rev 20220429

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Directions: Ask how many times each event happened, and how much it affected the child when it happened and now.

  • 1. Has your child ever been in or seen a very bad accident?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 2. Had someone you know been so badly injured or sick that s/he almost died?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 3. Known somebody who died?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 4. Been so sick or hurt that you or the doctor thought you might die?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 5. Been unexpectedly separated from some who you depend on for love and security for more than a few days?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 6. Has your child ever had somebody close to him/her try to kill or hurt themselves?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 7. Has your child ever been physically hurt or threatened by someone?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 8. Has your child ever been robbed or seen someone get robbed?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 9. Has your child ever been kidnapped by somebody?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 10. Has your child ever been in or seen a hurricane, earthquake, tornado, or bad fire?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 11. Has your child ever been attacked by a dog or other animal?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 12. Has your child ever seen or heard people physically fighting or threatening to hurt each other?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 13. Has your child ever seen or heard somebody shooting a gun, using a knife, or using another weapon?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 14. Has your child ever seen a family member arrested or in jail?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 15. Has your child ever had a time in your life when s/he did not have the right care (e.g. food, clothing, a place to live)?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 16. Has your child ever been forced to see or do something sexual?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 17. Has your child ever seen or heard someone else being forced to do something sexual?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 18. Has your child ever watched people using drugs (like smoking, sniffing, or using needles)?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • 19. Has your child ever seen something else that was very scary or where s/he thought somebody might get hurt or die?
  • NeverOnce2-3 times4-10 times10 times
  • Not at all (1)A little bit (2)Moderately (3)Quite a bit (4)Extremely (5)
  • Not at all (1)A little bit (2)Moderately (3)Quite a lot (4)Extremely (5)
  • Please click SUBMIT when complete