DATA LAYOUT - STATE-ADDED QUESTIONS



CHILDHOOD EXPERIENCES SURVEY

I’d like to ask you some questions about events that happened during your childhood. This information will allow us to better understand how certain childhood experiences may affect people later in life.

These are sensitive questions that may make some people feel uncomfortable. Please keep in mind that you can skip any question you do not want to answer.

All of the following questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age …

| |

|1 |As a child, how often did your family experience serious financial problems? |1 = Never |

| | |2 = Rarely |

| |Would you say never, rarely, sometimes, often, or very often? |3 = Sometimes |

| | |4 = Often |

| | |5 = Very often |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|2 |How often were you hungry because your family could not afford food? |1 = Never |

| | |2 = Rarely |

| |Would you say never, rarely, sometimes, often, or very often? |3 = Sometimes |

| | |4 = Often |

| | |5 = Very often |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|3 |How often were you homeless when you were growing up? |1 = Never |

| | |2 = Rarely |

| |Would you say never, rarely, sometimes, often, or very often? |3 = Sometimes |

| | |4 = Often |

| |(Note: This means having to stay somewhere like a transitional housing program, a |5 = Very often |

| |shelter, a hotel/motel paid by voucher, someone else’s home, a car or other vehicle, an | |

| |abandoned building, anywhere outside, or anywhere else not meant for people to live). |7 = Don’t know |

| | |9 = Refused |

|4 |How often did a parent or adult in your home ever swear at you, insult you, or put you |1 = Never |

| |down? |2 = Rarely |

| | |3 = Sometimes |

| |Would you say never, rarely, sometimes, often, or very often? |4 = Often |

| | |5 = Very often |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|5 |How often were you bullied or severely teased by other children or adolescents? |1 = Never |

| | |2 = Rarely |

| |Would you say never, rarely, sometimes, often, or very often? |3 = Sometimes |

| | |4 = Often |

| |(Note: This refers to bullying or teasing by children or adolescents of any age. They |5 = Very often |

| |could have been older than you, younger than you, or the same age. It does not include | |

| |experiences with adults or with siblings.) |7 = Don’t know |

| | |9 = Refused |

|6 |Before age 18, how often was there an adult in your household who tried hard to make |1 = Never |

| |sure your basic needs were met? By "basic needs" we mean food, shelter, clothing, and |2 = Rarely |

| |medical care. |3 = Sometimes |

| | |4 = Most of the time |

| |Would you say never, rarely, sometimes, most of the time, or always? |5 = Always |

| | | |

| |(Note: This could be any adult in the household, not just a parent) |7 = Don’t know |

| | |9 = Refused |

|7 |How often was there an adult in your household who made you feel safe and protected? |1 = Never |

| | |2 = Rarely |

| |Would you say never, rarely, sometimes, most of the time, or always? |3 = Sometimes |

| | |4 = Most of the time |

| | |5 = Always |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|8 |Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or |1 = Never |

| |physically hurt you in any way? Do not include spanking. |2 = Once |

| | |3 = More than once |

| |Never, once, or more than once? | |

| | |7 = Don’t know |

| | |9 = Refused |

|9 |How often did your parents or adults in your home ever slap, hit, beat, kick, or |1 = Never |

| |physically hurt each other? |2 = Once |

| | |3 = More than once |

| |Never, once, or more than once? | |

| | |7 = Don’t know |

| | |9 = Refused |

|10 |How often did an adult, or anyone at least 5 years older than you, touch you sexually, |1 = Never |

| |try to make you touch them sexually, or force you to have sex? |2 = Once |

| | |3 = More than once |

| |Never, once, or more than once? | |

| | |7 = Don’t know |

| | |9 = Refused |

|11 |Did you live with anyone who was depressed, mentally ill, or suicidal? | |

| | |1 = Yes |

| | |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|12 |Did you live with anyone who was a problem drinker or alcoholic? | |

| | |1 = Yes |

| | |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|13 |Did you live with anyone who used illegal street drugs or who abused prescription | |

| |medications? |1 = Yes |

| | |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|14 |Did you live with anyone who served time or was sentenced to serve time in a prison, | |

| |jail, or other correctional facility? |1 = Yes |

| | |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|15 |Were your parents separated or divorced? |1 = Yes |

| | |2 = No (Parents were married) |

| | |3 = No (Parents were not married) |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|16 |Was either one of your parents absent from your life for a long period of time? Do not |1 = Yes |

| |include absence due to death of parent. |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|17 |Before age 18, did you experience the death of a parent, caregiver, or sibling? |1 = Yes |

| | |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|18 |Before age 18, were you ever the victim of a violent crime? This refers to any violent |1 = Yes |

| |act that was perpetrated by someone other than a parent or household family member. |2 = No |

| | | |

| | |7 = Don’t know |

| | |9 = Refused |

|19 |Overall, how uncomfortable did you feel answering the questions on this survey? |1 = Not at all |

| | |2 = Slightly |

| | |3 = Moderately |

| | |4 = Very |

| | |5 = Extremely |

| |If a client experiences discomfort, a home visitor can opt to refer her to a local | |

| |agency for assistance. In addition, the client can be directed to dial 211 or | |

| |1-800-422-4453 (Childhelp) to reach a referral service to locate an agency in the local | |

| |area. | |

ACE LIST (Questions for each ACE)

a. Poverty (Q1; Q2; Q3)

b. Psychological Abuse (Q4)

c. Peer Victimization (Q5)

d. Physical Neglect (Q6)

e. Emotional Neglect (Q7)

f. Physical Abuse (Q8)

g. Domestic Violence (Q9)

h. Sexual Abuse (Q10)

i. Household Mental Illness (Q11)

j. Household Substance Abuse (Q12; Q13)

k. Incarcerated Household Member (Q14)

l. Parental Divorce, Separation, or Absence (Q15; Q16)

m. Death of Parent, Caregiver, or Sibling (Q17)

n. Victim of Violent Crime (Q18)

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