Work and Health Survey

WORK AND HEALTH SURVEY

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

CDC estimates the average public reporting burden for this collection of information as 45 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to response 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Section A – Taxi/rideshare driving

First, I’m going to ask you questions about driving a taxi/rideshare.

1a. What month and year did you start working as a taxi/rideshare driver?

________________mm/yy

1b. What month and year did you start working as a taxi/rideshare driver in this city?

________________mm/yy

1c. What month and year did you start working for this company?

_______________ mm/yy

1d. In a typical week, what is your work schedule at this company?

___ days/week AND ___ hours/day

1e. Have you had any breaks in service from driving a taxi/rideshare in this city?

Yes ------1 (Go to 1f)

No -------2 (Go to 2a)

1f. How long did you stop driving?

___ yrs ____ months ____ days

1g. Why did you stop driving?

_________________________________

1h. Why did you return to driving a taxi/rideshare?

_________________________________

2a. Do you drive for other companies or hold any other jobs?

Yes -------1 (Go to 2b)

No -------- 2 (Go to 3)

2b. What other jobs do you currently hold? Please include your occupation and how many hours you work in a typical week. Include driving for other companies.

A ________________| ____ hrs/ week

B ________________| ____ hrs/ week

C ________________| ____ hrs/ week

2c. Do you own another business?

Yes……1, describe: ___________

No…….2

3. Which of the following apply to you?

Check all that apply.

I have my own medallion……..1

I own the taxi/rideshare vehicle that I drive…..2

I drive somebody else’s taxi on a gas-and- gates basis by the:

____shift

____ 24 Hours

____weekly

____other, describe _________

4. Do you own another taxi/rideshare vehicle?

Yes……1, how many? _____

No…….2

5. Which shift do you typically drive your taxi/rideshare?

___ Day (7am-7pm) ___ Night (7pm-7am) ___ Other, please describe: __________

6a. In a typical work day, how many miles do you drive your taxi/rideshare? _______ miles per day

6b. In a typical work day, how many hours do you drive your taxi/rideshare? _______ hours per day

6c. In a typical work week, how many days do you work? _______ days

6d. In a typical work week, what percentage of driving is highway? ___%

7a. What types of breaks do you take? Circle all that apply.

To eat …………1 To rest/take a nap…….4

To stretch…......2 To use the restroom….5

To socialize…...3 Other…..6

7b. Where do you take breaks? Circle all that apply.

At taxi/rideshare zone/airport……1 At a park……….3

At a restaurant/café…..2 Other……………4 Describe: _______________

8. How many times do you take a break from driving during a typical shift? ______ times

9a. Do you have to drive to pick up your taxi/rideshare? Yes……1 (Go to 9b) No……..2 (Go to Section B)

9b. How far do you drive from home to pick it up? ____ miles

9c. How long does it take to pick it up from home? ____ minutes

9d. How long does it take to get home after dropping it off? ___ minutes

Section B – Job Demands

The next questions are about your job demands as a taxi/rideshare driver. Work duties include driving, cleaning the vehicle, refueling and cashiering. On a scale from 1 to 5 with 1 being “Never/Rarely” and 5 being “Very often/All the time”:

Questions	1 Never/ rarely	2 Not often	3 Some-times	4 Often	5 Very often/all the time
1. How often does your work as a taxi/rideshare driver make you feel rushed?
2. How often do your work duties as a taxi/rideshare driver require you to work very hard?
3. How often is there a great deal of work/duties to be done (as a taxi/rideshare driver)?
4. How often do your work duties as a taxi/rideshare driver leave you with little time to get things done outside of your job?

Section C – Passenger Violence

The next questions are about your contact with passengers (not another driver).

1. In the past year (12 months), have you been verbally assaulted? This includes being yelled at, threatened or insulted (such as racial/ethnic or sexual slurs) by a passenger.

No------0 Yes-----1

Refused to Answer ---99

2. In the past year (12 months), have you had a passenger refuse to pay their fare (theft of service)?

No---- 0 Yes-----1

Refused to Answer ---99

3. In the past year (12 months), have you been physically assaulted by a passenger? This includes being hit, pushed or grabbed.

­­

No------0 Yes-----1

Refused to Answer ---99

4. In the past year (12 months), has your taxicab/rideshare been stolen?

No------0 Yes-----1

Refused to Answer ---99

5. In the past year (12 months), has your phone, wallet, or other items been stolen?

No------0 Yes-----1

Refused to Answer ---99

6. In the past year (12 months), have you been robbed by an armed passenger (such as with gun, knife, or other weapon)?

No------0 Yes-----1

Refused to Answer ---99

Section D – Crash #1

The next questions ask about any crashes you may have been involved in while driving your taxicab/rideshare.

1a. In the past year (12 months) were you involved in a motor vehicle crash while driving a taxi/rideshare? This includes being hit by another car, rear-ending another car, being rear-ended, hitting a parked vehicle, a cyclist, or a pedestrian.

No------0 (Skip to Section E, page 7)

Yes-----1

1b. In the last year, how many crashes total?

__________

Now I will ask you some questions about each crash you were involved in during the past year (12 months) while driving a taxicab, beginning with the most recent.

For crash #1:

2 a.1.1 How did the crash happen?

Prompt driver to describe and select all accurate responses.

The taxicab:

struck another vehicle ………..…1

was struck by another vehicle..…2

hit an object or animal................. 3

ran off the road………………. ….4

struck a pedestrian…………….…5

struck a cyclist..… ……………….6

lost control…………………….…..7

fell asleep………………………….8

hit a curb…………………………..9

Other……………………………….10 Specify:____________________________

2.a.1.2 Around what time did the crash happen?

____:_____ am pm

2.a.1.3 What was the weather like at the time of the crash? Read all to driver and select all that apply.

Clear………….………….1

Cloudy………….………..2

Fog, Smog, Smoke….....3

Rain………………..……..4

Sleet, hail………..……….5

Severe crosswinds………6

Blowing sand, soil, dirt…..7

Other……………………...8

Specify______________

Unknown……………………..98

2a.2.1. How much was the estimated total property damage for the taxicab/rideshare?

$_______ Write amount -or- Unknown…98

2a.2.2 How much was the estimated total property damage for the other vehicle?

$_______ Write amount

Unknown…..……98

-or- N/A……97

2a.2.3 How much was your medical costs?

Taxi/rideshare driver: $_______ Write amount Unknown………98

N/A….…....97

Section D – Crash #2

Please complete this section if the driver had more than one crash in the last year.

3. In the past year (12 months) were you involved in a second motor vehicle crash while driving a taxi/rideshare? This includes being hit by another car, rear-ending another car, being rear-ended, hitting a parked vehicle, a cyclist, or a pedestrian.

No------0 (Skip to Section E, page 7)

Yes-----1

Now I will ask you some questions about the crash you were involved in while driving a taxi/rideshare, before the most recent.

For crash #2:

4a.1.1 How did the crash happen?

Prompt driver to describe and select all accurate responses.

The taxicab/rideshare:

struck another vehicle ………..…1

was struck by another vehicle…..2

hit an object or animal................. 3

ran off the road………………..….4

struck a pedestrian…………….…5

struck a cyclist..… ……………….6

lost control………………………...7

fell asleep………………………….8

hit a curb…………………………..9

Other……………………………….10 Specify:____________________________

4.a.1.2 Around what time did the crash happen?.

____:____ am pm

4.a.1.3 What was the weather like at the time of the crash? Read all to driver and select all that apply.

Clear………….…………….1

Cloudy………….……….....2

Fog, Smog, Smoke…........3

Rain………………..……....4

Sleet, hail………..………...5

Severe crosswinds…….…6

Blowing sand, soil, dirt…...7

Other……………………....8

Specify______________

Unknown……………………..98

4a.2.1. How much was the estimated total property damage for the taxi/rideshare?

$_______ Write amount -or- Unknown…98

4a.2.2 How much was the estimated total property damage for the other vehicle?

$_______ Write amount

Unknown…..……98

-or- N/A……97

4a.2.3 How much was your medical costs?

Taxi/rideshare driver: $_______ Write amount Unknown………98

N/A….…....97

Section E – Safety equipment

The next questions are about safety equipment installed in your taxi/rideshare.

1. What is the year, make, and model of the taxi/rideshare you usually drive?

   1. Year ___________

   2. Make __________

   3. Model ___________

2. Does your taxi/rideshare have any of the following features:

https://mycardoeswhat.org/safety-features/, select all that apply:

1. Anti-Lock Braking System o. Lane Departure Warning cc. Traction Control

2. Automatic Emergency Braking p. Drowsiness Alert

3. Adaptive Headlights q. Lane Keeping Assist

4. Bicycle Detection r. Blind Spot Warning

5. Brake Assist s. Sideview Camera

6. Forward Collision Warning t. Back-up Camera

7. Left Turn Crash Avoidance u. Back-up Warning

8. Obstacle Detection v. Rear Cross Traffic Alert

9. Pedestrian Detection w. Automatic Parallel Parking

10. Traction Control x. Parking Sensors

11. Curve Speed Warning y. Temperature Warning

12. High Speed Alert z. Tire Pressure Monitoring System

13. Adaptive Cruise Control aa. Hill Assist

14. Adaptive Headlights bb. Electronic Stability Control

3. On a scale of 1 to 10, with 1 being “no safer than before” and 10 being “extremely safe”

how does having driving safety features (for example, lane assist) in your taxicab make you feel?

1 2 3 4 5 6 7 8 9 10

No safer than before Extremely safe

Section F – Safety Training and Habits

The next questions ask about your safety training and habits.

1a. Have you received driver safety training to be a taxicab/rideshare driver in this city?

No…..0 1b. Would you benefit from such a training?

Yes……1 No…….0 Maybe……3 Skip to Question 3 below

Yes….1 1c.1.When was your most recent training? ___________mm / yy

1c.2. Who provided the training _____ SFMTA ______ taxi/rideshare company ___other, describe: ____________

1c.3. Was the training: _______ in person _______ online

1c.2.How long did it last? ____________ hours

1c.3. Did your training cover the following topics (select all that apply)

1. Driver safety from passenger violence

2. Safe road behaviors

3. Dangers of fatigue

4. How to identify and reduce fatigue

2. On a scale of 1 to 10 with 1 being least useful and 10 being most useful,

how do you rate the driver safety training for the following:

1. Helpful in identifying and reducing fatigue:

(Least useful) 1 2 3 4 5 6 7 8 9 10 (Most useful)

2. Helpful in describing safety measures for de-escalating violence from passenger:

(Least helpful) 1 2 3 4 5 6 7 8 9 10 (Most helpful)

3. Helpful in describing effective road safety measures to minimize events/accidents while driving:

(Least helpful) 1 2 3 4 5 6 7 8 9 10 (Most helpful)

Please think about safety practices at the company you drive for.

Please rate how much you agree with the following statement ranging from Strongly agree to Strongly disagree.

3. Taxicab/rideshare drivers new to this company learn quickly that they are expected to follow good safety practices.

Strongly agree-₁ Agree-₂ Disagree-₃ Strongly Disagree-₄

4. This company tells taxi/rideshare drivers when they do not follow good safety practices.

Strongly agree-₁ Agree-₂ Disagree-₃ Strongly Disagree-₄

5. Taxi/rideshare drivers and taxi/rideshare company management work together to ensure the safest possible conditions.

Strongly agree-₁ Agree-₂ Disagree-₃ Strongly Disagree-₄

6. There are no shortcuts taken when taxi/rideshare driver health and safety are at stake.

Strongly agree-₁ Agree-₂ Disagree-₃ Strongly Disagree-₄

7. The health and safety of taxi/rideshare drivers is a high priority with the company’s management.

Strongly agree-₁ Agree-₂ Disagree-₃ Strongly Disagree-₄

8. I feel free to report safety problems to the taxi/rideshare company where I drive.

Strongly agree-₁ Agree-₂ Disagree-₃ Strongly Disagree-₄

The next questions are about your driving habits as a taxi/rideshare driver.

On a scale from 1 to 5, with 1 being rarely/never and 5 being very often:

9. How often do you wear your seat belt while driving?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

10. How often do you exceed the speed limit on a residential road?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

11. How often do you exceed the speed limit on a highway or freeway?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

12. How often do you exceed the speed limit when travelling to do pickups?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

13. How often do you exceed the speed limit when travelling with a passenger?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

14. How often do you not signal to change lanes when no other traffic is around?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

15. How often do you perform a U-turn in a non-designated zone?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

16. How often do you not come to a complete standstill at a stop sign?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

17. How often do you use a handheld device while driving?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

18. How often do you drive while thinking about how to get to your destination?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

19. How often do you drive while thinking about your next pickup or work task?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

20. How often do you drive while thinking about your work-related problems/issues?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

21. How often do you drive while tired?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

22. How often do you have difficulty driving because of tiredness or fatigue?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

23. How often do you find yourself nodding off while driving?

(Rarely/Never) 1 2 3 4 5 (Very often/all the time)

SECTION G

Please think about your health, including your sleep, eating and exercising habits.

24. Have you ever undergone a heart operation or procedure? Yes No

25. Have you been told by a healthcare provider that you have any of the following conditions:

1. A sleep disorder (for example, obstructive sleep apnea, insomnia, narcolepsy) Yes No

If yes:

• Do you take medication for your sleep disorder? Yes No

• If yes, what __________________________

2. Heart Disease Yes No

If yes:

1. Do you take medicine for your heart disease? Yes No

2. If yes, what __________________________

3. High Blood Pressure Yes No

If yes:

1. Do you take medicine for your high blood pressure, including diuretics (fluid pills)? Yes No

2. If yes, what __________________________

4. Stroke Yes No

If yes:

1. How long ago did you have your stroke? _____ months ______ weeks ______ days

2. Do you take medicine for your stroke? Yes No

3. If yes, what __________________________

5. Diabetes Yes No

If yes:

1. Do you take medicine for your diabetes? Yes No

2. If yes, what __________________________

6. Heartburn Yes No

If yes:

1. Do you take medicine for heartburn? Yes No

2. If yes, what __________________________

7. Emphysema Yes No

If yes:

1. Do you take medicine for your emphysema? Yes No

2. If yes, what __________________________

8. Asthma Yes No

If yes:

1. Do you take medicine (e.g., inhalers) for your asthma? Yes No

2. If yes, what __________________________

9. Depression, anxiety, schizophrenia, or personality disorders? Yes No

If yes:

1. Do you take medicine for your mood disorder or personality disorder? Yes No

2. If yes, what __________________________

10. ADHD (Attention-deficit/hyperactivity disorder)? Yes No

If yes:

1. Do you take medicine for your ADHD? Yes No

2. If yes, what __________________________

Medications

26. Do you take any other medicines not included above? Yes No If yes, what medicine _____________________

Health and Sleep Habits

27. In a typical week, how many minutes of exercise do you get? _________ minutes total

28. In the past 30 days, for about how many of those days have you felt you did not get enough rest or sleep? ____ days

29. In a typical day, how many hours of sleep do you get? ___________ hours

30. In a typical day, how many times do you get up to use the restroom while sleeping? ____times

31. Do you have a sleep routine?

Yes No

While getting ready to sleep:

31a. Do you adjust the lighting? Yes No

31b. Do you adjust the temperature? Yes No

31c. Do you adjust your TV viewing? Yes No

31d. Do you make any other adjustments? Yes No

Please specify: _________________________________

32. Considering your work schedule, how many days did you sleep in a bed in the last 30 days? __________ days

32a. How many times did you sleep (not nap) in your car/taxi in the last 30 days? ________ days

33. How many people are living in your household, including yourself? _________

33a. How many of these are children age 18 and younger? _________

34. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

_____ days per week _____ days in the past 30 days _____None (Go to Q)

35. One drink is a 12-oz beer, a 5-ounce glass of wine, or a drink with one shot (1.5 oz) of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on average?

_____ No. of drinks/day

36. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on an occasion?

___No. of times

37. During the past 30 days, what is the largest number of drinks you had on any occasion?

____ No. of drinks

38. Have you smoked at least 100 cigarettes in your entire life?

___ Yes _____ No

39. Do you now smoke cigarettes every day, some days, or not at all?

___ Every day ____Some days ____ Not at all

40. When you are driving and getting drowsy, what do you do to try to stay alert? Check all that apply.

____ pull over and take a nap

____ pull over and rest

____ get out of the car and walk around

____ drink coffee

____ drink something with caffeine other than coffee – please specify: _________

____ roll down the window

____ turn up the radio

____ eat something with sugar

____change driving position (e.g., move seat forward, sit more upright)

____ take pills – please specify: _____________

____ Other, please specify: ______________

40a. How frequently do you do these things to stay alert?

____ times per shift

____ times per workweek

STOP-Bang Questionnaire

41. Do you snore loudly? (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)

Yes-----1 No-------2

41. Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving)?

Yes-----1 No-------2

41. Has anyone observed you stop breathing or choking/gasping during your sleep?

Yes-----1 No-------2

41. Do you have or are being treated for high blood pressure?

Yes-----1 No-------2

41. Is your Body Mass Index more than 35 kg/m²?

Yes-----1 No-------2

41. Are you older than 50 years old?

Yes-----1 No-------2

41. Is your neck size large with a circumference of 40cm or 16 inches or greater? (Measured around Adams apple)

Yes-----1 No-------2

41. Is your gender male?

Yes-----1 No-------2

Sleepiness

In your current, usual way of life, how likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired? Even if you haven't done some of these things recently, try to work out how they would affect you. It is important that you answer each question as best you can.

Using the following scale, choose the most appropriate number for each situation.

Top of Form

	No chance	Slight chance	Moderate chance	High chance
Situation
49. Sitting and reading	0	1	2	3
50. Watching TV	0	1	2	3
51. Sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)	0	1	2	3
52. As a passenger in a vehicle for an hour or so without stopping for a break	0	1	2	3
53. Lying down to rest when circumstances permit	0	1	2	3
54. Sitting and talking to someone	0	1	2	3
55. Sitting quietly after a meal without alcohol	0	1	2	3
56. In a vehicle, while stopped for a few minutes in traffic or at a light	0	1	2	3

Now think about the majority of days and nights during the past month.

57. What time have you usually gone to bed after your work shift? ___:___ hrs pm/am

58. How long (in minutes) has it usually taken you to fall asleep when going to bed after your work shift? __________ number of minutes

59. What time have you usually gotten up after your main sleep period during a work week ?

___:___ hrs pm/am

60. On average how many hours of actual sleep did you get during your main sleep period? ________ hours

How often have you had trouble sleeping because you….

	Not during the past month	Less than once a week	Once or twice a week	Three or more times a week
61. Cannot get to sleep within 30 minutes?	1	2	3	4
62. Wake up in the middle of your sleep between work shifts?	1	2	3	4
63. Have to get up to use the bathroom?	1	2	3	4
64. Cannot breathe comfortably?	1	2	3	4
65. Cough or snore loudly?	1	2	3	4
66. Feel too cold?	1	2	3	4
67. Feel too hot?	1	2	3	4
68. Had bad dreams?	1	2	3	4
69. Have pain?	1	2	3	4
70. Have any other reason(s)? Please describe: ______________________	1	2	3	4

Still thinking about during the past month…

71. How would you rate your sleep quality overall?

Very good ________1

Fairly good _______2

Fairly bad_________3

Very bad__________4

72. How often have you taken medicine to help you sleep (prescribed or "over the counter")?

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

73. How often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

74. How much of a problem has it been for you to keep up enough enthusiasm to get things done?

No problem at all __________

Only a very slight problem __________

Somewhat of a problem __________

A very big problem __________

75. Do you have a bed partner or roommate?

No bed partner or room mate __________

Partner/roommate in other room __________

Partner in same room, but not same bed __________

Partner in same bed __________

76. If you have a roommate or bed partner, how often has he/she told you in the past month you have had . . .

a) Loud snoring

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

b) Long pauses between breaths while asleep

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

c) Legs twitching or jerking while you sleep

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

d) Episodes of disorientation or confusion during sleep

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

e) Other restlessness while you sleep; please describe__________________________________

___________________________________________________________________________

Not during the past month____ Less than once a week____ Once or twice a week___ Three or more times a week___

© 1989, University of Pittsburgh. All rights reserved. Developed by Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R., and Kupfer, D.J. of the University of Pittsburgh using National Institute of Mental Health Funding.

Fatigue

77. The company I drive for has written policies about obstructive sleep apnea management.

Yes……….1 No……..2 Don’t know……..3

78. How much of a problem is fatigue to you personally in your job?

A major problem……….1 A minor problem………..2 Not a problem at all…………3

79. How much of a problem is fatigue to other drivers in the company you drive for?

A major problem……….1 A minor problem………..2 Not a problem at all…………3

80. What main difficulties do you have in avoiding driving while drowsy? (Mark any that apply to you).

1. Not enough time between rides to take breaks…………………………..1

2. Lack of available places to stop to take a break when I need it……….…2

3. Lack of safe places to stop to take a break when I need it………….……3

4. Not enough hours to sleep during my main sleep time…………………..4

5. Difficulty sleeping well at home……………………………………........5

6. Difficulty sleeping well in my car…………………………………….….6

7. Never have had the difficulty of driving while drowsy………………7

8. Cannot afford to take breaks………………………………………….8

9. Other—Please specify:________________________

81. How well do you think other drivers in your company avoid drowsy driving?

1. Extremely poorly………….1

2. Quite poorly……………….2

3. Quite well…………………3

4. Extremely well……………4

5. Don't have an opinion…….5

82. How well do you think you avoid drowsy driving?

1. Extremely poorly………….1

2. Quite poorly……………….2

3. Quite well…………………3

4. Extremely well……………4

5. Don’t have an opinion……5

83. In general, how would you rate your health today?

a. Poor…………1

b. Fair…………..2

c. Good…………3

d. Very Good…..4

e. Excellent…….5

Section H – Demographics

The following questions are about you.

1. In the past year (12 months) how many motor vehicle crashes have you been involved in not related to your job as a taxicab driver?

______ number of crashes

2. Are you of Hispanic or Latino origin?

No………..0 Yes……….1

3. What is your race? Show driver card with options and let driver check all that apply.

American Indian or Alaska Native....……...1

Asian……………………………………..…..2

Black or African American…………...…….3

Native Hawaiian or Other Pacific Islander……………………………...............4

White………………………………...…….....5

4. What is your age today? ______ years

4a. Pregnant? No……1 Yes……..2

5. What sex were you assigned at birth, on your original birth certificate?

1. Male……..1 Female…….2

5a. How do you describe your gender identity?

Male……………………………………..1

Female………………………………….2

Male-to-female transgender (MTF)….3

Female-to-male transgender (FTM)…4

Other gender identify (specify) ………5

6. Were you born in the US?

No………0 Yes…….1 Go to Q8

7a. What is the name of your country of birth/origin?

_____________________________________

7b. What was your primary occupation before you came to the US?

_____________________________________

7c. How many years have you lived in the

U.S.?

________ years

7d. What is the primary language spoken in your home?

_________________

8. What is the highest level of formal education you have completed?

Grade school…………………………1

Secondary school……………….…..2

Some high school………………..….3

High school diploma……………...…4

Technical/trade school……….……..5

Associate’s degree………………..…6

Bachelor’s degree…….....................7

Master’s degree…………………......8

Professional degree..…………….…9

Doctoral degree………………….…10

9. What is your marital status?

Married……………..…………………..1

Not married, but in a long-term relationship…………………………....2 Separated……………………..………3

Divorced………………….……………4

Widowed……………….……………...5

Single……………….………………….6

Refused……….………………………96

10. What religion do you practice?

None……………….0

Buddhism……..…..1

Islam…..…………..2

Christianity…..……3

Judaism….………..4

Sikhism……..……..5

Hinduism…………..6

Other……..………..7 Specify______

Refused…….…….96

Section I – Mood

The following questions are about you. Which best describes how often you felt or behaved this way DURING THE PAST 2 WEEKS.

0 Not at all

1 Several days

2 More than half the days

3 Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems?

1.Little interest or pleasure in doing things

2.Feeling down, depressed or hopeless

3.Feeling nervous, anxious or on edge

4.Not being able to stop or control worrying

The following questions are about your participation in this survey.

1. Why did you participate in the survey?

2. Did you understand that your participation in the survey was voluntary?

No………0, Why not? ___________________

Yes…….1

3. Did you understand you could stop the survey at any time?

No………0, Why not? ___________________

Yes…….1

4. If you have any questions or concerns about the survey, do you know who you can contact?

No………0, Why not? ___________________

Yes…….1

5. Did you feel that you could be completely honest in your responses in this survey?

No………0, Why not? ___________________

Yes…….1

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