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 sk ip 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 1 = Never financial problems? 2 = Rarely 3 = Sometimes Would you say never, rarely, sometimes, often, or very ofte 4 = Often n? 5 = Very often

7 = Don’t know 9 = Refused 2 How often were you hungry because your family could not 1 = Never afford food? 2 = Rarely 3 = Sometimes Would you say never, rarely, sometimes, often, or very 4 = Often 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 3 = Sometimes often? 4 = Often 5 = Very often (Note: This means having to stay somewhere like a transitional housing program, a shelter, a hotel/motel paid 7 = Don’t know by voucher, someone else’s home, a car or other vehicle, an 9 = Refused abandoned building, anywhere outside, or anywhere else not meant for people to live). 4 How often did a parent or adult in your home ever swear at 1 = Never you, insult you, or put you down? 2 = Rarely 3 = Sometimes Would you say never, rarely, sometimes, often, or very 4 = Often often? 5 = Very often

7 = Don’t know 9 = Refused

1 5 How often were you bullied or severely teased by other 1 = Never children or adolescents? 2 = Rarely 3 = Sometimes Would you say never, rarely, sometimes, often, or very 4 = Often often? 5 = Very often

(Note: This refers to bullying or teasing by children or 7 = Don’t know adolescents of any age. They could have been older than 9 = Refused you, younger than you, or the same age. It does not include experiences with adults or with siblings.) 6 Before age 18, how often was there an adult in your 1 = Never household who tried hard to make sure your basic needs 2 = Rarely were met? By "basic needs" we mean food, shelter, 3 = Sometimes clothing, and medical care. 4 = Most of the time 5 = Always Would you say never, rarely, sometimes, most of the time, or always? 7 = Don’t know 9 = Refused (Note: This could be any adult in the household, not just a parent) 7 How often was there an adult in your household who made 1 = Never you feel safe and protected? 2 = Rarely 3 = Sometimes Would you say never, rarely, sometimes, most of the time, 4 = Most of the time or always? 5 = Always

7 = Don’t know 9 = Refused 8 Before age 18, how often did a parent or adult in your hom 1 = Never e ever hit, beat, kick, or physically hurt you in any wa 2 = Once y? Do not include spanking. 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 sla 1 = Never p, hit, beat, kick, or 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 tha 1 = Never n you, touch you sexually, try to make you touch 2 = Once them sexually, or force you to have sex? 3 = More than once

Never, once, or more than once? 7 = Don’t know 9 = Refused

2 11 Did you live with anyone who was depressed, mentally ill, 1 = Yes or suicidal? 2 = No

7 = Don’t know 9 = Refused 12 Did you live with anyone who was a problem drinker or alc 1 = Yes oholic? 2 = No

7 = Don’t know 9 = Refused 13 Did you live with anyone who used illegal street drugs or w 1 = Yes ho abused prescription medications? 2 = No

7 = Don’t know 9 = Refused 14 Did you live with anyone who served time or was sentence 1 = Yes d to serve time in a prison, jail, or other correctional f 2 = No acility? 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 l 1 = Yes ong period of time? Do not include absence due to 2 = No death of parent. 7 = Don’t know 9 = Refused 17 Before age 18, did you experience the death of a parent, 1 = Yes caregiver, or sibling? 2 = No

7 = Don’t know 9 = Refused 18 Before age 18, were you ever the victim of a violent crime? 1 = Yes This refers to any violent act that was perpetrated by 2 = No someone other than a parent or household family member. 7 = Don’t know 9 = Refused 19 Overall, how uncomfortable did you feel answering the 1 = Not at all questions on this survey? 2 = Slightly 3 = Moderately 4 = Very 5 = Extremely

3 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 1-800-422-44 53 (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)