bothered by:
Not at all

A little bit

Moderately

Quite a bit

Extremely

a. Repeated, disturbing, and unwanted memories of the
stressful experience?
b. Repeated, disturbing dreams of the stressful
experience?
c. Suddenly feeling or acting as if the stressful
experience were actually happening again (as if you
were actually back there reliving it)?
d. Feeling very upset when something reminded you of
the stressful experience?
e. Having strong physical reactions when something
reminded you of the stressful experience (for example,
heart pounding, trouble breathing, sweating)?
f. Avoiding memories, thoughts, or feelings related to the
stressful experience?
g. Avoiding external reminders of the stressful
experience (for example, people, places, conversations,
activities, objects, or situations)?
h. Trouble remembering important parts of the stressful
experience?
i. Having strong negative beliefs about yourself, other
people, or the world (for example, having thoughts such
as: I am bad, there is something seriously wrong with
me, no one can be trusted, the world is completely
dangerous)?
j. Blaming yourself or someone else for the stressful
experience or what happened after it?
k. Having strong negative feelings such as fear, horror,
anger, guilt, or shame?
l. Loss of interest in activities that you used to enjoy?
m. Feeling distant or cut off from other people?
n. Trouble experiencing positive feelings (for example,
being unable to feel happiness or have loving feelings for
people close to you)?
o. Irritable behavior, angry outbursts, or acting
aggressively?
p. Taking too many risks or doing things that could cause
you harm?
q. Being “superalert” or watchful or on guard?
r. Feeling jumpy or easily startled?
s. Having difficulty concentrating?
t. Trouble falling or staying asleep?

Light Survey - Time 2 (M)

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Q14 The next set of items ask about potentially stressful situations you may be currently
experiencing. Think about whether or not the stressful situation described happened in the past
4 months. If the situation IS NOT occurring for you, choose "N/A" and go to the next item. If the
situation IS occurring, please rate the extent to which it is NOW stressful/distressing to you on a
scale from 1-10.
N/A

Not at all
distressing
1

2

3

4

Somewhat
distressing
5

6

7

8

9

Extremely
distressing
10

a. Laid off or fired from work
b. At risk for losing your
home/lost your home
c. Caring of seriously ill
and/or disabled dependents
(e.g., children, elders)
d. Divorce or separation
from romantic partner
e. Legal problems, court
proceedings, ongoing
litigation
f. Major negative change in
financial status
g. Major problems at
school/At risk of losing spot
at school or Veteran
subsidies
h. Major health problem
i. Major problem with your
significant other or child(ren)
j. Moved to a new home

Light Survey - Time 2 (M)

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Q15 Over the past two weeks how often have you been bothered by any of the following problems?
Not at all

Several days

More than half Nearly every
the days
day

a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself – or that you are a failure or
have let yourself or your family down
g. Trouble concentrating on things, such as reading the
newspaper or watching television
h. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless that
you have been moving around a lot more than usual
i. Thoughts that you would be better off dead, or of hurting
yourself
j. Feeling nervous, anxious, or on edge
k. Not being able to stop or control worrying
l. Worrying too much about different things
m. Trouble relaxing
n. Being so restless that it's hard to sit still
o. Becoming easily annoyed or irritable
p. Feeling afraid as if something awful might happen

Q16 Have you been diagnosed with any of the following emotional/mental health conditions within the past 4
months? Select all that apply.
Post-traumatic Stress Disorder (PTSD)
Depression
Anxiety Disorder (for example, panic disorder, generalized anxiety disorder)
None
Other mental health problem(s) (please specify):

Light Survey - Time 2 (M)

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Please check the one box beside the statement or phrase that best applies to you.
Q17a Have you thought about or attempted to kill yourself in the past 4 months? Check one only.
Never
It was just a brief passing thought
I have had a plan at least once to kill myself but did not try to do it
I have had a plan at least once to kill myself and really wanted to die
I have attempted to kill myself, but did not want to die
I have attempted to kill myself, and really hoped to die

Q17b How often have you thought about killing yourself in the past 4 months? Check one only.
Never
Rarely (1 time)
Sometimes (2 times)
Often (3-4 times)
Very often (5 or more times)

Q17c Have you ever told someone in the past 4 months that you were going to commit suicide, or that you
might do it? Check one only.
No
Yes, at one time, but did not really want to die
Yes, at one time, and really wanted to die
Yes, more than once, but did not want to do it
Yes, more than once, and really wanted to do it

Q17d How likely is it that you will attempt suicide someday? Check one only.
Never
No chance at all
Rather unlikely
Unlikely
Likely
Rather likely
Very likely

Having thoughts of hurting yourself can be a common response to feeling distressed. We
want you to know that help is available. We recommend that you contact your primary care
provider or call the Veterans Crisis Hotline (1-800-273-8255) if you are experiencing suicidal
thoughts.

Light Survey - Time 2 (M)

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Q18 Thinking over the past month, check the option that best describes the amount of time you felt
that way.
None or
All or almost
almost none A little of the Some of the Most of the all of the
of the time
time
time
time
time

a. I found myself getting angry at people or situations.
b. When I got angry, I got really mad.
c. When I got angry, I stayed angry.
d. When I got angry at someone I wanted to hit them.
e. My anger prevented me from getting along with people
as well as I'd have liked to.

Q19

What is your current marital status?
Never married
Married - first and only marriage → Go to question 21
Married - second or later marriage → Go to question 21
Separated
Divorced
Widowed

Q20

Are you currently in a romantic relationship?
Currently in a relationship and living as a couple
Currently in a relationship but not living as a couple
Not currently in a relationship → Go to question 22

If you are married or currently in a romantic relationship, please answer the following
questions. If you are not married or in a romantic relationship, please skip to question 22:
Q21 Over the past month, how often have you done the following in your romantic relationship:
Never

Rarely

Sometimes

Often

Most or all of
the time

a. Provided your significant other with the emotional
support they sought?
b. Shared your intimate thoughts and feelings?
c. Done your fair share of day-to-day tasks. (for example,
grocery shopping, errands, planning activities)?
d. Initiated leisure time activities that both you and your
significant other enjoy?
e. Made effort to work through disagreements
respectfully?
f. Expressed interest and/or willingness to engage in
regular sexual or physical intimacy?

Light Survey - Time 2 (M)

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If you currently have parenting responsibilities for any children 18 or under, please answer
the following questions. If not, please skip to question 25.
Q22 All parents have strengths and weaknesses. Over the past month, how often have you:
Never

Rarely

Sometimes

Often

Most or all
of the time

a. Provided a healthy environment for your children. (for
example, preparing healthy meals, caring for their health,
keeping them safe)?
b. Been a good example for your children. (for example,
being respectful during disagreements with others,
taking good care of your own health)?
c. Been actively involved in your child(ren)’s activities.
(for example, regularly attending sporting and school
events, giving your full attention during time together)?
d. Met your children’s needs for physical affection and
emotional support. (for example, giving them hugs, being
sympathetic to their problems)?
e. Been able to successfully manage your child(ren)’s
unique challenges. (for example, effectively disciplining
children)?

Light Survey - Time 2 (M)

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Q23 Parents have different ways of trying to raise their children. Please read each statement and rate
how much each one best describes your parenting during the past two months with your
child/children:
Never

Almost
Never

Sometimes

Often

Always

a. I express affection by hugging, kissing, and holding my child.
b. If my child whines or complains when I take away a privilege,
I will give it back.
c. I am afraid that disciplining my child for misbehavior will
cause her/him to not like me.
d. I argue with my child.
e. I use threats as punishment with little or no justification.
f. The punishment I give my child depends on my mood.
g. I have warm and intimate times together with my child.
h. I yell or shout when my child misbehaves.
i. My child talks me out of punishing him/her after he/she has
done something wrong.
j. I show respect for my child's opinions by encouraging him/her
to express them.
k. If my child does his/her chores, I will recognize his/her
behavior in some manner.
l. I let my child out of a punishment early (like lift restrictions
earlier than I originally said).
m. I explode in anger toward my child.
n. I give reasons for my requests (such as "We must leave in
five minutes, so it's time to clean up.").
o. I lose my temper when my child doesn't do something I ask
him/her to do.
p. I encourage my child to talk about her/his troubles.
q. If I give my child a request and she/he carries out the
request, I praise her/him for listening and complying.
r. I warn my child before a change of activity is required (such
as a five-minute warning before leaving the house in the
morning).
s. If my child gets upset when I say “No,” I back down and give
in to her/him.
t. My child and I hug and/or kiss each other.
u. I listen to my child’s ideas and opinions.
v. I feel that getting my child to obey is more trouble than it’s
worth.
w. If my child cleans his room, I will tell him/her how proud I am.
x. I give in to my child when she/he causes a commotion about
something.
y. I tell my child my expectations regarding behavior before my
child engages in an activity.

Light Survey - Time 2 (M)

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(continued)
Never

Almost
never

Sometimes

Often

Always

z. When I am upset or under stress, I am picky and on my
child’s back.
aa. I tell my child that I like it when he/she helps out around the
house.
bb. I provide my child with a brief explanation when I discipline
his/her misbehavior.
cc. I avoid struggles with my child by giving clear choices.
dd. When my child misbehaves, I let him know what will happen
if she/he doesn't behave.

Q24 The following questions ask about potentially stressful situations you may be experiencing as a
parent. To what degree do the following concerns about your child(ren) cause distress? Think
about whether or not the stressful situation described happened in the past month. If the
situation IS NOT occurring for you, choose N/A and go to the next item. If the situation IS
occurring, please rate the extent to which it is NOW stressful/distressing to you on a scale from 1
-10.
My child...
NA

Not at all
distressing
1

2

3

4

Somewhat
distressing
5

6

7

8

9

Extremely
distressing
10

a Has difficulty making
friends?
b. Gets in trouble with peers
(e.g., getting into fights)?
c. Regularly receives failing
or near-failing grades in
school?
d. Receives special
education services/IEP
(Individualized Education
Plan) for a disability, such as
autism, intellectual disability,
deafness, or emotional
disturbance?
e. Gets in trouble with the
law (e.g., arrested or police
involvement)?
f. Has a chronic health
condition, such as diabetes,
cystic fibrosis, sickle cell
anemia, or epilepsy?
g. Gets bullied by his or her
peers?

Light Survey - Time 2 (M)

11

The following questions ask about your neighborhood and community.
Q25 We are interested in how you feel about the following statements. Read each statement carefully.
Indicate how you feel about each statement.
Strongly
disagree

Disagree

Agree

Strongly
agree

a. There is a lot of graffiti in my neighborhood.
b. My neighborhood is noisy.
c. Vandalism is common in my neighborhood.
d. There are a lot of abandoned buildings in
my neighborhood.
e. My neighborhood is clean.
f. People in my neighborhood take good care of their
houses and apartments.
g. There are too many people hanging around on
the streets near my home.
h. There is a lot of crime in my neighborhood.
i. There is too much drug use in my neighborhood.
j. There is too much alcohol use in my neighborhood.
k. I’m always having trouble with my neighbors.
l. In my neighborhood, people watch out for each other.
m. My neighborhood is safe.

Q26

In the past 4 months, how often have you
heard gunshots associated with crime or
violence in your neighborhood?

Q29

Have you ever seen someone threatened with
a gun in the neighborhood within the last 4
months?

Never

Yes

Once or twice

No

Three to five times
More than five times

Q30
Q27

How common would you say it is for people to
belong to street gangs in your neighborhood?

Have you ever seen someone shot with a gun
in the neighborhood within the last 4
months?

Very common

Yes

Somewhat common

No

Somewhat uncommon
Very uncommon

Q31
Q28

How common do you think it is for people to
carry guns in the neighborhood?

If a fight were to break out near your home,
how likely is it that your neighbors would
attempt to break it up?

Very common

Very likely

Somewhat common

Somewhat likely

Somewhat uncommon

Somewhat unlikely

Very uncommon

Very unlikely

Light Survey - Time 2 (M)

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Q32

If a fight were to break out near your home,
how likely is it that the police would be called?

The following questions ask about your
health.

Very likely
Somewhat likely

Q36

Somewhat unlikely
Very unlikely

During the past month, what time have you
usually gone to bed at night (hh:mm)?
:

Q33 How safe do you feel…
Very safe

SomewhatSomewhat Very
safe
unsafe
unsafe

a. Alone inside
your house?
b. Outside in your
neighborhood
during the day?
c. Outside in your
neighborhood at
night?
d. Walking alone
toward a group of
people that you
don’t know?

Q34

In this neighborhood, it is sometimes
necessary for people to carry guns to protect
themselves or their family.

Q37

During the past month, how long, has it
usually taken you to fall asleep each night?
Number of hours:
Number of minutes:

Q38

During the past month, what time have you
usually gotten up in the morning (hh:mm)?
:

Q39

Strongly agree

During the past month, how many hours of
actual sleep did you get at night? (This may
be different from the number of hours you
spent in bed.)

Agree
Hours of sleep per night:

Disagree
Strongly Disagree

Q35

In this neighborhood, it is sometimes
necessary for people to join a gang to protect
themselves or their family.

Q40

How often do you exercise for 30 minutes or
more?
Daily or almost daily

Strongly agree

3 to 4 times per week

Agree

2 to 3 times per week

Disagree

1 to 2 times per week

Strongly disagree

Fewer than once per week

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Please answer the following questions
related to your current substance use. Skip
any questions that are irrelevant to you.

Q46

In the past month, did you use marijuana? If
YES, how many times in a typical week?
No → Go to question 48
Yes

Q41

How many cigarettes did you smoke on an
average day in the last month (if you do not
smoke write 0)?

Times in a week:

Q46a Does your marijuana use cause any
problems?
Yes

For alcohol, one drink equals:
· 4 oz. wine
· 1 wine cooler
· 12 oz. beer
· 1 cocktail with 1 oz. hard liquor

No
N/A, I do not use marijuana

Q46b Did anyone else think your marijuana use
caused a problem?
Yes

Q42

How often do you currently have a drink
containing alcohol?
Never → Go to question 45
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week

Q43

No
N/A, I do not use marijuana

Q47 In the past month, did you use other drugs,
other than alcohol or marijuana? If YES, how
many times in a typical week did you use, if at
all? This includes cocaine, crack, heroin, acid,
speed, ecstasy, methamphetamines, steroids,
and medicines prescribed for someone else.
No → Go to question 49

How many standard drinks containing alcohol
do you have on a typical day?

Yes
Times in a week:

1 or 2
3 or 4
5 or 6

Q44

Q47a Does your use of drugs other than alcohol or
marijuana cause any problems?

7 to 9

Yes

10 or more

No

On average, how often do you have 5 or more
drinks on one occasion?
Never

N/A, I do not use drugs, not including alcohol
or marijuana

Q47b Did anyone else think your use of drugs other
than alcohol or marijuana cause a problem?

Less than monthly

Yes

Monthly

No

Weekly

N/A, I do not use drugs, not including alcohol
or marijuana

Daily or almost daily

Q48
Q45

Have you been diagnosed with alcohol abuse
or dependence in the past 4 months?

Have you been diagnosed with drug
(including prescription drugs) abuse or
dependence in the past 4 months?

No

No

Yes

Yes

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If you are prescribed pain medication please answer the following questions, otherwise skip
to item 50.
Q49 In the past 4 months…
Never

Rarely

Sometimes

Often

Almost
Always

Not at all

A little bit

Somewhat

Quite a bit

Very much

a. I abused prescription pain medication.
b. I ran out of my prescription pain medication early.
c. I got prescription pain medication from someone other
than my healthcare provider.
d. I used more of my prescription pain medication than I
was supposed to.
e. I experienced cravings for pain medication.
f. I used more pain medication before the effects wore
off.

Q49a In the past 4 months…
When my prescription for pain medication ran out, I felt
anxious.

Q50

What is your current weight?

lbs
Q51

Have you ever experienced any of the
following events in the past 4 months?
Select all that apply.
Blast or explosion (IED, RPG, Landmine,
Grenade, etc)
Vehicular accident/crash (any vehicle
including aircraft)
Fragment wound or bullet wound above the
shoulders
Fall
Blow to the head (head hit by falling/flying
object, head hit by another person, head hit
against something, etc)
Strangulation

Q51a Did you have any of these immediately after
any of the events in Q51? Select all that
apply.
Losing consciousness/"knocked out”
Being dazed, confused, or “seeing stars”
Not remembering the event
Concussion
Head injury that resulted in broken bones in
head, neck, face, damaged teeth, or ruptured
eardrum
None of the above

Shaken violently
None of the above → Go to question 52

Light Survey - Time 2 (M)

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Q51b Did any of the following problems begin or get
worse afterwards? Select all that apply.
Memory problems or lapses
Balance problems or dizziness

The following questions ask about your use
of healthcare and thoughts about mental
health treatment.
Q53

Sensitivity to bright light
Irritability
Headaches

Do you get any healthcare (physical and/or
mental health) at Veterans’ Administration
(VA) hospitals or clinics in the
past 4 months?
Yes

Sleep problems

No → Go to question 54

None of the above

Q53a If NO, why not?
Not eligible
Distance to VA facilities/transportation
concerns
My VA does not provide the services I need

Q51c In the past week, have you had any of the
symptoms from question 51? Select all that
apply.

I don’t feel comfortable seeking services at
the VA
Preference for my current healthcare
providers
Other (please specify):

Memory problems or lapses
Balance problems or dizziness
Sensitivity to bright light
Irritability
Headaches
Sleep problems

Q54

None of the above

I think that I am suffering from mental health
problems (for example, feeling anxious
depressed, or too angry).
True
False

Q52

Have you been diagnosed with any new
medical conditions in the past 4 months?

Q55

I think that I might benefit from mental health
treatment.

Yes

True

No

False

Q56
If yes, please specify the condition(s):

Are you currently receiving mental health
services (e.g., seeing a therapist, counselor,
or medications) to help with distress?
Yes
No

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Q56a If NO, what prevents you from seeking mental
health treatment? Select all that apply.
Concern for job security

Q57 If I thought that I were suffering from serious
depression, anxiety, anger, or fear, I would
seek assistance from (Select all that apply):
Good female friends

Judgment from others

Good male friends

Distance/transportation to mental healthcare
providers

Spouse or intimate partner

Don’t think it will help me

Family member (brother, sister, mother, father,
etc.)
Coworker

No insurance coverage
I don't need mental health treatment

Religious leader (e.g. pastor, priest, rabbi)

Other (please specify):

Medical doctor (primary care doctor)
Therapist or counselor
Information on the internet
Self-help books or magazine articles
Other (please specify):

Q58 We are interested in your use of mental health services in the past 4 months. If you received any
help (even if it was only once or for a little while), please mark where you received this help. Mark
the no column only if you did not receive any of that type of help in the past 4 months.
Yes, from a
Yes, from
No, I did not
community both a VA and
get this kind Yes, from
(non-VA) a community
of help
a VA provider provider
provider

a. Medication for a mental health problem (e.g., an
antidepressant)
b. Individual counseling or therapy for a mental health program
c. Group counseling or therapy for a mental health problem
d. Family therapy
e. Inpatient or partial hospitalization program for a mental
health problem
f. Another type of mental health treatment (please specify):

Q59

If you felt as though you needed mental
health treatment other than what you are
currently receiving, do you feel your health
care provider could get it for you?

Q60

If you have received any mental health
treatments within the past 4 months, how
satisfied were you with the care you received?
Not at all satisfied

Yes

Slightly satisfied

No

Moderately satisfied

N/A

Very satisfied
Extremely satisfied
N/A

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Q61

If you have received any mental health
treatments within the past 4 months, how
helpful was this care in reducing your
distress?

Q62

If you have received any mental health
treatments within the past 4 months, how
difficult was it to find a therapist and schedule
your mental health appointments?

Not at all helpful

Very difficult

Slightly helpful

Difficult

Moderately helpful

Moderately difficult

Very helpful

Neutral

Extremely helpful

Easy

N/A

Very easy
N/A

Q63 The next set of items refer to how people in your life such as friends, family and coworkers would
react *if* you were to have a mental health problem. PLEASE NOTE THAT YOU DO NOT NEED TO
HAVE A CURRENT MENTAL HEALTH PROBLEM TO COMPLETE THESE QUESTIONS. Please rate
the extent to which you agree or disagree with the following statements.
Strongly
disagree

Somewhat
disagree

Neutral

Somewhat
agree

Strongly
agree

a. A problem would have to be really bad for me to be
willing to seek mental health care.
b. I would feel uncomfortable talking about my problems
with a mental health provider
c. If I had a mental health problem, I would prefer to deal
with it myself rather than to seek treatment.
d. Most mental health problems can be dealt with without
seeking professional help.
e. Seeing a mental health provider would make me feel
weak.
f. I would think less of myself if I were to seek mental
health treatment.
g. If I were to seek mental health treatment, I would feel
stupid for not being able to fix the problem on my own.
h. I wouldn’t want to share personal information with a
mental health provider.

Q64 If I had a mental health problem and friends and family knew about it, they would…
Strongly
disagree

Somewhat
disagree

Neutral

Somewhat
agree

Strongly
agree

a. ...think less of me.
b. ...see me as weak.
c. …feel uncomfortable around me.
d. …not want to be around me.
e. …think I was faking.
f. …be afraid that I might be violent or dangerous.
g. …think that I could not be trusted.
h. …avoid talking to me.

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The next set of questions ask you about your current support system and coping strategies.
Q65 We are interested in how you feel about the following statements. Read each statement carefully.
Indicate how you feel about each statement.
Very
strongly
disagree

Strongly
disagree

Mildly
disagree

Neutral

Mildly
agree

Strongly
agree

Very
strongly
agree

a. There is a special person who is around
when I am in need.
b. There is a special person with whom I can
share my joys and sorrows.
c. My family really tries to help me.
d. I get the emotional help and support I
need from my family.
e. I have a special person who is a real
source of comfort to me.
f. My friends really try to help me.
g. I can count on my friends when things go
wrong.
h. I can talk about my problems with my
family.
i. I have friends with whom I can share my
joys and sorrows.
j. There is a special person in my life who
cares about my feelings.
k. My family is willing to help me make
decisions.
l. I can talk about my problems with my
friends.

Q66 Please indicate how many times you have done each of these things to someone else in the past
4 months.

Once

Twice

3-5
times

6-10
times

11-20
times

Not in the
past 4
months,
but it did This has
More than happen
never
20 times
before
happened

a. I insulted, swore, shouted
or yelled at someone.
b. I pushed, shoved, or
slapped someone.
c. I punched, kicked, or beatup someone.
d. I destroyed something
belonging to someone else or
threatened to hit someone.

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Q67 The following questions ask you about how you generally cope with daily events.
I usually
don’t do this at
all

I usually do
this a little bit

I usually do
this a medium
amount

I usually do
this a lot

a. I turn to work or other activities to take my mind off
things.
b. I concentrate my efforts on doing something about the
situation I'm in.
c. I say to myself "this isn't real."
d. I use alcohol or other drugs to make myself feel
better.
e. I get emotional support from others.
f. I give up trying to deal with it.
g. I take action to try to make the situation better.
h. I refuse to believe that it has happened
i. I say things to let my unpleasant feelings escape.
j. I get help and advice from other people.
k. I use alcohol or other drugs to help me get through it.
l. I try to see it in a different light, to make it seem more
positive.
m. I criticize myself.
n. I try to come up with a strategy about what to do.
o. I get comfort and understanding from someone.
p. I give up the attempt to cope.
q. I look for something good in what is happening.
r. I make jokes about it.
s. I do something to think about it less, such as going to
movies, watching TV, reading, daydreaming, sleeping, or
shopping.
t. I accept the reality of the fact that it has happened.
u. I express my negative feelings.
v. I try to find comfort in my religion or spiritual beliefs.
w. I try to get advice or help from other people about
what to do.
x. I learn to live with it.
y. I think hard about what steps to take.
z. I blame myself for things that happened.
aa. I pray or meditate.
bb. I make fun of the situation.

THANK YOU FOR YOUR CONTINUED PARTICIPATION IN THIS SURVEY.
PLEASE RETURN YOUR SURVEY IN THE ENCLOSED ENVELOPE.
ONCE WE RECEIVE THE SURVEY, $20 WILL BE MAILED TO YOU.

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