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SECTION FAM: FAMILY OF ORIGIN/HOME

Now I would like to talk about who you have lived with in your life and ask you some questions about these people.

 

FAM1. Who were the people that you lived with before starting first grade, that is until about age 6?

Please tell me the relationships.

CODE ALL THAT APPLY

a.

How many ( ) did you live with during this time?

FAM2. Who were the main people who took care of you before elementary school?

CODE ALL THAT APPLY

a.

How many ( ) took care of you during this time?

FAM3. Who did you live with during elementary school, that is about ages 6 through 12?

CODE ALL THAT APPLY

a.

How many ( ) did you live with during this time?

FAM4. Who were the main people who took care of you during elementary school?

CODE ALL THAT APPLY

a.

How many ( ) took care of you during this time?

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

BABYSITTER 29

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________

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MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

BABYSITTER 29

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________

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MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

BABYSITTER 29

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:__________________

__________________

OTHER NON-RELATIVE 37

SPECIFY:__________________

__________________

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MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

BABYSITTER 29

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:__________________

__________________

OTHER NON-RELATIVE 37

SPECIFY:__________________

__________________

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FAM5. Who were the people that you lived with during middle school and high school, that is about ages 13 through 18?

CODE ALL THAT APPLY

a.

How many ( ) did you live with during this time?

FAM6. Who were the main people who took care of you during middle school and high school?

CODE ALL THAT APPLY

a.

How many ( ) took care of you during this time?

FAM7. Who have you lived with since high school, about age 18?

CODE ALL THAT APPLY

a.

How many ( ) did you live with during this time?

FAM8. Who were the main people who have taken care of you since high school?

CODE ALL THAT APPLY

a.

How many ( ) took care of you during this time?

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________

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MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________

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MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:__________________

__________________

OTHER NON-RELATIVE 37

SPECIFY:__________________

__________________

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MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:__________________

__________________

OTHER NON-RELATIVE 37

SPECIFY:__________________

__________________

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FAM9. All in all, how many brothers do you have, including step and half brothers?

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# OF BROTHERS

 

FAM10. All in all, how many sisters do you have, including step and half sisters?

|___|___|

# OF SISTERS

 

IF NO BROTHERS OR SISTERS AT ALL (LIVED WITH OR NOT LIVED WITH),

CODE N/A IN FAM11, ASK FAM12.

 

FAM11. Thinking about all these brothers and sisters, were you the oldest, the youngest, or in between?

OLDEST 01

YOUNGEST 02

IN BETWEEN 03

N/A 09

Now I’d like to talk about activities that people do. Thinking about all the people who took care of you while you were growing up, how many of them regularly did the following while you were growing up?

  

NONE OF THEM

VERY FEW OF THEM

A FEW OF THEM

SOME OF THEM

MANY OF THEM

ALL OF THEM

FAM12. How many of them went to religious services regularly while you were growing up? Would you say none of them, very few of them, some of them, many of them, or all of them?

1

2

3

4

5

6

FAM13. READ STEM IF NECESSARY: Thinking about all the people who took care of you while you were growing up, how many of them regularly did the following while you were growing up?

How many of them regularly had a job while you were growing up?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM14. READ STEM IF NECESSARY: Thinking about all the people who took care of you while you were growing up, how many of them regularly did the following while you were growing up?

How many of them regularly volunteered their time while you were growing up?

READ CATEGORIES IF NECESSARY

PROBE: For example: Salvation Army, retirement home or nursing home, fraternity or sororities, neighborhood beautification, soup kitchen, tutoring mentor, Big Brother or Big Sister, Boys and Girls Club, YMCA & YWCA, church organization, athletic coaching, Boy Scouts hospital volunteer, etc)?

1

2

3

4

5

6

FAM15. READ STEM IF NECESSARY: Thinking about all the people who took care of you while you were growing up, how many of them regularly did the following while you were growing up?

How many of them regularly were involved in political causes or activities?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM16. READ STEM IF NECESSARY: Thinking about all the people who took care of you while you were growing up, how many of them regularly did the following while you were growing up?

How many of them regularly attended school?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

How many of the people who took care of you while you were growing up did any of the these activities?

  

NONE OF THEM

VERY FEW OF THEM

A FEW OF THEM

SOME OF THEM

MANY OF THEM

ALL OF THEM

FAM17. How many of them used legal drugs, including alcohol, heavily while you were growing up? Would you say none of them, very few of them, some of them, many of them, or all of them?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM18. READ STEM IF NECESSARY: How many of the people who took care of you while you were growing up did any of the these activities?

How many of them used drugs such as marijuana, heroin, or cocaine while you were growing up?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM19. READ STEM IF NECESSARY: How many of the people who took care of you while you were growing up did any of the these activities?

How many of them were ever fired or laid off from a job because of behavior, attitude, or work performance?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM20. READ STEM IF NECESSARY: How many of the people who took care of you while you were growing up did any of the these activities?

How many of them were ever put in jail, arrested, or convicted of a crime, other then drunk driving?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

  

NONE OF THEM

VERY FEW OF THEM

A FEW OF THEM

SOME OF THEM

MANY OF THEM

ALL OF THEM

FAM21. With how many of them did you do things together that you both enjoyed like going to the movies, or just spending time together?

Would you say none of them, very few of them, a few of them, some of them, many of them, or all of them?

1

2

3

4

5

6

FAM22. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

With how many of them did you share warm feelings of affection while you were growing up?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM23. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

With how many of them did you share your private thoughts and feelings while you were growing up?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM24. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

How many of them spoke to you with a warm and friendly voice?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM25. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

How many of them were affectionate with you?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM26. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

How many of them enjoyed talking things over with you while you were growing up?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM27. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up...

How many of them could make you feel better when you were upset?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM28. READ STEM IF NECESSARY: Now thinking about the relationships you had with the people who took care of you while you were growing up . . .

How many of them seemed to understand your problems or worries?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

The next set of questions is about settling disagreements. There are many different ways families handle disagreements. When you were growing up and had disagreements with your caregivers, how often did any of the following things happen?

  

NEVER

RARELY

SOME-TIMES

OFTEN

MOST OF THE TIME

ALWAYS

FAM29. How often did your caregivers talk to you about the issue? Would you say never, rarely, sometimes, often, most of the time, or always?

1

2

3

4

5

6

FAM30. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers avoid talking about the issue with you?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM31. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers insult, swear, or yell at you?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM32. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers threaten to end their relationships with you?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM33. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers threaten to hit you?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM34. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers push, grab, slap, or shove you?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM35. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers threaten you with a weapon?

READ CATEGORIES IF NECESSARY

1

2

3

4

5

6

FAM36. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers hit you hard enough to cause a bruise?

READ CATEGORIES IF NECESSARY

IF "Never" GO TO FAM37.

1

2

3

4

5

6

 

FAM36a. How old were you?

CODE ALL THAT APPLY

Before elementary school, until

age 6 1

In elementary school, between

ages 6-12 2

In middle/high school, between

ages 13-18 3

Since high school, about

age 18 4

  

NEVER

RARELY

SOME-TIMES

OFTEN

MOST OF THE TIME

ALWAYS

FAM37. READ STEM IF NECESSARY: When you were growing up and had disagreements with your caregivers, how often did any of the following happen?

How often did your caregivers hit you hard enough to cause bleeding or break a bone?

READ CATEGORIES IF NECESSARY

IF "Never" GO TO FAM38.

1

2

3

4

5

6

 

FAM37a. How old were you?

CODE ALL THAT APPLY

Before elementary school, until

age 6 1

In elementary school, between

ages 6-12 2

In middle/high school, between

ages 13-18 3

Since high school, about

age 18 4

 

FAM*1. Have any of your caregivers ever had two weeks or more of feeling sad, blue, or depressed or lost all interest or pleasure in things?

YES 01

NO (GO TO FAM*2) 02

DON’T KNOW (GO TO FAM*2) 03

 

FAM*1a. What is that person’s relationship to you?

CODE UP TO THREE PEOPLE

PERSON 1: |___|___|

PERSON 2: |___|___|

PERSON 3: |___|___|

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________
 

FOR EACH PERSON IN FAM*1a, ASK FAM*1b AND FAM*1c

 

FAM*1b_p1. Was (he/she) only depressed during a physical illness or mourning after a death?

YES 01

NO 02

DON’T KNOW 03

 

FAM*1c_p1. When did (he/she) last have a period of two weeks or more of feeling depressed?

|___|___| |___|___|___|___|

MONTH YEAR

 

FAM*1b_p2. Was (he/she) only depressed during a physical illness or mourning after a death?

YES 01

NO 02

DON’T KNOW 03

 

FAM*1c_p2. When did (he/she) last have a period of two weeks or more of feeling depressed?

|___|___| |___|___|___|___|

MONTH YEAR

 

FAM*1b_p3. Was (he/she) only depressed during a physical illness or mourning after a death?

YES 01

NO 02

DON’T KNOW 03

 

FAM*1c_p3. When did (he/she) last have a period of two weeks or more of feeling depressed?

|___|___| |___|___|___|___|

MONTH YEAR

 

FAM*2. Have any of your caregivers ever been bothered by thoughts about killing himself/herself?

YES 01

NO (GO TO FAM*3) 02

DON’T KNOW (GO TO FAM*3) 03

 

FAM*2a. What is that person(s) relationship to you?

CODE UP TO THREE PEOPLE

PERSON 1: |___|___|

PERSON 2: |___|___|

PERSON 3: |___|___|

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________
 

FAM*3. Have any of your caregivers ever threatened to commit suicide?

Yes 01

No (GO TO FAM*4) 02

Don’t Know (GO TO FAM*4) 03

 

FAM*3a. What is that person’s relationship to you?

CODE UP TO THREE PEOPLE

PERSON 1: |___|___|

PERSON 2: |___|___|

PERSON 3: |___|___|

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________
 

FAM*4. Have any of your caregivers ever hurt (himself/herself), but was not trying to kill (himself/herself)?

YES 01

NO (GO TO FAM*5) 02

DON’T KNOW (GO TO FAM*5) 03

 

FAM*4a. What is that person’s relationship to you?

CODE UP TO THREE PEOPLE

PERSON 1: |___|___|

PERSON 2: |___|___|

PERSON 3: |___|___|

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________
 

FAM*5. Have any of your caregivers ever tried to commit suicide?

YES 01

NO (GO TO FAM*6) 02

DON’T KNOW (GO TO FAM*6) 03

 

FAM*5a. What is that person’s relationship to you?

CODE UP TO THREE PEOPLE

PERSON 1: |___|___|

PERSON 2: |___|___|

PERSON 3: |___|___|

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________
 

FOR EACH PERSON IN FAM*5a, ASK FAM*5b AND FAM*5c

 

FAM*5b_p1. Did (he/she) actually kill (himself/herself)?

YES 01

NO 02

 

FAM*5c_p1. Did (he/she) try to kill (himself/herself) in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*5b_p2. Did (he/she) actually kill (himself/herself)?

YES 01

NO 02

 

FAM*5c_p2. Did (he/she) try to kill (himself/herself) in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*5b_p3. Did (he/she) actually kill (himself/herself)?

YES 01

NO 02

 

FAM*5c_p3. Did (he/she) try to kill (himself/herself) in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*6. Have any of your caregivers ever had a serious mental illness, emotional problem, or nervous breakdown?

YES 01

NO (GO TO FAM*7) 02

DON’T KNOW (GO TO FAM*7) 03

PERSON 3: |___|___|

FOR EACH PERSON IN FAM*6a, ASK FAM*6b

 

FAM*6b_p1. Did (he/she) have any of these problems in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*6b_p2. Did (he/she) have any of these problems in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*6b_p3. Did (he/she) have any of these problems in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*7. Have any of your caregivers ever seen a psychiatrist, psychologist, social worker, doctor, or other health professional for a psychological or emotional problem, or a drug or alcohol problem?

YES 01

NO (GO TO FAM38) 02

DON’T KNOW (GO TO FAM38) 03

 

FAM*7a. What is that person’s relationship to you?

CODE UP TO THREE PEOPLE

PERSON 1: |___|___|

PERSON 2: |___|___|

PERSON 3: |___|___|

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

SPECIFY:_________________

_________________

OTHER NON-RELATIVE 37

SPECIFY:_________________

_________________
 

FOR EACH PERSON IN FAM*7a, ASK FAM*7b AND FAM*7c

 

FAM*7b_p1. Has (he/she) been seen by a health professional for a psychological or emotional problem, or a drug or alcohol problem in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*7c_p1. Has (he/she) ever stayed overnight in a hospital or treatment facility because of a psychological or emotional problem, or a drug or alcohol problem?

YES 01

NO 02

DON’T KNOW 03

 

FAM*7b_p2. Has (he/she) been seen by a health professional for a psychological or emotional problem, or a drug or alcohol problem in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*7c_p2. Has (he/she) ever stayed overnight in a hospital or treatment facility because of a psychological or emotional problem, or a drug or alcohol problem?

YES 01

NO 02

DON’T KNOW 03

 

FAM*7b_p3. Has (he/she) been seen by a health professional for a psychological or emotional problem, or a drug or alcohol problem in the past year?

YES 01

NO 02

DON’T KNOW 03

 

FAM*7c_p3. Has (he/she) ever stayed overnight in a hospital or treatment facility because of a psychological or emotional problem, or a drug or alcohol problem?

YES 01

NO 02

DON’T KNOW 03

The next questions are about the resources you had while you were growing up.

 

FAM38. Who provided the main financial support for your family or household while you were growing up?

IF YA OFFERS MORE THAN ONE PERSON, PROBE:

Which one earned the most money?

MOTHER (BIOLOGICAL) 01

FATHER (BIOLOGICAL) 02

STEP-MOTHER 03

STEP-FATHER 04

ADOPTIVE MOTHER 05

ADOPTIVE FATHER 06

FOSTER MOTHER 07

FOSTER FATHER 08

FULL SISTER 09

FULL BROTHER 10

HALF SISTER 11

HALF BROTHER 12

STEP SISTER 13

STEP BROTHER 14

FOSTER SISTER 15

FOSTER BROTHER 16

ADOPTIVE SISTER 17

ADOPTIVE BROTHER 18

AUNT 19

UNCLE 20

MATERNAL GRANDMOTHER 21

MATERNAL GRANDFATHER 22

PATERNAL GRANDMOTHER 23

PATERNAL GRANDFATHER 24

COUSIN 25

GIRLFRIEND 26

BOYFRIEND 27

SPOUSE 28

BABYSITTER 29

SON 30

DAUGHTER 31

SELF 32

FRIEND 33

ROOMMATE 34

PARENTS 35

OTHER BLOOD RELATIVE 36

OTHER NON-RELATIVE 37

SELF 38

DON’T KNOW D

REFUSED R

 

FAM38b. What kind of work did (he/she) do for a living most of the time while you were growing up? That is, what was (his/her) main occupation?

 

________________________________

TITLE

 

FAM38c. Can you tell me a little more about what (he/she) did on (his/her) job?

 

________________________________

________________________________

________________________________

________________________________

 

FAM38d. What was the highest level of education or grade completed by [FILL FROM FAM38]?

IF RESPONDENT SAYS COLLEGE, PROBE: Would you say junior college towards an associates degree, some college towards a bachelor’s degree, some graduate school, no degree, master’s degree, Ph.D. or other doctoral degree, or professional degree (such as a law or medical degree)?

KINDERGARTEN 01

FIRST GRADE 02

SECOND GRADE 03

THIRD GRADE 04

FOURTH GRADE 05

FIFTH GRADE 06

SIXTH GRADE 07

SEVENTH GRADE 08

EIGHTH GRADE 09

NINTH GRADE 10

TENTH GRADE 11

ELEVENTH GRADE 12

TWELFTH GRADE 13

GED 14

JUNIOR COLLEGE TOWARDS AN

ASSOCIATES DEGREE 15

SOME COLLEGE TOWARDS A BACHELORS

DEGREE 16

VOCATIONAL/TECHNICAL/BUSINESS 17

ASSOCIATES DEGREE 18

BACHELORS DEGREE 20

SOME GRADUATE SCHOOL, NO DEGREE 21

MASTERS 22

PHD OR OTHER DOCTORAL DEGREE 23

PROFESSIONAL (LAW, MEDICAL) 24

 

FAM41. When you were growing up, how much of the time did anyone in your household receive benefits or financial assistance from the government such as AFDC, food stamps, free or reduced lunch, or public housing?

Would you say never, rarely, sometimes, often, most of the time, or always?

NEVER 01

RARELY 02

SOMETIMES 03

OFTEN 04

MOST OF THE TIME 05

ALWAYS 06

 

FAM42. The next questions are about your life now. How much would you say that the people who took care of you while you were growing up keep tabs on where you are and who you are with now?

Would you say not at all, very little, a little, somewhat, pretty much, or very much?

NOT AT ALL 01

VERY LITTLE 02

A LITTLE 03

SOMEWHAT 04

PRETTY MUCH 05

VERY MUCH 06

 

FAM43. How much would you say they set and enforce rules for you now?

PROBE: Would you say not at all, very little, a little, somewhat, pretty much, or very much?

NOT AT ALL 01

VERY LITTLE 02

A LITTLE 03

SOMEWHAT 04

PRETTY MUCH 05

VERY MUCH 06

 

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