The next section asks questions about events that happened during your childhood. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of the survey we will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you may skip any question you do not want to answer. All questions refer to the time period years of age. Now, looking back before you before you were 18 were 18 years of age… While you were growing up, during your first 18 years of life: I don’t 47. Did you live with anyone who was depressed, mentally ill, or suicidal? YES NO know/Not sure I don’t Did you live with anyone who was a problem drinker or alcoholic? YES NO know/Not sure I don’t 49. Did you live with anyone who used illegal street drugs or abused prescription YES NO know/Not medications? sure I don’t Did you live with anyone who served time or was sentenced to serve time in YES NO know/Not prison, jail, or other correctional facility? sure I don’t Were your parents separated or divorced? YES NO know/Not sure How did your parents or adults in your home ever slap, hit, kick, punch, More than Never Once beat EACH OTHER up? once Before age 18, how often did a parent or adult in your home ever hit, beat, More than kick, or physically hurt YOU in any way? Do not include spanking. Would Never Once once you say… How often did a parent or adult in your home ever swear at you, insult you, or More than Never Once put you down? once How often did anyone at least 5 years older than you or an adult, ever touch More than Never Once you sexually? once How often did anyone at least 5 years older than you or an adult, try to make More than Never Once you touch them sexually? once How often did anyone at least 5 years older than you or an adult, force you to More than Never Once have sex? once You are almost done! Just one last question! Is there anything else you’d like to tell us or add about the issues we have asked about today? [Please write your comments in the box below.
The next section asks questions about events that happened during your childhood. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of the survey we will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you may 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… While you were growing up, during your first 18 years of life: 47. Did you live with anyone who was depressed, mentally ill, or suicidal? YES NO I don’t know/Not sure Did you live with anyone who was a problem drinker or alcoholic? YES NO I don’t know/Not sure 49. Did you live with anyone who used illegal street drugs or abused prescription medications? YES NO I don’t know/Not sure Did you live with anyone who served time or was sentenced to serve time in prison, jail, or other correctional facility? YES NO I don’t know/Not sure Were your parents separated or divorced? YES NO I don’t know/Not sure How did your parents or adults in your home ever slap, hit, kick, punch, beat EACH OTHER up? Never Once More than once Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt YOU in any way? Do not include spanking. Would you say… 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? Never Once More than once How often did anyone at least 5 years older than you or an adult, ever touch you sexually? 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? Never Once More than once How often did anyone at least 5 years older than you or an adult, force you to have sex? Never Once More than once You are almost done! Just one last question! Is there anything else you’d like to tell us or add about the issues we have asked about today? [Please write your comments in the box below.
2018%20NM%20Community%20Survey%20in%20English_CORE_%20gamble%20ACES_2-20-18.docx