SECTION FAM: FAMILY OF ORIGIN/HOME
|___|___| : |___|___|
Time
Now I would like to talk about who you have lived with in your life and ask you some questions about these people.
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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:_________________ _________________ |
|___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |
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:_________________ _________________ |
|___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |
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:__________________ __________________ |
|___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |
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:_________________ _________________ |
|___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |
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:_________________ _________________ |
|___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |
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:__________________ __________________ |
|___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |___|___| |
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? |
|___|___| # OF BROTHERS |
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FAM10. All in all, how many sisters do you have, including step and half sisters? |
|___|___| # OF SISTERS |
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IF NO BROTHERS OR SISTERS AT ALL (LIVED WITH OR NOT LIVED WITH), CODE N/A IN FAM11, ASK FAM12. |
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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?
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NONE OF THEM |
VERY FEW OF THEM |
A FEW OF THEM |
SOME OF THEM |
MANY OF THEM |
ALL OF THEM |
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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 |
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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 |
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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 |
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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 |
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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?
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NONE OF THEM |
VERY FEW OF THEM |
A FEW OF THEM |
SOME OF THEM |
MANY OF THEM |
ALL OF THEM |
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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 |
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2 |
3 |
4 |
5 |
6 |
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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 |
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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 |
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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 . . .
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NONE OF THEM |
VERY FEW OF THEM |
A FEW OF THEM |
SOME OF THEM |
MANY OF THEM |
ALL OF THEM |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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2 |
3 |
4 |
5 |
6 |
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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?
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NEVER |
RARELY |
SOME-TIMES |
OFTEN |
MOST OF THE TIME |
ALWAYS |
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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 |
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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 |
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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 |
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2 |
3 |
4 |
5 |
6 |
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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 |
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2 |
3 |
4 |
5 |
6 |
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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 |
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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 |
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2 |
3 |
4 |
5 |
6 |
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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 |
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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 |
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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 |
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NEVER |
RARELY |
SOME-TIMES |
OFTEN |
MOST OF THE TIME |
ALWAYS |
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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 |
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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 |
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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 |
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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:_________________ _________________ |
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FOR EACH PERSON IN FAM*1a, ASK FAM*1b AND FAM*1c |
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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 |
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FAM*1c_p1. When did (he/she) last have a period of two weeks or more of feeling depressed? |
|___|___| |___|___|___|___| MONTH YEAR |
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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 |
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FAM*1c_p2. When did (he/she) last have a period of two weeks or more of feeling depressed? |
|___|___| |___|___|___|___| MONTH YEAR |
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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 |
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FAM*1c_p3. When did (he/she) last have a period of two weeks or more of feeling depressed? |
|___|___| |___|___|___|___| MONTH YEAR |
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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 |
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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:_________________ _________________ |
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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 |
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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:_________________ _________________ |
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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 |
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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:_________________ _________________ |
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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 |
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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:_________________ _________________ |
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FOR EACH PERSON IN FAM*5a, ASK FAM*5b AND FAM*5c |
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FAM*5b_p1. Did (he/she) actually kill (himself/herself)? |
YES 01
NO 02 |
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FAM*5c_p1. Did (he/she) try to kill (himself/herself) in the past year? |
YES 01
NO 02 DON’T KNOW 03 |
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FAM*5b_p2. Did (he/she) actually kill (himself/herself)? |
YES 01
NO 02 |
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FAM*5c_p2. Did (he/she) try to kill (himself/herself) in the past year? |
YES 01
NO 02 DON’T KNOW 03 |
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FAM*5b_p3. Did (he/she) actually kill (himself/herself)? |
YES 01
NO 02 |
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FAM*5c_p3. Did (he/she) try to kill (himself/herself) in the past year? |
YES 01
NO 02 DON’T KNOW 03 |
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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: |___|___|
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FOR EACH PERSON IN FAM*6a, ASK FAM*6b |
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FAM*6b_p1. Did (he/she) have any of these problems in the past year? |
YES 01
NO 02 DON’T KNOW 03 |
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FAM*6b_p2. Did (he/she) have any of these problems in the past year? |
YES 01
NO 02 DON’T KNOW 03 |
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FAM*6b_p3. Did (he/she) have any of these problems in the past year? |
YES 01
NO 02 DON’T KNOW 03 |
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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 |
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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:_________________ _________________ |
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FOR EACH PERSON IN FAM*7a, ASK FAM*7b AND FAM*7c |
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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 |
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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 |
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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 |
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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 |
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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 |
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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.
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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 |
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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 |
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FAM38c. Can you tell me a little more about what (he/she) did on (his/her) job? |
________________________________ ________________________________ ________________________________ ________________________________ |
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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 |
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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 |
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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 |
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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 |