47075
Form Approved
OMB# 0935-0118
Exp. Date 11/30/2022
2021
Your health is affected by many social, environmental, and behavioral influences. This survey focuses on your well-being, ability to meet basic needs, and your social and family experiences. This information will help us better understand how these external influences affect health. Your participation is important for increasing this understanding.
Please answer every question by marking one box "
."
If you are unsure about how to answer a question, please give the best answer you can.
Your participation is voluntary and all of your answers will be kept confidential to the extent permitted by law. Since some of the questions are personal, we suggest you complete the survey in a private setting. Some of the questions are on sensitive topics and may make some people feel uncomfortable. There is a list of resources at the end of the questionnaire in case you would like to speak to someone. If you have any questions about how to complete this booklet, please call Alex Scott at 1-800-945-MEPS (6377).
This Survey Should Be Completed By:
NAME:
DOB: MONTH: DAY: YEAR:
REGION:RUID: PID:
This survey is authorized under 42 U.S.C. 299a. Privacy is protected by the Privacy Act and Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. The confidentiality of your responses to this survey is protected by Section 944(c). Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 7 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.
The Agency for Healthcare Research and Quality and The Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services
How satisfied are you with your life as a whole these days?
Completely satisfied
Very satisfied
Somewhat satisfied
A little satisfied
Not at all satisfied
How satisfied are you with the house or apartment where you live?
Completely satisfied
Very satisfied
Somewhat satisfied
A little satisfied
Not at all satisfied
How would you rate the following characteristics of your neighborhood?
| Characteristics | Excellent |
Very Good |
Good |
Fair |
Poor |
|---|---|---|---|---|---|
a. Availability of places to get medical care |
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b. Availability of parks and playgrounds |
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c. Availability of places to buy healthy food |
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d. Safety from crime and violence |
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e. Access to public transportation |
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f. Availability of affordable housing |
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In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
Yes
No
Was there any time in the past 12 months when your household did not pay the full amount of the rent or mortgage, or was late with a payment because your household could not afford to pay?
Yes
No
Don't Know
Was there any time in the past 12 months when your household was not able to pay the full amount of electric, gas, oil, or water bills on time?
Yes
No
Don't Know
Was there any time in the past 12 months when the electric, gas, oil, or water company threatened to shut off services in your home?
Yes
No
Already shut off
Don't Know
Think about the place you live. Do you have problems with any of the following?
MARK ALL THAT APPLY.
Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above
Some people have made the following statements about their food situation. Please answer whether the statements were often, sometimes, or never true for you in the last 12 months.
| Statements | Often True |
Sometimes True |
Never True |
|---|---|---|---|
a. Within the past 12 months, you worried that your food would run out before you got money to buy more. |
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b. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. |
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How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is...?
Very hard
Somewhat hard
Not hard at all
How confident are you that you could come up with $400 if an unexpected expense arose within the next month?
Not at all confident
Not too confident
Somewhat confident
Very confident
In the past 12 months, have you missed a payment on a credit card or a loan (do not include missed payments on a mortgage)?
Yes
No
In the past 12 months, have you been contacted by a debt collection agency?
Yes
No
In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?
0
1
2
3
4
5
6
7
On average, how many minutes did you usually spend exercising at this level on one of those days?
0
10
20
30
40
50
60
Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days?
Not at all
A little bit
Somewhat
Quite a bit
Very much
If you had a problem with which you needed help (for example, sickness or moving), how much help would you expect to get...
| Sources of Help | All of the help needed |
Most of the help needed |
Very little of the help needed |
No Help |
|---|---|---|---|---|
a. From family? (Including any of your relatives or your spouse/partner's relatives if applicable, whether or not they are living with you.) |
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b. From friends? |
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c. From other people in the community besides friends and family, such as a social agency or church? |
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In a typical week, how many times do you talk on the telephone (or by video) with family, friends, or neighbors?
Never
1 time
2 times
3 times
4 times
5 times
6 or more times
In a typical week, how often do you get together with friends or relatives (for example, going out together or visiting in each other's homes)?
Never
1 time
2 times
3 times
4 times
5 times
6 or more times
How often do you attend church or religious services (in-person or online)?
Never
1-3 times per year
4-6 times per year
7-9 times per year
10-12 times per year
13-15 times per year
16 or more times per year
How often do you attend meetings of the clubs or organizations you belong to (in-person or online)?
Never
1-3 times per year
4-6 times per year
7-9 times per year
10-12 times per year
13-15 times per year
16 or more times per year
The next questions are about how you feel about different aspects of your life. For each one, mark how often you feel that way.
First, how often do you feel that you lack companionship?
Never
Rarely
Sometimes
Often
How often do you feel left out?
Never
Rarely
Sometimes
Often
How often do you feel isolated from others?
Never
Rarely
Sometimes
Often
Have you ever used an electronic nicotine product, even one or two times? (Electronic nicotine products include e-cigarettes, vape pens, personal vaporizers and mods, e-cigars, e-pipes, e-hookahs and hookah pens.)
Yes
No
Have you ever personally experienced discrimination in any of the following situations?
At a doctor's office, clinic, or hospital?
Yes
No
At work?
Yes
No
When applying for jobs?
Yes
No
When trying to rent a room or apartment, or buy a house?
Yes
No
When interacting with police or law enforcement?
Yes
No
When applying for social services or public assistance?
Yes
No
At a restaurant or store?
Yes
No
Violence and abuse happens to many people, which can affect their health. The following questions ask about your experiences with physical violence and abuse to help us better understand how this affects health.
How often does anyone, including family and friends, physically hurt you?
Never
Rarely
Sometimes
Fairly often
Frequently
How often does anyone, including family and friends, insult or talk down to you?
Never
Rarely
Sometimes
Fairly often
Frequently
How often does anyone, including family and friends, threaten you with harm?
Never
Rarely
Sometimes
Fairly often
Frequently
How often does anyone, including family and friends, scream or curse at you?
Never
Rarely
Sometimes
Fairly often
Frequently
The following questions are about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. Page 11 includes phone numbers for organizations that can provide information and referrals for these issues. Please keep in mind that you can skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age.
Now, looking back before you were 18 years of age, did you live with anyone who was depressed, mentally ill, or suicidal?
Yes
No
Did you live with anyone who was a problem drinker or alcoholic?
Yes
No
Did you live with anyone who used illegal street drugs or who abused prescription medications?
Yes
No
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
Yes
No
Were your parents separated or divorced?
Yes
No
Parents not married
How often did your parents or adults in your home ever slap, hit, kick, punch, or beat each other up? Was it...
Never
Once
More than once
Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it...
Never
Once
More than once
How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it...
Never
Once
More than once
How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it...
Never
Once
More than once
How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it...
Never
Once
More than once
How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it...
Never
Once
More than once
Please go to the "Date Completed" box on the back cover.
We appreciate your time and recognize the important contribution you have made by participating in this survey. We realize some of the topics covered are personal and can be difficult to think about. Sometimes when people participate in a survey like this, they realize they want to follow-up on an issue asked about with someone who is professionally trained. The following are toll-free numbers of resources that can provide additional information and referrals that you can use now or in the future if you want to speak further with someone.
The National Domestic Violence Hotline at 1-800-799-SAFE (7233).
The National Sexual Assault Hotline at 1-800-656-HOPE (4673).
The National Child Abuse Hotline at 1-800-4-A-Child (1-800-422-4453).
The National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Date completed: MONTH: DAY: YEAR:
Who completed this form?
Person named on front of this form
Someone else
If Someone Else, what is person's relationship to the person named on the front of this form?
Husband or wife
Unmarried partner
Mother, father, or guardian
Son or daughter
Other relative
Not related
Thank you for taking the time to complete this survey.
Please place this survey in the envelope provided to you and give it to the MEPS interviewer.
If the interviewer is no longer available, place the survey in the return envelope provided to you by the interviewer and mail as soon as possible. If the envelope is missing, mail this survey to:
MEPS
c/o Westat
1600 Research Blvd, Room GA51
Rockville, MD 20850
21-234