1
********
IMPORTANT
********
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survey data in the files. Please do not remove the sheet yourself. If you complete the
survey, we assume that you have given your consent to use the information you provide.
THANK YOU!
• Please print your name and the address where we should mail your check:
Name: First______________________Middle______________Last_________________________
Street Address: ______________________________________ Apt. No.: _______________
City: _______________________ State: __________________ Zip Code: ______________
Telephone: (_______)__________________ Social security : ___________-_____-___________
What is today's date?
male?
Month______ Day______ Year______
Are you
female
• Has your name changed or will it change soon? If yes, please fill out the following:
former name
current name
future name
• We'd like to be able to contact you again in the future. Please print the name and
address of someone who will know where you are in the event that you move (use a
different address from your own):
Name of Contact: ____________________________________ Telephone: (____)___________
Relationship to you:
Street Address: ______________________________________
Apt. No.: ________________
City: _______________________ State: __________________ Zip Code: ________________
PLEASE READ AND SIGN !
I understand that...
• I will be asked about my plans and beliefs about things like work, family, and school.
• My participation in this project is voluntary.
• My answers will be kept confidential.
• I may skip any questions I don't want to answer.
• This survey should take me 60 to 90 minutes to finish.
• I will receive $25 when the survey arrives in your office.
- your signature
date
2
ANY QUESTIONS OR CONCERNS? Call us toll-free at (888) 285-3414.
3
TIME USE Think about the kinds of things you usually do each week. We would like to know how
much time you spend on these activities in a typical week.
(CHECK ONE LINE FOR EACH QUESTION):
About how many hours do you usually spend each week ...
doing work/job-related activities at home?
_____none
_____4-6 hours
_____1 hour or less
_____7-10 hours
_____2-3 hours
_____11-15 hours
_____16-20 hours
_____21 or more hours
spending focused time with your spouse/romantic partner/dates?
_____none
_____4-6 hours
_____16-20 hours
_____1 hour or less
_____7-10 hours
_____21 or more hours
_____2-3 hours
_____11-15 hours
spending focused time with your children?
_____none
_____4-6 hours
_____1 hour or less
_____7-10 hours
_____2-3 hours
_____11-15 hours
(check here if you have no children)
_____16-20 hours
_____21 or more hours
hanging out with close friends other than your spouse/romantic partner?
_____none
_____4-6 hours
_____16-20 hours
_____1 hour or less
_____7-10 hours
_____21 or more hours
_____2-3 hours
_____11-15 hours
doing indoor housework/chores at home?
_____none
_____4-6 hours
_____1 hour or less
_____7-10 hours
_____2-3 hours
_____11-15 hours
_____16-20 hours
_____21 or more hours
doing yard work and other outdoor chores at home?
_____none
_____4-6 hours
_____16-20 hours
_____1 hour or less
_____7-10 hours
_____21 or more hours
_____2-3 hours
_____11-15 hours
watching TV?
_____none
_____1 hour or less
_____2-3 hours
_____4-6 hours
_____7-10 hours
_____11-15 hours
doing things with your parent(s)?
_____none
_____4-6 hours
_____1 hour or less
_____7-10 hours
_____2-3 hours
_____11-15 hours
_____16-20 hours
_____21 or more hours
_____16-20 hours
_____21 or more hours
doing organized and/or competitive athletic or sports activities?
_____none
_____4-6 hours
_____16-20 hours
_____1 hour or less
_____7-10 hours
_____21 or more hours
_____2-3 hours
_____11-15 hours
exercising or doing other fitness activities?
_____none
_____4-6 hours
_____1 hour or less
_____7-10 hours
_____2-3 hours
_____11-15 hours
_____16-20 hours
_____21 or more hours
4
About how many hours do you usually spend each week ...
(CHECK ONE LINE FOR EACH QUESTION)
using a computer at home (for example: internet, AOL)?
_____none
_____4-6 hours
_____16-20 hours
_____1 hour or less
_____7-10 hours
_____21 or more hours
_____2-3 hours
_____11-15 hours
reading?
_____none
_____1 hour or less
_____2-3 hours
_____4-6 hours
_____7-10 hours
_____11-15 hours
_____16-20 hours
_____21 or more hours
doing other intellectual activities?
Please specify the activities:
_____none
_____7-10 hours
_____1 hour or less
_____11-15 hours
_____2-3 hours
_____16-20 hours
_____4-6 hours
_____21 or more hours
playing a musical instrument?
_____none
_____7-10 hours
_____1 hour or less
_____11-15 hours
_____2-3 hours
_____16-20 hours
_____4-6 hours
_____21 or more hours
working on other creative activities or hobbies? Please specify the activities:
_____none
_____7-10 hours
_____1 hour or less
_____11-15 hours
_____2-3 hours
_____16-20 hours
_____4-6 hours
_____21 or more hours
providing volunteer or community service? Please specify type of organization/what you do:
_____none
_____7-10 hours
_____1 hour or less
_____11-15 hours
_____2-3 hours
_____16-20 hours
_____4-6 hours
_____21 or more hours
participating in clubs or organizations?
_____none
_____7-10 hours
_____1 hour or less
_____11-15 hours
_____2-3 hours
_____16-20 hours
_____4-6 hours
_____21 or more hours
Please specify:
doing other leisure activities?
_____none
_____7-10 hours
_____1 hour or less
_____11-15 hours
_____2-3 hours
_____16-20 hours
_____4-6 hours
_____21 or more hours
Please specify:
In the last year, how many times did you and your spouse/partner/dates do enjoyable activities together?
(CHECK ONE)
____ Never
____ Monthly (about 12 times last year)
____ Once or twice
____ Weekly
____ 3 or 4 times last year
____ More than once a week
____ Daily
5
POLITICAL INVOLVEMENT
How would you describe your political beliefs? (CHECK ONE)
______ Very conservative
______ Conservative
______ Moderate
______ Liberal
______ Very liberal
______ Radical
______ None of the above
______ Don't know
Do you identify with a specific political party?
_____Yes
_____No
If yes, please indicate the party with which you identify most strongly (choose one):
_____Democrat
_____Republican
_____Reform
_____Libertarian
_____Green (Ralph Nader)
_____Socialist
_____Independent
_____Other (Please specify) ____________
How strongly do you identify with the party you just chose?
Not very
strongly
1
2
Somewhat
identified
3
4
5
Are you registered to vote? _____Yes
6
Very
strongly
7
_____No
Did you vote during the past election? _____Yes
_____No
If no, not voting is fairly common, and people have many different reasons for not voting. What is (are) the most
important reason(s), for you personally, for not voting in past elections?
In the last year have you been involved in a political cause or group (worked for a candidate, petition drive,
boycott)?
_____Yes
_____No
If yes, please specify what you have done:
6
COMMUNITY INVOLVEMENT
In the last year, have you participated in, or helped out, a charitable organization (gave your time or money)?
_____Yes
_____No
If yes, please specify what you have done:
In the last year, have you participated in or helped an environmental cause or group (gave your time or money)?
_____Yes
_____No
If yes, please specify what you have done:
Would you consider yourself to be politically active and/or active in your community?
_____Yes
_____No
If yes, please tell us why you are active in your community or with politics. In other words, what kinds of things
do you get out of it?
BELIEFS ABOUT THE GOVERNMENT AND SOCIETY
Please use the scale below to indicate the extent to which you agree with each statement:
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
7
_____They say that getting an education helps you get a good job, but it hasn’t worked that way for people in my family.
_____No matter how well educated you are, it’s hard for people like us to get a good job.
_____America is basically a fair society where everyone has an equal chance to get ahead.
_____We would be better off if the national government stayed out of our lives.
_____We have the ability to change the government if we don’t like what it is doing.
_____The government will do whatever it wants to, no matter what people like us feel.
_____The government doesn’t care about us ordinary people.
_____It makes me angry when I think about the conditions some people have to live in.
_____I get mad when I hear about people being treated unfairly.
_____The government doesn’t really care what people like me and my family think.
_____It is the responsibility of the community to take care of people who can’t take care of themselves.
_____Most people can be trusted.
_____People mostly look out for themselves.
_____Most people would take advantage of you if they got a chance.
7
How often did you attend religious services in the past year? Specify religion:
____ Never
____ 1-3 times
____ 4-8 times
____ About once a month
____ Once a week
____ More than once a week
How important is religion in your life? (CHECK ONE)
______ Not important
______ A little important
______ Pretty important
______ Very important
How important is spirituality in your life? (CHECK ONE)
______ Not important
______ A little important
______ Pretty important
______ Very important
VALUES
Below, you will find a list of values. Please take a minute to read through the entire list. Once you have looked over the
entire list, choose ONE value that you would consider to be MOST important to you and give it a 7. NEXT, choose ONE
value that you are most OPPOSED to or that you would consider to be LEAST important to you, and give it a 1. Once you
have rated the MOST and LEAST important values, continue using the following scale to rate the importance of the
remaining values as GUIDING PRINCIPLES IN YOUR LIFE.
Most Opposed
To My values
1
2
Not
Important
3
4
___ EQUALITY (equal opportunity for all)
___ SOCIAL POWER (control over others, dominance)
Somewhat
Important
5
6
Of Most
Importance
7
___ SOCIAL JUSTICE (correcting injustice, caring for the
weak)
___ FREEDOM (freedom of action)
___ INDEPENDENCE (self-reliance, self-sufficiency)
___ AN EXCITING LIFE (stimulating experiences)
___ LOYALTY (faithfulness to friends, one’s group)
___ WEALTH (material possessions, money)
___ AMBITION (hard work, aspirations)
___ RESPECT FOR TRADITION (preservation of timehonored customs)
___ BROADMINDEDNESS (tolerance of different ideas and
beliefs)
___ SELF-DISCIPLINE (self-restraint, resistance to
temptation)
___ DARING (sense of adventure, risk-taking)
___ A VARIED LIFE (filled with challenge, novelty, and
change)
___ OBEDIENCE (meeting obligations, duties)
___ HONORING PARENTS AND ELDERS (showing respect)
___ ENJOYING LIFE (enjoying, food, sex, leisure, etc.)
___ AUTHORITY (the right to lead or command)
___TRUE FRIENDSHIP (close, supportive friends)
___ DEVOUT (holding to religious faith and beliefs)
___ SUCCESSFUL (achieving goals)
7
Think about the last 6 months.
About how often in those 6 months did you ...
...do something you knew was dangerous just for the thrill of it?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
...damage public or private property?
_____never
_____4-6 times
_____once
_____7-10 times
_____2-3 times
_____11-20 times
_____21 or more times
...get into a physical fight?
_____never
_____4-6 times
_____once
_____7-10 times
_____2-3 times
_____11-20 times
_____21 or more times
...engage in unprotected sex?
_____never
_____4-6 times
_____once
_____7-10 times
_____2-3 times
_____11-20 times
_____21 or more times
...drive when you were drunk or high on drugs?
_____never
_____4-6 times
_____once
_____7-10 times
_____2-3 times
_____11-20 times
_____21 or more times
...ride with a driver who had too much to drink?
_____never
_____4-6 times
_____once
_____7-10 times
_____2-3 times
_____11-20 times
_____21 or more times
...use marijuana?
_____never
_____once
_____2-3 times
_____11-20 times
_____21 or more times
_____4-6 times
_____7-10 times
...use non-prescribed stimulants (i.e. cocaine, crack, crystal meth, speed, uppers, ephedra)?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
...use non-prescribed psychotropic substances (i.e. LSD, PCP, ecstasy, special K, mushrooms)?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
...use non-prescribed opiates (Heroin, Morphine, Codeine, Vicadin)?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
...use non-prescribed barbiturates (Valium, downers etc.)?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
...do something else illegal you could have been arrested for?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
8
Think about the last 6 months.
About how often in those 6 months did you ...
...use prescribed anti-depressants (Prozac, Zoloft etc.)?
_____never
_____4-6 times
_____once a week
_____once
_____7-10 times
_____2-6 times a week
_____2-3 times
_____11-20 times
_____daily
...use prescribed stimulants (Ritalin, Aderol etc.)?
_____never
_____4-6 times
_____once
_____7-10 times
_____2-3 times
_____11-20 times
_____once a week
_____2-6 times a week
_____daily
...use prescribed tranquilizers (Valium, barbiturates, etc.)?
_____never
_____4-6 times
_____once a week
_____once
_____7-10 times
_____2-6 times a week
_____2-3 times
_____11-20 times
_____daily
...drink alcohol?
_____never
_____once
_____2-3 times
_____4-6 times
_____7-10 times
_____11-20 times
_____21 or more times
...drink five or more drinks (5 glasses of beer/wine or 5 or more ounces of alcohol) at one sitting?
_____never
_____4-6 times
_____11-20 times
_____once
_____7-10 times
_____21 or more times
_____2-3 times
...get drunk?
_____never
_____once
_____2-3 times
_____4-6 times
_____7-10 times
_____11-20 times
_____21 or more times
When you drank alcohol, how often were you at a party, bar, or nightclub with friends?
Never
1
2
3
4
5
6
Always
7
When you drank alcohol, how often were you with a date or partner?
Never
1
2
3
4
5
6
Always
7
5
6
Always
7
When you drank alcohol, how often were you alone?
Never
1
2
3
4
9
For the next two questions, one drink of alcohol is equal to one beer, one glass of wine, a mixed drink, or
a shot of liquor.
When you drink, how many drinks do you usually have?
____ One drink
____ 3 or 4 drinks
____ Two drinks
____ 5 or more drinks
_____ check here if you never drink
Some people drink more on some days of the week than on other days of the week.
Thinking of the last week, how many drinks of alcohol did you have on. . .
Monday ____
Friday _____
Tuesday _____
Saturday _____
Wednesday _____
Sunday _____
Thursday _____
Have you ever been arrested for driving under the influence of alcohol?
_____never
_____once (How old were you? _____years old)
_____more than once (How old were you each time? ____years, ____years,
____years)
Have you ever been arrested for something other than driving under the influence?
_____never
_____once (How old were you? _____years old)
_____more than once (How old were you each time? ____years, ____years, ____years)
Have you ever been on probation for an offense?
_____never
_____once (How old were you? _____years old)
_____more than once (How old were you each time? ____years, ____years,
____years)
Have you ever served time in jail for an offense?
_____never
_____once (How old were you? _____years old)
_____more than once (How old were you each time? ____years, ____years,
____years)
How often do you wear a seat belt?
_____never
_____about 3/4 of the time
_____once in a while
_____almost always
_____about half the time
_____always
How often do you drive within the speed limit?
_____never
_____about 3/4 of the time
_____once in a while
_____almost always
_____about half the time
_____always
10
CIRCLE ONE NUMBER FOR EACH QUESTION BELOW.
How often do you...
Never
lose your appetite or eat
a lot when you get upset.......................................1
2
3
4
5
6
7
feel sure of who you are
(what kind of person you are) ...............................1
2
3
4
5
6
7
feel you are good at learning from your
mistakes ...............................................................1
2
3
4
5
6
7
feel very anxious about what others think
about you ..............................................................1
2
3
4
5
6
7
worry that you will not get a good
job in the future.....................................................1
2
3
4
5
6
7
feel like beating or injuring someone ....................1
2
3
4
5
6
7
feel nervous when meeting new people1 .............2
3
4
5
6
7
feel unhappy, sad, or depressed ..........................1
2
3
4
5
6
7
feel satisfied with yourself the way you are ..........1
2
3
4
5
6
7
feel shy .................................................................1
2
3
4
5
6
7
feel lonely .............................................................1
2
3
4
5
6
7
feel good about yourself .......................................1
2
3
4
5
6
7
feel you are part of a group of friends ..................1
2
3
4
5
6
7
enjoy being with other people ...............................1
2
3
4
5
6
7
feel that difficulties are piling up
so high you can't overcome them .........................1
2
3
4
5
6
7
feel capable of coping with most of your
problems...............................................................1
2
3
4
5
6
7
have a hot temper ................................................1
2
3
4
5
6
7
feel you have a lot in common with
the people around you ..........................................1
2
3
4
5
6
7
feel self-conscious when you're around
people ...................................................................1
2
3
4
5
6
7
CIRCLE ONE NUMBER FOR EACH QUESTION BELOW.
Daily
11
How often do you...
Never
avoid getting involved with others.........................1
2
3
4
5
6
Daily
7
feel you are very good at bouncing back
quickly from bad experiences ...............................1
2
3
4
5
6
7
feel tired out all of the time ...................................1
2
3
4
5
6
7
worry that you may not have enough money
to pay for things ...................................................1
2
3
4
5
6
7
feel very satisfied with your life the way it is .........1
2
3
4
5
6
7
feel discouraged about the future .........................1
2
3
4
5
6
7
keep a cool head in emergencies ........................1
2
3
4
5
6
7
act without stopping to think .................................1
2
3
4
5
6
7
give in to your impulses ........................................1
2
3
4
5
6
7
see the humor in life even when things
are not going well .................................................1
2
3
4
5
6
7
worry you might make a serious mistake .............1
2
3
4
5
6
7
have temper outbursts you can't control ..............1
2
3
4
5
6
7
feel like breaking or smashing things ...................1
2
3
4
5
6
7
have trouble fitting in with others ..........................1
2
3
4
5
6
7
feel nervous about performing in front of others
or making a presentation ......................................1
2
3
4
5
6
7
THE FOLLOWING QUESTIONS DEAL WITH ISSUES YOU MAY FIND SENSITIVE. IF THERE ARE ANY QUESTIONS
THAT YOU FEEL UNCOMFORTABLE ANSWERING, PLEASE FEEL FREE TO SKIP THEM.
How often do you...
Never
think about death—either your own,
someone else's, or death in general ....................1
Daily
2
3
4
5
6
7
feel like you want to die ........................................1
2
3
4
5
6
7
think about committing suicide .............................1
2
3
4
5
6
7
Have you ever tried to commit suicide? ___yes ___no
While interviewing for a job, speaking up in a meeting, or making a presentation, does your heart
beat faster?
12
not at all
faster
1
2
3
4
5
6
a lot
faster
7
Does the hand you write with shake when you are taking a test?
not at
it shakes
all
a lot
1
2
3
4
5
6
7
When you are talking to your boss about your performance or having an employee evaluation,
how nervous do you get?
not at
very
all nervous
nervous
1
2
3
4
5
6
7
You have just answered questions about your more recent feelings. Now we would like you to think about the
last five years. At any time during these five years…
Have you had two weeks or more during which you felt sad, blue, or depressed, or lost pleasure in things that
you usually cared about or enjoyed?
____yes ____no If so, at what age(s)? ________________________________________
If not, please go to the next page.
Please think of the two-week period when you had the most sadness and/or loss of interest in things. During that
time did the sadness and/or loss of interest usually last:
___all day long ___most of the day ___about half the day ___less than half of the day
During those two weeks, did you feel this way…
___every day ___almost every day ___less often
Thinking about those same two weeks, did you feel more tired out or low on energy than is usual for you?
____yes ____no
During those two weeks, did you gain or lose weight without trying, or did you stay the same?
___gained ___lost ___ stayed the same ___I was intentionally gaining or losing weight
About how much did you gain or lose? _____pounds
Did you have more trouble falling asleep than you usually do during those two weeks?
____yes ____no
How often did that happen? ___every night ___nearly every night ___less often
During those two weeks, did you have a lot more trouble concentrating than usual? ____yes ____no
People sometimes feel down on themselves, no good, or worthless. During that two-week period, did you feel
this way? ____yes ____no
Have you had a period of a month or more in the last five years when most of the time you felt worried, tense, or
anxious about everyday problems such as family, school, or work?
____yes ____no
If so, at what age(s)? ________________________________________
13
If not, please go to the next page.
Has that period ended or is it still going on? ____has ended _____still going on
How long is/was the longest period in the last five years you have had of feeling worried, tense, or anxious?
During that period, was (or is) your worry stronger than in other people? _____yes
Did (do) you worry most days? _____yes
_____no
_____no
Did/Do you usually worry about one particular thing, such as your job security or the failing health of a loved one,
or more than one thing?
______ one thing _____ more than one thing
Did (do) you find it hard to stop worrying? _____yes
_____no
Did/Do you ever have different worries on your mind at the same time? _____yes
_____no
How often was/is your worry so strong that you couldn’t/can’t put it out of your mind no matter how hard you
tried/try?
___often
___sometimes
___rarely ___never
How often did/do you find it difficult to control your worry?
___often
___sometimes
___rarely ___never
What sort of things did/do you mainly worry about?
When you were (are) worried or anxious,
Were you (are you) also restless? _____yes
_____no
Were you (are you) keyed up or on edge? _____yes
Were you (are you) easily tired? _____yes
_____no
_____no
Did you (do you) have difficulty keeping your mind on what you are doing? _____yes
Were you (are you) more irritable than usual? _____yes
_____no
Did you (do you) have tense, sore, or aching muscles? _____yes
_____no
Did you (do you) have trouble falling asleep or staying asleep? _____yes
_____no
_____no
14
HEALTH HISTORY
Do you go for annual checkups at the doctor?
_____ yes _____ no
Do you go for annual checkups at the dentist?
_____ yes _____ no
How would you rate your overall health?
____ poor
____ fair
____ good
____ very good
____ excellent
A-1. Do you have any health conditions or disabilities that limit what you can do?
____ yes ____ no (IF NO, SKIP TO QUESTION A-2 )
IF YES, What are these health conditions or disabilities? (specify)
How much do these health conditions or disabilities keep you from doing the activities most people
routinely do?
____ not at all
____ a little
____ some
____ a lot
A-2. Have you had any major illnesses in the last four years that required medical treatment?
____ yes ____ no (IF NO, SKIP TO QUESTION A-3 )
IF YES, What illnesses? (specify)
A-3. Have you had any major accidents in the last four years that required you to go to the hospital
emergency room? ____ yes ____ no (IF NO, SKIP TO QUESTION A-4 )
IF YES, What was the accident? (specify)
A-4. Have you ever had major surgery?
____ yes ____ no (IF NO, SKIP TO QUESTION A-5 )
IF YES, For what?
A-5. Have you ever received treatment from a psychiatrist or psychologist for a psychological problem?
____ yes ____ no (IF NO, SKIP TO QUESTION A-6 )
IF YES, When, and for what?
A-6. Have you ever been in drug or alcohol treatment or rehab?
____ yes ____ no (IF NO, SKIP TO Question A-7 )
IF YES, When, and for what?
A-7. Have you ever smoked cigarettes on a regular basis? ____ yes
____ no
15
If yes, how many packs a day at your highest level? ____
A-8. Do you smoke now? ____ yes
____ no
If yes, how many packs a day?____
A-9. Have you ever used chewing tobacco on a regular basis? ____ yes
____ no
If yes, how many cans a day at your highest level? ____
A-10. Do you use chewing tobacco now? ____ yes
____ no
If yes, how many cans a day? ____
A-11. Has your mother ever smoked on a regular basis? ____ yes
A-12. Has your father ever smoked on a regular basis? ____ yes
____ no
____ no
A-13: If you ever drink beverages containing alcohol . . .
No
Yes
If yes, at
what age(s)
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt guilty or bad about your drinking?
Have you ever had a drink first thing in the morning to “steady your nerves” or
to get rid of a hangover?
Have you ever attended a meeting of Alcoholics Anonymous (AA)?
Have you ever lost friends or girlfriends/boyfriends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have family members ever expressed concern or anger about your drinking?
Have you ever been unable to remember events that took place after drinking?
Have you ever been hospitalized because of drinking?
Have you ever engaged in sex after drinking and later regretted it?
A-14. Has your mother ever gotten into trouble at work because of drinking? ____ yes
____ no
A-15. Has your mother ever had difficulties in family relationships because of drinking?
____ yes
____ no
A-16. Has your father ever gotten into trouble at work because of drinking? ____ yes
A-17. Has your father ever had difficulties in family relationships because of drinking?
____ yes
____ no
____ no
16
LIFE EVENTS
Place a check next to any of the following things that has happened to you in the past year.
Work
_____ Have you changed jobs for a better one?
_____ Promoted or had significant success at work?
_____ Conditions at work improved, not including promotion or other personal successes?
_____ Took on a greatly increased work load?
_____ Has your spouse been laid off or promoted? Which?____________________
Love and Marriage
_____ Started a love affair
_____ Engagement was broken
_____ Ended a relationship
_____ Left by partner
_____ Discovered partner’s sexual infidelity
Family
_____ Close relative died - Who?_______________________
_____ Distant relative died – Who?________________________
_____ Family member seriously ill – Who?____________________
_____ Friend died – who?__________________________
_____ Serious family argument, other than with spouse
Residence
_____ Have you moved?
If so, is the quality of your new neighborhood compared to your last one ____better
____worse?
____same
Crime and Legal Matters
_____ Have you been threatened with a knife or gun? Was anything of value taken? ____yes ____no
_____ Have you been robbed/burgled?
_____ Been involved in a lawsuit?
Social Activities
_____ Have you experienced a recent event involving a pet, and what happened?
(new pet, death, or illness)
_____ Have you won any community awards (PTA, community service), and if so, what kind?____________________
17
EDUCATION AND TRAINING INFORMATION
I. EDUCATION AND TRAINING HISTORY
1. What is the last year of school you have completed? (CHECK ONE)
_____9th grade
_____10th
_____11th
_____12th grade, no high school diploma
_____GED, no high school diploma
_____12th grade graduate with diploma
_____1 year of post-high school vocational training
_____2 years of post-high school vocational training
_____2 years of post-high school vocational training with certificate
_____1 year of college
_____2 years of college
_____2 Year College Graduate (for example, Associates Degree)
_____3 years of college
_____4 years of college
_____4 Year College Graduate (Bachelor’s degree)
_____1 year of Graduate school
_____2 years of Graduate school
_____2 year Graduate school degree completed (Master’s degree)
_____3 years of Graduate school
_____Other
2. Beginning with 1996, please list ALL of the post-high school training programs, schools, colleges, or
universities you have attended or are currently attending.
Name of Place
(School and/or Program Name)
Status
Certificate or
Attendance
Part/
degree earned?
From Mo/Yr To Mo/Yr Full-time? (ex: B.A., M.S.)
Major?
(ex: History,
Business)
Final/
Current
GPA?
_____________________________________________________________
____________________________________________________________
_____________________________________________________________
If you received a vocational training certificate or Associate’s degree, or are in a vocational training program
now, ANSWER QUESTION 3.
(If you have not received vocational training or an Associate’s degree, GO TO TOP OF PAGE 18)
3. How much do you agree or disagree with the following statements about your vocational training
experiences or Associate’s Degree? (Please use the following scale for the next set of questions. WRITE A
NUMBER ON THE LINE FOR EACH ITEM)
Strongly
Disagree
1
2
3
4
5
____ The training has provided me with the basic job-finding skills I need.
____ The training has helped me get the job I wanted.
____ The training has helped me succeed in my job.
6
Strongly
Agree
7
18
If you’ve received a Bachelor’s degree since 1996, or have attended college since
1996 but are not currently enrolled as an undergraduate student, GO TO QUESTION 4.
(If you are currently enrolled in graduate training, GO TO QUESTION 4)
(If you are currently enrolled in college, GO TO QUESTION 9 below)
(If you have not attended college, GO TO QUESTION 23, PAGE 20)
4. Please list ALL majors you considered while you were in college.
5. Did your future job plans affect the kinds of courses you took in college?
____ Yes ____ No
If yes, in what ways? __________________________________________
6. Did you participate in a job internship as a way of getting college credit?
_____Yes (Please specify type)
_____No
7. If you participated in a job internship during college, how useful do you think this internship
has been? (CIRCLE ONE)
Not at all
useful
1
2
3
4
5
6
Very
useful
7
8. How much do you agree or disagree with the following statements about your college education? (WRITE A
NUMBER ON THE LINE FOR EACH ITEM)
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
7
____ My college education provided me with the basic job-finding skills I need.
____ My college education helped me get the job I wanted.
____ My college education helped me succeed in my job.
II. PRESENT EDUCATION AND TRAINING
A. COLLEGE OR GRADUATE SCHOOL
9. Are you currently taking any undergraduate or graduate college courses?
____ Yes, undergraduate courses (GO TO QUESTION 10)
____ Yes, graduate courses (GO TO QUESTION 19, NEXT PAGE)
____ No (GO TO QUESTION 23, PAGE 20)
10. Have you decided on a college major?
____ Yes
(GO TO QUESTION 11)
____ No
(GO TO QUESTION 12)
11. What is your college major? __________________________ (if double major, please list both)
12. Please list ALL majors you have considered.
19
13. What is your current college GPA?
14. How are you funding your college education? (Check all that apply)
Scholarships/fellowships/grants
Money from spouse/partner
Money from parents/other relatives
Loans
Employment related to your degree
Employment not related to your degree
Savings
Other (Please specify):
15. Have your future job plans affected the kinds of courses you are taking in college?
____ Yes
____ No
If yes, in what ways? __________________________________________
16. How much do you agree or disagree with the following statements about your educational experiences?
(WRITE A NUMBER ON THE LINE FOR EACH ITEM)
Strongly
Strongly
Disagree
Agree
1
2
3
4
5
6
7
____ My education is providing me with the basic job-finding skills I need.
____ My education will help me get the job I want.
____ My education will help me succeed in my job.
17. Have you participated in a job internship as a way of getting college credit?
_____Yes (Please specify type)
____
_____No
(skip to Question 23)
18. If you participated in a job internship, how useful do you think this internship will be for the kind of job you
want after you finish college? (CIRCLE ONE)
Not at all
useful
1
2
3
4
5
6
Very
useful
7
IF YOU ARE NOT TAKING ANY GRADUATE COURSES, PLEASE SKIP TO QUESTION 23, next page.
19. What type of graduate program are you enrolled in?
20. When did you start this program?
21. When do you expect to finish this program?
22. How are you funding your graduate training? (Check all that apply)
Scholarships/fellowships
Money from spouse/partner
Money from parents/other relatives
Loans
Employment related to your degree program (research assistant, teaching assistant)
Employment not related to your degree program
Savings
Other (Please specify):
20
NOW GO TO QUESTION 27
B. JOB TRAINING ACTIVITIES
23. Are you involved in any vocational/technical training now?
_____Yes
_____No
If yes, what type of training?______________________________
(IF NO, GO TO QUESTION 27)
(GO TO QUESTION 24)
24. Has this training been: (CHECK ONE)
____ On the job training
____ Training outside of work, not paid for by employer
____ Training outside of work, paid for by employer
25. How many hours per week do you spend in vocational/technical training?
hours/week.
26. How much do you agree or disagree with the following statements about your vocational training
experiences? (Please use the following scale for the next set of questions. WRITE A NUMBER ON THE LINE
FOR EACH ITEM)
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
7
____ This training is providing me with the basic job-finding skills I need.
____ This training will help me get the job I want.
____ This training will help me succeed in my job.
C. MILITARY SERVICE
27. Have you ever served in any branch of the Armed Services?
____ Yes, I am in the Armed Services now.
Please specify branch:_______________________
Circle whether you are serving: full-time/part-time.
(GO TO QUESTION 28)
____ Yes, I was in the Armed Services before. Please specify branch:_______________________
Circle whether you served: full-time/part-time.
(GO TO QUESTION 28)
____ No
(IF NO, GO TO TOP OF PAGE 21)
28. How much do you agree or disagree with the following statements about your military experiences?
(WRITE A NUMBER ON THE LINE FOR EACH ITEM)
Strongly
Disagree
1
2
3
4
5
6
____ My military experience has provided me with the basic job-finding skills I need.
____ My military experience has helped me get the job I wanted.
____ My military experience has helped me succeed in my job.
Strongly
Agree
7
21
EVERYONE CONTINUE HERE:
29. Knowing what you know now, is there anything you would have done differently in terms of your past
educational and training experiences?
III. FUTURE EDUCATION AND TRAINING PLANS
Do you want to get any more education in the future? ____yes ____no (if no, skip to Question 36)
30. Ideally, how much education would you like to get in the future? (CHECK ALL THAT APPLY)
______ General Education Development (GED)
______ Vocational Training or
Training Certificate
In what field ? __________________
______ An associate arts degree
from a community college In what field ? __________________
______ A bachelor's degree
In what field ? __________________
______ A master's degree
In what field? ___________________
______ An advanced degree
What degree (e.g., a Ph.D., a law degree, an MD, etc.)? __________
In what field? ___________________
______ Other
What type of education and degree? _______________________
In what field? ___________________
31. How likely do you think it is that you will get to earn the highest degree or certificate you would like to get?
Not at all
likely
1
2
3
4
5
6
Very
likely
7
32. How much education do you expect you will actually get? (CHECK ALL THAT APPLY)
______ General Education Development (GED)
______ High School Diploma
______ Vocational Training or
Training Certificate
In what field ? __________________
______ An associate arts degree
from a community college In what field ? __________________
______ A bachelor's degree
In what field ? __________________
______ A master's degree
In what field?___________________
______ An advanced degree
What degree (e.g., a Ph.D., a law degree, an MD, etc.)? __________
In what field? ___________________
______ Other
What type of education and degree? __________In what field? ________________
33. What do you need in order to get the full amount of education you would like to have?
34. What might keep you from getting the full amount of education you would like to have?
35. How likely do you think it is that you will get a bachelor's degree from a four-year college or university?
______ (Check here if you already have one)
Not at all
likely
1
2
3
4
5
6
Very
likely
7
22
IV. JOB INFORMATION
JOB HISTORY
36. Beginning with January 1, 1996, please list ALL of the jobs you’ve had in the past four years. Please indicate
the type of work you were doing at that job. Please tell us the month and year you started and ended at each
place, and complete the rest of the information.
If you have not worked since January 1996, check here _____ and GO TO QUESTION 40.
Name of Place
Type of Work
Length of Employment
number $ earned per
From Mo/Yr To Mo/Yr of hours week when
per week you left job
Why did you leave this job?
__________________________________/_________/__________________
__________________________________/_________/__________________
__________________________________/_________/__________________
__________________________________/_________/__________________
__________________________________/_________/__________________
37. How many jobs have you had since 1996? _________
38. Since 1996, how many times have you been unemployed (and not a full-time student) for a month or more?
times (IF NONE, go to Question 40)
39. For each time you were unemployed, please indicate the date you stopped and why you stopped.
Date stopped
working
Mo/Yr
Why did you stop working?
(list 2 reasons)
(1)
Time #1
(2)
(1)
Time #2
(2)
(1)
Time #3
(2)
40. Knowing what you know now, is there anything you would have done differently in terms of your past work
experience?
23
PRESENT WORK SITUATION
41. What is your present work situation? (CHECK ALL THAT APPLY)
_____ Employed by others; part-time
_____ Employed by others; full-time
_____ Self-employed owner of own business, service, or professional practice
_____ Not employed, because in school full-time
_____ Temporarily laid off
_____ Unemployed but looking for work
_____ Unemployed but NOT looking for work
_____ On long-term sick leave
_____ On maternity leave
_____ On parental leave
_____ Permanently disabled
_____ Full-time homemaker
_____ In the military; part-time (e.g., Reserves)
_____ In the military; full-time
_____ Working, not for money (Please specify: ___________________________________)
_____ Other (If other, please explain: __________________________________________)
IF YOU ARE NOT WORKING FOR MONEY NOW, GO TO SECTION B , TOP OF PAGE 27
IF YOU ARE WORKING FOR PAY, CONTINUE HERE WITH SECTION A, QUESTION 42.
A. FOR THOSE WORKING FOR PAY...
42. Currently, what is your MAIN occupation or job? (Please be specific, for example, if you are a secretary,
also indicate the type of business; if you are in retail, indicate what you sell; if you work in child care,
indicate the age group of the children you are responsible for, etc.)
43. What kind of work do you do on this job?
44. How many hours per week do you work at this job? _____________ hours per week
45. Do you think of this job as... (CHECK ONLY ONE)
_____ a long-term job
_____ as a step in your career
_____ a short-term job (you are planning to do something else in the future)
46. Approximately how much do you earn in this job? (FILL IN ONE AMOUNT ONLY)
$________per hour
$________per week
$__________per month
$______________per year
(If you make tips, please include tips in your estimate of your weekly or monthly earnings)
24
47. Please use the following scale for the next set of questions about your current job.
(WRITE A NUMBER ON THE LINE FOR EACH ITEM)
Never
1
2
3
4
5
6
Daily
7
_____ My job allows me to use my skills and abilities.
_____ My job matches what I like to do.
_____ I am overqualified for the work that I do in this job.
_____ A person with my experience or training should be in a better job.
_____ I wonder whether my education and experience could be put to better use in another job.
_____ I have a flexible work schedule in this job.
_____ In this work, I am my own boss.
_____ There is a lot of stress and tension in this job.
_____ This job gives me opportunities for advancement.
_____ This job gives me the amount of independence I like.
_____ I really enjoy the people I work with in this job.
_____ I am expected to do things that are not formally a part of my job (like running errands for another worker).
_____ I have to work too many hours on this job.
_____ My work is pretty repetitious.
_____ My boss is a fair and honest person.
_____ My boss actively supports me in my home and family roles.
_____ My job gives me a chance to learn a lot of new things.
_____ Most of my interests are centered around my job.
_____ I have too much work to do everything well.
_____ I am unclear about what I have to do on my job.
_____ I feel drained of my energy when I get off work.
_____ I have a lot of freedom to make important decisions about what I do at work and how I do it.
_____ I feel free to disagree with my supervisor.
_____ I feel that my work is meaningful and important.
_____ I learn things that will be useful to me later in my life.
_____ My job has influenced my career choice.
_____ I admire my supervisor.
_____ This job provides good job security.
_____ I am concerned that I might lose this job.
_____ My boss helps me develop in my career.
_____ My boss is creative and flexible in helping me balance my work and family demands.
_____ People treat me disrespectfully at work.
25
48. SEXUAL HARASSMENT
A. At your current place of work, have you ever had a situation when your job benefits depended on submitting
to unwelcome sexual advances or have you ever been penalized for refusing to participate in unwelcome
sexual conduct?
_____yes
_____no
_____not sure
Who did this to you? _____Direct supervisor
Was the person a male or female?
_____Co-worker
_____male
_____other (please specify ____________)
_____female
B. In any other previous job or school setting, have you ever had a situation when your benefits/grades
depended on submitting to unwelcome sexual advances or have you ever been penalized for refusing to
participate in unwelcome sexual conduct?
_____yes
_____no
_____not sure
Who did this to you? _____Direct supervisor
Was the person a male or female?
_____Co-worker
_____male
_____other (please specify ____________)
_____female
C. In your current place of work, have you experienced unwelcome sexual advances, requests for sexual favors
or other verbal or physical conduct of a sexual nature that created an intimidating or hostile work
environment or interfered with your ability to do your work?
_____yes
_____no
_____not sure
Who did this to you? _____Direct supervisor
Was the person a male or female?
_____Co-worker
_____male
_____other (please specify ____________)
_____female
D. In any other previous job or school setting, have you experienced unwelcome sexual advances, requests for
sexual favors or other verbal or physical conduct of a sexual nature that created an intimidating or hostile
work environment or interfered with your ability to do your work?
_____yes
_____no
_____not sure
Who did this to you? _____Direct supervisor
Was the person a male or female?
_____Co-worker
_____male
_____other (please specify ____________)
_____female
E. Have you ever experienced any kind of behavior at school or work that you would consider sexual harassment
but doesn’t fit any of the situations given above?
____yes ____no ____not sure
F. Have you ever experienced any kind of unwanted sexual overtures, requests for sexual favors or other sexual
conduct that was annoying or offensive to you at school or work that you would not label sexual harassment?
_____yes _____no _____not sure
G. Have you ever reported or filed a formal complaint for sexual harassment?
_____ yes
_____ no
H. Have you ever quit a job or changed jobs because you were sexually harassed?
____ yes _____ no
26
49. Please use the following scale for the next set of statements.
(WRITE A NUMBER ON THE LINE FOR EACH ITEM)
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
7
_____ My job has helped me to get more education/training.
_____ My job has gotten in the way of getting the education/training I would like to get.
_____ I plan to return to school full-time because I do not like what I am doing at my job (if not currently enrolled full-time).
_____ I do not plan to return to school full-time because I like what I do at my job (if not currently enrolled full-time).
50. How satisfied are you with your current employment? (CIRCLE ONE)
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
51. How effective do you think you are in your job? (CIRCLE ONE)
Not at all
effective
1
2
3
4
5
6
Very
effective
7
52. Are you currently looking for a different job?
_____ Yes
_____ No
If yes, why? _______________________________________________________
53. Do you have a second job?
____ Yes
____ No (IF NO, GO TO QUESTION 68, page 29)
If yes, what type of job is it and what do you do? _______
_
54. How many hours per week do you work at your second job? __________ hours/week
55. Do you think of this job as... (CHECK ONLY ONE)
_____ a long-term job
_____ a step in your career
_____ a short-term job (you are planning to do something else in the future)
56. Approximately how much do you earn in your second job? (FILL IN ONE AMOUNT ONLY)
$________per hour
$________per week
$__________per month
PLEASE GO TO SECTION D, QUESTION 68, Page 29
$______________per year
27
B. FOR THOSE WHO ARE NOT PRESENTLY WORKING BUT ARE LOOKING FOR A JOB, CONTINUE ON THIS
PAGE, QUESTION 57.
IF YOU'RE NOT LOOKING FOR WORK GO TO PAGE 28, SECTION C, QUESTION 64.
57. What kind of job would you like to have right now? (Please be specific. For example, if you would like to be a
secretary, also indicate the type of business you'd like to work in; if you
would like to work in retail, indicate what you would like to sell; if you'd like to work with
children, indicate the age group of the children you want to be responsible for, etc.)
___________________________________________________________________________
58. What kind of work would you do on this job?
_____________________________________________________________________________
59. How much do you think you could make at this job ? (FILL IN ONE AMOUNT ONLY)
$________per hour
$________per week
$__________per month
$______________per year
60. What do you need in order to get the job you would like to have?
61. What might keep you from getting the job you would like to have?
62. What kind of work do you feel most qualified to do?
_____________________________________________________________________________
_____________________________________________________________________________
63. What have you been doing in the last four weeks to find a job? (CHECK ALL THAT APPLY)
_____ Nothing
_____ Contacted state employment agency(s) If yes, how many times in last 4 weeks?
_____ Contacted private employment agency(s)
times
_____ Contacted military recruiter
times
_____ Contacted employer(s)directly
times
_____ Contacted friends or relatives
times
_____ Placed or answered ads
times
_____ Looked in the newspaper
times
_____ Used a school employment service
times
_____ Other (SPECIFY):
PLEASE GO TO SECTION D, QUESTION 68, PAGE 29
times
28
C. THOSE WHO ARE NOT PRESENTLY WORKING AND ARE NOT LOOKING FOR A JOB...
64. Tell us the reasons you are not looking for work right now. (CHECK ALL THAT APPLY)
_____ Taking care of my children
_____ Pregnancy
_____ Own health problems, disability
_____ In school
_____ Can’t find a job
_____ Lost hope of finding a job
_____ Can’t make enough money, wouldn’t pay to work
_____ Don’t want or need to work
_____ Spouse or partner doesn’t want me to work
_____ Lack the necessary schooling, training, skills
_____ Can’t find child care
_____ Can’t afford to pay for child care
_____ Other (SPECIFY):
65. Do you plan to return to work in the future? _____yes
_____no (skip to Question 68)
If yes, when?
66. What kind of job would you like to have when you return to work?
___________________________________________________________________________
67. What kind of work do you feel most qualified to do?
_____________________________________________________________________________
_____________________________________________________________________________
29
D. JOB AND FINANCIAL QUESTIONS
68. Do you have any of the following? (PLEASE CHECK EACH ITEM BELOW)
YES
NO
A savings account or savings bonds
A bank credit card like a VISA or Mastercard in your name
A department store charge card like Sears or Penney's or other charge card in your name
Your own car, van, or truck
Health benefits or medical insurance
House (bought in what year?__________________)
69. Have you ever borrowed money from a bank? _____Yes ______No
70. Do you have a mortgage? _____Yes
______No
71. Do you have credit card debt? _____Yes ______No
72. Do you have any student loans? _____Yes
______No
73. From which of these sources have you received income over the last 12 months?
(PLEASE CHECK EITHER YES OR NO FOR EACH ITEM BELOW)
YES
NO
Income from a full or part-time job
Income from a partner or spouse
Any public assistance, such as AFDC
Social Security or Supplemental Security Income
Unemployment compensation or Workmen's Compensation
Child Support
Money from parent
Money from relative other than your parent
A large loan from a friend
Money from another source (Specify)____________________________________
74. From all the sources of income you have, please indicate your total household income by checking one box
below: (YOU CAN INCLUDE MONEY YOU RECEIVE FROM YOUR PARENTS BUT DO NOT INCLUDE YOUR
PARENTS' INCOME)
Less than $5,000
Between $70,000-$79,999
Between $5,000-9,999
Between $80,000-$89,999
Between $10,000-19,999
Between $90,000-$99,999
Between $20,000-29,999
Between $100,000-$109,999
Between $30,000-39,999
Between $110,000-$119,999
Between $40,000-49,999
Between $120,000-$129,999
Between $50,000-59,999
Between $130,000-$139,999
Between $60,000-69,999
Between $140,000-$19,999
More than $150,000
30
75. Over the past 12 months, how much difficulty have you had paying your bills?
No difficulty
at all
1
2
3
4
A great deal
of difficulty
6
7
5
76. Compared to one year ago, would you say your standard of living today is...
Much lower
than 1 year
ago
1
2
About
the same
3
4
Much higher
than 1 year
ago
6
7
5
77. How upset or worried are you because you do not have enough money to pay for things?
Not at all
upset
1
2
3
4
5
6
Very
upset
7
78. In the last 12 months, have you made any of the following adjustments because of financial need? (PLEASE
CHECK EITHER YES OR NO FOR EACH ITEM BELOW)
YES
NO
Borrowed or used credit more than you used to
Changed food shopping or eating habits to save money
Reduced household utility use
Cut back on social activities and entertainment expenses
Postponed medical or dental care
Fallen behind in paying bills
Not registered for classes
Anything else
(specify)
79. Are there people you could turn to for financial help if you needed to? ____Yes ____No
IF YES, who? (check all that apply)
_____ mother
_____ father
_____ other (who?)__________________
_____ sibling
_____ grandparent
_____ friend
_____ spouse/romantic partner
RESPONSIBILITIES
As people get older they begin to take more responsibility for themselves.
USING THE FOLLOWING SCALE, WRITE A NUMBER ON THE LINE NEXT TO EACH ITEM.
Somebody else
does this for me
all of the time
1
Somebody else
has most of this
responsibility
2
I share
this responsibility
equally
3
I have
most of this
responsibility
4
80. How much responsibility do you currently take for each of the following:
_____ earning your own living
_____ paying rent
_____ paying your other bills
_____ making sure your household runs smoothly
I am completely
responsible for this
all of the time
5
31
(FOR QUESTION 81, PLEASE WRITE A NUMBER ON THE LINE NEXT TO EACH ITEM.)
Not at all
Extremely
well
well
1
2
3
4
5
6
7
81. How well do you think you can handle each of the following:
_____ organizing your time/schedule
_____ earning your own living
_____ using your credit cards
_____ managing money
_____ making sure your household runs smoothly
82. How often do you think of yourself as an adult?
rarely
1
2
3
4
5
6
all of the time
7
83. When do you feel most like an adult?
84. Why do you feel like an adult in those situations?
85. What makes a person an adult?
E. FUTURE EXPECTATIONS NOW WE WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT WHAT YOU
EXPECT IN THE FUTURE.
PLEASE USE THE SCALE BELOW. (WRITE A NUMBER ON THE LINE NEXT TO EACH ITEM.)
Very
Very
unlikely
likely
1
2
3
4
5
6
7
86. When you think about your future, how likely do you think each of the following will be in the next 10 years?
_____you will be laid off from your job
_____you will have a job that pays well
_____you will get divorced
_____you will have difficulty supporting your family financially
_____life will turn out to be harder for you than it was for your parents
_____life will turn out to be easier for you than it was for your parents
_____you will be satisfied with what you have made of your life
87. What job would you most like to have when you are 35?
32
88. Describe what you think you would do on this job.
89. How much would you like to make at this job? (FILL IN ONE AMOUNT ONLY)
$________per hour
$________per week
$__________per month
$______________per year
90. List three reasons why you want this job.
a.
b.
c.
91. How likely is it you will have this job?
Very
unlikely
1
2
3
4
5
6
Very
likely
7
92. What do you need in order to get the job you would like to have?
93. What might keep you from getting the job you would like to have?
94. If you think you may not get the job you want most, what type of job do you think you will actually have when
you are 35?
GOALS FOR YOUR LIFE AND YOUR FUTURE (PLEASE USE THE SCALE BELOW TO RESPOND)
Not at all
important
1
2
3
4
5
6
Very
important
7
95. When you think about your life and your future, how important is it to you to
____Promote equality
____Improve race relations
____Help to stop prejudice
____Help people who are poor
____Help the less fortunate
____Provide service to your country
____Help your community (like doing volunteer work, be involved in your children’s school)
____Be actively involved in a faith-based community
We would like to know to what extent you feel you have fulfilled your expectations for yourself. Please use this
scale:
33
Not at all
1
2
3
4
5
6
Greatly exceeded
expectations
7
96. How much do you feel you have met your expectations regarding. . .
____ your education?
____ your job?
____ your financial status?
____ your relationship with your romantic partner?
____ yourself as a parent?
____ yourself as a community member?
____ yourself as a citizen?
____ yourself as a spiritual person?
YOUR GENERATION
97. When talking about certain generations, people often refer to them with nicknames that
supposedly say something about the kinds of social issues they faced and the kinds of people
that generation produced. For example, there are the children of the Great Depression, and the
60’s Generation.
Thinking about your generation as a whole, what kinds of qualities or other descriptions do you think
would BEST characterize the people of your generation? (List at least 3)
Thinking about your generation, what would you consider to be some of the most pressing
issues facing people of your generation?
What worries you the most about your generation and the future of your generation?
What would you consider to be some of the most positive characteristics of your generation as
a whole?
34
FAMILY AND FRIENDS
The next set of questions asks about your relationship with your mother and father.
Please check to whom you will be referring for the questions that have to do with relationships with parents.
(Check one line for each parent)
For “mother”
___ biological mother
___ stepmother
___ adoptive mother
___ other (please specify
___ no one; mother is deceased
For “father”
___ biological father
___ stepfather
___ adoptive father
)
___ other (please specify
___ no one; father is deceased
)
Did you live with your parents at any time in the past four years? ___yes ____no
If yes, how many months did you live with your parents? _____months
Where do you live now? (CHECK ONE)
_____ parents’ home or apartment
_____ your own house or condo
_____ college fraternity or sorority
_____ college dorm/residence hall
_____ romantic partner’s home
_____ other relative’s home
_____ an apartment
_____ rented room
_____ rented house
_____ other (please specify)___________________
How many times have you moved in the last THREE years?
times
During the months when you were not living with your parents in the past year, how often have you been in
touch with your parents through phone calls, letters, email, or visits? If your parents live apart, please answer
this question about your mother, and answer the next one about your father.
(Check one line)
_____Not applicable -- I lived with them (her) the whole time
_____Never
_____Once or twice
_____3 or 4 times last year
_____Monthly (about 12 times last year)
_____Weekly
_____More than once a week
If your father lives separately from your mother, how often have you been in touch with your father in the past
year through phone calls, letters, email, or visits? (Check one line)
_____ Not applicable -- I lived with him the whole time
_____Never
_____Once or twice
_____3 or 4 times last year
_____Monthly (about 12 times last year)
_____Weekly
35
_____More than once a week
36
During the past month when you and your mother/father have spent time talking or doing things together, how
often did your mother/father:
(Leave column blank if question does not apply in your situation)
Never
1
2
3
WRITE A NUMBER ON EACH LINE:
4
5
6
Always
7
Mother Father
Listen carefully to your point of view
Let you know s/he really cares about you
Shout or yell at you because s/he was mad at you
Respect your judgement
Ignore you when you tried to talk to him/her
Try to make you feel guilty
Act loving and affectionate toward you
Get into a fight or argument with you
Act supportive and understanding toward you
Ask you for your opinion about an important matter
Do things you asked him/her to do
In the past year, how much support did you get from your mother and father in each of these areas?
A little
1
2
3
WRITE A NUMBER ON EACH LINE:
Makes you feel worthwhile, special, and unique.
Assists you with major tasks (like moving) when you really need it.
Shares a reliable relationship with you that will last no matter what.
Has helped you to become the kind of person you want to be.
Provides significant financial assistance in times of need.
Provides money for your education or training.
Provides room and board while you obtain education or training.
Helps you in times of stress with minor chores or work.
Makes you feel like you are good at many things.
Makes you feel better when you are upset.
Makes you feel admired and respected.
Makes you feel proud of yourself.
Listens to you when you are under stress.
Will still be close to you even if you get into quarrels and fights.
4
5
Mother
6
A lot
7
Father
37
MOTHER INFLUENCE
If you needed someone to talk to about a personal problem, how willing would your mother be to
talk with you?
Not at all
Very
willing
willing
1
2
3
4
5
6
7
How much does your mother take an interest in your activities?
Not at all
1
2
3
4
5
6
My mother and I talk about my future job plans.
Never
1
2
3
4
A great deal
7
5
6
A lot
7
My mother and I talk about my future education plans.
Never
1
2
3
4
5
6
A lot
7
My mother and I talk about my future family plans.
Never
1
2
3
4
5
6
A lot
7
My mother and I talk about my personal problems.
Never
1
2
3
4
5
6
A lot
7
My mother and I talk about conflicts that might arise in the future between family and work
responsibilities.
Never
A lot
1
2
3
4
5
6
7
How satisfied are you with how supportive your mother is?
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
How much would you say your mother has influenced you?
Not at all
1
2
3
4
5
6
A great deal
7
Right now, how close do you feel to your mother?
Not at all
close
1
2
3
4
5
6
Very
close
7
Right now, how much do you admire your mother?
Not at all
1
2
3
4
5
6
A great deal
7
How much do you want to be like the kind of person your mother is when you are her age?
Not at all
A great deal
1
2
3
4
5
6
7
38
FATHER INFLUENCE
If you needed someone to talk to about a personal problem, how willing would your father
be to talk with you?
Not at all
Very
willing
willing
1
2
3
4
5
6
7
How much does your father take an interest in your activities?
Not at all
1
2
3
4
5
6
A great deal
7
My father and I talk about my future job plans.
Never
1
2
3
4
5
6
A lot
7
My father and I talk about my future education plans.
Never
1
2
3
4
5
6
A lot
7
My father and I talk about my future family plans.
Never
1
2
3
4
5
6
A lot
7
My father and I talk about my personal problems.
Never
1
2
3
4
5
6
A lot
7
My father and I talk about conflicts that might arise in the future between family and work
responsibilities.
Never
A lot
1
2
3
4
5
6
7
How satisfied are you with how supportive your father is?
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
How much would you say your father has influenced you?
Not at all
1
2
3
4
5
6
A great deal
7
Right now, how close do you feel to your father?
Not at all
close
1
2
3
4
5
6
Very
close
7
Right now, how much do you admire your father?
Not at all
1
2
3
4
5
6
A great deal
7
How much do you want to be like the kind of person your father is when you are his age?
Not at all
A great deal
1
2
3
4
5
6
7
39
FAMILY ENVIRONMENT
FOR THE FOLLOWING QUESTIONS, PLEASE THINK ABOUT YOUR PARENTS AND YOUR SIBLIINGS, AND
CIRCLE ONE NUMBER.
Our family enjoys doing things together.
never
1
2
3
4
5
a lot
7
6
Family members are supportive of each other during difficult times.
never
1
2
3
4
5
6
a lot
7
6
strongly
agree
7
Members of my family are very close and get along very well.
strongly
disagree
1
2
3
4
5
How satisfied are you with the emotional support you get from your sibling(s)?
not at all
satisfied
1
very
2
3
4
5
satisfied
7
6
Now, we would like to know how you think your parents feel about how you have done in each of these areas.
Please use this scale to answer the questions below for each of your parents.
Note: Please use “N/A” if a category does not apply to you. For example, if you are not a parent, please use “N/A” for the
last item.
Not at all
well
1
2
3
4
Mother
How well do they think you have done in…
your education?
your job?
your financial status?
your relationship with your mother?
your relationship with your father?
your relationship with your romantic partner?
how responsible you are?
the kind of person you have become?
the progress you have made toward figuring out
what you want to do as an adult?
being a parent?
5
6
Father
Very
well
7
40
CLOSEST FRIEND
The next set of questions asks about your relationship with the friend you are most likely to turn to for emotional
support. Please select your closest friend who is not your romantic partner (we ask about your romantic partner
later).
If you do not have a close friend like that, check here _____ and skip to page 41.
Is your closest friend a
woman
man?
How long have you known this person?
years
During the past month when you and your closest friend have spent time talking or doing things together, how
often did your closest friend…
Never
1
2
3
4
5
6
Always
7
____ Listen carefully to your point of view
____ Let you know s/he really cares about you
____ Shout or yell at you because s/he was mad at you
____ Ignore you when you tried to talk to him/her
____ Try to make you feel guilty
____ Act loving and affectionate toward you
____ Get into a fight or argument with you
____ Act supportive and understanding toward you
____ Ask you for your opinion about an important matter
____ Do things you asked him/her to do
In the past year, how much support did you get from your closest friend in each of these areas?
A little
1
2
3
4
____ Makes you feel worthwhile, special, and unique.
____ Assists you with major tasks (like moving) when you really need it.
____ Shares a reliable relationship with you that will last no matter what.
____ Has helped you to become the kind of person you want to be.
____ Provides significant financial assistance in times of need.
____ Provides money for your education or training.
____ Provides room and board while you obtain education or training.
____ Helps you in times of stress with minor chores or work.
____ Makes you feel like you are good at many things.
____ Makes you feel better when you are upset.
____ Makes you feel admired and respected.
____ Makes you feel proud of yourself.
____ Listens to you when you are under stress.
____ Will still be close to you even if you get into quarrels and fights.
CLOSEST FRIEND INFLUENCE
5
6
A lot
7
41
If you needed someone to talk to about a personal problem, how willing would your closest friend be
to talk with you?
Not at all
Very
willing
willing
1
2
3
4
5
6
7
My closest friend and I talk about my future job plans.
Never
1
2
3
4
6
A lot
7
My closest friend and I talk about my future education plans.
Never
1
2
3
4
5
6
A lot
7
My closest friend and I talk about my future family plans.
Never
1
2
3
4
5
6
A lot
7
My closest friend and I talk about my personal problems.
Never
1
2
3
4
5
6
A lot
7
5
My closest friend and I talk about conflicts that might arise in the future between family and work
responsibilities.
Never
A lot
1
2
3
4
5
6
7
How satisfied are you with how supportive your closest friend is?
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
How much would you say your closest friend has influenced you?
Not at all
1
2
3
4
5
6
A great deal
7
Right now, how close do you feel to your closest friend?
Not at all
close
1
2
3
4
5
6
Very
close
7
42
SEXUALITY
IN THIS SECTION, WE WOULD LIKE TO ASK YOU SOME PERSONAL QUESTIONS. WE REALIZE THAT AT THIS
TIME IN YOUR LIFE, SEX MAY BE AN IMPORTANT ISSUE FOR YOU. BECAUSE OF THIS, WE WOULD LIKE TO
KNOW WHAT ROLE SEX IS PLAYING IN YOUR LIFE. YOU MAY FIND SOME OF THESE QUESTIONS TO BE
SENSITIVE. IF THERE ARE ANY QUESTIONS THAT YOU FEEL UNCOMFORTABLE ANSWERING, PLEASE FEEL
FREE TO SKIP THEM.
How old were you the first time you had sex?
_______ years old
____check here if you have not had sex before (if you have not, SKIP TO PAGE 42 )
When you have sex, are your partners... (CHECK ONE)
____ all males
____ mostly males
____ males and females
____ mostly females
In the last four weeks, how often did you have sex? (CHECK ONE)
____ every day
____ almost every day
____ once or twice a week
____ once or twice in the past four weeks
____ not at all
In the last four weeks, what kind of birth control/safe sex method did you use (if any)?
____ None
____ Birth control pill
____ Condom or rubber
____ Withdrawal or pulling out
____ Foam, jelly, or cream only
____ Rhythm (safe period by calendar)
____ Depro Pro Vera, Norplant
____ Diaphragm with jelly or cream
____ IUD, coil, loop
____ Operation—female sterilization
____ Operation—male sterilization
____ Other (please specify) ____________
In the past four weeks, how many sexual partners have you had?
____ None
____ One person
____ Mainly one person but others as well
____ A number of persons
How satisfied are you with your sex life?
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
How often do you have sex for the following reasons? (CHECK ONE FOR EACH ITEM)
How often does it happen because you are forced into it?
never
about 3/4 of the time
once in a while
almost always
about half the time
always
How often does it happen because you are pressured into it?
never
about 3/4 of the time
once in a while
almost always
about half the time
always
____ all females
43
ROMANTIC PARTNER
The next questions ask about your relationship with your romantic partner(s). If you are married, living with
someone, or in a committed relationship, please answer these questions about that person. If you are not in a
committed relationship, please answer the questions about the person or people you are dating, or have dated in
the past year.
_____Check here if you have not dated in the past year, and skip to page 45.
During the past month when you and your spouse/partner(s)/date(s) have spent time talking or doing things
together, how often did your partner (or dates)...
Never
1
2
3
4
5
6
Always
7
____ Listen carefully to your point of view
____ Let you know s/he really cares about you
____ Shout or yell at you because s/he was mad at you
____ Ignore you when you tried to talk to him/her
____ Try to make you feel guilty
____ Act loving and affectionate toward you
____ Get into a fight or argument with you
____ Act supportive and understanding toward you
____ Ask you for your opinion about an important matter
____ Do things you asked him/her to do
____ Tell you he/she loves you
In the past year, how much support did you get from your spouse/partner(s)/date(s) in each of these areas?
A little
1
2
3
4
____ Makes you feel worthwhile, special, and unique.
____ Assists you with major tasks (like moving) when you really need it.
____ Shares a reliable relationship with you that will last no matter what.
____ Has helped you to become the kind of person you want to be.
____ Provides significant financial assistance in times of need.
____ Provides money for your education or training.
____ Provides room and board while you obtain education or training.
____ Helps you in times of stress with minor chores or work.
____ Makes you feel like you are good at many things.
____ Makes you feel better when you are upset.
____ Makes you feel admired and respected.
____ Makes you feel proud of yourself.
____ Listens to you when you are under stress.
____ Will still be close to you even if you get into quarrels and fights.
PARTNER INFLUENCE
5
6
A lot
7
44
If you needed someone to talk to about a personal problem, how willing would your
spouse/partner/dates be to talk with you?
Not at all
willing
1
2
3
4
5
6
Very
willing
7
6
A lot
7
My spouse/partner/dates and I talk about my future job plans.
Never
1
2
3
4
5
My spouse/partner/dates and I talk about my future education plans.
Never
1
2
3
4
5
6
A lot
7
6
A lot
7
6
A lot
7
My spouse/partner/dates and I talk about my future family plans.
Never
1
2
3
4
5
My spouse/partner/dates and I talk about my personal problems.
Never
1
2
3
4
5
My spouse/partner/dates and I talk about conflicts that might arise in the future between family
and work responsibilities.
Never
1
2
3
4
5
6
A lot
7
How satisfied are you with how supportive your spouse/partner/dates is/are?
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
How much would you say your spouse/partner/dates has/have influenced you?
Not at all
1
2
3
4
5
6
A great deal
7
6
Very
close
7
Right now, how close do you feel to your spouse/partner/dates?
Not at all
close
1
2
3
4
5
45
How many times in the past 12 months did your spouse, partner, or date(s)...
throw something at you?
never
once
twice
3-5 times
6-10 times
11-20 times
more than 20 times
push, grab, hit, kick, or shove you or hit you with something?
never
3-5 times
once
6-10 times
twice
11-20 times
more than 20 times
threaten you with a knife or gun?
never
once
twice
11-20 times
more than 20 times
3-5 times
6-10 times
How many times in the past 12 months did you do the following to your spouse, partner, or date(s)…
throw something at them?
never
once
twice
3-5 times
6-10 times
11-20 times
more than 20 times
push, grab, hit, kick, or shove them or hit them with something?
never
3-5 times
once
6-10 times
twice
11-20 times
more than 20 times
threaten them with a knife or gun?
never
once
twice
11-20 times
more than 20 times
3-5 times
6-10 times
46
The following questions ask about whether you have been a victim of violence. If you are uncomfortable
providing any of this information, please feel free to skip to the next page.
A. Have you ever gotten beaten up or been physically abused or attacked? (Do not include sexual assault or
rape -- we ask about those in questions B - C)
____ Yes ____ No (skip to question B)
IF YES:
once
How many times has this happened to you?
2-3 times
4 or more times
Can you tell us about the most recent time you were beaten up -How old were you the most recent time?
years old
Who did this the most recent time?
stranger
acquaintance
date/partner
relative
other (please specify _____________
Was the person a male or female? _____male
)
_____female
B. Have you ever been sexually assaulted? (Include only those assaults that did not also result in rape -- rape
experiences should be reported in Question C)
____ Yes
IF YES:
____ No (skip to question C)
How many times has this happened to you?
once
2-3 times
4 or more times
Can you tell us about the most recent time -How old were you the most recent time?
years old
Who did this the most recent time?
stranger
acquaintance
date/partner
relative
other (please specify _____________
Was the person a male or female? _____male
)
_____female
C. Have you ever been raped?
____ Yes
IF YES:
____ No (skip to the next page)
How many times has this happened to you?
once
2-3 times
4 or more times
Can you tell us about the most recent time -How old were you the most recent time?
years old
Who did this the most recent time?
stranger
acquaintance
date/partner
relative
other (please specify _____________
Was the person a male or female? _____male
_____female
)
47
ROMANTIC LIFE
We would like to ask you some questions about your romantic life. Some of you may be married, others of you
may be seriously involved with one person, others of you may be dating several people, and still others of you
may not be currently romantically involved with anyone.
We would like to ask you about your relationship with your dates, partner, or spouse. Please check the line
which best describes your current situation:
I am married (or I have had a commitment ceremony with my partner).
*How long have you BEEN MARRIED? _____ months
OR ____ years (FILL IN ONE LINE)
(GO TO PAGE 48, QUESTION a)
I am living with someone in a steady, marriage-like relationship.
*How long have you lived together? _____ months
OR ____ years (FILL IN ONE LINE)
What is your current marital/partnership status? (circle all numbers that apply)
1. Never married
2. Engaged to be married
3. Divorced (date:___________)
4. Separated (date:___________)
5. Other (Please specify ____________)
(GO TO MIDDLE OF PAGE 48, QUESTION b)
I am not living with him or her, but I have a steady, romantic relationship with one person.
*How long have you been together? _____ months
OR ____ years (FILL IN ONE LINE)
What is your current marital/partnership status? (circle all numbers that apply)
1. Never married
2. Engaged to be married
3. Divorced (date:___________)
4. Separated (date:___________)
5. Other (Please specify ____________)
(GO TO TOP OF PAGE 49, QUESTION c)
None of the above.
What is your current marital/partnership status? (circle all numbers that apply)
1. Never married
2. Divorced (date:___________)
3. Separated (date:___________)
4. Other (Please specify ____________)
(GO TO TOP OF PAGE 47)
48
THIS PAGE IS FOR PEOPLE WHO ARE NOT MARRIED, LIVING TOGETHER, OR INVOLVED IN A COMMITTED
RELATIONSHIP.
In the past four weeks, how often have you been going out or dating? (CHECK ONE)
____ every day
____ almost every day
____ once or twice a week
____ once or twice in four weeks ____ not at all
In the past four weeks, how many different people have you gone out with? (CHECK ONE)
____ None
____ One person
____ Mainly one person but others as well
____ A number of persons
When you go out, are your dates... (CHECK ONE)
____ all males
____ mostly males
____ males and females
____ mostly females
____ all females
How satisfied are you with your dating life? (CIRCLE ONE)
Not at all
satisfied
1
2
3
4
5
6
Very
satisfied
7
Do you want to be in a committed relationship right now? ____no
____yes
How important is it to you to be involved in a steady, committed relationship with one person?
Not at all
Important
1
2
3
4
5
NOW SKIP TO PAGE 53, SECTION h (Marriage Plans)
6
Very
Important
7
49
THIS SECTION IS FOR PEOPLE WHO ARE EITHER MARRIED, OR LIVING WITH SOMEONE, OR CURRENTLY
INVOLVED IN A STEADY, ROMANTIC RELATIONSHIP WITH ONE PERSON.
a. IF YOU ARE MARRIED OR HAVE HAD A COMMITMENT CEREMONY WITH YOUR PARTNER, ANSWER THESE
QUESTIONS.
In what month and year was your wedding or commitment ceremony? _____ (month) / _____ (year)
How long did you date your spouse/partner before you were married or had your ceremony?
___________ months
OR
___________ years (FILL IN ONE LINE)
Did you live together before you got married?
IF YES, for how long?
____yes ____no
___________ months
OR
___________ years (FILL IN ONE LINE)
Is this your first marriage? ____yes ____no
How good a spouse/partner do you think you are (how good at having an excellent marriage)?
not at all
extremely
good
good
1
2
3
4
5
6
7
How do you feel about being married to your partner?
very
unhappy
1
2
3
4
5
6
very
happy
7
(NOW GO TO MIDDLE OF PAGE 49, SECTION d)
*************************************************************************
b. IF YOU ARE LIVING TOGETHER BUT NOT MARRIED, ANSWER THESE QUESTIONS.
How long did you date your partner before you began living together?
___________ months
OR
___________ years (FILL IN ONE LINE)
How good a partner do you think you are (how good at having an excellent relationship)?
not at all
extremely
good
good
1
2
3
4
5
6
7
How important is it to you to be involved in a steady, committed relationship with one person?
Not at all
Important
1
2
3
4
5
6
Very
Important
7
6
Very
happy
7
How do you feel about living with your partner?
Very
unhappy
1
2
3
4
5
(NOW GO TO MIDDLE OF PAGE 49, SECTION d)
50
51
c. IF YOU ARE INVOLVED IN A STEADY RELATIONSHIP, BUT NOT LIVING TOGETHER, ANSWER THESE
QUESTIONS.
How good a partner do you think you are (how good at having an excellent relationship)?
not at all
extremely
good
good
1
2
3
4
5
6
7
How important is it to you to be involved in a steady, committed relationship with one person?
Not at all
Important
1
2
3
4
5
6
Very
Important
7
How do you feel about being involved in a steady, committed relationship with your partner? (CIRCLE ONE)
Very
Very
unhappy
happy
1
2
3
4
5
6
7
*************************************************************************
d. Please keep in mind: In the following questions we use the term "partner" to refer to your romantic
relationship, that is, the person you are living with, the person you are married to, or the person you have a
steady relationship with.
d-1. How old is your partner? ___________years old
d-2. Is your partner a ____ female
____ male
d-3. What is the highest grade in school your partner has completed?
Grade: 6 7 8 9 10 11 12
/Years of College: 1 2 3 4
/College Grad? Yes No
/Grad. school Degree:________
d-4. Was your partner employed full time for more than four months at any time in the last 12
months?
____ yes
____ no (IF NO, GO TO Question d-7)
d-5. What kind of job did your partner have in the past 12 months? Please be specific – include job title or duties
if possible.
d-6. Approximately how much does your partner earn? (FILL IN ONE AMOUNT ONLY)
$________per hour
$________per week
$__________per month
$______________per year
d-7. How likely is it that you and your partner will still be together five years from now?
Very
Very
unlikely
likely
1
2
3
4
5
6
7
d-8. If you are not yet married, how likely is it you will marry your partner?
Very
Very
unlikely
likely
1
2
3
4
5
6
7
For this set of questions, please use the following scale: (WRITE A NUMBER ON THE LINE FOR EACH ITEM)
52
Not at All
Satisfied
1
2
3
4
5
Extremely
Satisfied
6
7
d-9. How satisfied are you with these parts of your relationship?
How we communicate
My partner's attitudes about having children
How the house is kept (answer if you are living together)
The amount of influence I have over the decisions we make
Our social life
How we express affection for each other
With your relationship in general
How would your partner rate his/her satisfaction with your relationship in general?
d-10. How much do your parents approve of your partner/spouse?
Not at
all
1
2
3
4
5
6
Very
much
7
IF YOU ARE IN A RELATIONSHIP BUT NOT LIVING TOGETHER, SKIP TO QUESTION f, page 51.
IF YOU ARE LIVING TOGETHER OR MARRIED, ANSWER THESE QUESTIONS.
e. FINANCIAL ARRANGEMENTS
e-1. Who brings in more money to the household—you, or your partner? (Circle one)
1. My partner brings in all the income
2. My partner brings in most of the income
3. We bring in the same amount of income
4. I bring in most of the income
5. I bring in all of the income
e-2. In your household, who controls the decisions about how household income is spent?
(Circle one)
1. You, all of the time
2. You, most of the time
3. Both you and your spouse/partner equally
4. Your spouse/partner most of the time
5. Your spouse/partner all the time
e-3. Do you and your spouse/partner have a joint checking and/or savings account?
____Yes
____No
e-4. Do you have an individual checking and/or savings account? ____Yes
____No
e-5. Does your partner have an individual checking and/or savings account? ____Yes ____No
f. TIME SPENT TOGETHER
53
Do you typically do activities related to... (Circle one)
Things that
you are more
interested in
1
2
Things that both
of you are
interested in
equally
4
3
5
6
Things that your
partner is more
interested in
7
On the average, how many evenings a week do both you and your partner spend together?
0
1
2
3
4
5
6
7
(Circle one)
During a typical week, how many days do you and your partner have dinner together?
0
1
2
3
4
5
6
7
(Circle one)
Would you prefer to spend more or less time with your partner?
Much
less
1
2
3
The
same
4
5
6
Much
more
7
Sometimes couples experience serious problems in their relationship and have thoughts of ending their
relationship. Even people who get along quite well with their partner sometimes wonder whether their
relationship is working out.
Have you ever thought your relationship might be in trouble? ____ yes ____ no
Has the thought of separating crossed your mind? ____ yes ____ no
Have you discussed separating from your partner with a close friend? ____ yes ____ no
Have you or your partner ever seriously suggested the idea of ending your relationship?
____ yes ____ no
How likely is it you could find another good partner if you and your partner separated?
Very
unlikely
1
2
3
4
5
6
Very
likely
7
Even when there are problems in my relationship, it is better than being alone.
Strongly
disagree
1
2
3
4
5
6
Strongly
agree
7
How much do you and your partner get out of your relationship?
My partner gets
much more
1
2
3
We get
the same
4
5
I get
much more
6
7
If your relationship with your partner failed, how easily could you find someone else you'd like to be with?
Not at all
Very
easily
easily
1
2
3
4
5
6
7
IF YOU ARE IN A STEADY RELATIONSHIP OR LIVING TOGETHER, SKIP TO QUESTION g BELOW
54
IF YOU ARE MARRIED, ANSWER THESE QUESTIONS.
Have you and your partner talked about consulting a counselor or therapist about a possible divorce or
separation? ____ yes ____ no
Have you and your partner talked about consulting an attorney about a possible divorce or separation? ____
yes ____ no
How likely is it you will ever get separated/divorced?
Very
unlikely
1
2
3
4
5
6
Very
likely
7
g. My partner wants us to have children.... (CHECK ONE)
never.
some day but not very soon.
soon.
We already have children, but she/he wants more.
We already have children, and she/he does not want more.
He/she is unsure about whether he/she wants children.
We have not talked about having children/ I don't know.
IF YOU ARE ALREADY MARRIED, SKIP TO PAGE 54.
55
h. MARRIAGE PLANS
IF YOU ARE NOT MARRIED, PLEASE ANSWER THE FOLLOWING QUESTIONS:
Thinking of the future, CIRCLE ONE of the following...
1. I would like to marry fairly soon.
2. I would like to marry sometime but not right now.
3. I am unsure about whether I would like to ever marry.
4. I would prefer to never get married.
IF YOU CIRCLED #3 or #4, why would you consider not getting married?
How likely is it you will ever marry? (CIRCLE ONE)
Very unlikely
1
2
3
4
5
6
Very likely
7
If you'd like to get married, at what age would you like to get married? ________years old
How likely is it you will not marry but will have a long-term committed relationship or commitment ceremony?
Very unlikely
1
2
3
4
5
6
Very likely
7
If you would like to have a long-term committed relationship or commitment ceremony, when would you like to
begin such a relationship? ________years old
How good a spouse/committed partner do you think you would be (how good at having an excellent
marriage/partnership)?
not at all
good
1
2
3
4
5
extremely
good
6
7
How upset would you be if you never got married or had a commitment ceremony?
Not at all
Extremely
upset
upset
1
2
3
4
5
6
7
56
CHILDREN
A. Thinking of the future, (BE SURE TO CIRCLE ONE NUMBER BEFORE YOU SKIP )
1. I already have children. YOU ARE FINISHED WITH THIS BOOKLET; PLEASE GO TO THE PARENTING
SURVEY BOOKLET
2. I would like to have children fairly soon. GO TO QUESTION C
3. I would like to have children sometime but not right now. GO TO QUESTION C
4. I am unsure about whether I would like to ever have children. GO TO QUESTION B
5. I would prefer not to have children at all. GO TO QUESTION B
B. If you are unsure about whether or not you would like to have children or would prefer not
to have children, why would you consider not having children?
NOW CONTINUE WITH QUESTION C.
C. ALL PEOPLE WHO DO NOT HAVE CHILDREN CONTINUE HERE:
How likely is it you will ever have children?
Very unlikely
1
2
3
4
5
6
Very likely
7
If you would like to have children, at what age would you like to have your first child?
________ years old
How upset would you be if you did not have children?
Not at all
upset
1
2
3
4
5
6
Extremely
upset
7
How much would having a child/children affect the amount of time you work outside the home?
I would work
I would work the
I would work
much less
same amount
much more
1
2
3
4
5
6
7
How would you feel about that change (if any) in your work hours?
Very negative
1
2
3
4
5
6
Very positive
7
How much would having a child affect your career or educational advancement?
Slow it down
No
Speed it up
a lot
effect
a lot
1
2
3
4
5
6
7
How would you feel about that effect (if any) on your career or educational advancement?
Very negative
Very positive
1
2
3
4
5
6
7
57
In general, how good of a parent do you think you will be? (CIRCLE ONE)
Not a very good
parent
1
2
3
4
An excellent
parent
6
7
5
Do you plan to take time off from work or school to raise your children? ____yes ____no
If yes, how long do you plan to take off?
Would you expect your partner to take time off from work or school to raise your children?
____yes ____no
If yes, how long do you expect your partner to take off?
Have you (or your partner) ever been pregnant?
____ yes ____ no
IF YES, Please answer the following for your most recent pregnancy...
What did you do (or do you plan to do)? (Check one):
kept (keep) the baby
put the baby up for adoption
gave the baby to a relative to raise
had an abortion
had a miscarriage
nothing yet (have not decided)
other (specify
)
IF NO, please answer the following . . .
Have you and your partner ever tried to get pregnant? ___ yes ___ no
Have you ever had concerns about your fertility or your partner’s fertility? ___ yes ___ no
If yes, how long did you try to get pregnant?
Did you try any fertility methods (like medical options or alternative medicine)?___ yes ___ no
IF YES, what did you try?
How long did you attempt to have children using this alternative?
If you continued to have problems with fertility, did you try another way to have children, or pursue other
alternatives (like adoption)?
___ yes ___ no
IF YES, what else did you try?
How long did you try to have children using this alternative?
What did/will you do next?
58
59
WE ALWAYS LIKE TO LEAVE SPACE FOR YOU TO TELL US WHAT YOU ARE MOST PROUD OF, WORRIED
ABOUT, OR WHAT YOU THINK WE MISSED ABOUT YOU IN THIS SURVEY. IS THERE ANYTHING ELSE YOU
WOULD LIKE US TO KNOW?
YOU HAVE NOW COMPLETED THE SURVEY.
PLEASE ENCLOSE THIS BOOKLET IN THE POST-PAID RETURN ENVELOPE
AND DROP IT IN THE MAIL.
THANK YOU VERY MUCH FOR YOUR
CONTINUED PARTICIPATION!!
*****************************************************
This survey should be returned to: The Michigan Study of Life Transitions /School of Family & Consumer Resources /
University of Arizona/ Tucson AZ 85721-0033.
60
If you need another envelope or have any questions, please call us toll free at 888-285-3414