0001 Questionnaire

ICPSR 13599 Project on Human Development
in Chicago Neighborhoods
(PHDCN): Stanford-Binet, Wave 1,
1994-1997
Felton J. Earls
Harvard Medical School
Jeanne Brooks-Gunn
Scientific Director. Columbia University.
Teacher's College. Center for the Study of
Children and Families
Stephen W. Raudenbush
Scientific Director. University of Michigan.
School of Education and Survey Research
Center
Robert J. Sampson
Scientific Director. Harvard University.
Department of Sociology
Questionnaires for Wave 1 Longitudinal

Cohort Study
Inter-university Consortium for

Political and Social Research
P.O. Box 1248
Ann Arbor, Michigan 48106
www.icpsr.umich.edu
W V A l W SCHOOL OF PUBLIC HEALTH
Project on Human Development

ASSESSMENT
PRIMARY CAREGIVER,
COHORT: PRENATAUO
FIELD COPY #2
TABLE OF CONTENTS
Age: Prenatal (PC)
1. Demographic & Cultural Information

2. Prenatal Health Screen
3.
3
Family Structure & Health History
4. Family Mental Health & Legal History
5. Employment & Income
6. Conflict Tactics Scale: Spouse
7. Family Environment Scale (short)
8. Provision of Social Relations
9. Home (Observation of Physical Environment Only)
DEMOGRAPHIC dk CULTURAL
INFORMATION
Demographic and Cultural Information Interview: PC me/postnatal cohort]
mm dd yy
Interviewer ID:
Now I have some general questions.
First, I will ask you about where you and ***** have lived during the past five years;
Second, I am going to ask about where you, *****, and other members of your family
were born;
Third, I will ask about different languages you might speak;
Fourth, I will ask for some general descriptive information about yourself;
Fifth, I am going to ask about your school background; and
Finally, I will ask about your ethnic and religious background.
Let's start with checking that I have your current address recorded correctly.
ed.init. ed.date
2
&
Your current address is (readfrom contact sheet): Is that right?
1. Yes - Go toQ. 1
0. No - Record complete address below:
street addrkss apt. # ... ,
-
< I
. I
_. _.
5.
.
I
city state zip code --!
_ .
1. Do you: (read choices) m-L
:.
1. rent your home

_I
2. own your home

4. live with someone (your parents, guardians or partner) who rents this home
5 . live with someone (your parents, guardians or partner) who owns this home
3. live here under some other type of living arrangement
1A. How long in years and months have you lived here?
years months
IF at current address for 2 5 years Go to Q. 3
IF at current address for less than 5 years, Go to Q. 2.

Continue to record addresses until you have covered the past 5 year period.
2. Please tell me all the other addresses you have had in the past five years, starting with
your most recent one before your current address.
3
2A.
- L -
w
(street address)" (city) (state) (zip code)
2A1. Why did you move from this address [2A]? [circle up to three] 3BGCAd
1 = change of job 8 = went to school
2 = evicted 9 = could no longer afford rent
3 = moved off-campus 10 = found a better apartment/house
4 = f x e / q e r hazardous condition 11 = wanted to live away from parents
5 = change in marital/romantic status 12 = roommates left (had to move)
6 = moved in w/ someone due to f m c e s 13 = on vacatiordgraduated from school
7 = living quarters too small/found bigger apartment/home
25 = other I '
2A2. How long did you live at this address [2A]? 4&A
years months
Calculate Cumulative Total

Years months
2B. And where did you live before living here?

- I
-
(street addregsf (city) (state) (zip code)
2B1. Why did you move from this address [2B]? [circle up to three] ~8A5 1

3 = moved off-campus 10 = found a better apartmedhouse
4 = fire/other hazardous condition 11 = wanted to live away from parents
6 = moved in w/someone due to finances 13 = on vacatiodgraduated from school
7 = living quarters too small/found bigger apartmenthome
25 = other
Y V
2B2. How long did you live at this address [2B]?

Years months
4
2C. And where did you live before living here?

- -
(street add&! (city) (state) (zip code)
2C1. Why did you move from this address [2C]? [circle up to three] B73
3 = moved9,pff-campus 10 = found a better apartment/house
4 = fire/other hazardous condition 11 = wanted to live away fiom parents
6 = moved in w/ someone due to finances 13 = on vacatiordgraduated fi-om school
7 = living quarters too small/found bigger apartmentlhome
25 = other
V'
2C2. How long did you live at this address [2C]? C&
years months

YWS months
2D. And where did you live before living here?
(street ad&&) (city) (state) (zip code)
2D1. Why did you move from this address [2D]? [circle up to three] OZ B4-
3 = moved offcampus 10 = found a better apartmentlhouse
4 = firelother hazardous condition 11 = wanted to live away from parents
25 = other
/*
2D2. How long did you live at this address [2D]?
years months

Y- months
5
2E. And where did you live before living here?

- - -
(city) (state) (zip code)
2E1. Why did you move from this address [2E]? [circle up to three] HA E
3 = movqoff-campus 10 = found a better apartment/house
4 = */other hazardous condition 11 = wanted to live away from parents
25 = other
Y V
2E2. How long did you live at this address [2E]?

M otEA years months

Y- months
2F. And where did you live before living here?

c - -
(street ad&es"s) (city) (state) (zip code)
2F1. Why did you move from this address [2Fj? [circle up to three] & j=d
1 = change ofjob 8 = went to school
3 = moved offcampus 10 = found a better apartmendhouse
4 = frre/other hazardous condition 11 = wanted to live away from parents
5 = change in mariWromantic status 12 = roommates left (had to move)
6 = moved in w/ someone due to finances 13 = on vacatiodgraduated from school
25 = other
2F2. How long did you live at this address [2F]?

years months
MOeFA
years months
6
2G. And where did you live before living here?

c
- I
I
(street add&ss) (city) (state) (zip code)
2G1. Why did you move from this address [2G]? [circle up to three] ;873 Bd
1 -= change of job 8 = went to school
3 = moved.pff-campus 10 = found a better apartmentlhouse
25 = other
rfl
2G2. How long did you live at this address [2G]?
years months
($5373 & ~ &
Y-S months
2H. And where did you live before living here?

- - _L
(street addreg)' (city) (state) (zip code)
2H1. Why did you move from this address [2m? [circle up to three] p&'3 4f i / /
3 = moved off-campus 10 = found a better apartmenthouse
4 = firelother hazardous condition 11 = wanted to live away from parents
25 = other
Y V
2H2. How long did you live at this address [2m?
years months

years months
7
21. And where did you live before living here?

3_
(zip code)
211. Why did you move from this address [2IJ? [circle up to three] &% OZ z4
3 = move$ off-campus 10 = found a better apartmentmouse
4 = fxdoiher hazardous condition 11 = wanted to live away from parents
5 = change in maritd/romantic status 12 = roommates left (had to move)
6 = moved in w/someone due to f m c e s 13 = on vacatiodgraduated from school
25 = other
Y t
2I2. How long did you live at this address [2Q?
years months
Calculate Cumulative TOM

Ye= months

- c -
(street add&$ (city) (state) (zip code)
251. Why did,you move from this address [a?

[circle up to three] ad?2 h
5 = change in mariWromantic status 12 = roommates left (had to move)
6 = moved in w/ someone due to finances 13 = on vacation/graduated from school
25 = other
272. How long did you live at this address [a?

Y- months

Y- months
8
If **** has been born, Go to Q. 6
Otherwise, Ask Q. 3.
3. Has ***** had any different addresses than you since shehe was born? 8733
0. NO Go toQ. 5.
il
1. YES Go to Q. 4.1
4.1. How long in years and months has ***** lived at your current address?
rn 4- 1
years months
4. Please tell me all the addresses ***** has had since she/he was born, starting with the most
recent one before the current address.
4A.
-c- - -
(state)
r -
(street address) (city) (zip code)
4A1. Why did ***** move from this address [4A]? [circle all that apply] +& d
1 = change in custody/shared custody 7 = child hospitalized (medical)

2 = lived with another family member 8 = parent was hospitalized (medical)
3 = parent was in prison 9 = foster placement/adopted
4 = parent abandoned child
5 = child hospitalized (emotionalhehavioral) or in residential treatment
6 = parent was hospitalized (emotional/behavioral) or in drug treatment
25 = other
4A2. How long did ***** live at this address [4A]?

YWS months
&a73
//Ab
Calculate Cumulative-Total
Y- months
9
4B. And where did ***** live before living here?
v r
I_ I.c-- -
(street address) (city) (state) (zip code)
4B1. Why did ***** move from this address [4B])? [circle all that apply] L/& 4.
>
3 7,parent was in prison 9 = foster placement/adopted
6 = parent was hospitalized (emotionalhehavioral) or in drug treatment
25 = other
V I
4B2.How long did ***** live at this address [4B]?

years months
rn4/3&
Y- months
4C. And where did ***** live before living here?

- - -
(street addre'ss) (city) (state) (zip code)
4C1. Why did ***** move from this address [4C]? [circle all that apply] 4Cf

3 = parent was in prison 9 = foster placementiadopted
5 = child hospitalized (emotionalkhavioral) or in residential treatment
6 = parent was hospitalized (emotionalkhavioral) or in drug treatment
25 = other
Y '
4C2. How long did ***** live at this address [4C]? .
years months
4C&
years months
10
4D. And where did ***** live before living here?
I
- - -
(street add:ess) (city) (state) (zip code)
4D1. Why did ***** move from this address [4D]? [circle all that apply] 953d
*
3 =qiarent was in prison 9 = foster placement/adopted
25 = other
Y .
4D2. How long did ***** live at this address [4D]?

years months
A% 4aA
Ye= months
4E. And where did ***** live before living here?

- - -
(street addregsf (city) (state) (zip code)
4E1. Why did ***** move from this address [4E]? [circle all that apply] 873 A/ 4
6 = parent was hospitalized (emotional/behavioral) or in drug treatment
25 = other
4E2. How long did ***** lfve at this address [4E]?
years months

Years month
Now I have some questions about where different people in your family were born.
5. Where was ***** born?
A. city B. State c. country -

IF not born in the USA, Ask Q. 5A and 5B:
1
y.9
5A. When did ***** come to live in the USA? year: 19
6873 5/94 8. Don't Know
5B. How old was ***** when heishe came to live in the USA? age:
8. Don't Know
j3-735/31
6. Where were you born?
A. city B. State
- c. country
-
IF' not born in the USA, Ask Q. 6A and 6B:
6A. When did you come to live in the USA? year: 19
i%736 8 4 8. Don't Know
6B. How old were you when you came to live in the USA? age:
8. Don't Know
;le737
7. Is your mother still living? 1. Yes 0. No 8. Don't Know
8. Where was she born?
A. City B. State
- c. country -
If PC's mother is alive, ask Q. 9.1
If PC's mother has died, ask Q. 9.2
12
a
9.1 Where does she live now?
A. city B. State c
C. Country
-
9.2 Where did she live when she died?
A. City B. State
c
c. country -
IF NOT born in US, but lives or lived in US, Ask Q. 9A and 9B:
9A. When did she come to live in the USA? year: 19
940 8. Don't Know
9B. How old was she when she came to live in the USA? age:
8 . Don't Know
9430
10. ?
Is your ather still living? 1. Yes 0. No 8. Don't Know
-
11. Where was he born?
A. City B. State
- c. country
If PC's father is alive, ask Q. 12.1
If PC's father has died, ask Q. 12.2
12.1 Where does he live now?
A. City B. State
- c.country
-
12.2 Where did he live when he died?
A. City B. State
- c. country
12A. When did he come to live in the USA? year: 19
m
s/am 8. Don't Know
12B. How old was he when he came to live in the USA? age:
8. Don't Know
13
Now I have some other questions about you.
13. Are you a U.S.citizen? rn Y 3

0. NO Go to Q. 13A
1. YES Goto Q. l3B
13A. Are you (read choices) 1. currently applying, Go To

Q. 14
''4
m f3AO 2. planning to apply, or
3. not planning to become a citizen
13B. Are you registered to vote in the U.S.? 0. NO 1. YES

m /3AO
14. What is your social security number? - ----
Record # or circle choice
Don't Know Don't have one Refused
(NAP)
15. What is your marital status? Are you (Readall choices): m f5

1. Single Go to Q. 15A
2. Separated Go to Q. 15A
3. Divorced Go to Q. 15A
4. Married Go to Q. 15AA
5. Widowed Go to Q. 15A
6. Living with Someone as a Partner Go to Q. 15B1
15A. Are you currently living with a partner? Ab3 f 5 H O
1. Yes Go to Q. l5Bl
0. No GotoQ. 16
15AA. Are you currently living with your spouse? &?3 /Tfi&O
1. Yes Go to Q. 15B1
0. No Go to Q. 15AA.1
15AA. 1 Are you living apart because you are not getting along or for some sther
- reason? Code answer and prompt if necessary: What is the reason?
1. Not getting along Record and mv5-mU

2. Jobs in different places Go To Q. 15B1
3. Partner is in prison
4. Other
14
15B1. Is your partner/spouse the biological parent of [*****/the child you will be havhg]?
1. Yes m
0.No
If not currently living With partner or spouse, Go to 0.16
15B2. How long have you lived with your partner/spouse? A73 / 5 &A
9 years months
16. What is your birth date? I '
rnm dd YY
17. What was the first language you learned? ;a73 LF

1. English 7. Russian
2. Polish 8. Italian
3. Portuguese 9. French
4. Spanish 10. Other language (
. 5 . German
I'
6. Lithuanian
-
11. English AND another language (spec@:)
12. Two other languages (specifL:)

A. -
B. L
18. What is your primary language now? /413 48

1 . English 7. Russian
4. Spanish 10. Other language (specifi:)
5. G e m
-
r F
6 . Lithuanian 11. English AND another language (spec@:)
12. Two other languages (specifi:)

A.
B. c
IF 17 and 18 are English, Go to Q. 20

If?either 17 OR 18 are BOT * ,GotOQ.19
~
15
19. 6473 i9
Please note: Insert the name of the languuge(s)provided in response to Q. 17 and 18
whenever the term [language(s)]appears in the text in Q. 19
Would you say that you speak mostly [language(s)] or do you speak mostly English, or do you speak
[language(s)] and English about the same?
*
a. v t l y [language(s)] b. Mostly English C. Both about the same
Hand "CARD 1: LANGUAGES" to the respondent
I'd like to know what language you use in your daily activities. After each question please
tell me whether you use English only, mostly English, both English and [language(s)]
equally, mostly Panguage(s)l, or Panguage(sl1 only.
19A. What language do you speak with your children? 3'940
1. English only 4. Mostly [language(s)]

2. Mostly English 5. [language(s)] only
3. Equally 7. NAP (doesn't have children)
19B. What language (doldid) you speak with your mother? %5 {PA 0
2. Mostly English 5 . I m s w F ( s ) l only
3. Equally
19C. What language (do/did) you speak with your father? ;bn49

2. Mostly English 5 - C1anguage(s)l only
3. Equally
IF respondent has a partner, ASK Q. 19D:
19D. What language do you speak with your partner? Y g m
1. English only 4. Mostly panguage(s)]

- 2. Mostly English 5 . rl~guage(s)lonly
3. Equally
16
19E. What language do you speak with friends? m f9EO
2. Mostly English 5 . [lanpage(s)] only
3. Equally
19F. What language do you speak with people at work or school? Y9FO
9 2. Mostly English 5 . [lanpage(s)] only
3. Equally 7. NAP (Not in school or in a job)
19G. In what language are television programs you watch? d&3 fQ 60

2. Mostly English 5. [lwww(s)l o w
3, Equally
19H. How about the radio stations you listen to? &3 /97L/o
2. Mostly English 5 . [language(s)l only
3. Equally
191. Do you consider your [language(s)] to be ... (read choices). #9 1 0

1. Very Good
2. PrettyGood
3. Fair, or
4. Not good at all
19J. Do you consider your English to be .... (read choices) fP20

1. Very Good
2. Pretty Good
3. Fair, or
4. Not good at all
19K. How often has it been hard for you to get along with others because you don't
speak English well? Would you say.. . (read choices)
1. Never
2. Sometimes
3. Often, or
4. Always
17
19L. How often has it been hard to get good grades or do well at a job because of
problems understanding English? Would you say.. .(read choices)
1. Never
2. Sometimes
ar 9 L O
3. Often, or
4. Always
yv
Now I have some questions about your education.
20. Have you attended school in another country, this country (the US), or both? %+3a
1. another country only Go to Q. 20A
2. usonly Go to Q. 21
3. another country and US Go to Q. 21
/8-i73##0
20A. How many years of school did you have? years (1 - 20)
2W5rnhO
20B. At what age did you stop attending school? years old
2OC. Did you receive any type of degree? miu,co

0. NO GotoQ.22
1. YES GotoQ.20Cl
20C1. What degree did you receive? M m C d Goto

Q. 22
21. Did you finish high school? J M oezi

0. NO GotoQ.2lB
1. YES GotoQ.21A
21A. And have you done any studying beyond high school?
0. NO G o t o Q . 2 2
1. YES GotoQ.21Al
@3defAf
21A1. How many years of studying beyond high school have you done?
L
-years months
21A2. What is the highest degree you have reached? , 8 7 3 ~ ~ ~ ~
1. No degree
2. Associate's degree or technical degree
3. Bachelor's degree
4. Master's degree
5 . Doctoral degree (J.D., M.D., Ph.D., DDS., DO, Ed.D.)
6. Other
21A3. Are you currently in school? A373 42093
0. NO Go to
1. YES Q. 22
21B. What is the last grade you completed? (1 - 12) r n R f f i 0
21B1. Are you still in high school? AM3 aan/
0. NO GotoQ.21C
1. YES GotoQ.22
21C. Have you gotten a GED or had any other schooling or training since then?
0. NO GotoQ.22
1. YES GotoQ. 21C1
21C1. What have you received? 1. GED

2. other degreekertificate:
3. other schooling:
21C2. Are you currently in school or training?
0. NO Got0 rnRfC44
1. YES Q. 22
22. What country(s) best represents your national origin or ancestry?

19
23. Do you identify with an ethnic group? ma3

0. NO GotoQ.26
1. YES GotoQ.24
24, Which group(s) do you identi@ with?
1.
f r
2. iq
-
4.
c
IF more than one ethnic group listed, Ask Q. 24B.

24B. Which of these groups do you primarily or mainly identifj with?
In Q. 24, circle the number of the 'primary' ethnic group.
25. How American or [ethnic group] are your customs? Would you say ...(read choices)
1. Very American Go to Q. 25A r n R 5

2. Mostly American Go to Q. 25A
3. Mostly [ethnic group], or Go to Q. 26
4. Very [ethnic group] GotoQ. 26
25A. How often have you had problems with your family because you prefer American
customs? Would you say.. .(read choices)
1. never mA5AO
2. sometimes, or
3. often
26. Are you Latino or Hispanic? ;413&$
- 0. NO GotoQ.27
1. YES GotoQ.26A
I Hand "CARD 2: LATINO/HISPANIC"to the respondent

20
26A. Which of the following represents your origins? Circle all that apply.
1. Cuba &'3 &640

2. Mexico
3. PuertoRico
4. Spain
5. South America
h 6. Other Central American
7. Other
'-4
Hand "CARD 3: RACE/ETHNICITY" to the respondent
27. If you were asked to put yourself into only one of these groups, in which one would you place
yourself?
Circle ONE only.
1. Asian
2. Pacific Islander
3. African American / Black
4. Caucasian / White
5 . Native American
6. Other
28. How often do people dislike you because of your ethnic group or race? Would you say ...(read
choices)
1. never m
2. sometimes, or
3. often
29. How often are you treated unfairly at school or work because of your ethnic group or race?
Would you say.. .(read choices)
1. never
m c49
2. sometimes, or
3. often
30. How often have you seen friends treated badly because of their ethnic group or race? Would
you say. ..(read choices)
1. never %30
-
2. sometimes, or
3. often
I Please note that Questions 31 - 32 have been intentiomlh, omitted. I

21
-
I Hand "CARD4: RELIGION" to the respondent I
0. NO GotoQ.36
B73 3 3
1. YES Circle group indicated and Go to Q. 34
&f3 3 3 C 4 d
1. Buddhist
2. ,Catholic
3. thurch of Christ
4. Evangelical
5 . Hindu
6 . Islamic
7. Jehovah's Witness
8. Jewish &73 33c#&
a. Orthodox
b. Conservative
c. Reformed
d. Other
9. Mormon
10. Pentecostal
11. protestant &% 33- 3
a. Anglican
b. Baptist &3
' 33- 9
1. American Baptist Association
2. American Baptist Church
3. National Baptist Convention
4. Southern Baptist Convention
5 . Other Baptist
C. Episcopalian
d. Lutheran ~ ~ 373 Q3Y$-
1. American Lutheran Church
2. Lutheran Church in America
e. Methodist %5 3 3 CY 6
1. Episcopalian
2 African Methodist Episcopal Church
3. African Methodist Episcopal Zion Church
4. United Methodist Church
5 . Other Methodist Churches
f. Presbyterian &3 3 3 C Y q
1. Presbyterian Church in the U.S.A.
- 2. United Presbyterian Church in the U.S.A.
3. Other Presbyterian Church
g- Seventh Day Adventist
12. Other
22
34. Would you say your religion provides you with.. .(Read choices) 34 - -.-?
1. a great deal of guidance

2. quite a bit of guidance
3. some guidance, or . .~
4. no guidance at all
. .
35. How often do you attend religious service? Do you attend.. . (Read choices)
s.'
1. almost every week or more 3 5
. 2. once or twice a month
3. a few times a year
4. almost never, or
! :
5. never , ....
Reminder for the Interviewer:
This interview DOES NOT end here.

Answer the following questions yourself and follow the instructions provided: .. .
',,.._.
A. Is the PC married or living with a partner?
Yes --> Go to Q. 36
No -> Go to Instruction B
B. Have you obtained i n f o m i o n about the biological father?

Yes -> Go to Q. 68
NO -> GO to Q . 51
23
Now some questions about your partner:
36. what is hidher first name? r r
37. What is [partnerl's age? ;413 3'2,
1. Under 20 years 4.40 to 49 years

2.20 to 29 years 5. 50 to 59 years
?-4
3. 30 to 39 years 6. 60 or above
8. Don't Know
37A. When was [partner] born?

mm
38. Where was [partner] born?
A. city B. State
- c. Country
-
IF not born in US, Ask Q. 38A and 38B:
38A. When did she/he come to live in the USA? &% 3 8 A f year: 19
8. Don't Know
38B. How old was she/he when shehe came to live in the USA? age:
38/34 8. Don't Know
m 39
39. Is [partner's] mother still living? 1. Yes 0. No 8. Don't Know
a. city be B. State
c
e. country
L
If [partner's] mother is alive, ask Q. 41.1

If Ipartner's] mother has died, ask Q. 41.2
A. city -& B. State

- c. country
-~
A. city W B. State
4
c. Country
_c_
24
IF NOT born in US, but lives or lived in US,Ask Q. 41A and 41B:
41A. When did she come to live in the USA? &3 4 / 8 0 year: 19
. 8. Don't Know
* 41B. How old was she when she came to live in the USA? age:
q=4
rn 4//30 8. Don't Know
42. Is [partner's] father still living? 1. Yes 0. No 8. Don't Know

-
B. State
c
A. City C. Country
If cpartner's] father is alive, ask Q. 44.1

If [partner's] father has died, ask Q. 44.2
A. city M- B. State
- c. country
-
44.2
A. city
Where did he live when he died?
B. State
- c. country
-
44A. When did he come to live in the USA? 4440 year: 19
8. Don't Know
8. Don't Know
AW544'bO
'25
Has [partner] attended school in another country, this country (the US), or both?
1. another country only Go to Q. 45A 45-

m45m
45A. How many years of school did [partner] have? years (1 - 20)
45B. At what age did [partner] stop attending school? years old
' 45C. Did [partner] receive any type of degree?

373 4 5 b O
m 45co
0. NO GotoQ.47
1. YES GotoQ.45Cl
45C1. What degree did [partner] receive? 874 45cd Go to

Q. 47
46. Did [partner] finish high school? m 46

0. NO GotoQ.46B
1. YES GotoQ.46A
46A. Has bartner] done any studying beyond high school? &3 46 &)
0. NO GotoQ.47
1. YES GotoQ.46Al
46A1. How many years of studying beyond high school has she/he done?
years months
%'346Al
46A2.What is the highest degree [partner] has reached?
m464A . 1. No degree
4. Master's degree
5 . Doctoral (J.D., M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other
M 3 & 6 A 3 46A3. Is Cparmer] currently in school? 0.

1.
NO
YES
Go to
Q. 47
26
46B. What is the last grade [partner] completed? 4=m (1 - 12)

46B1. Is [partner] still in high school?
0. NO GotoQ.46C - -_
1. YES Go toQ. 47
4 ;
n
46C. Has [partner] gotten a GED or any other schooling or training since then?
0. NO GotoQ.47 m 4 6 C O
k
1. YES GotoQ.46Cl
46C1. What has [partner] received? 1. GED

2. other degreekertificate:
/613 4 6 C f
3. other schooling:
46C2. Is [partner] currently in school or training? 0. NO Go to

1. YES Q. 47
AM3 4 6 C &
47. What country(s) best represents [partner's] national origin or ancestry?
1.
2.
c
48. Does [partner] identify with an ethnic group? +&

0. NO GotoQ.49
1. YES GotoQ.48A
48A. Which group(~)does he/she identify with?
1.
2.
7
-
x
3.
27
49. Is Ipartner] Latino or Hispanic? m 49

0. NO GotoQ.50
1. YES GotoQ.49A
Hand "CARD 2: LATINO/HISPANIC" to the respondent

*
49A. Which of the following represents hidher origins? Circle all that apply.
y? Cuba 4940
1.
2. Mexico
3. Puerto Rico
4. Spain
5. South America
6. Other Central American
7. Other
Hand "CARD 2: RACE/E"ICITY" to the respondent

L
50. If you were asked to put Cpartner] into only one of these groups, in which one would you
place W h e r ?
Circle ONE only.
1. Asian
2. Pacific Islander
5. Native American
6. Other
28
This interview MAY or MAY NOT end here.

Answer the following question yourself and follow the instructions provided:
A. Have you obtained informution about B O W the biological mother and

?
biqgical father?
Yes -- > END INTERVIEW and record time in box below

No - > Go to Instruction B
B . Have you obtained informution about the biological father?

Yes -> Go to Q . 68
NO--> GOto Q. 51
Time stopped:
29
Now some questions about [*****Is fathedthe father of the child you will have]:
51. What is his first name? Don't Know
52. Is he still living? 1. Yes Go to Q. 53.1 rn 5 A

0. No Go To Q. 53.2
'9 8. Don't Know Go to Q. 53.1
53.1 What is his age? m 53- f

1. Under 20 years 4. 40 to 49 years
2 . 2 0 to 29 years 5 . 5 0 to 59 years
8. Don't know
53.2 What was his age when he died? Am 53-J5

1. Under 20 years 4.40to 49 years
2 . 2 0 to 29 years 5.50 to 59 years
8. Don't know
53A. When was he born?

mm dd yy
A. city B. State
~
c. country -
If *****Is father is alive, ask Q. 55.1
If *****Is father has died, ask Q. 55.2
A. city B. State
- c. country
-
A. city W B. State
c _
c. country
-
30
IF NOT born in US, but lives or lived in US, Ask Q. 55A and 556.
55A. When did he come to live in the USA? fi-&O year: 19
8. Don't Know
8. Don't Know
z
Az? S f i O
'y
56. Is his mother still living? 1. Yes 0. No 8. Don't Know
57. Where was his mother born?

-
A. city akwwd B. State
c
C. Country
If [ *****Is father's] mother is alive, ask Q. 58.1

If [*****Is father's] mother has died, ask Q. 58.2
A. City
c
B. State
._
.C.Country
-
A. City
- B. State
- C.Country
-
IF NOT born in US,but lives or lived in US, Ask Q. 58A and 58B.
58A. When did she come to live in the USA? 58rQO year: 19
8. Don't Know
8. Don't Know
5 4 A O
59. Is his father still living? 1. Yes 0. No 8. Don't Know &% 59

-
60. Where was his father born?
A. City
c-
B. State
- c. country
-
31
If [*****Is father's] father is alive, ask Q. 61.1

If [*****Is father's] father has died, ask Q. 61.2
c.
t z
A. city B. State country

61.2
A. City
Where did he live when he died?
1.
- 3. State
- c. country
-
IF NOT born in US, but lives or lived in US, Ask Q. 61A and 61B.
61A. When did he come to live in the USA? &S6/#0. year: 19

8. Don't Know
6B. How old was he when he came to live in the USA? /413 61/40 age:
8. Don't Know
62. Has [*****Is fatherhe father of the child you will be having] attended school in another
country, this country (the US), or both?
1. another country only Go to Q. 62A Am

2. usonly GotoQ.63
62A. How many years of school did he have? years (1 - 20) JJBsAAo
62B. At what age did he stop attending school? years old 373 6a
62C. Did he receive any type of degree? &f3 6 R C O
0. NO GotoQ.64
1. YES GotoQ.62C1
&3 6 A C L
-
62C1. What degree did he receive? GO TO
Q* 64
8
32
63. Did he finish high school? dr413 63
0. NO Go to Q. 63B
1. YES Go to Q. 63A
63A. And has he done any studying beyond high school? &3 6 3 40
0. NO GotoQ.64
1. YES GotoQ. 63A1
h
63A1. How many years of studying beyond high school? 63 41
years months
63A2. What is the highest degree he has reached? J

3z36 3 A A
1. No degree
4. Master's degree
5. Doctoral degree (J.D., M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other
63A3. Is he currently in school? 0. NO Go to

1. YES Q- 64
p75 6 3 A 3
63B. What is the last grade he completed? (1-12) 8)1363AO
63B1 Is he still in high school? a7363 A /

0. NO GotoQ.63C
1. YES GotoQ.64
63C. Has he gotten a GED or any other schooling or training since then? 64c 0
0. NO GotoQ.64
1. YES GotoQ. 63C1
63C1. What has he received? 1. GED

)3?363C{ 2. other degreekertificate:
3. other schooling:
~&3 6 3 C f 0 1
63C2. Is he currently in school or training? 0. NO Go to

rn63CA 1. YES Q- 64
64. What country(s) best represents his ~ t i o n aorigin
l or ancestry?
1.
2.
c
3.
-
65. D q t he identify with an ethnic group?
0. NO GotoQ.66
1. YES GotoQ. 65A
65A. Which group(s) does he identify with?
1.
v y
z
2.
66. Is he Latino or Hispanic? 66
0. NO GotoQ.67
1. YES GotoQ.66A
1 Hand "CARD 2: LATINO/HISPANIC" to the respondent 1

66A. Which of the following represents his origins? Circle all that apply.
1. Cuba
2. Mexico
3. Puerto Rico
4. Spain
5. South America
7. Other
34
I .
Hand "CARD3: RACE/ETHNICITY" to the respondent I)

67. If you were asked to put him into only one of these groups, in which one would you place
him?
---
Circle ONE only. I__.
I)
1. Asian
2. Pwific Islander
5. Native American
6. Other
This interview MAY or MAY NOT end here.

Answer the following questions yourself and follow the instruMions provided:
. _.
A. Have you obtained information about the biological mother?
Yes -> END INTERVIEW and record time in box below

No-> Got0 Q . 68
-
End Interview and Record Time.
Time Stopped: J
L d
34
Now some questions about *****Is mother
68. What is her first name? Don't Know

Y f
69. Is she still living? 1. Yes Go to Q. 70.1

0.No Go To Q.70.2
4 KT 8. Don't Know Go to Q. 70.1
70.1 What is [*****Is motherl's age?

2, 20 to 29 years 5. 50 to 59 years
8. Don't know
70.2 What was [*****Is motherl's age when she died? 70-
f a
1. Under 20 years 4,40 to 49 years

2. 20 to 29 years 5 . 5 0 to 59 years
8. Don't know
7OA. When was [*****'s mother] born? -

mm %d yy
71. Where was [*****Is mother] born?
A. city B. State
- c. country
c
If *****Is mother is alive, ask Q. 72.1

If *****Is mother has died, ask Q.72.2
A. City
- B. State
- c.country
A. City -
c
B. State c-
c. country -
35

rn.3:dZAo 8. Don't Know
rn 7&/30 8. Don't Know
)I
9
73. Is [*****Is motherl's mother still living? 1. Yes 0. No 8. Don't Know
3% 33
A. city B. State
- c. country
-
If [ *****'s mother's] mother is alive, ask Q. 75.1
If [*****Is mother's] mother has died, ask Q.75.2

- -
A. City B. State
c _
c. country
A. City
- B. State
- c. country
-
75A. When did she come to live in the USA? &3 75A70 year: 19
8. Don't Know
m r5/ao 8. Don't Know
B 3 36
76. Is [*****Is motherl's father still living? 1. Yes 0. No 8. Don't Know

x
c. country
._
A. City B. State
c
If [ *****Is mother's] father is alive, ask Q. 78.1

If [*****Is mother's] father has died, ask Q. 78.2
36

- c-
A. City c
B. State c. country

n - -
c. country
_c
A. City B. State
b
8. Don't Know
)W3 7 8 A O 8. Don't Know
79. Has [*****Is mother] attended school in another country, this country (the US), or both?
m FY
1. another country only Ask Q. 79A
79A. How many years of school did [*****'s mother] have? years (1 - 20)
3,980 79B. At what age did she stop attending school? years old
Am F9CO 79C. Did she receive any type of degree?
0. NO GotoQ.81
1. YES GotoQ. 79C1
79C1. What degree did she receive? Go to

Q. 81
rn T 9 C L
. .
37
80. Did [*****Is mother] f ~ s high

h school? JM 80
0. NO Go to Q. 80.1
1. YES GotoQ.80A
80A. And has she done any studying beyond high school? $Ofi 0
z 0. NO GotoQ.81
1. YES GotoQ. 8OA1
'.I
80A1. How many years of studying beyond high school? cPor4i
-years months
80A2.What is the highest degree she has reached? 80Ah
1. No degree
4. Master's degree
5 . Doctoral degree (J.D., M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other
80A3.Is she currently in school? &0&3

0. NO G o to
1. YES Q. 81
80B. What is the last grade she completed? M g o43O (1 - 12)
80B1 Is she still in high school? Bs14 $ O B 4

0. NO GotoQ.8OC
1. YES GotoQ.81
80C. Has she gotten a GED or any other schooling or training since then?
0. NO GotoQ. 81
1. YES GotoQ. 80C1
80C1.What has she received? 1. GED 80ct

2. other degree/certificate:
3. other schooling:
38
80C2. Is she currently in school or training? ,&580Cfi

0. NO Go to
1. YES Q. 81
$1. What country(s) best represents *****Is mother's national origin or ancestry?
1. 'q M
-c.
2.
-
3.
82. Does *****'s mother identify with an ethnic group? &f,
0. NO GotoQ.83
1. YES GotoQ.82A
82A. Which group@)does she identify with?
1.
l/u
3.
L
83. Is [*****Is mother] Latino or Hispanic? 2% &3

0. NO GotoQ.84
1. YES GotoQ.83A
Hand "CARD 2: LATINO/HISPANIC" to the respondent
83A. Which of the following represents her origins? Circle all that apply.
1. Cuba 83AO
2. Mexico
3. PuertoRico
4. Spain
5. South America
7. Other
..
39
I Hand "CARD 3: RACEETHNICITY" to the respondent

u
'
84. If you were asked to put her into only one of these groups, in which one would you place
her?
Circle ONE only
~ 1. Asian
8+3 89
2. Pacific Islander
3. AI$ican American / Black
5. Native American
6. Other
/I Time Stopped:
PRENATAL HEALTH SCREEN
..
J
PrenatalHealthScreen
FIELD COPY 2 &24/ece i
Now,I have some questions about your pngnautcp.

p,vd 1. About how many weeks pngnant yOU Whcn YOU h t found out you were pngnant?
2a. Whatistheapproxiume date o r e that you think you became pregpaat?

L i
Record as s p d c a date as possible. I f d y a window oftime is kwwn, record the dateson

either side of the window
2a2. DF, you know betwtenwhattwo dates you became pfcpnt?

BetwecntheseDates:
.,$
year
ir
ed. init. ed. date

.,. . , . .. . .... ....,- . . . . .. . . . . .". .,. . . .. . , . . . . . . . . .. . . ,. . .._L.. . , . .. . ..._....
Record as specific a date as possible. If only a window of time is known, record the dates on - ?
either side of the window.

b
3al.
specificDate: pa'&&
month
3a2. Between these Dates:
V i U & month
3b. What is *****Is birth date? fl+&2-'dk 9

-
month &Y
4. Was this pregnancy planned?

FW4
1. Yes
FAMILY STRUCTURE & HEALTH
HISTORY
1
Subject ID:
Interviewer: If the baby has been born, please remember to substitute the baby's name in place of
the words "the baby" or "the child you will be having".
PART I: Family Structure
Now I would like to ask some questions about the family of the child you will be having.
This year I will only be getting a general outline of who is in the family. Next year we
will come back to this information and we will draw out a tree to complete it.
First, let me review a few details.

l.A You told me earlier that you are *****Is: r-.%YQO
(READ AND CIRCLE APPROPRIATE CHOICE)
a. biological mother d. step-mother g. adoptive mother

b. foster mother e. grandmother h. aunt
c. femalecousin f. sister i. other
l.B You told me earlier that you are *****'s: FEY /no
a. biological father d. step-father g. adoptive father

b. foster father e. grandfather h. uncle
c. malecousin f. brother i. other
Is that right? Y N
IF biological mother, GO TO SECTION 1, PAGE 2, Q. 2
IF biological father, GO TO SECTION 2, PAGE 14, Q. 12
-- IF NOT biological parent, GO TO SECTION 3, PAGE 26, Q. 22.
ed.init. &.date
2
SECTION 11: BIOLOGICAL MOTMER
2. What is the baby's biological father's name? m r

? DON'T KNOW
Ast name
If the baby's father is not living, ask questions 3.2, 4.2, and 5.2 (in italics).
??#
3.1 How old is he? /=/3 3- DON'T KNOW

(years old)
3.2 How old was he when he died? DON'T KNOW

(years old)
Ffi 3-A
4.1 What is your marital status with the baby's biological father? 4-
1a married--still involved
lb divorced
IC married, but separated
2a never married--still involved
2b never married-no longer involved
4.2 what was your marital status with the baby'sfather when he died?
l a married-still involved FA+-&
lb divorced
2a never married-still involved
5.1 Are you living together now? 1 . N o GotoQ.5A

2. Yes Go to 6.1A
F;4 5- L
3
5.2 Were you living with the baby's biological father when he died? 1. No Go to Q. 5A
F / 3 5- 4 4
2.Yes Go to 6.2A
9
5A. Was there a time that you lived together? 1. No Goto Q.
6.1A if
Fk5 5-40 father is
alive or 6.2A
_.' ifheis
dead.
2. Yes Go to Q.
5A1
5A1. When did you stop living together? FA FAIL

@ear>
If the baby has been born, ask 6.1A or 6.1B. If the baby has not been born, Go To Q. 8
..
If *****Is father is not living, ask question 6.2A (in italics).
.-
6.1A How much time has *****'s biological father spent with W h e r since s h e was born?
FA 6- /A0
a. none
b. intermittent and unpredictable (less than once a month)
c. intermittent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
4
6.1B DELIBERATELY OMITTED
6.2A Before he died, how much time did *****'s father spend with hidher since s/he was
born?
F f i 6-J A D
a. none
b. intermittent and unpredictable(1ess than once a month)
e. intermittent at set times (less than once a month)
d. once a year
e. twice a month
f. once a week
g. daily
h. other
Y Y
6.2B DELJBERATELY OMITTED
7. DELIBERATELY OMITTED
5
/=/3 8
8. - wiU be
Now I have some questions about the brothers and sisters of the child you
having, including biological, step, foster, or adoptive siblings.
Does the baby have any siblings? 2.Yes 1.No
For each one, I need to know their name, age, whether they are a boy or a girl,
whether they are a biological, step, foster, or adoptive sibling of the baby, and
whether they are still living. If any siblings have a partner or child, I will need to
'*ask you some additional questions about them. Why don't you start with the
oldest sibling?
BROTHERS ~&p,~iT;rs SISTERS
# l b name: m ! b 1s name:
living: Y N age/age died: rA84NA/ living: Y N aie/age died: F&8%4+
cause of death: Fed'A%s/A cause of death: F&&B 2 5
Ffi8RE.S
~ ~
FA8R
bio? step? foster? adopt?
bio'l mom's name:
- bio? step? foster? adopt?
bio'l mom's name: -
bio'l dad's name: - bio'l dad's name: -
If under 12, do not ask - NAP If under 12, do not ask: - NAP
F&?PA/S F&W//S /=&&P6flS
partner? Y N age: gender: M/F
..
Children? Y N
.
# girls:kZ%Wfi # boys : F M B ~ ~
from AgeaWS to F43804)LS
#2b name: # 2 s name:

living: Y N agdage died: %WWJ1(3/ living: Y N age/age died: F/3 #&A
cause of death: f A8%RdA cause of death: F/3B.r7ibdS
YY V"
/=A&RE .r/3 f ABREZ S
bio? step? foster? adopt? bio? step? foster? adopt?
bio'l mom's name:
d
bio'l mom's name: -

bio'l dad's name: - bio'l dad's name: c
If under 12, do not ask: - NAP
Children? Y N F / 3 8 K Z %
# girls:FA&'6irzA # boys : F A 8 B A A
.fromAge to
6
Q. 8 Continued
BROTHERS SISTERS
#3b name: # 3s name:
living: Y N age/age died: living: Y N age/age died:
cause?of death: cause of death:

bio'l morn's name: bio'l mom's name:
bio'l dad's name: bio'l dad's name:
If under 12, do not ask: - NAP If under 12, do not ask: - NAP
partner? Y N age: -gender: M/F
.
..
Children? Y N
# girls:
from Age -to
.
# boys :
Children? Y N
# girls:
bfromAge to
.
# boys :
# 4 b name: #4s name:

living: Y N agelage died: living: Y N agelage died:
cause of death: cause of death:

bio'l mom's name: bio'l mom's name:
partner? Y N age: -gender: M/F partner? Y N age: -gender: M/F
.
Children? Y N
# girls:
wfkomAge to
.
# boys :
Children? Y N
# girls:
wfromAge to
.
# boys :
7
Q. 8 Continued
1
BROTHERS SISTERS
#5b name:
~~
# 5s name:

.
partner? Y N age: vender: M/F
Children? Y N
# girls:
.fromAge to
.
# boys :
Children? Y
# girls:
.fromAge
N
# boys :
to

[funder 12, do not ask: - NAP If under 12, do not ask: - NAP
.
)artner? Y N age:
.
vender: M/F
Zhildren? Y N
# girls:
.fromAge to
# boys :
Children? Y N
# girls:
bfromAge to
.
# boys :
8
Q. 8 Continued
BROTHERS SISTERS
#7b name: '# 7s name:
living: Y N agelage died: living: Y N age/age died:
bio? ,step? foster? adopt? bio? step? foster? adopt?

partner? Y N age: --gender: MIF partner? Y N age: -gender: M/F

Children? Y N Children? Y N
b # girls: b # boys : + # girls: b # boys :
bfromAge to bfromAge to

living: Y N agelage died: living: Y N agelage died:

partner? Y N age: gender: M/F partner? Y N age: -gender: M/F

b # girls: b # boys : + # girls: - b # boys :
bfkomAge to bfkomAge to
9
F/5 9'
9. You told me about (READ NAMES OF SIBLINGS). Are there any
other siblings of the baby, either yours or the baby's biological father's children, that
you may not have mentioned? 2.YES 1.NO
IF the respondent mentions additional siblings, record them on the chart on Item 8.
For definitional purposes "partner" here refers to a sexual relationship with someone of the
same or opposite sex that includes sharing of living quarters for most of the time, without
being married to himher at that time.
L*
10. Have you been married to anyone other than the baby's biological father or lived with
someone else as a partner other than the relationships you have just told me about?
(CIRCLEONE)
1 - NO: GO TO QUESrION 11, PAGE 11.

2 - YES: G O TO 1OA
F/3 fO&O
10A. How many other relationships have you had?
# of relationships
10B. For each of the people you had a relationship with, I need to know their first
name. I also need to know whether you were married or living with them and
whether you are still in the relationship. If the relationship has ended, I need to
know if it was due to divorce, separation or being widowed.
F/3 f O f i gf
1. Gender: M/F -1-
(first name)
Fk3 YO h/Yf
la married-still involved 2a never married-still involved
lb divorced 2b never married-no longer
IC married, but separated involved
Id widowed 2c never married, partner died
-
2. Gender: M/F .1
-
(first name)
F/35fQ/3&%
la married--still involved 2a never rnamed--still involved
lb divorced 2b never married--no longer
Ff3fDk563
3. Gender: M/F .1
(first name)
/=e
5/043w3
4. Gender: M/F
(first name)

5 . Gender: M/F .1
(first name)
la married--still involved 2a never married-still involved

11
c
6. Gender: M/F
(first name)
la married--still involved 2a never married--still involved

x
'*#
F& I'C%~G~
7. Gender: M/F .1 7
(first name)
/erRm/3M-Z-
F/s 77
11. Has the baby's biological father been married to anyone or lived with someone else as
a partner other than the relationships you've just told me about? (CIRCLEONE)
1 - DON'T KNOW: GO TO Q. 37, PAGE 43.

2 - NO: GO TO Q. 37, PAGE 43
3 - YES: GO TO 11A
11A. How many other relationships has he had?

# of relationships
FeJ77./30
12
11B. For each of the people the baby's biological father had a relationship with, I need to
know their first name. I also need to know whether he was married or living with
them In;ALIVE:and whether he is still in the relationship]. If the relationship has
ended, I need to know if it was due to divorce, separation or being widowed.
1. Gender: M/F .1
F .YYk5 Gf * I
(first name)
I
'*4
~ f i Mi la married-still involved 2a never married--still involved
Id widowed 2c never married, either partner
died
2k don'tknow
-
2. Gender: M/F .1
(first name)

died
2k don'tknow
3. Gender: M/F .1
(first name)

died
2k don'tknow
13
-.
4. Gender: ME 1
(first name)
l a married--still involved 2a never rnanied-still involved

l b divorced 2b never married-no longer
IC married, but separated . involved
died
2k don'tknow
5 . Gender: M/F .1
(first name)

died
2k don'tknow
6. Gender: M/F .1
-
(first name)

died
2k don'tknow
-
7.Gender: M E .1
(first name)
- la married-still involved 2a never married-still involved

F/s'JnM-7- lb divorced 2b never married-no longer
- IC married, but separated involved
died
2k don'tknow
14 ....
SECTION 2: BIOLOGICAL FATHER

..
*
L
-1
12. What is *****Is biological mother's name? DON'TKNOW , ,
firYst m e
If *****'s mother is not living, ask Questions 13.2,14.2, and 15.2 (initalics).
Fn i3- f DON'T KNOW

)..
13.1 How old is she?

'=4 (years old)
13.2 How old was she when she died? DON'T KNOW
/=nf 3 - A (years old)
14.1 What is your marital status with *****Is biological mother?
la married-- still involved FA 7w-f

lb divorced
14.2 What was your marital status with *****Is mother when she died?
la married-still involved F n f4-&
lb divorced
15.1 Are you living together now? ~6 /,y- 1 1.No Go to Q. 15A

2.Yes Go to Q. 16.M
15.2 Were you living with *****Is 1.No Go to Q. 15A

biological mother when she died? 2. Yes Go to Q. 16.2A
15
15A. Was there a time that you lived together? 1. No Go to

Q. 16.1A
F/3 r5.a if mother is
alive or Q.
16.2A if she
is dead.
*
2. Yes Go to Q. 15Al
9 F A YSAd -
15A1. When did you stop living together? (Year)
If the baby has been born, ask 16.lA or 16.U. If the baby bas not been born Go To Q.
18
If *****Is mother is not living, ask Question 16.2A (in italics).
16.1A How much time has *****Is biological mother spent with W h e r since s h e was
born?
F& ;/sf40 a. none

C. intermittent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g. daily
h. other
16.24 Before she died, how much time did *****'s biological mother spend with himher
since she wcrs born?
7'62 AO a. none
d. once a year
e. twice a month
f. once a week
g-
h. other
16
17. DELIBERATELY OMMlTTED

17
Fi3
18. Now I have some questions about *****'s brothers and sisters, induding
biological, step, foster, or adoptive siblings.
Does he/she have any siblings? 2.Yes 1.No
whether they are a biological, step, foster, or adoptive sibling of *****, and
whether they are still living. If ***** has siblings who have a partner or child, I
will need to ask you some additional Q.s about them. Why don't you start with
'-4
the oldest sibling?
BROTHERS F/3/8LlYS SISTERS

r
# l b name: # Is name:
living: Y N agelage died: fh&?!MA, h i n g : Y N age/age d i e d : F e M q
cause of death: F/3 /84Ab?? cause of death: /=& i8UB /<
&
F . / 8 RE L3
Y'
f / a &&E f&
bio'l mom's name: dapyed. bio'l mom's name: -
bio'l dad's name: y, bio'l dad's name: -
F& /&/??/A F/3f&Pf/.. F&fdpd/.. f&PA 123 #p7'fs /4a@Pgi s
partner? Y N age: -gender: M/F partner? Y N age: gender: M/F
Children? Y N P n A 2 X Z f l & Children? Y N ,f%3/8XZYS
b # girls: b # boys : F L ~ A ~ R O ~ %
b fi-om Age to FI3/80~/&

#2b name: #2s name:
living: Y N age/age died: & k W ~ s living: Y N age/age died:
cause of death: Fs 48 &&a&cause of death:
h h
F/3i'BRARR FA /8E E d S
bio'l mom's name: - bio'l mom's name: -
bio'l dad's name: bio'l dad's name: -
[funder 12,do not ask: - NAP
''8p4#q
3artner.
&3/8#?i&58
F&/c?Kd&
N age: -gender: M/F
Zhildren? Y N ~fii&/c.z&A
' # girls: c # boys : F f i 7 " g o a R
bfromAge to F&i& O R R g
18
Q. 18 Continued
BROTHERS SISTERS
# 3 b name: '# 3s name:

partner? Y N age: vender: M/F partner? Y N age: -gender: M/F

# girls: b # boys : # girls: # boys :
bfiomAge to

living: Y N age/age died: living: Y N agelage died:

[f under 12, do not ask - NAP [funder 12, do not ask: - NAP
?artner? Y N age: -gender: M/F partner? Y N age: gender: M/F

Mdren? Y N Children? Y N
b # girls: b # boys : b # girls: b # boys :
bfiomAge to bfromAge to
19
Q. 18 Continued
BROTHERS SISTERS
~


Ifunder 12, do not ask: - NAP If under 12, do not ask: - NAP
partner? Y N age: partner? Y N age: -gender: M/F
. .
gender: WF
# girls: # boys : # girls: # boys :
.fromAge to .fkomAge to
# 6 b name: # 6s name:
living: Y N agelage died: living: Y N age/age died:

gender: M/F
. .
partner? Y N age: .- partner? Y N age: gender: M/F
+ # girls: b # boys : # girls: # boys :
wfkomAge to .fkomAge to
20
1 Q. 18 Continued
BROTHERS SISTERS
~
#7b name: "# 7s name:

b

-
. .
partner? Y N age: gender: M/F partner? Y N age: gender: M/F
.
Children? Y N
# girls:
bfromAge to
.
# boys :
Children? Y N
# girls:
.fromAge to
# boys :
# 8 b name: # 8 s name:

bio'l mom's name: - bio'l mom's name:
If under 12, do not ask: - N W If under 12, do not ask: - NAP
.
Children? Y N
# girls:
bfromAge to
.
# boys : .
Children? Y N
# girls: -
bfromAge to
.
# boys :
-- ,
21
a 3 ./9
other siblings of *****, either yours or *****Is biological mother's children, that you
may not have mentioned? 2.Yes 1.No
1 IF the respondent mentions additional siblings record them on the chart on Q. 18. I
1 .
being married to W h e r at that time.
20. Have you been married to anyone other than *****Is biological mother or lived with
someone else as a partner other than the relationships you've just told me about?
(CIRCLE ONE)
1. - NO: GO TO Q. 21.
2. - YES: GO TO Q. 20A

# of relationships
whether you are still in the relationship. If the relationship has ended, I need
to know if it was due to divorce, separation or being widowed.
1. Gender: M/F --1

first name
la married-still involved 2a never married--still involved

22
2. Gender: M/F .1
I_
first name

3. Gender: M/F -1
-
frrst name
l a married-still involved 2a never married-still involved

4. Gender: M/F .1
fmst name

IC mari-ied, but separated involved
5 . Gender: M/F .I -
first name

F/3mA6 6 6. Gender: WF .1 22
first name
F/sm/3M ' la
lb
married--still involved
divorced
2b never married-no longer
IC manied, but separated involved
._I
23
fb3 RD A64 7. Gender: M E .1

-
first name
FI3dLD /3M 3. la married-still involved 2a never married-still involved

IC married, butseparated . involved
Id widowed 2c .never married, partner died
%
?=&AS
21. Has *****Is biological mother been married to anyone or lived with someone else as a
partner other than the relationships you've just told me about? (CIRCLEONE)
1 - DON'T KNOW: GO TO Q. 37, PAGE 43.

2 - NO: GO TO Q. 37, PAGE 43.
3-YES: GO TO Q. 21A
ff3444448
21A. How many other relationships has she had?
# of relationships
21B. For each of the people *****Is biological mother had a relationship with,I need
to know their first name. I also need to know whether she was married or
living with them [ IF ALIVE: and whether she is still in the relationship]. If
the relationship has ended, I need to know if it was due to divorce, separation
or being widowed.
c-
1. Gender: M/.F .1
first name
la married-stiU involved 2a never married-still &volva

Id widowed 2c never married, either
partner died
2k don'tlcnow
i
GR
o&{h 2. Gender: M/F .1
fKst name
/fi WtX, l a manied--still involved 2a never married-still involved

partner died
?.I 2k don'tknow
3. Gender: M/F .1
-
first name.

partner died
2k don'tknow
4. Gender: I/F
-
first name
la married-still involved 2a never married-stili involved

partner died
2k don'tknow
5 . Gender: M/F .1
first name

partner died
2k don't know
F
6. Gender: M/F .1
first name
l a married--still involved 2a never married-still involved

partner died
2k don'tknow
.-c
7. Gender: M/F .1
first name

partner died
2k don't know
I GO TO Q. 37, PAGE 43. I

26
SECTION 3: Other Caregiver

[Male/Female]
First I have some questions about *****Is biological mother and father.
22. wt is *****'s biological mother's name? DON'TKNOW

'first name
If *****Is mother is not living, ask Q.s 23.2 and 24.2A (in italics).
23.1 How old is she? Ffi R 3- f DON'T KNOW

(years old)
Fs;Jot?3-~ (years old)
If the baby has been born, ask Q.24.1A or 24.2A. If the baby has not been born, G o To
Q. 25.
24.1A How much time has *****Is biological mother spent with W h e r since s h e was
born?
f E3 R4- /A0
a. none
d. once a month
e. twice a month
f. once a week
g. daily
h. other

-
27
/!=&&$-
2 4 . 2 Before she died, how much time did *****Is mother spend with himlher since
slhe was born?
a. none
d. once a month
e. twice a month
f. once a week
g. daily
9
h. other
25 What is *****Is biological father's name? DON'TKNOW

"first m e
If *****'s father is not living, ask Questions 26.2 AND 27.2A (in italics).
26.1 How old is he? Ffi 6-4 DON'T KNOW

(years old)

Fna6-A (years old)
If the baby has been born, ask Q. 27.1A or 27.2A. If the baby has not been born, Go To
Q. 28.1
27.IA How much time has *****Is biological father spent with himmer since she was
born? /=/3oz 7-/ A 0
a. none
d. once a month
e. twice a month
f. once a week
g- daily
h. other
28
27.24 Before he died, how much time did *****Is biological father spend with
hidher since s/he was born?
F/3A7-RhO
a. none
% c. intermittent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g. daily
h. other
27.B DELIBERATELY OMITTED
28.1 Are *****Is biological parents living together now? 2.Yes 1. No 3.DON'T
F e a&-f KNOW
If either of *****Is pakents are not living, ask questions 28.2 and 29.2 (in italics).
28.2 Were *****Is biological parents living together when *****Is motherflather
died?
2. Yes 1. No 3. DON'T KNOW
29.1 What is the marital status of *****Is biological father and mother?
Fna9- 3! la married-still involved

lb divorced
29
29.2 What was the marital status of *****Is biological father and mother when
*****Is mothergather died?
l a married--still involved
FnA9-a l b divorced
..
2b never married--no longer involved
, .,
30
F A 30
30. Now I have some questions about *****Is brothers and sisters, including
Does he/she have any siblings? 2.Yes 1.No 3. DON'T KNOW
5
?uyiu need to ask you some additional questions about them. Why don't you start L A
&th the oldest sibling.
BROTHERS f630LI& SISTERS

# l b name: # Is name:
living: Y N age/age died:h32DHA/& bhg:Y N age/age d i e d : F i r ' s
cause of death: F&37/9B& cause of death: F4&&23fS
:
30& A43 f 45
~
F&LDRE~S
bio'l mom's name: - bio? step? foster? adopt?
bio'l mom's name: -
bio'l dad's m e : - bio'l dad's name: -
w&fA 30@6 /A
F/;s rt/330/?4& F&3W6/5
-
f&zu3p1& /=m3OHfS
partner? Y N age: gender: M/F partner? Y N age: -gender: M E
Children? Y N fk336kZ7'43
b #girls: b # boys : F 2 3 ~ ~ ~ A -1
bfromAge to F R 3 0 O A /A id
I '
#2b name: - # 2 s name:

c
living: Y N
living: Y N
cause of death:
age/age died: FZ?d@AW
-
FA3 3Ombtx cause of death: -age/age died: FA3QWO
F/33QAW
Fk330RZA f&30RAS
bio'l mom's name: - bio? step? foster? adopt?
bio'l mom's name: -
bio'l dad's name:
- bio'l dad's name:
-
[f under 12, do not ask: - NAP If under 12, do not ask: - NAP
3
/: 3 Q m 5 /=/32BPG/PS /=43o=*s*
Childyn<06TAs N FA
b # gas: # boys : FA30-
bfromAge to
31
Q. 30 Continued
BROTHERS SISTERS
~


bio'l dad's name: bioi dad's name:
partner? Y N age: -gender: MLF partner? Y N age: -gender: M/F

'# girls: # boys : b # girls: - # boys :
bfiomAge to bfiomAge to

living: Y N age/agedied: living: Y N age/age died:

partner? Y N age: ,-gender: ME partner? Y N age: gender: M E

b # girls: # boys : b # girls: b # boys :
bfiomAge to bfromAge to
32
II Q. 30 Continued I
BROTHERS SISTERS
# 5 b name: -# 5s name:


Children? Y N
# girls:
.fromAge to
# boys : .
Children? Y N
# girls:
.f'romAge to
.
# boys :


K under 12, do not ask: - NAP If under 12, do not ask: - NAP
.
.
Children? Y N
# girls:
bfromAge to
.
# boys :
Children? Y N
# girls:
.fromAne to
# boys :
30
33
1 Q. 30 Continued
BROTHERS SISTERS
#?b name: # 7s name:

If under 12, do not ask: - NAP If under 12, do not ask - NAP
partner? Y N age: -gender: M/F partner? Y N age: __ gender: M/F

b # girls: b # boys : b # girls: b # boys :
bfromAge to bfiomAge to


partner? Y N age: oender: M'F partner? Y N age: ,-gender: ME

t # girls: b # boys : # girls: b # boys :
bfiomAne to- bfiomAge to

34
FB 3i
31. You told me about (READ NAMES OF SXBLINGS). Are there any
other siblings of ***** that you may not have mentioned?
2.Yes 1.No 3. DON'T KNOW
~
IF the respondent mentions additional siblings record them on the chart on Q. 30.
n
same Zr opposite sex that includes sharing of living quarters for most of the time, without
being married to him/her at that time.
32. Do you know if either of *****Is biological parents were married to anyone else or
lived with someone else as a partner? (CIRCLEONE)
1 - DON'T KNOW: GO TO Q. 33.

2 -NO: GO TO Q. 33.
3 -YES: GO TO Q 32A
32A. How many other relationships has he/she had?
F 5 3oZAM-l
Bio mother: # of relationships
f /3 3pz A Ff
Bio father: # of relationships
32B. For each of the people [the biological mother/father] had a relationship with, I need to
know their fust name. I also need to know whether [she/he they] [were/was] married
or living with them ALIVE:and whether [she/he/they] [idare] still in the
relationship]. If the relationship has ended, I need to know if it was due to divorce,
separation or being widowed.
Biological mother:
1. Gender: M/F .1 r r
first name
,c& 32 ~ ~ f l l a4 married-still
- involved 2a never married-still involvg
partner died
2k don'tknow
35
2. Gender: M/F .1
lirst name

partner died
2k don'tknow
3. Gender: WF .1
fEst name

partner died
2k don'tknow
4. Gender: M/F -1
first name

partner died
2k don'tknow
5 . Gender: M/F -1
first name

lb divorced 2b never married-no longer .
Id widowed 2c never married, either .
partner died
2k don'tknow
6. Gender: M/F .1
first name
k
partner died
2k don'tknow
.1
#=/33AAMG+-7. Gender: M/F
first-: '
F/3 3a f i la married-still involved 2a never married--still involved
partner died
2k don'tknow
Biological father:
/=s3otA&i 1. Gender: M/F .1 &

fist name

rmnnH4 lb divorced 2b never married-no longer
partner died
1
2k don'tknow
f
2. Gender: M/F .1
first name

partner died
2k don'tknow
.F
3. Gender: M/F .1
first name
1a married-still involved 2a never married--still involved

'4 partner died
2k don'tknow
4. Gender: M/F .1
frst name

partner died
2k don'tknow
5 . Gender: WF .1
fmt name

partner died
2k don'tknow
L
6. Gender: M/F .1
fxst name
1a married--still involved 2a never married-still involved

partner died
I 2k dontknow
7. Gender: M/F 1

Id widowed 2c never married,either
partner died
2k dontknow
33. How old was ***** when he/she first came to live with you? ?=/333
Age
39
34. What circumstances led to ***** living with you?

(WRITEIN RESPONSE AND CIRCLE CODES)
1. biological mom died 9. biological mom hospitalized: substance use

2. biological dad died 10. biological dad hospitalized: substance use
3. biological mom in prison 11. biological mom hospitalized: medical reason
4. biological dad in prison 12. biological dad hospitalized: medical reason
5. biological mom abandoned ***** 13. biological mom hospitalized: psychiatric
6. biological dad abandoned ***** 14. biological dad hospitalized: psychiatric
7. biological mom in another country 15. biological mom lost custody(specify reason)
8. biological dad in another country
16. biological dad lost custody (specify reason)
17. biological parents put ***** up for adoption

~ ~~~~~
40.other reason (specify reason)

F1s 35-
35. Has ***** always lived with you since the fvst time she/he came or have there been
periods during which she/he did not live with you? (CIRCLEONE)
a. Always lived with me: GO TO Q. 36.

b. Has not always lived with me: GO TO Q. 35A.
35A. Describe other living arrangements since ***** first came to live with you:
b
41
Now I have some questions about the time since ***** first came to live with you.
36. I need to know whether you have lived with anyone as a partner while ***** has been
living with you. (CIRCLEONE)
F / s 36 1 - NO: GO TO Q. 37.
2 - YES: GO TO Q. 36 A
36A. How many relationships have you had during this time?
# relationships
F/W20
.36B. For each of the people you had a relationship with, I need to know their first
1. Gender: M/F .1
first MI4
Y

w
2. Gender: M E .1
I
first name

3. Gender: M/F .1
-2-
first name
1 la
lb
married--still involved
divorced
2a never married-still invorved
42
4. Gender: M/F .1
first name

le married, but separated involved
i Id widowed 2c never married, partner died
5 . Gender: M E .1
first name

6. Gender: M/F .1
first name

~3 36 A G 7 7. Gender: M/F .1
first Iliimtj
,E&3 6 f5H3-
43
37. Does ***** regularly spend any nights of the week in another household or anywhere
else? phis does not include day care]
F/3 3-2- 2.Yes 1.No
Relation to *****
B = biological [parent, sibling,
N = nonbiological auntluncle,
M = maternal grandparent, child,
P = paternal other]
A B C D
)=/337-j& Fk337-/L f /3 37- /w
.1 BorN MorP
E Other relation
I
F Nights each week:
G Nights each month:
H Other arrangement:
C
-
A B D
.2 Name BorN MorP
E Other relation
I
F Nights each week:
B C
-
A D
.3 Name BorN MorP
E Other relation
I I
F Nights each week:
38.DELIBERATELY OMITTED
CHECK HOUSEHOLD COMPOSITION
39. Now I need to list all the people who live in this household. For each person who
lives here, I would like you to tell me how he or she is related to the baby you will be
having. For example, I want you to tell me if the person you list is the baby's brother or
aunt or cousin. Even if a person who lives here is not related to the baby, I need you to
list thepl also.
?
1 Record first name and relationshb of each Derson in household to *****(the unborn child). I
Relation to *****
B = biological Eparent, sibling,
N = nonbiological aunt/uncle,
P = paternal other]
A B C D
.39-713 F A 3 9 / C
=E
f
.1 Name B or N M or P
I f
.2 Name B or N
1
.3 Name B or N
.4 Name BorN M or P
, \
.7 Name B or N M or P w
-8 Name B or N M or P
.10 N&e B or N M or P
Part II: Family Health History
40. Now, I have some questions about the baby's family's health hidory. I need to know
if anyone in the baby's family including everyone that was just mentioned, has any of the
following health problems. For each person you list, please tell me how he or she is
related to the baby whether he or she is a biological or non-biological relation. Please
include yourself.
Diabetes: (circle one) 2.YEs 1.NO

[Suga? Diabetes, Sugar in Blood/UrineJ
=d
ati
P = paternal other]
A B C D
f 59Q- /& F/3&- 1'c
.1 Name
LMorP YY
.2 Name BorN MorP
.3 Name BorN MorP
-4 Name BorN MorP
.5 Name BorN MorP
-6 Name BorN MorP
.7 Name BorN MorP
-8 Name BorN MorP
.9 Name BorN MorP
.10 Name BorN MorP
.ll Name BorN MorP
.12 Name BorN MorP

46
Fn4d -
41. High Blood Pressure: (circle one) 2.Yes 1.No
/Hypertension]
Relation to *****
P = paternal other]
k
A B C D
/5&4j-J&3 Fey-
.1 Name BorN , M o r P
(I/
.2 Name BorN MorP
-3 Name BorN MorP
-4 Name BorN MorP
.5 Name BorN MorP
-6 Name BorN MorP
.7 Name BorN MorP

\-
.8 Name BorN MorP
.9 Name BorN MorP
.10 Name BorN MorP
. l l Name BorN MorP
.12 Name BorN MorP
-13 Name BorN MorP
-14 Name BorN MorP
.15 Name BorN MorP
-16 Name BorN MorP

. ......
.,& . . . .
47
fb4&
42. Heart Problems: (circle one) 2.YES 1.NO
[Heart Attacks, Coronary, Arrhythmia]
Relation to *****
B = biological. [parent, sibling,
f$ P = paternal other]
A B C D
F54d- /& /=&'/2-I C
.1 Name BorN MorP
L v r
-2 Name BorN MorP
-3 Name BorN MorP
-4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
-7 Name BorN MorP
.8 Name BorN MorP
.9 Name BorN MorP
.10 Name BorN MorP
-11 Name BorN MorP
.12 Name BorN MorP
:13 Name BorN MorP
.14 Name BorN MorP
I
48
43
43. Stroke: (&de one) 2.YEs 1.NO
Relation to *****
* N = nonbiological aunthncle ,
i=4 P = paternal other]
I'
A B C D
/5343-/A F2543- fz-
.1 Name BorN MorP
4
.2 Name BorN MorP
.3 Name BorN MorP
-4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN MorP
.8 Name BorN MorP
.9 Name BorN MorP
.10 Name BorN MorP
-11 Name BorN MorP
-12 Name BorN MorP
-14 Name B orN M or P
49
Fh44
44. Cancer: (circle one) 2.YEs 1.NO
rumors, Leukemia]
Relation to *****
B = biological Cparent, sibling,
N = nonbiological aunthcle ,
P = paternal other]
A B C D
F43 44- T I 3 /=/344- K.
-1 Name BorN MorP
fl
.2 Name BorN MorP
.3 Name BorN MorP
.6 Name B orN M or P
.7 Name B or N MorP
S O Name B or N M or P
-15 Name
- BorN MorP
.16 Name BorN MorP

50
Fk3 4-45-
45. Asthma, Chronic Bronchitis or Emphysema: (circle one) 2.YEs 1.NO
[Smokers Cough, Wheezing]
Relation to *****
N = nonbiological aunthncle ,
P = paternal other]
'.4
A B c D
.2 Name BorN MorP
.3 Name BorN MorP
.4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN MorP
.8 Name BorN MorP
.9 Name BorN MorP
.10 Name BorN MorP
.11 Name BorN MorP
-12 Name BorN MorP
.13 Name BorN MorP
-14 Name BorN MorP
.15 Name BorN MorP

51
F/3 46
46. Other chronic problems (specify): (circle one) 2.YES 1.NO
Relation to *****
N = nonbiological aunthncle,
M = maternal- grandparent, child,
* P = paternal other]
S 1
A B C D
fa&- /& F&-J/S- c
.1 Name BorN MorP
/ f
E ILLNESS (please specify):
.2 Name
A
- B C
p-/3&L7zA F 3 4 6 - R C
BorN MorP
D
__

-
A B C D
- FABd-3/8 Ffi46-3C -
.3 Name BorN MorP

-
.4 Name
A
L_
B
f434'6-443
BorN
C
FA4g-4c
MorP
- D
E ILLNESS (please specify): c _

-
I
FAMILY MENTAL HEALTH &
LEGAL HISTORY
Family Mental Healfh and Legal History
Subject ID: SkB/&r
Interviewer ID:
FIELD COPY 2 1 FMh/t/R&/B-
Now I'm going to ask you some more Questions about all the people in *****'s/p=
famiiy that you've mentioned today.
1. Has drinking ever caused any of the people mentioned to have problems with health,
M y , job, or police?
FiY 1 2.YEs 1.NO
h
to *****
N = nonbiological Wuncle,
M = materna! grandparent, chiid,
P = paternal O*l
.1 Name BorN MorP
.2 Name BorN 1M o r P
.3 Name BorN MorP
.4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN 'MorP
.8 Name BorN MorP

-
e!d.init. &.date
2
F/yd/
2. Has drug use ever caused any of the people mentioned to have problems with health,
family, job,or police?
2.YES 1.NO
5
*****
B = biological Iparent, sibling,
iY N = nonbiological auntlunclc,
M = mated grandparent, child,
P = paternal 0-1
A B C D
FW&-f/3 F N d - fC f/y d - #*
.1 Name BorN MorP
V f
.2 Name .1. BorN MorP
.3 Name BorN MorP
.4 Name BorN MorP
.S Name BorN MorP

.6 Name BorN MorP
.7 Namc BorN MorP
.8 Name BorN MorP
.9 Name BorN MorP
-10 Name BorN MorP
.ll Name BorN MorP
-12 Name BorN MorP
.13 Name BorN MorP
.14 Name BorN MorP

F / l j d - i3-B FMdZ - fsc FMd- f3w
.15 Name BorN MorP
3
fM3
3. Has anyone mentioned ever suffered from depression, that is, they have felt so low for a
period of at least two weeks that they hardly ate or slept, or couldn't work or do whatever
they usually do?
2.YES 1.NO
RdatiQU to *****
B = biological w e n t , sibling,
M = maternal - &randparent, child,
P = patemal other]
.1 Name BorN MorP
.2 Name BorN MorP
.3 Name BorN MorP
.4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN MorP
.8 Name BorN MorP
.9 Name BorN MorP
.10 Name BorN MorP
.12 Name BorN MorP
.13 Name BorN MorP

-
.14 Name BorN MorP
. ..
4
PP74
4. Has anyone mentioned ever had frequent trouble with the law, often become involved in
, trouble holding a job, or was a frequent discipiine probiem in school?
fiatshad
2.YES 1.NO
tc) *****
7=t B = biological w e n t , sibling,
N = nonbiological amtluncle,
M=maternal grandparent, child,
P = paternal other]
A B C D
.1 Name
. FMI/-JA FM4- K
B or N M or P
j=#4- /*
.2 Name B or N M or P \1
-3 Name BorN MorP
.4 Name B or N MorP
-5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN M or P
.8 Name BorN MorP
.9 Name BorN M or P
.10 Name B or N MorP
. l l Name B or N M or P
.12 Name BorN MorP
.13 Name
- B or N M or P
5
FN 5-
5. Ha anyone mentioned ever had problems with their nerves or had a nervous breakdown?
2.YES 1.NO
to *****
B = biological w e n t , sibling,
M = maternal &randparent, child,
P =pated other]
.1 Name BorN MorP
.2 Name BorN MorP
.3 Name BorN MorP
-4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN MorP
.8 Name BorN MorP
.9 Name B or N MorP
.10 Name BorN MorP
.11 Name BorN MorP
.12 Name BorN MorP
.13 Name BorN MorP
.14 -Name BorN MorP
-15 Name BorN MorP

6
FM 6
6. Has anyone mentioned ever talked to a doctor or a counselor about any emotional
problems or probiems they might have had with alcohol or drugs?
2.YES 1.NO
to *****
h B = biological barcnt, sibling,
N = nonbiological aunt/uncie,
P =pated other]
A- k C D
.3 Name BorN MorP
E Reasonfortreatment: L.
A
.-
B C D
.4Name BorN MorP
.5Name -
A B
BorN
C
MorP
D
E Reasonfortreatment -
.6Name -
A B
BorN
C
MorP
D
E Reason for treatment: -

F/Y *
7. Has anyone mentioned ever been hospitalized because of emotional probiem, or because
7
of drug or alcohol problems?
2.YEs 1.NO
to *****
P =paternal other]
F#X-/A FN?-/C F/Y?-fB

A B C D
.1 Name BorN MorP
E Reason for treatment:
A B C D
.2Name - BorN MorP
E Reason for treatment: -

B C D
.3Name -
A
BorN MorP

-
.4 Name
-
A B
BorN
C
MorP
D
E Reason for tteatment:

-
A B C D
.SName - BorN MorP
E . Reason for treatment:

-
A B C D
.6Name
-
- BorN MorP
E Reason for treatment

-
. - .
FM 8
8. Have any of the people youve mentioned ever attempted suicide?
2.m 1 .NO
to *****
at
M=mattrnai grandparent, child,
P = paternal other]
.1 Name BorN MorP
.2 Name BorN MorP
.3 Name BorN MorP
.4 Name BorN MorP
.5 Name BorN MorP
.6 Name BorN MorP
.7 Name BorN MorP
.8 Name BorN MorP
.9 Name BorN MorP
-10 Name BorN MorP
.12 Name BorN MorP
.13 Name BorN MorP
.14 Name BorN MorP
.15 Name BorN MorP

9
FM9
9. Have any of the people youve mentioned ever committed suicide?
2 . m 1 .NO
to *****
N = nonbioiogical aduncle,
M =mated grandparent, child,
P =paternal other]
A B C D
FM 9-723 FN9- I C FNQ- m
B or N M or P
1
.1 Name
1
.S Name B or N M or P
.8 Name B or N MorP
.9 Name BorN M or P
_- * 10 Name B or N M or P
.llName B or N M or P
-
Name B or N M or P
-14 -Name B or N M or P
-15 Name BorN M or P
10
9A. SO,none of the people mentioned have had ally problems with alcohol or drugs,
getting into trouble, or emotional problems?
(CIRCLE ONE)
FM m 0
-
%
1 no one else
2 -tJadditiod family member listed
committed suiade - page 9

Attempted suicide - page 8
Hospftalized for alcohol, emotional problems, or drugs - page 7

Talked to a eotmselor about drugs, alcohol or emotional problems - page 6
-
Nemous breakdown page 5
Fights, freqaent trouble with law, trouble holding a job - page 4

suffered fiom depression - page 3
Drug use caused problems with health, family, job, or police - page 2
Drinldng caused problems with health, family, job, or police - page 1
-11
Now I have some questions about whether there is anyone mentioned who has had
trouble with the police or who has been arrested. Please do not include rolrtine traffic
violations or speeding tickets.
FM i o
10. Has anyone that you've mentioned had trouble with the police or been mated?(CIRCLE
om
1. NO:
2. YES
1OA. What is hisher name and how is he/she related to *****?

FM5/8AoL fM7z?!3 9
2 3 4
&&%d B o r N M or P
Name Relation
FM7k3CO 1OC. And were there any other reasons hdshe was in trouble with the police?
(CIRCLE ONE)
2.m 1 .NO
1OD. Is he/* in jail or prison now? (CIRCLEONE) 2 . m 1.NO

FfllZlPO
12
F2Y ff
11. Has anyone else had trouble with the police or been arrested? (CIRCLEONE)
1. NO:
I eENDOFINTERVIEW8 RECORDTIME
11~. is hisher name and how is he/she related to *****?

F/Y/f&Z FMHA 3 FMiA4q
1 2 3 4
I
B or N M or P
yName Relation
TM//&O 11B. Do you know what he/& did? (CIRCLEONE) 2.m 1.NO
z
,y
, yyco 11C. And were thert any other reasons ht/she was in trouble with the police?
(CIRCLE ONE)
Fm7/m
11D. Is he/* in jail or prison now? (CIRCLEONE)
-
2.m 1 .NO
13
Fwd25
12. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
B 8 END OF INTERVIEW 8 RECORD TIME

I
q 2. YES
12A. What is hisher name and how is he/she related to *****?

FN#&Aoe FMJzA3 f M*&
1 2 3 4
v
B or N M or P
Name Relation
FMA&&O 12B. Do you know what he/she did? (CIRCLE ONE) 2.m 1 .NO
E ,. ...............?
............................. ....,.
.....................
......
what did he/she do?
12B1.
12C. And were there any other reasons he/& was in trouble with the police?
FM/&Co (CIRCLE ONE)
2.m 1.NO
12C1. What other offenses Ied to himher having trouble with the police?
FHzw-Q 12D. Is hehhe in jail or prison now? (CIRCLE ONE) 2.m 1.NO
14
FMf3
1. NO:
1 8 END OF INTERVIEW B RECORD TIME I

Z! YES
13A: What is hisher name and how is hdshe related to *****?

FM##h FMSA3 f%ft3&4
1 2 3 4
r
B or N M or P
bme Relation
m+/3& 13B. Do you know what he/& did? (CIRCLEONE) 2.m 1.NO
13B1. *= whatdidhc/shcdo~
............,
............-..........
..__ii
IFM f3co 13C. And wcrc therc any other ~cas011s

Wshe was in troubie with the poiice?
(CIRCLEONE)
2.m 1 .NO
13C1. :@$@ I&

What othcr offenses led to him/her having trouble with thc police?
13D. Is hdshe hjad or prison now? (CIRCLEONE) 2.m 1 .NO

FM13m -
15
F=M 7y
1. NO:
8 END OF INTERVIEW. 0 RECORD TIME
14A. What is hisher name and how is he/& related to *****?

FM /4&R F M f 4 A 3 FM7W34
1 2 3 4
- & BorN M or P
Name Relation
fMf4k30 14B. Do you know what he/she did? (CIRCLE ONE) 2.m 1 .NO
14B1. w =g
.............................
.................
........................
...............
what did he/she do?
14C. And were there any other reasons he/she was in trouble with the police?
FMI4Co (CIRCLE ONE)
2.m 1.NO
14C1. What other offenses led to him/her having trouble with the police?
heishe in jail or prison now? (CIRCLE ONE) 2.- 1 .NO

16
FMf5
1. NO:
n
I 0 END OF INTERVIEW 8 - RECORD TlME I
l5A. What is hisher name and how is he/she reiated to *****?

FMf5Aa /Gw45-##3 FMf5A4
*eoe
1
Name
2
B or N
3
M or P
4
Relation
15B. Do you know what he/& did? (CIRCLE ONE) 2.m 1.NO
FNir5BO
15B1. ElMESi What did he/& do?
/=Mfco 15C. And were there any other nasons k/&ewas in trouble with the police?
(CIRCLE ONE)
15D. Is hdshe in jail or prison now? (CIRCLEONE) 2.m 1 .NO

FW7+5-&9 -
17
FM
1. NO:
8 END OF INTERVIEW*@ RECORD TIME
"4 2. YES
16A. What is hisher name and how-is he/& related to *****?

FM f 6 A R FM 1'6A3 FM f6 &
1 2 3 4
&eQP?t?d
r *
B or N M or P
Name Relation
FMf6430 16J3. Do you know wbat he/she did? (CIRCLE ONE) 2.m 1.NO
.............. ..,....
16B1 mi
...........:.:.:.:............. What did he/she do?
F~ f6 ~0 16C. And were there any other reasons hdshe was in trouble with the police?
_-
(CIRCLE ONE)
2.m 1.NO
.....................
16Cl. What other offenses led to himmcr having trouble with the police?
Y
F/yJsBq 16D. Is he/she in Jailor prison now? (CIRCLE ONE) 2.YEs 1.NO
I
ia
F/y jfq
1. NO:
"
2. YES
17A. What is hisher name and how is he/she related to *****3

FMf?#R F/Y/?A3 fMf?A&
1 2 3 4
B or N M or P
Relation
FWf380 17B. Do you know what he/she did? (CIRCLEONE) 2 . m 1.NO

1m 1. ...........:.;..................,...
W4-f
...................
t
What did he/& do?
- .,
F/yf?po 17D. Is he/she in jail or prison now? (CIRCLEONE) 2 . m 1.NO

L
EMPLOYMENT & INCOME
Employment & Income Interview
Date: &?P?Bm
mm dd yy
Interviewer ID:
FIELD COPY 2 . w U C & S&?L ie#/x,
PART I: Primary Caregiver/Adult Subject Employment

%
1. Please t d me which of these statements best describes your present work situation.
For this interview, "full-time"is 35 or more hours each week and "part-time"is less than 35
hours each week.
Hand respondent response card #1 1
--
ed. init. ed. date
i
Page 2
.F 1
2AEawmm
1. Working full-time in one job
2. Working full-time in one job AND

working Nupart-time in additional job(s)
3. On leave (temporary illness)

from full-time job or jobs
4. Permanent leave (disability)

5. Working part-time in one job
6. Working part-time in two or more jobs -

from part-time job or jobs

9. Temporaq jobs, ocsasional work
10. Retired, working full-time
11. Retired, working part-time jobs
12. Retired, working temporary jobs
13. Retired, not working
14. Homemaker fuR-titne
15. Unemployed, looking for work
16. Unemployed, not loolung for work -

(NOT a homemaker)
17. Volunteer work only, full/part-time -

Page 3
2. Have you been employed in a paying position in the past 5 years? (CIRCLE ONE)
NO: Have you done volunteer work in the past 5 years?

.. ... . .. .. . .. . ...
YES: ...
2A. Which of these statements best describes your most recent employment?
(CIRCLE RESPONDENT'S CHOICE)

'
'?'9

working Euwpart-time in additional job(s)
3. On leave (temporary illness) -


from N1-time job or jobs


9. Temporaryjobs, occasional work
10. Retired,working full-time
11. Retired,working part-time jobs ---

12. Retired,working temporary jobs
17. Volunteer work only, full/part-time

Page 4
PART: I
SECTION: 1
Section 1. Full / Part-timo
22 3 3. How many jobs do you currently hold? (CIRCLEONE)

1. OEJOb.
2. Two Jobs
3. Thre Jobs
3A. Of these jobs, I want you to first tell me about the one you consider to be your
primary or mainjob:
L
4. What is your job title? b / . . d &

/ y
5. What are your main responsibilities? Y@$&,'4h
I Hand respondent response card #2 I

Which of these numbers best fits your salary in this job? (CIRCLEONE)
e.16 6.
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,000
8. don'tknow
7. How long have you been in this job?

2n- Y- months
8. How many hours each week do you usually work? h

E/ C P hourdweek
If 1 Job ONLY,GO TO Page 15, (part I) Question 45A.

w And
: your other job?
9. What is your job title?
10. What are your main responsibilities?

b
11. Which of these numbers best fits your salary in this job? (CIRCLEONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know

Y- months
13. How many hours each week do you usually work?

hours/week
If2 Jobs ONLY,GO TO Page 15, (part I) Question 45A.

And your other job?
14. What is your job title? tYaQ&d&
1 I
Y
Hand respondent response card #2
16. Which of these numbers best fits your salary in this job? (CIRCLE ONE)
1. lessthan5,ooo
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don'tknow
22-a 17. How long have you been in this job?

Y- months
/e 18. How many hours each week do you usually work?

hours/week
II I
1
Page 7
PART: I
SECTION: 2
cs/ -5/9 19. How many jobs did you hold before you went on leave/disability? (CIRCLE ONE)
1. One Job
2. Two Jobs
3. Three Jobs .
le#
19A. Of these jobs, I want you to first tell me about the one you considered to be your
primary or main job:
20. What was your job title? va,czz,dh
21. What were your main responsibilities? ~-24.5

/ f l
&/ A#& 22. Do you eonhue to receive money from this position? (CIRCLEONE)
1. YES
2. NO
d i op*z.kw 22B. Which of these numbers best fit(s) your full salary in this job? (CIRCLE ONE)
1. less than5,OOO
2. between 5,000 and 9,999
3. between 10,OOO and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,000
8. dont know
22A. Do you receive your N1salary or part of your salary? (CIRCLE ONE) I
1. Full
2. Partial
22c. Which of these numbers best fit(s) your partial salary, inciuchg
pension plan, SSI or any benefits? (CIRCLE ONE)
1. lessthan5,OOo
3. between 10,OOoand 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. morethan50,000
8. dont know
23. How long had you been in thisjob

before you went on leave/disability?
Y= months
24. How many hours each week were you usually working
hours/week
25. How long have you been on leave from this job?
Y= months
If 1Job ONLY,GO TO Page 15, (part I) Question 45A,

Y
If More than 1Job, GO TO Next Page, (part I) Question 26. h

Secondary job 2: And your other job?
26. What was your job title?
27. What were your main responsibilities? l/-Gihdk &&/

//
28. Do you continue to receive money from this position? (CIRCLE ONE)
S/L&?
1. YES
2. NO
Hand respondent response card #2 I

&/'adso 28B. Which of these numbers best fit(s) your full salary in this job? (CIRCLE ONE)
1. less than 5,Ooo

2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than 50,OOO
8. don't know
28A. Do you receive yoyr full salary or part of your salary? (CIRCLE ONE)
1. Full t,
2. Partial
Page 10
28C. Which of these numbers best fit($ your partial salary, inciudmg
1. less than5,OOo
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
How long had you been in this job

Y- months
62-30 30. How many hours each week were you usually worlung
hours/wetk
31 Y- months
If2 Jobs ONLY, GO TO Page 15, (part 9 Question 45A.

If More than 2 Jobs, GO TO Next Page, (ppft I) Question 32.
&Q&QQQU
And your other job?
33. What were your main responsibilities? .Yw&& &&e&y&&

Y f l
%!
25/39 34. Do you continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO

9 34/40 34B. Which of these numbers best fit(s) your full Saiary in this job? (CIRCLE ONE)
1. less than5,oOo
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between-30,OOOand 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. dont know
s/ 34.40 34A. Do you receive your full salary or part of your salary? (CIRCLE ONE)
.....
1. Full
2. Partial
Page 12
cs/' 34Ceb 34C. Which of these numbers best fit(s>your partial salary, including pension
plan, SSI or any benefits? (CIRCLE ONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't h o w

Y=S
-
months
2738 36. How many hours each week were you usually working
hours/week
How long have you been on leave from this job?

Y- months
I GO TO Page 15, Question 45A (part I).

I
.
Page 13
PART: I
SECTION: 3
38. What types of jobs have you done recently? U&*dh
Y
!*
39 39. About how many hours each week do you usually work? hourdweek
I
40. How much money have you earned from these jobs in the past year? (CIRCLE ONE)
1. less than5,Ooo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
art I) Question 45A.

Page 14
PART: I
SECTION: 4
Section 4. Volunteer work I
42. What types of volunteer work have you done recently (for what organizations)?
v%aLk42k
43. How many hours usually volunteer? (ClRCLE ONE)
1. 1-2
2. 3-5
3. 6-12
-
-
4. 13 20
5. > 20
44. How long have you been doing this work?

Cv44 years months
I GO TO Page 15, (part I) Question 45A.

Page 15
PART: I
SECTION: 5
IF respondent has more than 1 job listed during the interview, start with the
Iprimary/Only Job]
4%. Where is your job located? (7ftravelr to various locmiOnr, record address of main e c e - )
L
YW&dk
address
city zip code
E/ ~K&J 45B. How far is your work from where you live? (CIRCLEONE)
0 - works at home 4 - 6 t 0 lomiles
1 - less than a mile 5 - greater than 10 miles
2-1tO2miies 6 - Varies according to
3-3to5miles work site
6/ &7CQ 45C. How do you usually get to work? (CIRCLEall that apply)
1-walk -
6 ~arp001
2 - drive myself -
7 driven by relativehiend
3 - budsubway 8 - commuter train
4 - bicycle
5 - other
?/Q$-~Q 45D. On the average, how long does it usually take you to get to work?
(using the mode of transportation listed in Question 45C) h
minutes
If 1 Job ONLY, If there is a partner, go t o Page 18, (partn)Question 1.

Page 16
[Seconuy job 21
46A. Where is your job located? (If traveir to various locations record address of main office.)
P@%dh
address
city Sfate zip code

'-4
O1/6&0 46B. How far is your work from where you live? (CIRCLE ONE)
0 - works at home 4 - 6 to 10 miles

2-1to2miles 6 - Varies according to
3-3to5miIes work site
&'Q6 co 46C. How do you usually get to work? (CIRCLEall that apply)
1-walk 6--1
2 - drive myself 7 - driven by reiative/friend
-
3 budsubway 8 - commuter train
-
4 bicycle
5 - other
Q+&ao 46D. On the average, how long does it take you to get to work?
(using the mode of transportation listed in Question 46C)
If 2 Jobs ONLY, If there is a partner, go to Page 18, (part II)Question 1.

If there is PQ partner, go to Page 35, (part m),Question 1.
Page 17
[Secondary job 31
47.A. Where is your job located? (rf traveh to various Locations, record address of m ' n ofice.)
$4*2& d
address
city State zip code
Wa30 47B. How far is your work from where you live? (CIRCLEONE)
9 0 - works at home . .. 4-6tolOmiies
2 - 1 to 2 miies 6 - Varies according to
3 - 3 to 5 miles work site
di/&gc~ 47C. How do you usually get to work? (CIRCLEall that apply)
1-walk 6 - carp001
2 - drive myself 7 - driven by relativehiend
4 - bicycle
5 - other
5/.c/-7rse, 47D. On the average, how long does it take you to get to work?
(using the mode of transportationlisted in Question 47C)
minutes
Page 18
PART: II
PART II:Partner Employment
1. Please tell me which of these statements best describes your spouse's/partner'spresent

work situation:
Hand respondent response card # 1

Page 19
Cshfv
I%Iummm
1. Working full-time in one job -
2. Workiug full-time in one job AND --
working full/part-time in additional job(s)

4. Permanent leave (disability) -- GO


9. Temporary jobs, occasional work
-
11. Retired, workmg part-time jobs
12. Retired, w o r m temporary jobs
14. Homemaker full-time
15. Unemployed, loolung for work
16. Unemployed, not looking for work -

(NOTa homemaker)
17. Volunteer work only, fuWpart-time -- 2
Page 20
2. Has your partner been employed in a paying position in the past 5 years? (CIRCLE ONE)
AS= Has your partner done volunteer work in the past 5 years?
...............
2. NO: ...........
1 -Yes
2-NO
1. ,&K%
.........................
.............................
2A. Which of these statements best describes your partner's recent employment?

working fullipart-time in additional job(s)




9. Tempora~yjobs, occasional work

Page 21
PART: II
SECTION: 1
Z/P3 3. How many jobs does he/she currently hold (CIRCLE ONE)?
1.. One Job
2. Two Jobs
3. Three Jobs
y.4 3A. Of these jobs, I want you to first tell me about the one he/she considers to be hidher
4. What is hidher job title?
5. What are hisher main responsibilities? b4-2b

6. Which of these numbers best fits hisher salary in this job? (CIRCLEONE)
1. less than5,Ooo
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don't know
How long has heishe been in this job?

82.i4- 7.
Y- months
E/P 8 8. How many hours each week does he/she usually work? hours/week
Page 22
I 1 Job ONLY, GO TO Page 32, (part n)Question 45A

If More than 1 Job, GO TO the Next Page,(part II) Question 9.
w:
And hisher other job?
9. What is hisher job title?
'-#
10. What are his/her main responsibilities?- N
1 Hand respondent response card #2 I

cz/P // 11. Which of these numbers best fits hisher salary in this job? (CIRCLEONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
4. betwten 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
12. How long has he/she been in this job?

Ez-p Y- months
How many hours each week does he/she usually work?

/d
6/fQ 13. hourdweek
If 2 Jobs ONLY, GO TO Page 32, (part II) Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part II)Question 14.
Page 23
15. What are hisher main responsibilities?
,STp i/6 16. Which of these numbers best fits hisher salary in this job? (CIRCLE ONE)
1. lessthan5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 3 9 . M
7. more tban50,OOO
8. don't know
,sJ
' ~/& 17. How long has he/she been in thisjob?
SZ@/& 18. HQWmany hours each week does he/she usually work? hours/week
I
Page 24
PART: II
SECTION: 2
1 Section 2. On leave/disabiIity I
i?iP/9 19. How many jobs did he/she hold before he/she went on leave/disability? (CIRCLE ONE)
1. One Job
2. Two Jobs
3. Three Jobs
19A. Of these jobs, I want you to first tell me about the one heishe considered to be his/her
20. What was hisher job title? b&+z-&dk

I
2 1. What were hisher main responsibilities? AidZ-idk &F&
&PJ& 22. Does he/she continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO
Page 25
22B. Which of these numbers best fit(s>hisher full salary in this job? (CIRCLE ONE)
.&~P,&R~Q
1. less than5.000
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,'OOO and.49,999
7. more than50,OOO
8. don't know
~ ~Does he/she receive hisher full salary or part of his/her salary? (CIRCLE ONE)
g T p ~ a22A.
1. Full
2. Partial
22C. Which of these numbers best fit(@ his/her partial salary, including pension plan,
SSI or any benefits? (CIRCLEONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,OO
8. don't know
How long had he/she been in this job

before he/she went on leave/disability?
Years months
How many hours each week was he/she usually working

before he/she went on leave/disability? hourdweek
&*,
How long has he/she been on leave from this job?
Years months
Page 26
Secondary job 2: And hisher other job?
26. What was hisher job title? ha&%f/*&& &s?g?p&g

//
27. What were hisher main responsibilities? Ya-A%&?f& & ? &

4
&/flA$ 28. Does he/she continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO

gpa&&~ 28B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
1. lessthan5,OOo
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
7. morethan50,OOO
8. dont know
aP&&A 0 28A. Does he/she of hisher salary? (CIRCLEONE)
i.,
Page 27
Which of these numbers best fit(s>hisher p a r t d salary, including pension plan, SSI or any
benefits? (CIRCLE ONE)
-
1. less than5,OOO
2. between 5,000 and 9,999
4. between 20,000 and-29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
'i4 - 7. -more than 50,OO
8. don't know
29. How long had he/she been in this job

before he/she went on leaveldisability?
Years months
30. How many hours each week was he/she usually working
before he/she went on leave/disability? hours/week
31. How long has he/she been on leave from this job?
Years months
~ ~ ~~ ~~ ~ -~
If2 Jobs ONLY,GO TO Page 32, (part n)Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part XI) Question 32.
..-,e .I.. .
Page 28
lob 7; And hisher other job?

32. What Was hisher job title? Lta/- d d
r *
33. what were hisher main responsibilities? L/-+d& &&

/ J
34. Does he/she continue to receive money from this position? (CIRCLE ONE)
c?/P 34
1. YES
2. NO
8flt39&Q 34B. Which of these numbers best fit(s) hisher full salary in thisjob? (CIRCLE ONE)
1. lessthan5,OOo
2. between 5,000 and 9,999
3. between 10,OOOand 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
7. morethan50,OOO
8. don't know
a
34A. Does he/she receive hisher full salary or part of hisher saiary? (CIRCLE ONE)
1. Full
2. partial
Page 29
cf/pp 3 ~ ~34C. 0 Which of these numbers best fit(s) hisher partial d a r y , including pension plan,
1. less than5,OOO
2. between 5,000and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5 . between 30,000 and 39,999
6. between 40,000 and 49,999
7. .more than 50,000
8. don't know

&7P35 before he/she went on leave/disability? -
YWS months

before heishe went on leave/disability? hours/week

- Y- months
Page 30
PART: II
SECTION: 3
Section 3. Temporary work 1
38. What types of jobs has he/she done recently? ya*eclaa)& M,
t ' / p 39 39. About how many hours each week does he/she usually work?
hours/week

40. How much money has he/she earned from these jobs in the past year? (CIRCLE ONE)
csip 4s
1. lessthan5,OOO
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
7. morcthan50,000
8. don't know
I
--I
GO TO Page 32, (part II) Question 45A.

-~
Page 31
PART: II
SECTION: 4
42. What types of volunteer work has heishe done recently (for what organizations)?
v2w4..poJ&
How many hours each week does he/she usually volunteer? (CIRCLEONE)
&/P 93 43.
1. 1-2
2. 3-5
3. 6 -12
4. 13 - 20
5. > 20
44. How long has he/she been doing this work?

SZ$&Q Y- months
Page 32
PART: 11
SECTION: 5
Section 5. Job Distance
IF partner has more than 1job listed during the interview, start with the primary job, THEN
go on to Secondary job 2, etc.
mimary/Only Job]
4& Where is your partner's job located? (if travels to various locmiOnr, record address of main
once.)
YW*dCe- &
address
city State zip code
z/p,jbya 45B. How far is hisher work from where you live? (CIRCLEONE)
0 - works at home 4-6t010mile~

1-lessthanamile -
5 greater than 10 miles
2-1to2miles -
6 Varies according to
45C. How does he/she usually get to work? (CIRCLEall that apply)
G9P45CO
1-walk 6 - carp001
2 - drive myself 7 - driven by relative/friend
3 - bushubway -
8 commuter train
-
4 bicycle
5 - other
i S/P453(? 45D. On the average, how long does it take m e r to get to work?
1
(using the mode of transportationlisted in Question 4 5 0 h

1 minutes
Page 33
[Secondary job 23
46A. Where is hisher job located? (If traveLs to various locm*onr,record address of main office.)
city state zip code
FhQY6BS ,46B. How far is hisher work from where youlive? (CIRCLE ONE)
0 - works at home 4-6tolOmiles
1-lessthanamile 5 - greater than 10 miles
2-lto2miles 6 - Varies according to
l-walk 6 - q l
3 - bushubway 8 - commuter train
4 - bicycle
5 - other
46D. On the average, how long does it take himmer to get to work?
minutes
I If2 jobs ONLY,GO TO Page 35, (part m)Question 1. I

than 2 Jobs, GO TO Next Page, (part E)Question 47A.
Page 34
[Secondary job 31
47A. Where is hisher job located? flf travels to vanous locations, record Mress of main ofice.)
city State. zip code
s / p , q ? a 4T. How far is hisher work fiom where you B e ? (CIRCLEONE)

0 - works at home -
4 6 to 10 miles
s/pqRo 47C. How does he/she usually get to work? (CIRCLEaU that apply)
1-walk 6-carp001
2 - drive myself -
3 - budsubway -
8 commuter train
4 - bicycle
5 - other
&/$ g g ~ o47D. On the average, how long does it take m e r to get to work?
(using the mode of transportation listed in Question 4 7 0
minUteS
I GO TO NEXT PAGE, (part m) Question 1.

PART ID.
1, other than from your job, please tell me whether you received income from any of these
' sources in the past tax year. Have you received.... (read each choice and circle all that apply)
a. income from partner or spouse 1. YES 2. NO
k"/p9A6 (NOTchild support or alimony),combined
'>+
income or supported by p h e r
E~A6fi0 b. child support or alimony 1. YES 2. NO

c. any public assistance, such as DPA or AFDC 1. YES 2. NO
d. social security or supplemental security income 1. YES 2. NO
2//9/&
0 e. unemployment compensation 1. YES 2. NO
or worker's compensation
S/&."Fe, f. money from relatives (NOTpartner or spouse) 1. YES 2. NO
such as: tuition, rent, loan
g. federal grant, financial aid, scholarships 1. YES 2. NO

z. money from any other source 1. YES 2. NO
&*%VZO (please specify)
,
Now I am going to ask you some questions about your total income. First, I will ask about your
personal income, and then I will ask about your total household income.
//$A 0 2A. From these sources of income AND the income from any jobs you had in the last tax year,
what was your total income before taxes in the last tax year, using these choices?
1. less than$5,OOO
2. between $5,OOO and $9,999
3. between $10,000and $19,999
4. between $20,000and $29,999
5. between $30,000and $39,999
6. between %40,000and $49,999
7. more than $50,000
8. don't h o w
2B. From these choices, what was your total household income in the last tax year before taxes?
Household income includes your income and any income coming in from anyone else in the
household.
1. lessthan$5,OOo
2. between $5,000 and $9,999
3. between $10,000 and $19,999
4. between $20,000and $29,999
5. between $30,000and $39,999
6. between $40,000and $49,999
7. more than $SO,OOO
8. don't know
CONFLICT TACTICS SCALE
4
CONFLICT TACTICS SCALE: PartnedSpouse Introduction,
Now, I have some questions about your relationships.

1. Are you currently involved with someone? GTj
A. Are you married to, engaged to, or dating this person? C7.~
84
1. married
2. engaged
3. dating
B. Are you currently.living with this person? C-/fA30

1. Yes
0. No
C. How long have you been in the relationship? C7YCO
Y- months
I BEGIN INTERVJEW I
2. Have you been involved with someone in the past year?
(If more than one person, select most "significant"relationship) C7-b
1. YES
0. NO
A. Were you married to,engaged to, or dating this person? c7Auo

1. married
2. engaged
3. dating
B. Were you living with this person?

1. Yes
2. No
\
C. How long were you in this relationship?
months
I BEGIN INTERVIEW 1
-. . . . . . ... ~ .
3. Have you dated anyone at all in the past year? c7-3

1. YES
For this interview, I would like you to think of all your dating
relationships in the past year.
0. NO .
Conflict Tactics Scale: Partner/Spouse
Interviewer ID:
C/SPRA/S
No matter how well a couple gets along, there are times when they disagree, get annoyed with
the other person, or just have fights because they're in a bad mood or tired or for some other
reason. They also use many different ways of trying to settle their differences. I'm going to
read some things that you and your partner might have done when you had an argument in
...
the past year, that is, since
Refer to first month on the time line
I want you to think about how many times EACH of you have done the following, using one of
these responses.
Hand respondent the response card, and read choices 1 to 6
ed. init. ed. date

When you had an argument with your partner in the past year,
1A. How many times have you discussed an issue calmly? c/ /?+
0 1 2 3 4 5
never O W twice 3-5 6-10 1 1-20
times times times
4
1B. How m a y times has he/she discussed an issue calmly? c77%

0 1 2 3 4 5
never once twice 3-5 6-10 11-20
times times times 20 times
IC. ast this ever happen^ e7 f G 1 =yes 0 = No
2A. How many times have you gotten i n f o d o n to back up your side of thmgs? CIA&
0 1 2 3 4 5 6
never once twice 3-5 6-10 11-20 more than
2B. How many times has he/she gotten information to back up hisher side of things? c TA&
0 1 2 3 4 5 6
never once twice 3-5 610 11-20 more than
P
2C. Has this ever happened? 1 =Yes O=No a-b6

5
3A. How m,any times have you brought in or tried to bring in someone else to help settle things?
0 1 2 3 4 5 6
-$ - times times times 20 times
3B. How many times has he/she brought in or tried to bring in someone else to help settle things?
0 1 2 3 4 5 6
3C. Has this ever happened? 1 =Yes 0 = No
4A. How many times have you insulted or swore at himmer?
0 1 2 3 4 5 6
never once twice 3-5 6-10 1 1-20 more than
4B. How many times has he/she insulted or swore at you?
0 1 2 3 4 5 6
h
4C. Has this ever happened? 1 = Yes 0 = No

C T s# SA. How many times have you sulked and/or refused to talk about an issue?
0 1 2 3 4 5 6
"d
c7-5& 5B. How many times has he/she sulked andor refused to talk about an issue?
0 1 2 3 4 5 6
C T 3-c# 5C. Has this ever happened? 1 = Yes 0 = No
6A. How many times have you stomped out of the room, house or yard?
0 1 2 3 4 5 6
6B. How many times has he/she stomped out of the room, house or yard?
0 1 2 3 4 5 6
never Ollce twice 3-5 6-10 11-20 more than
h

C 7 6C
How many times have you cried?
0 1 2 3. 4 5 6
How many times has he/she cried?
0 1 2 3 4 5 6

C77C
8A. How many times have you done or said something to spite W e r ?
0 1 2 3 . 4 5 6
8B. How many times has he/she done or said something to spite you?
0843
0 1 2 3 4 5 6
times times times $0 times

6
9A. How many times have you threatened to hit or throw somethmg at himher?
0 1 2 3 4 . 5 6
never Ollce twice 3-5 6-10 1 1-20 more than
tq
9B. How many times has he/she threatened to hit or U o w somewing at you?
0 1 2 3 4 5 6
9C. Has this ever happened? 1=Ys 0 = No
1OA. How many times have you thrown,smashed, hit, or kicked w ?

0 1 2 3 4 5 6
never Ozlce twice 3-5 610 1.1-20 more than
tims times times 20 times
10B. How many times bas he/she thrown,smashed,.hit, or kicked w ?

0 1 . 2 3 4 5 6
1OC. Has this ever happened? 1 =Yes 0 = No

C7J%4 11A. How many times have you thrown somettYng af him/her?
0 1 2 3 4 5 6
times . times times 20 times
.r
CT7f7V3 11B. How many times has he/she thrown something af you?
0 1 2 3 4 5 6
12A. How many times have you pushed, grabbed, or shoved himher?
GW&4
0 1 2 3 4 5 6
12B. How many times has he/she pushed, grabbed, or shoved you?
ci-vxf4
0 1 2 3 4 5 6

a
13A. How many times have you slapped him/her?
0 1 2 3 4 5 6 .
never once , twice 3-5 6- 10 1 1-20 more than
13B. How many times has he/she slapped you?

0 1 2 3 4 5 6
13C. Has this ever happened? l=Yes 0 = No
14A. How many times have you kicked, bit, or hit m e r m?
0 1 2 3 4 5 6
14B. How many times bas heishe kicked, bit, or hit you w?
0 1 2 3 4 5 6

9
15A. How many times have you hit or tried to hit himher * ?
0 1 2 3 4 5 6
never once twice 3-5 ' 6-10 11-20 more than
15B. How many times has he/she hit or tried to hit you ?
0 1 2 3 4 5 6
16A. How many times have you beat him/her up?
0 1 2 3 4 5 6
16B. How many times bas heishe beat you up?
0 1 2 3 4 5 ' 6
16C. Has this ever happened? 1. = Yes 0 = No

10
C?//;7& 17A. How many times have you choked him/her?
0 . 1 2 3 4 5 6
"4
17B. How many times has he/she choked you?
c7 /a3
0 1 2 3 4 5 6

C7f7C
-7v4 18A. How many times have you threatened m e r with a knife or gun?
0 1 2 3 4 5 6
S7-/8/3 18B. How many times has he/she threatened you with a knife.or gun?
0 1 2 3 ' 4 5 6
never OIlce twice 3-5 6-10 11-20 more than
4
... ..
18C. Has this ever happened? 1 =Yes 0 =No

O/BC .
11
When you had an argument with your partner in t h e past year,
19A. How many times have you used a knife or fued a gun?
0 1 - 2 3 4 5 6
never once twice 3-5 ' 6-10 11-20 more than
'a4
19B. How many times has he/she used a knife or fired a gun?
0 1 2 3 4 5 6
CT YQC 19c. Has this ever happened? 1 = Yes 0 = No
I RECORD TIME: C7S.lo.25 'T/M

FAMILY ENVIRONMENT SCALE
Family Environment Scale: Short Version
Date: ---
FSi3777
I I L ~dd yy
Subject ID: SLC/3/B
Interviewer ID:
F,FSRA/%
There are 27 statements in this survey. They are statements about families. YOU81p to
decide which of these statements are true of your curre!nt family and which are false.
YOUmay feel that some of the statements are true for some family members and false for
others. Say "me if the statement is true for most members. Say False if the statement is
false for most members. Ifthe members are evenly divided, decide what is the stronger
overall i m p d o n and answer accordingly.
Remember, we would like to know what your ament family seems like to you. So do not
try to Sgure out how other members see your family.
1. We fight a lot in our family
1. T 2. F
FER
2. Family members attend church, synagogue, or Sunday School fairly often
1. T 2. F
f 3
3. Family members are!rarely ordered around
1. T 2. F
ed.init. ed. date

2
I
4. Famiiy members rarely become openly angry
1. T 2. F
r5. We don't say pmym in our family
"8 1. T 2. F
6. There are very few rules to follow in our family

1. T 2. F
7. Family members sometimes get so angry they throw things
1. T 2. F
8. We oftenraUc about the religious meaning of Christmas,Passover, or other holidays
1. T 2. F
9. *re is one M y member who malus most of the decisions
1. T 2. F
10. Family members hardly ever lose their tempers
1. T 2. F
11. We don't believe in heaven or hell
1. T 2. F
12. mere an set ways of doing things at home
1. T 2. F
FE f 3
13. Family members often criticize each other
- 1. T 2. F
F rq
14. Family members have strict ideas about what is right or wrong
1. T 2. F
15. There is a strong emphasis on following rules in our family
i?d 1. T 2. F
16. Family members sometimes hit each other
1. T 2. F
17. We believe there are some things you just have to take on faith
1. T 2. F
18. Everyone has an equal say in family decisions
19. If there's a disagreement in our family, we try hard to smooth t h q p over and keep the
Peace
1. T 2. F
20. In our family each person has different ideas about what is right and wrong
1. T 2. F
21. We can do whatever we want to in our family
1. T 2. F
22. Family members often try to one-up or outdo each other
1. T 2. F
FA 3
23. The Bible is a very important book in our home
1. T 2. F
4
FA4
24. Rdes are pretty inflexible in our household
1. T 2. F
64% 5
25. In ow family, we believe you don't ever get anywhere by raising your voice
'*P 1. T 2. F
F E A ~
26. Family members believe that if you sin you will be punished
1. T 2. F
27. You can't get away with much in our family
1. T 2. F
I
I
I HAND SUBJECTREspoNsE CARD

~
F&S
28.- When you answered these questionS, who did you have in mimd?
1. Siblings 5. me
r
2. Parent
3. Rmmmate
4. Otherfamilymember
6. Spouse/PartllM.
7. Child/Chidren
ENDOFINTERVIEW
RECORD TIME:
PROVISION OF SOCIAL RELATIONS
Provision of Social Relations
Date: P S P r n Z
mm dd yy
Subject ID: S&e/..
Interviewer ID:
P?PRA/%
Now I would like to know something about your relationships with other ptoplc
I Hand Respondent the Response Card and Read Choices 1

For each of the statements I read, please use this scale and tell me the answer that best
describes your experience, with:
l= verytrue
2- somewhattrue
3= nottrue
PSP 1
1. Whedmwithmyfiien&I fkel complctdy able to relax and be myself,
1 -verytrue
-
2 somewhat true
3 -not true
PSPR
2. I share the same approachto life that many of my friendsdo.
-
1-mytrue
2 somewhat true
3-nottrue
ed.init. &.date
PSP 3
3. Peopie who know me trust me and respect me.
1 - very true
2 - somewhat true
3 - not true
3/ 4. No matter what happens, I know that my hudy will idways be there for me should I need
them.
'q 1-verytrue
-
2 somewhat true
-
3 not true
5. when I want to go out to do things, I know that many of my Gricnds would &(Zik)
doing these thingswith me.
1 -vnytrue
-
2 somewhat true
-
3 not true
6. I have at least one fiend that I could tell anything to.
1 -vcrytruc
-
2 somewhat true
-
3 not true
7. Sometimes I'm not sure if1 can completelyr,& (count) on my famiy.
1 -verytrue
-
2 somcwhat true
-
3 not true
.:
..
,
6.'
..*
PSP
J
8. My h d y lets me know they thiak I'm a (vohrable)persoe
1 -verytrue
Z-somewtrattrut
-
3 not true 4
PSP 9
9. I feel very close to some of my friends.
-
1 very true
-
2 somewhat true
3 - not true
10. People in my family have confidence in me.
1 - very true
v 2 - somewhat true
1 3 .
b
3 - not true
11. People in my f d y help me find solutionsto my problems.
1 - very true
-
2 somewhat true
-
3 not true
12. People who h o w me think I am good at what I do.
1 -verytrue
-
2 somewhat true
-
3 not true
13. My friends would take the timeto talk about my problems, should I ever want to.
1 -verytrue
-
2 somewhat true
3 -not true
14. I h o w my famiywiu always stand by me.
1 -verytrue
-
2 somewhat true
3 -nottrue
PSP f5
15. Even when I am with my fiimds, I feel alone.
-
1 vcryirue
-
2 somewhat true
-
3 not true
PSP y g
16. I have a teacher or coach who I can rely (count) on and talk to.
1 -verytrue
2 - somewhat true
.a -
3 not true
7. I have a grandparat, uncle, or aunt that I -f

d close to and who he .psme out.
1 -vexytme
-
2 somewhat true
3 -not true
18. I have a brother, a sister or a cousin who listens to me and understands my problems.
1 -vuytrue
2 - somewhat true .
..
-
3 not true
19. There is an adult outside my fimily, for example, a neighbor or religious or

wmrrmDity member, who I can go to for help if1 n d it.
1 -verytrue
-
2 somewhat true
-
3 not true
PSP /u3
20. Is there anyone in particular tbat you think helps you out when you need it?
1. Yes 0. No
PSPdzOAh
-
2Oa2. 1 Immediate F d y (sibling, child, parent, partner)
2 - Extended Family
3 - Friend or Neighbor
4 - Church Memberkeader
5 - School or Community MemberLeader
6 - Other
PSPaoALL
20bl. -& -
20b2. 1 Immediate F d y (sibling, child, parent, partner)
First name 2 - Extended Family
4 - Church MemberLeader
6-other
fiP/cc3Cle
20cl. M -
20c2. 1 Immediate F d y (sibling, child, parent, partner)
&stname -
2 Extended F d y
-
3 Friend or Neighbor
-
4 C b c h MembdLead~r
5 - School or Community MembernRader
6-0thm
8ENDOFINTERVIEW8
RECORD TIME:
...
HOME
mm COPY # 2
SUBID
SCALE vm.PHYSICAL E"MENT IN THE HOME?

-MOR OF HOME] rcrRc= ONE]
** 1. House or apartment is free of potentidy a. YES
#A 8-4 dangerous structural or health hazards. b.NO
(exposed outlets, broken widows, windaws
without screens or guard, leaking rdator,
pots hanging over edge of stove)
** 2. House or apartment has as least 100 square a. YES
feet of living space per person. b.NO
I
** 3. House or apartment is clean; all visible rooms a. YES

of the home are reasonably clean and b.NO
minimally cluttered.
** 4. In terms of available ,- the rooms a. YES
are not overcrowded with fumitun. b.NO
** The inteior of the house or apartment is not a. YES
m e -5
5.
dark or perceptdy monotonous. b.NO
1
** 6. House or apartment has at least two pictures a. YES
- or other types of art work on the walls. b.NO
** 7. House or apartment is not overly noisy &om - a. YES
noise in the house. b.NO
- (television,shouts of chil&en, d o )
** 8. House or apartment is not overly noisy h m - a. YES
noise outside the house. b. NO
(train, cars, people. muse)
* 9. Household members do not use tobacco. a. YES
I I b.NO
** 10. There are no obvious signs of recent alcohol a. YES
U88- f D or non-prescription drug consumption in the b. NO
home.
- ( h g ~ a p h e m a l i abeer
bottles)
, cans, liquor
TlME ENDED
SCALE E.PHYSICAL ENVIRONMENT
-OR OF HOME]
Date:
mm dd YY
' Dayofweek: M Tu W T h F sa su
(CIRCV ONE)
Time of day: Entered home: AM PM
Left home: AM PM
7449-1
1. street Layout:
1. Through - straight
2. Through - curved
3. H-layout
4. T-layout
5. L-layout
6. cul-de-sac
7. Boulevard
8. Divided Highway
9. othcr
#4 9- oe
2. How would you characterize the land use on this face-block, based on
frontage?
1. M y residential
2. primarily commercial
3. Mixed residential and commercial
4. Primariyindustrial
5. primarily vacant houses
6. primarily vacant lots and open space
-7. primarily services or institutions
.8. P r i m d y park, playground
9. Other
,
#& 9- 3
3. How would you rate the general condition of mQsT of the housing units or other buildings
in the face-block?
1. Well kept, good repair

2. Fair condition
3. Poor condition (peeling paint; broken windows)
4. Badly deteriorated
"Wfi9-4
4. Do any of the fronts of residential or commercial units have metal security blinds, gates,
or iron bars or grills?
1. None
2. Some
3. At least half
4. Most
#fig- 5
5. How would you rate the volume of traffic on the fa-block?
1. Notrafficpermitted
2. Verylight
3. Light
4. Moderate
5. Heavy
6. Veryhtavy
#AM 6
6. How would you rate the condition of the street in the face-block?
1. very good - recent resurfacing, smooth

2. Moderate - evidence kept in good repair
3. Fair - minor repairs needed, but not rough surface
4. Poor - potholes and other evidence of neglect
#A 9-4
7. Is there garbage, litter, or broken glass (except beedliquor bottles) in the street or on the
sidewalk?
1. None,or almost none

2. Yes,but not a lot
~ 3. Yes, @tea bit
4. Yes, just about everywhere
-h;4 9-8
8. Are there drug-related paraphernalia, condoms, beer or liquor containers or packaging,
cigarette butts or discarded cigarette packages in the street or on the sidewalk?
1. None, or almost none

2. Yes, but not a lot
3. Yes,quite a bit
#A 9-9
h
9. Are there children playing on the sidewalks or in the street of the face-block?
1. No children visible, or all in yards

2. Yes, one or two children
3. Yes, three or more children
#t9 9- ?D
10. Are there any adults or teenagers in the s t r t t t or on the sidewalk arguing, fighting,
drinking, or behaving in any kind of hostile or threatc- way?
1. No persons observed in the street or sidewalk

2. None observed behaving in hostile way
3. Yes,one or two behaving in a hostile manner
4. Yes,three or more behaving in a hostile manncr
gi4 9-+/
11. How did you fecl parking, walking, or waiting at the door in the face-block?
1. Very comfortable: can imagine living/workhg/shopping here

2. Comfomble: it seems to be a d e and f i i d y place
3. Fairly safe and comfortabe
4. I would be uncomfortable living/working/shopping here
5. I felt afraid for my personal sa-
Date:
m m dd yy
Subject ID:
Interviewer ID:
-
PROJECT ON HUMAN DEVELOPMENT IN CHICAGO NEIGHBORHOODS
Early Assessment of Risk of Attrition
y.Iy
Ask questions 1-6 ofthe respondent
1. Are you planning on movingheaving home in the next year? Y N

if "Yes,"
1a. when?
1b. where? eetl
f d )
If employed, ask Question #2, if unempfoyed, go to Question #3
2. Do you plan on changing jobs in the near future? Y N

if "Yes,":
2a when? (monthhrearl 2b. new employer?
2c. new employment address: 1
3. Do you think it is likely you will obtain work in the near future? Y N
if "Yes,":
3a. when? @&$war> 3b. employer?
3c. new employment address: 1
fcitvl (statel l
If cunently in schooi, ask Question #4
C:WMCINTOS\WPDOCS\ROANEW.FRM
1 TI-Yto make the following observations at the close of the session I
I J
7. Did the respondent seem (check all that apply):

a*- annoyed b. nervous c*- bored d. afraid
e. relaxed f. interested g. neutral h. curious
i. cooperative j. confused?
8. Please note any other observations about the respondent's demeanor:
9. Using the scale below, make your best assessment of the participant's likelihood of
participating next year:
Circle one:
i_
i
1 2 3 4 5
Little likelihood Great likelihood

of participating of participating
9a. Please explain the reason for your assessment:
10. Using the scale below, make your best assessment of the difficulty we will have in locating
this individual next year:
Circle one:
1 2 3 4 5
Great difficulty Little difficulty
in locating in locating
~ 1Oa. Please explain the reason for your assessment:

-~ ~
C:UMCINTOS\WPDOCS\ROANEW.FRM ROA 3
5
Date:
m m dd yy
Subject ID:
Interviewer ID:
To be completed by the Research Assistant at the conclusion of the assessment.
1. Was the entire assessment administered in English?

YES G o t 0 4 6
NO G o t 0 4 2
2. Was all or part of the assessment administered in Spanish or Polish?
YES Go to Q 2.1 Specify language

NO G o t 0 4 3
2.1 Was a translated version of the protocol used?
YES G o t o Q 5
NO GotoQ4
3. In what language(s) was the assessment conducted?
4. Who assisted with the translation?
1. Research Assistant
2. ParentlGuardian
!I.
3. SpouselPartner
4. Other family member
- 5. Other non-family household member .
* 6. Other
Comments Section:
PLEASE RECORD ANY ADDITIONAL COMMENTS:

NOTES
Date:
m m dd yy
ID:
Interviewer ID:
,
NOTES
,
NOTES
,
reject ~n Human Development

ASSESSMENT
CmGIVER
COHORT: 3
FIELD COPY #2
F CONTENTS
Age: 3 (PC)
1. emographic & Cultural Information

2. Home
3 School Screen: 3-6
4, Wealth Screen
5.' Family Structure & Health History
8. Conflict Tactics Scale: Partner/Spouse
9. Conflict Tactics Scale: Partner/Child
10. Child Behavior Checklist: 2-3
11. Exposure to Violence
12. EASI Temperament Survey
Cultural Information
First, P will ask you about where you and ***** have lived during the past five years;
were born;
Third, I will ask about merent languages you might speak;
Fourth, I w i l l ask for some general descriptive information about yourself;
Finally,I will ask about your ethnic and religious background.
Let's start with CherFldng that I have your current address recorded c o r r d y .
ed. init. ed. date
I
2
apt. #
city State zip code

.I
ma 1. Do you: (read choices)

1. rent your home
2. own your home
4. live with someone (yourparents, guardians or partner) who rents this home
5. live with someone (your parents, guardians or partner) who owns this home
1A. How long in years and months have you lived here?
2% A40 Y- months
2. Please tell me all the other addresses you have had in the past f n e years, starting with
-
( m e e t address) J ' (ciry) (state) (zip code)
B4RA-i 2Al. Why did you move from this address [2A]? [circie up 10 three]
1 = cbange of job 8 = went to school

2 = evicted 9 = could 110Ionger afford rent
3 = moved off-campus 10 = found a better apartmedhouse
4 = fuelotber hazardous condition 11 = wanted to live away from parents
5 = change in maritallromantic status 12 = roommates left (had to move)
6 moved in w/someone due to finances
>= 13 = on vacarionlgraduated from school
7 = living quarters too sdllfound bigger apartmendhome
25 = other ijdi#i &-&
s& 2A2. How long did you live at this address [2A]?
Y- months
$6;4R&-r' 231. Why did you move from this address [ZB]? [circle up to three]

3 = moved offcampus 10 = found a better apartmentmouse
4 = frrelother hazardous condition 11 = wanted to live away from parents
5 = change in maritallromantic s t a t u 12 = roommates left (had to move)
6 = moved in w/someone due to finances 13 = on vacationlgraduated from school
7 = living quarters too smalllfound bigger apartmendhome
25=
B&RA& 2B2. How long did you live at this address PB]?
Y= months
3
4
va&*dh 8L%Gq?&
(street address) Y / (city) (state) (zip code)
% 4 & c / 2C 1. Why did you move from this address [2C]? [circle up to three]

5 =a&angein marital/romantic status 12 = roommates left (had to move)
6 = moved in w/someone due to finances 13 = on vacation/graduated from school
7 = living qliarters too small/found bigger apartmenthome
25 = other
2C2. How long did you live at this address [ 2 q ?

Y- months
V&L&/dh &m&
~ /Why did you move from this address [2D]? [circle up to three]
3 ? 6 ~2D1.

5 = change in maritavromantic status 12 = roommates left (had to move)
25 =other tfiedk -/
9 6 LBL 2D2. How long did you live at this address [2D]?
Years months
Y- months
4
?E. And where did you live before living here?
2E1. w h y did you move from this address [2E]? [circle up to three]
f = change of job 8 = went to school

3 = moved off-wnpus 10 = found a bener apartmenfiouse
4 = firelother bazardous condition 11 = wanted to rive away from parents
5 = change io maritailromantic starus 12 = roommates left (had 10 move)
6 = moved in wl someone due to finances 13 = on vacationlgraduated from schooi
7 = living quarters t ~ smalYfound
o bigger aparunentmome
25 = other ~iidk ri+ d& &7g.L*J&/&
/ '
w3 R l k . 2E2. How long did you live at this address [2E]?
Y- months
2F. And where did you Iive before iivlng here?
%LF/ 2F1. Why did you move from this address [2F]? [circle up to three]

4 = FKelotber hazardous condition 11 = w a n d to live away from parents
5 = change in maritayromantic status 12 = roommates left (had to move)
6 = moved in wl someone due to finances 13 = on vmtiodgraduated from s c h d
7 = riving qwrters too sdllfuund bigger apartmenthome
25 = other ~'LL&,&~LL L d e d
/f
% / + ~ F L 2F2. How long did you live at this address [2Fj?
5
6
$&q/&,&/&/< && I
- CL
/ J
(street address) (city) (SQte) (zip code)
8 4,g/~ 2Gl. Why did you move from this address [2G]? [circle up to three]

3 = moved off-campus 10 = found a better aparunentfhouse
5 + change in marital/romantic stams . - 12 = roommates left (had to move)
6 = moved h-w/ someone due to finances 13 = on vacatiodgraduated from school
7 = living quarters too small/found bigger apartmentmome
25 = other y&ddb
%& &G.& 2G2. How long did you live at this address [2G]?
Y- months

c - -
bh&+\-/ 2H1. Why did you move from this address [2H]? [circle up to three]

3 = movedoff-campus 10 = found a better apartmentmouse
5 = change in marital/rom.antic status 12 = roommates left (had to move)
25 =other ~ma'hdh
/'
AH^ 2H2. How long did you live at this address [2H]?
YWS months
Years months
I -
7

L d L rkc. && (
&2 f e&&FeY?&di -- c _ -
(street address) (c:tY> (state) (zip code)
%6d, 211. Why did you move from this address [21]? [circle up to three]

3 = moved off-campus 10 = found a better aparcment/house
6 = moved in w/someone due.to f i c e s 13 = on vacatiodgraduated from school
25 = other LPLLS~ ~ ~ / t k L)- 8 - m -b

/ y
st&&ZL 212. How long did you live at this address [21]?
YWS months
Years months
2J. And where did you live before living here?
2J1. Why did you move from this address [2Jl? [circle up to three]
.ie;&R .jy
6 = moved in w/ someme due to finances 13 = on vacatiodgraduated from school
25 = other PC~A, ~ i d L 5-
d .*&
/ /
ab 2~ 2J2. How long did you live at this address [2g?

Yf=S months
3
8
Has ***e* had any different addresses than you in the past five years?
0. NO 6 0 t o Q . 5,
1. YES GotoQ. 4.3
How long in years and months has ***** lived at your current address?
4. Please tell me all the addresses ***** has had in the past fwe years, starting with the most
recent one before the current address..
4A.
imdd& - -
(state)
V I
(street address) (city) (zip code)
B43 94 ./ 4A1. Why did ***** move from this address [4A]? [circle all that apply]
2 = lived witb another famiiy member 8 = parent was hospitalized (medical)
5 = child hospitalized (emotionallbehavioral) or in residential treatment
6 = parent was hospitalized (emotionallbehavioral) or in drug treatment
25 = other ~ a & d h

Bfi9#/c# YWS months
Y- months
9
4B. h d where did ***** live before living here?

p=iid k&GCl&& d&L&?&
- pl
I
I 944
b y
(street address) (city) (sate) (zip code)
g43 YA3 1 4B 1. Why did ***** move from this address [4B])? [circle all that apply]
1 = change in custody/shared custody 7 = child hospitaiized (medical)

25 = other J~JLAL ~0d'Ll;~. &A5

f V
.+fik7 4B2. How long did ***** live at this address [4B]?
Y- months
a'&&yZs L&L& X&?&*&d

- _L- -
(street address)
1' (city)
(state) (zip code)
GeJ4c / 4C1. Why did ***** move from this address [4C]? [circle all that apply]

3 = parent was in prison 9 = foster placemenhiopted
5 = child hospitalized (emotionalhehavioral) or in residential freatment
25 =other V~;G&L& -
BY
m.qc& 4C2. How long did ***** live at this address [4C]?
Y- months
4
10
4D. And where did ***** live before living here?.
&ai
4D1. Why did ***** move from this address [4D]? [circle all that apply]

2 =.lived with another family member 8 = parent was hospitalized (medid)
t%$ 5 = child hospitalized (emotionalhehavioral) or in residential treatment
6 = parent was hospitalized (emotionahehavioral) or in drug treatment
2 5 = other
g&qa,(, 4D2. How long did ***** live at this address [4D]?
.. . . .....
Y'ears months
PG&.&.J&
- - -
/ 4E1. Why did ***** move from this address [4Q? [circle all that apply]
5 = child hospitalized (emotional/behavioral) or in residential treatment
6 = parent was hospitalized (emotionalhehaviord) or in drug treatment
z = other v i &
4E2. How long did ***** live at this address [4E]f '
Y- months
Y== months
11
Now I have some questions about where different people in your f a d y were born.
A. city d / ~ ~ ~ L c t B.
j State d d ~ + ?J4:L
~%
rn ;-A/ 5A. When did ***** come to live in the USA? year: 19
8. Don't Know
393 9-J%J 5B. How old was ***** when he/she came to live in the USA? age:
8. Don't Know
A. City B. State C. Country

8. Don't Know
8. Don't Know
s45 :? 7, Is your mother still living? 1. Yes 0. No 8. Don't Know

- o---
A. city Y~-UR~& B. State C. Country

12
A. City B. State C. Counuy -

-

I_
IF NOT os, ASEEQ. d 93k
940 ?j 9A. When did she come to live in the USA? year: 19
8. Don't Know
m $60 9B. How old was she when she came to live in the USA? age:
8. Don't Know
ja 10. Is your father still living? 1. Yes 0. No 8. Don't Know
Where was he born?

-
11.
A. City B. State
- c. country
A. City B. State
- c. counlq w
A. City B. State
- C. Country
-
B:
& 12A. When did he come to live in the USA? year: 19 I
8. Don't Know
37% r225s 12B. How old was he when he came to live in the USA? age:
8. Don't Know
13
Now 1 have some other questiom about you.
Are you a U.S.citizen?
0. NO
1. YES
13A. Are you (read choices) 1. currently applying, Grr To

2. pianning to apply, or Q. 14
13B. Are you registered'to vote in the U.S.? 0. NO 1. YE
$&&7'3- 15. What is your marital status? Are you (Read all choices):
n%3 f,j5-'&C:
15A. Are you currently living with a partaer?
1. Yes
0. No
w*+3-#& c, 15AA. Are you currently living with your spouse?
1. Yes
0. No
J33 /3-A&/ 15AA.1 Are you living apart because you are not getting along or for some other
reason? What is the reason?
1. Not getting along

2. Jobs in different places
4. Other d~c%
, i /
wk
14
15B1. Is your partnerhpouse the biological parent of *****?

1. Yes
0.
15B2. How long have you lived with your partner/spouse?
years months
16. What is your birth date?

'-4 mm dd yy
What was the first language you learned?
4. Spanish
5. German
6. Lithuanian
11. English AND another language (specrfy:)
12. Two other languages (spew:)

A.
B.
What is your primary language now?
4. Spanish 10. Other language (spec@:)
5. G e m
6.Lithuanian
12. Two other languages (spec@:)

15
%E5 'fG 19.
Please note: Insert the name of the lunguage(s) provided in response to Q. I7 and 18
L
whenever the term (lanpuagets)] appears in the terr in Q. 19
Would you say that you speak mostly [hguage(s)J or do you speak mostly English, or do you s p a t
a. Mostly [language(s)] b. Mostly English c. Both about the same
Hand "CARD 1: LANGUAGES" to the respondent I1

I'd like to h o w what language you use in your daily activities. After each question please
tell me whether you use English only, mostly English,both English and flanguage(s)]
equally, mostly PanguageWl, or Panguagetdl only.
19A. What language do you speak with your children?

2. Mostly English 5 . [language(s)l only
3. Equally
19B. What language (doidid) you speak with your mother?

2. Mostly English 5. r ~ ~ g u a g e ( Sonly
)l
3. Equally
19C. What language (do/did) you speak with your father?

2. Mostly English 5 - thguage(s)l only
3. Equally
IF mapandent has a partner, ASK Q. BD:

19D. What language do you speak with your partner?

3. Equally
IS
16
19E. What language do you speak with friends?

2. Mostly English 5 . [language(s)] only
3. Equally
19F. What language do you speak with people at work or school?
1. English only - 4. Mostly [language(s)]

2. Mostly English 5. U~guage(s)lonly
19G. In what language are television programs you watch?

2. Mostly English 5 . rl~guage(s)lO d Y
3. Equally
19H. How about the radio stations you listen to?

2. Mostly English 5 . Clanguage(s)l only
3. E s d Y
191. Do you consider your [language(s)] to be ... (read choices).

1. Very-
2. PrettyGood
3. Fair, or
4. Not good at all
19J. Do you consider your English to be.... (read choices)
1. Very Good
2. Pretty Good
3. Fair, or
4. Not good at all
speak English well? Would you say. .. (read choices)
1. Never
2. Sometimes
3. Often,or
4. Always
17
yq1.c 19L. How often has it been hard to get g d grades or do well at a job because of
1. Never
2 . Sometimes
3. Often,or
4. Always
Now 1 have some questions about your education.
fif3 zL; 20. Have you attended school in another country, this counny (the US), or both?
1. another country only

2. usonly
3. another country and US
20C. Did you receive any type of degree?
0. NO
1. YES
20C 1. What degree did you receive? Gotfl

Q- 22
Did you f ~ high

h school?
0. NO
1. YES
0. NO
1. YES
-years months
18
z f e ~ 21A2. What is the highest degree you have reached?

1. No degree
2. Associatesdegree or technical degree
3. Bachelors degree
4. Masters degree
5 . Doctoral degree (J.D., M.D., Ph.D., DDS.,DO, Ed.D.)
6. Other %% J7A-AO
21A3. Are you currently in school?
0. NO
1. YES
21B. What is the last grade you completed? (1 - 12)

0
Ai&-/ 21B 1. Are you still in high school?
0. NO
1. YES
B/3 eo 21C. Have you gotten a GED or had any other schooling or training since then?
0. NO
1. YES

2. other degreelcertifimte:
3. other schooling:
P&4&&&
fly
0. NO
1. YES
3.
19
RpjL3 23. Do you identify with an e h c group?

0. NO Gotr,Q126
1. YES GUtoQ2-4
2.
4.
VLk-&L&&Ci?: L - 2 6
24B. Which of these groups do you primargy or mainly identify with?
In Q. 24, circle the number ofthe 'primary' ethnic group.

__
25. How American or [ethnic group] are your cusstoms? Would you say ...(read choices)
1. Very American GQ to Q. Z5A

2. Mostly American G-0t o Q. 2%
3. Mostly [ e t h i c group], or b;o tu Q, 26
4. Very [ethnic group] Goto Q* 245
25A. How often have you had problems with your famdy because you prefer American
customs? Would you say,. .(rend choices)
1. never
2. sometimes, or
3. often
)'&L 6 26. Are you Latino or Hispanic?
0. NO
1. YES
Hand "CARD 2: LATINOlHISFANIC" to the respo

20
)&f~ 26A. Which of the following represents your origins? Circle all t?mtapply.
I. Cuba
2. Mexico
3. Puerto Rim
4. Spain
5. South America
7. Other &t&ia&-dce
K F
yoinelf!
1. Asian
2. Pacific Islander
5. Native American
6. Other
28. How often do people dislike you because of your ethnic group or race? Would you say.. .(read
choices)
1. never
2. sometimes, or
3. often
29. How often are you treated Uniairly at school or work because of your ethnic group or race?
1. never
2. sometimes, or
3. often
you say.. .(read choices)
1. never
2. sometimes, or
3. often
20
21
Hand "CARD 4: RELIGION" to the remondent
Do you follow or are you a member of any of the churches or religions bred here?
- 0. NO GOmQQ,36
1. YES C k k g r o u p h d h t a l bd Go to Q. 34
1. Buddhist
2. Catholic
3, Church of Christ
4. Evangelical
5 . Hindu
6 . Islamic
b, Conservative
c. Reformed
d. Other J & U .
9. Mormon
10. Pentecostal
5 5 C W ' 3 11. Protestant
a. Anglican
b. Baptist
5. Other Baptist f x-/rI KFT? 4 > #I
c. Episcopalian / J
d. Lutheran
1. h e r i m Lutheran Church
e. Methodist
1. Episcopalian
2 African Methcdist Episcopal Church
5. Other Methodist Churches ~ - @ d , d
f. Presbyterian
2. United Presbyterian Church in h e U.S.A.
3. O ~ e Presbyterian
r Church ( 2 V g - d
g. Seventh Day Adventisj / J
%'A 34' 34. Would you say your reIigion provides you with...(Read choices)

2. quite a bit .of guidance
3. some guidance, or
35 35. How often do you attend religious service? Do you anend.. . (Read choices)
1. almost every week or more

'.I
2. once or twice a month
3. a few times -a year
4. almost never, or
5. never
l7u3 imeniew NOT end here.

Annver the fohwing questions yourself and f o h the ~nmuCtionsprovided:
A. Is the PC mam'ed or living with a p a m r ?
Yes ->
NO -->
B . Have you obtained information about the biological faher?
Yes ->
NO ->
22
23
%
,PJ 2
J.7- 37. What is [partnerl's age?

2. 20 to 29 years 5. 50 to 59 years
8. Don't Know
37A. When was banner] born? gd,uyP2d

mm 'ldd yy
A. city dk~;~3,og~ B. State

- C. Country
A%% -3t? 4f 388. When did shehe came to live in the USA? year: 19
8. Don't Know
;*/3 33*&+/ 385. How old was shehe when shehe came to live in the USA? age:
8. Don't Know
$?/?I 39 39. Is [partner's] mother still living? 1. Yes 0. No 8. Don't Know
A. Ciry d,a;e&~a.~ B. State

-- C. Country
c _
If


-
B. State C. Country
4 1.2 Where did she live when she died?
B. State C. Country
b_l
24
IF NOT born in US, but Eves or K ~ e h
d US, A& Q. 41A and 41B:
&&1/m 41A. When did she come to live in the USA? year: 19
8. Don't Know
4/40 41B. How old was she when she came to live in the USA? age:
8. Don't Know
'd
stin 4b 42. Is [partner's] father still living? 1. Yes, 0. No 8. Don't Know
A. City B. State
-
C. Country
-
A. City B. State
-
C. Country
-
- -
.
44A. When did he come to live in the USA?
8% +V/m year: 19
8. Don't Know
44B. How old was he when he came to live in the USA?

rn age:
8. Don't Know
74
25
& -93- 45. Has [partner] attended school in another country, this country (the US), or both?
2 . US only
45A. How many years of school did [partner] have? years (1 - 20)
45B. At what age did Ipartner] stop attending school? years old
45C. Did [partner] receive any type of degree?
0. NO
1. YES
45C 1. What degree did [partner] receive?
46. Did [partner] finish high school?
0. NO
1. YES
468. Has Ipartner] done any studying ,eyonc high school?
0. NO
1. YES
46A1. How many years of studying beyond high school has shehe done?
46A2. What is the highest degree [partner] has reached?
1. No degree
4. Master's degree
5. Doctoral (J.D., M.D., Ph.D., D.D.S., D.O.,M.D.)
6. Other
46A3. Is [pkner] currently in school? 0. NO #3 io
1. YES Q- 47
25
46B. What is the last grade Ipartner] completed? (1 - 12)
46B 1. Is [partner] still in high school?
0. NO c
1. YES
0. NO
1. YES
46C 1. What has [partner] received? 1. GED
2. other degreelcertificate:
46C2. Is [partner] currently in school or training? 0. NO

1. YES
47. What country(s) best represents [partner's] ~ t i o n aorigin

l or ancestry?
9-8 48. Does [partner] identify with an ethnic group?
0. NO
1. YES
48A. Which group(s) does he/she identify with?

1. - ' . .af &&&
27
X B 49 49. Is ipartner] Latino or Hkpanic?
0. NO
1. YES
E
* YQHc! 49A. Which of the following represents hidher origins?
1. Cuba
2. Mexico
3. Puerto Rico
4. Spain
5. South America
6. Other Central Aqerican
7. Other . P ~ ~ ~ ~ L ~ ~ B ~ *
U H
* 3-i 50. If you were asked to put [partner] into only one of these groups, in which one would you
place himher?
1. Asian
2. Pacific Islander
4. Caucasian I White
5 . Native Ameri
6 . Other
23-
This interview MBy or nz9y NOT end here.
A m e r thefohwing questions yourself and follow rhe insrrucrions provided:
-
A. Have you obtained information about BOTH the biobgicd mother a&
biologicalfmher?
?I
B. Have you obtained information about the bioLogicaLfather?
~~
Time stopped:
2%
29
NOW some questions about *****'s father:
Don't Know
??7'?3 3-a. 52. Is he still living?
k% 55- f 53,l What is [*****Is fatherl's age?

8. Don't know
Sj3 3-3 ,& 53.2 What was [*****Is fatherl's age when he died?
1. Under 20 years 4 . 4 0 to 49 years

2.20 to 29 years 5 . 5 0 to 59 years
3. 30 to 39 years 6 . 60 or above
8. Don't know
53A. When was [*****Is father] born? d.

w
54. Where was [*****'s father] born?

.-
A. city oLL~~D-P~ B. State C. Country

- -
A. City f i k ~ c ~ - p ~ = ~B.' State C. Country

-
A. City B. state C. Country
c _
rn &z7r30 55A. When did he come to live in the USA? year: 19
8. Don't Know
8. Don't Know
56 5 6 ~ , Is [*****Is fatherl's mother still living? 1. Yes 0. No 8. Don't Know

-
C .Country
A. city -& -ec;& B. State .- c. country -

A. City B. State c _ _
C. Country
-
IF NOT us 58B.
ad 0 58A. When did she come to live in the USA? year: 19

8. Don't Know
b3 32
-3 60 58B. How old was she when she came to live in the USA? age:
8. Don't Know
$9 59. Is [*****'s fatherl's father still living? 1. Yes 0. No 8. Don't Know
A. City B. State - C. Country p_

31
A. ciry B. State
"-
C. Country
-
HIF NOT born in US, but lives or lived51 US, Ask (9.61A and 61B.
8. Don't Know
8. Don't Know
w3 6-2" 62. Has [*****'sfather] attended school in another country, this country (the US), or both?

2. usonly
62A. How many years of school did [*****Is father] have? years (1 - 20)
62B. At what age did he stop attending school? years old
62C. Did he receive any type of degree?
0. NO
1. YES
62C 1. What degree did he receive? Gs to

Q- 64
31
32
Did ' S father] f d h high school?

I*****
0. NO B
1. YES A
63A. And has he done any studying beyond high school?
0. NO
1. YES
63A1. How many years of studying beyond high school
63A2. What is the highest degree he has reached?
1. No degree
4. Master's degree
5. Doctoral degree (J.D.,M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other d
/v
63A3. Is he currently in school? 0. NO Go M
1. YES Q- 64
63B. What is the last grade he completed? (1 - 12)
63B1 Is he still in high school?
0. NO
..
1. YES
A+3 63 co 63C. Has he gotten a GED or any other schooling or training since then?
0. NO
1. YES
3
45 6 3 c-p' 63C1. What has he received?
Kjcfo
1. GED
-- >
3. other schooling:
c7&E%&w&
63C2. Is he cunently in school or training? 0. NO Go to

1. YES Q. 64
32
33
64. What counuy(s) best represents [*****'s fatherj's national origin or ancestry?
1. &a;.&
'&A?&<$ (;pL:&L:m &&
2 ,
M.+&".C
65. Does [*****Is father] identify with an ethnic group?
0. NO
1. YES
1. v & z 2 " d 62A&4
6.6 66. Is [*****'s father] Latino or Hispanic?
~ Which of the following represents his origins?

6 - g ~ 66A.
1. Cuba
2. Mexico
3. Puerto R i a
4. Spain
5. South America
7. other i+~h,ki& &
E
&
-*>
Yfl
5% &C+ 67. If you were asked to put him into only one of these groups, in which one would you place
him?
-
1. Asian
2. Pacific Islander
4. Caucasian / White -
5. Native American
6. Other Ya-ZeL'dh
This interview M A Y or MAY NOT end here.

Answer the following questions younelf and foUow the inrtnrctionS provided:
A. Have you obtained i n $ o m o n about the biological mother?
Yes ->
No-> .....__*
-..__...\..
v.; ..../_. ..........
Time stopped:
3Y
35
Now some questions about *+*23's mother
68. What is her frrst name? ?

Don't Know
69. Is she still living? 1. Yes

0. No
8. Don't

2. 20 to 29 years 5 . 50 to 59 years
3. 30 to 39 years 6 . a or above
8. Don't know
70.2 What was [*****'s motherl's age when she died?

8. Don't know
70A. When was [*****IS mother] born?

mm
~~~~~/~
A. city pGi;~ad B. state

- C.Country
A. City B. State
- C. Country -
-
+
A* city
d B. state -c--
C. Country
IF NOT born in IS, but Eves or lived in US, Ask Q. 72A and 72B.
7 -40 72A. When did she come to live in the USA? year: 19
8. Don't Know
,@73 ?z/30 72B. How old was she when she came to live in the USA? age:
8. Don't Know
8..
$3 73. Is [*****Is motherl's mother still living? 1. Yes 0. No 8. Don't Know
C. Country
-
A. City B. State
.- c . country
-
A. city m ~ ~B. State

d c _ _
C. Country
-
.
8. Don't Know
ps-/3 "75rsg 8. Don't Know
4p5 96 76. Is [*****'s motherl's father still living? 1. Yes 0. No 8. Don't Know
C. Country
-
*-
A. city ~:&;$.D&A& B. State C. Country
C. Country
*-
A. City B. State ----
IF NOT born in US,but Lives or lived in US, asEr Q. 78A and 7BB.
8. Don't Know
8. Don't Know
79. Has [+****Is mother] attended school in another country, this country (the US),or both?

2. usonly
79B. At what age did she stop attending school? years old
79C. Did she receive any type of degree?
0. NO
1. YES
79C1. What degree did she receive? -6 - 3&*
33
38
80 80. Did [*****Is mother] finish high school?
0. NO
1. YES
m 8Dr70 80A. h d has she done any studymg beyond high school?
0. NO
1. YES
80A1. How many years of studying beyond high school?
80A2.What is the highest degree she.has reached?
1. No degree
4. Master's degree
5. Doctoral degree (J.D.,M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other U # & i !
I V
80A3. Is she currently in school?
0. NO a,;t6
..............:.:.):,~,:"
..................
................
............
1. YES
2% &O&O 80B. What is the last grade she completed? (1 - 12)
A%&2(w 8OB 1 Is she still in high school?
NO
....................................
0.
1. YES
8OC. Has she gotten a GED or any other schooling or training since then?
#%a8UCD
0. NO
1. YES
80C1. What has she received? 1. GED

2
3. other schooling:
81. What country(s) best represents *****'s mother's national origin or ancestry?
3.
8% 82. Does *****'s mother identify with an ethnic group?

0. NO
1. YES
82A. Which group(s) does she idenufy with?
1. b=%&-LL-d& c9L@&H.d
//
&
' E5 83 83. Is [*****'s mother] Latino or Hispanic?
0. NO
1. YES
I
83A. Which of the following represents her origins?
2% 83AO
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
7. Other 6 ~ m - d /
34
40
I II
E/ETHNICIIY to the respondent
&& 84. If you were asked to put her into only one of these groups, in which one would you pIace
her?
1. Asian
2. Pacific Islander
.$
5 . Native American
6. Other y1-d& 6 x C f k - 4 M d

HOME
4 I-
. . .
Introduction: Now I'd like t o get an idea of what *****'s days are Like and what some of
the things are that you and ***** do together. A good way t o start is for you
to describe a typical day, like ysterday and then I'll ask a few more
questions. -
OBS SCALE I. I INTHEHOME?
- EMOTIONAL and VERBAL RESPONSlVlTY I
1
[CIRCLE ONE]
** 1. PC talks with subject during visit I a. YES
(beyond introduction and correction). I b. NO
** 2. PC answers m of the subject's questions or I a. YES
requests verbally. I b. NO
** 3. PC encourages subject to contribute to the a. YES
conversation during visit by getting himmer b. NO
to relate an experience OR by taking time to
listen to himher relate an experience.
** 4. PC mentions a particular skill, strength, or a. YES
accomplishment of subject during interview b. NO
OR sets up the situation that allows the
subject to show off during visit.
** 5. PC spontaneously praises subject's qualities a. YES
or behavior during the visit. b. NO
** 6. PC uses some term of endearment or some a. YES
diminutive for subject's name when taiklng b. NO
about or to the sub.@ e during visit.
** 7. When speaking of or to subject, PC's voice a. YES
conveys positive feelings. b. NO
** 8. PC caresses, kisses, cuddles, or hugs subject a. YES
during the visit. b. NO
** 9. PC shows some positive emotional response a. YES
to praise of subject offered by interviewer. b. NO
** 10. PC's speech is distinct, clear, and audible to a. YES
the interviewer. b. NO
11. PC initiates verbal interchanges with the a. YES
interviewer, asks questions, makes b. NO
spontaneous comments.
12. PC expresses ideas freely and easily and uses a. YES
statements of appropriate length for b. NO
conversation.
** 13. PC appears to readily understand the a. YES
interviewer's questions. I b. NO
HOME J ~ - x Y L & &
Inrroductlon: Now I'd like t o ask YOU about some of the different experiences **++* may
have had or is having.
OBS I SCALE 11. I INTHEHOME? School1

I VARIETY OF STIMULATION I [CIRCLE O m ] Day Care
*I
L I
1. Home has a pet. a. YES
Do you have a pet?
b. NO
2. Family visits or receives visits a. YES
from relatives or friends about
amonth. b. NO
How often do you Visit with
friends or relatives?
I
3. Subject eats ppf; meal per day, a. YES
on most days, with PC and
father (or father figure). b. NO
How do you handle mealtimes?
Does ***** eat at the table with
the family or does ***** eat
separately? (Who does he/she eat
with?)
4. Subject sees and spends some a. YES
time with father or father figure
M. b. NO
Does *****'s father (or father
figure) spend time With himher?
(About how often?)
5. PC or other family member a. YES
regularly engages in outdoor
recreation with subject b. NO
Does ***** do any outdoor

activities with any family
memberts)? (About how often?)
reads stories to subject
weekly, b. NO
Do you get a chance to read to
*****? (About how often?)
~~
SCALE 11. IN THE HOME? School/

VARIETY OF STIMULATION [CIRCLE ONE7 Dav Care
7. Subject has gone with a family a. YES

member on one outing every
Dther- b. NO
Does ***** go on outings with any
family members? (What kinds of
things do they do; about how
often?)
8. Family member has taken a. YES a. YES
subject, or arranged for subject
to go to a scientific, historical, b. NO b. NO
art, or cultural .museum wlthln
ll=wu=-
Has ***** been to any kind of
museum or exhibit this year?
(Who did he/she go with?)
to go on a trip more than 50 b. NO b. NO
miles from home
Dastvear
Has ***** been on any trips this
year?
to take a trip on a plane, train b. NO b. NO
(NOTsubway), or buswithin
kmu=
Has ***** been on a plane, train
or bus this year?
11. Family has arranged for subject a. YES a. YES
to receive lessons or
organizational membership to b. NO
....................
b. NO
support subject's talents within
lhLmu=*
(Y membership, gymnastic
lessons, art, dance, or music
lessons)
Does ***** belong to any clubs or
organizations or take any kind of
lessons? (Ask:Where?)
OBS I SCALE 11. I INTHEHOME? School/
I VARIETY OF STIMULATION I fCIRCLE OhEJ Dav Care
12. Subject is regularly included in a. YES

familys recreational hobby.
(biking, walking, playing in b. NO
park, pkying ball, swimming,
checkers, puzzles)
Does your family have any
hobbies? Does ***** join in on
BOME T n v a m y*, A &u,
oducUan; Now I'm going to ask you about some of the things that ***** likes to play
with and some of the things that helshe may be learning about. Maybe you
could start by telling me about any toys and/or books he/she may have.
OBS SCALE 111. IN THE HOME? School/

- DEVELOPMENTAL ADVANCE [CIRCLE O m ] Day Care
* 1. Subject has access &o;s,games,
_.L
_ a. YES a. YES
or books to learn &ka$ t w ~
v
colors. b. NO b. NO
Does ***** have any toys, books or
games that teach colors?
2. Subject has access to toys, games, a. YES a. YES

or books to learn ~ L ~ L W Q
sizes. b. NO b. NO
games that teach sizes?

or books to learn
shapes. b. NO b. NO
Does ***** have any toys, gams or
books that teach shapes?
4. Subject has access to W ~ W Q a. YES a. YES

toys, games, books or resources
to learn numbers. b. NO b. NO
Does ***** have any toys, games or
books that teach numbers?

or books to learn animal names
and behavior. b. NO b. NO
books that teach about animals?
SCALE 111. IN THE HOME? Scilooll
DEVELOPMENTAL ADVANCE [CIRCLE ONE1 Dav Care

or books to learn the alphabet.
Does ***** have any toys, games or b. NO b. NO
books that teach letters?
7. Subject is encouraged to learn to a. YES a. YES

read a few words.
Have you tried to teach ***** to- b. NO b. NO
read any words?

or books or other resources to
-
learn spatial relationships. b. NO b. NO
(up/dowR, undedover, big/litrle,
idout.)
books that teach up/down,
over/under, big/little, idout?
9. Subject has access to- a. YES
Does ***** have any puzzles? b. NO b.NO

(About how many?)
10. Subject has access to real or toy a. YES a. YES

musical instrument.
Does ***** have anything he/she b. NO
likes to make music with?
-
OBS SCALE 111. IN THE HOME? School/
DEVELOPMENTAL ADVANCE [CIRCLE ONE] Dav Care
* i 1. Subject has access to toys, games, a. YES a. YES
books, records, or other resources
to learn patterned speech. b. NO b. NO
(nursery rhymes, prayers, songs,
TV commercials)
Does ***** know any songs or
nursery rhymes? (How did he/she
learn them?)
4/453 -
* 12. Subject has access to $EQ toys or a. YES a. YES

games permitting fiee expression.
(clay, playdough, crayom, finger b. NO b. NO
paints, sand and waer)
Does ***** have anything that he
/she uses to make or draw things?
* 13. Subject has access to & y toys

~ or a. YES a. YES
games necessitating refined
(hand) movements. b. NO
. ...... b. NO
(paint by number, dot-todot
bookr, coloring boob, crayons,
b e d and string)
* 14. Subject has access to a record, a. YES a. YES

CD, or tape player and jjyg
children's records/CDs/tapes. b. NO b. NO
Is there a record player, CD, tape
player that ****** can use? Does
he/she have any of hisher own
tapes or records? (About how
many?) 3- f*5
* 15. Subject has access to fen a. YES a. YES
children's books.
Does ***** like to read? Does b. NO b. NO
helshe have any books heishe can
read in the house? (About how
m y
* 16. Subject has ~ e or e~ QI PLboobs a. YES

of hisher own.
Does ***** have any books of b. NO
hisher own? (About how many?)
HOME I n 7. v 0 w
ction: Now, Id like to ask you some questions about scheduling, d e s you might
have and how you handle discipline.
OBS SCALE IV. IN THE HOME?

SUPERVISION [CIRCLE ONEJ
1. Subject is taken regularly to a doctors office or a. YES
clinic for check-ups and preventive health care
tal!=ud- b. NO
Has ***** been to a doctor or clinic for a check-
up during the past year?
2. Family has a fairly regular and predictable a. YES
daily schedule for subject.
(meah, day care, bedtime, how much T V ) b. NO
Are things like mealtimes, bedtimes, daycare,
done about the same time everyday?
3. Family has TV, and it is used judiciously, not a. YES
3 left on continuously.
(No TV requires an automatic NO) b. NO
Do you generally keep the TV on or do you turn
it on for specific programs?
4. PC sets limits for subject and generally a. YES
enforces them.
@rcmngtoys away, bedtime, picking up toys) b. NO
Are there certain rules that ***** has to follow?
(Could you give me an example?) (Do you
generally try to get himher to follow them?)
5. PC is generally consistent in establishing or a. YES
applying family rules.
Do you have rules for other members of the b. NO
family? (Do you usually try to get them to follow
them?)
OBS SCALE V. IN THE HOME?
AVOIDANCE OF [CIRCLE Oi"'
- RESTRICTION AND PUNISHMENT
** 1. PC does not shout at subject during the visit. a. YES
b. NO
** 2. PC does not express overt annoyance with or a. YES
hostility toward the subject during the visit.
b. NO
** 3. PC neither slaps nor spanks subject or any a. YES
other family member during the visit.
b. NO
** 4. PC does not scold or criticize or put down the a. YES
subject during the visit.
b. NO
* 5. Subject is allowed to express negative feelings a. YES
toward PC or can disagree with PC without
harsh reprisal. b. NO
When ***** says things like "I Hate You" or
"No, I Won't Do That!", how do you handle it?
* 6. Subject is permitted to hit PC without harsh a. YES
reprisal.
When ***** hits you, how do you handle it? b. NO
* 7. PC reports that instance of a. YES
physical punishment occurred
Bek. b. NO
Have you had to spank or physically punish
***** recently? (How about this past week?)
*
-
OBS SCALE VI. IN THE HOME?
-
* 1. At least Lm books are present and visible in the a. YES
home.
(if not seen, Ask:) b. NO
Do you get a chance to read? Do you have a
- place you keep books?
** 2. PC does not violate rules of common courtesy. a. YES
- b. NO
** 3. PC introduces interviewer to subject. a. YES
4. Some delay of food gratification is demanded a. YES

of the subject.
(there are planned meallsnuck times and b. NO
subject is generally required to wait)
Does ***** eat whenever he/she wants or do you
have specific times to eat?
5. PC teaches subject some simple manners. a. YES
(to say, please, thank you, sorry)
Has ***** learned things like please, thank-you, - b.NO
sorry? (How did he/she learn?)
6. PC or other family member buys a newspaper a. YES

daily and reads it.
Does anyone in the house get a chance to read a b. NO
newspaper at home everyday?
7. PC or other family member subscribes tobuys a. YES
one magazine monthly.
Does anyone in the house buy or subscribe to any b. NO
I
8. PC regularly participates in religious or a. YES
community activities.
Are you involved in any religious or community b. NO
activities?
9. PC participates in child oriented organization. a. YES
How about any organizations that do things for
children? b. NO
53
10. PC has not cried or been visibly upset in
subject's presence more than once
@ . 6-;f'8
When you feel unhappy or sad, do you let *****
see how you're feeling or do you try to bide your
Invmrorv: A o d
Introduction: Now I'd like to ask you about different responsibilities ***** might have.
-~ ~ __
OBS SCALE VI1. IN THE HOME? 1 School/

FOSTERING INDEPENDENCE (CIRCLE O M J 1 DayCare
1. Subject is permitted some a. YES

choice in lunch or breakfast
7-4 menu. b. NO
Does ***** ever choose what
he/she has for breakfast or lunch?
2. PC allows subject to choose a. YES
certain favorite food products
or brands at grocery store. b. NO
How about at the grocery store?
Does ***** ever choose any food
or brands?
3. PC tries to get subject to help
pick up and put away toys.
Does ***** help you put hisher b. NO
toys away?
4. Subject has a place to keep a. YES

hisher toydtreasures or
belongings. b. NO
Does ***** have a place to keep
hisher toys, treasures or
belongings?
FLELD COPY w 2
SUBID TIME STARTED
INTID DATE
dangerous structural or health hazards.
of the home are reasonably clean and
noise in the house.
I b. NO
or non-prescription drug consumption in the b. NO
home.
( h g paraphernalia, beer cans, liquor
bottles)
TIME ENDED
SCALE IX.PHYSICAL ENVIRONMENT
EXTERIOR OF HOME]
mm dd YY
Day of week: M Tu W Th F Sa Su
(CIRCLE ONE)
Time of day: Entered home: 9 AM PM

a hrmin
1. Street Layout:
2. Through - curved
3. H-lay out
4. T-layout
5. L-layout
6. Cul-de-sac
7. Boulevard
8. Divided Highway
9. Other ridZ&c4&d & .eG%
2. How would you characterize the land use on this face-block, based on greet-level
9-*;?, frontage?
1. primarily residential
4. Primarily industrial
6. Primarily vacant lots and open space
7. primarily services or institutions
8. primarily park, playground
9. Other YG&U& -&
3. How would you rate the general condition of m of the housing units or other buildings
in the face-block?

2. Fair condition
3. Poor condition (peeling paint, broken windows)
4. Do any of the fronts of residential or commercial units have metal security blinds, gates,
'" or iron bars or grills? .
1. None
2. Some
3. At least half
4. Most
5. How would you rate the volume of traffic on the face-block?
2. Verylight
3. Light
4. Moderate
5. Heavy
6. Veryheavy
6. How would you rate the condition of the street in the face-block?
1. Very good - recent resurfacing, smooth

7. Is there garbage, litter, or broken glass (except beer/liquor bottles) in the street or on the
sidewalk?

3. Yes, quite a bit

3. Yes, quite a bit
1. No children-visible, or all in yards

10. Are there any adults or teenagers in the street or on the sidewalk arguing, fighting,
&inking, or behaving in any kind of hostile or threatening way?

3. Yes, one or wo behaving in a hostile manner
4. Yes, three or more behaving in a hostile manner
11. How did you feel parkmg, walking, or waiting at the door in the face-block?
1. Very comfortable: can imagine living/working/shoppirig here

2. Comfortable: it seems to be a safe and friendly place
3. Fairly safe and comfortable
5. I felt afraid for my Dersonal safetv
SCHOOL SCREEN:PC [3-6]
1. Does * * * * * attend school daycare, or preschool? SA 9

(Code YES if currently on vacation, suspension, etc. and will return to school.)
1. YES SI3 Y-
a. preschool
b. daycare
c. school
d. Headstart or Headstart-type program
2. NO
4. What is the name and address of the p'erchoor' -.i2ycare ***** attends?
1. vwk4b h m d c
Name of preschool/ dayc&e person
5. When did ***** enroll?
month Y W
ed. init. ed. date

2
6. How many hours per week is ***** in preschool/ daycare?

Si5 6
- hours per week
7. Is this preschool/ daycare a home-based or center-based program? (circie one)
1. home-based - SI3 7
2. center-based
Id
8. What is the naqe and address of the school ***** currently attends?
1. 5/39--5/ 2. SA 9-A
month Y=
10. What is *****Is school ID number?
11. What type of school is it? sfi f!

1. Pubk
2. Catholic
3. home school
4.
5.
Private, non-Catholic
Otherbleasespecify) - ~/ca&J& d / / w .d
3
13. What grade is ***** currently in? s/3/3

(Lfduxing summer break and
will be entering in the fall.)
1. 90. Ungraded school

grade
SA 74 14. h the past year, was ***** ever truant (skipped school without an excuse)?
"t
1. YES
2. NO
15 . On the average, how often was ***** truant? (Circle one)

S& 15
a. more than once a week
b. once a week
c. a few times a month
d. once a month
e. a few times a year
SA A& 22. Has ***** ever skipped a grade? 1. YES 2. NO
23. Has ***** ever repeated a grade? 1. YES 2. NO

SA3 R.3
24, Many students receive special teaching or help in school. At any point in *****IS
education, has s h e received any hefp or special teachug in any of the folIowing
areas?
-
Bead aloud circle all that apply.)
m44~ a. Giftedclass 1. YES 2. NO
s43 w43 b. Special remediation clasdtutoring program

(includes summer school)
1. YES 2. NO
$6 &4c c. Learning problems 1. YES 2. NO
sfi ~ 4 %d. Class/ program for developmentally 1. YES 2. NO

delayed or mentally retarded
s/3,44& e. English as a Second Language or 1. YES 2. NO

Limited English Speaking
~ f i ~ 4 ,f. ~ - therapy classes

Speech 1. YES 2. NO
g. Class/ program for physically 1. YES 2. NO

525446 handicapped, hearing problems,
sight problems
,SaAq&l A Emotional or behavior problems 1. YES 2. NO

S/ES#wI i. Special music or art school I. YES 2. NO
j. Special science program 1. YES 2. NO

S/3&4J
5
25. Is ***** routinely involved in extracumdar activities directly connected with
hisher schooi, such as school sports teams, school clubs, music groups, etc.
1. YES
2. NO
SA .46 26. How many hours does this take place? hours per week
'$
27. What kind of program is this? (Circle all that apply)
1. Recreational (sports, games, crafts)

2. Artistic (music, dance, art)
3. Academic emkbment (tutorbg, classes)
4. ~ther@ieasespecify) - ~ a ~ c ; t % d AmH-ed
e
28. Is ***** involved in any other kind of d e r school program?

(Tus may be at *****Is school, but is more of an after school program rather than
extracurricuiar activity.)
1. YES
2. NO
29. How many hours does this take place? hours per week

3. Academic enrichment (tutoring, classes)
4. Other @lease spec@) m , b BCc daopped
6
3 1. what schoois has ***** attended in the past?
a. DavcareFreschool or Headstart-type program

SchooU person's name Address (include city, state) Dates enrolled
I
7
For RA.s only: for Elementary School type, use the following codes:
1 -Public
2 - Catholic
3 - home school
4 - private, non-Catholic
5 - Other (please seecify)
c-
69
8
How ofien do you attend scheduled parent/ teacher conferences? (Read choices.)
1. almost always
2. often
3 . seldom
4. never
How often do you attend PTA meetings, local school council meetings or any school
related meetings? (Read choices.)
I. almost dways
2. often
3. seldom
4. never
34. How would you describe the education ***** is receiving in hid her current school?
G43 34 (Read choices.)
a. excellent
b. good
c. fair
d. poor
HEALTH SCREEN
3 2
HEALTH SCREEN: PC Version
Interviewer ID:
J/L7.##eA/#I3
'=8
FlELD COPY 2 \Sauce
I-Time Started:
~
- - -
I
Now I have some questions about *****Is health.
1. Would you say that in general *****Is health is excellent, very good, good, fair, or poor?
1. excellent
2. verygood
3. good
4. fair
5. poor
2. Now thinking about *****Is physical health, including being sick or injured, for how many
days during the past 30 days was *****Is physical health not good?
HLLJ
number of days
3. Now thinking about *****Is mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was *****Is mental
health not good?
N73
number of days
ed. init. ed. date

4. During the past 30 days, for about how many days did poor physical or m e n d health keep
*-*** fiom doing [hidher] usual activities, such as self-care, work, or recreation @lay)?
474
~-
number of days
END OF I W
FAMILY STRUCTURE &
HEALTH HISTORY
n from the Demographic
Now I would like to ask some questions about *****Is family. This year I wiU only be
getting a general outline of who is in the family. Next year we will come back to this
information and we will draw out a tree to complete it.
F-23t-40 1.A You told me earlier that you are *****'y:

(READ CIRCLE APPROPRLATE CHOICE)
+
b. foster mother
c. femaie cousin
e. grandmother
f. sister
h. aunt
i. other v w d A - p6-d
l.B YOUtold me earlier that you are *****Is:
F h ik3Q (READ AND CIRCLE APPROPRIATE CHOICE)
a. biological father d. stepfather g. adoptive father

c. malecousin f. brother i. other I.L;LRL'dfh=c, I -4
Is that right? Y N
ed. init. ed. date

SECTION 8 : BIOLOGICAL MOTHER
2. What is *****Is biological father's name? DON'T KNOW

first name
3.1 How old is he? DON'T KNOW

(years old)
(,4 3.2 How old was he when he died? DON'T W O W

(years old)
4.1 What is your marital status with *****'sbiological father?
la married-still involved
lb divorced
4.2 What was your marital s t a with *+***'s faher when he died?
lb divorced
5.1 Are you living together now? 1 .No

2.Y-
5.2 Were you living with*****'s 1 .No

biological father when he died? 2.Yes
3
5A. Was there a time that you lived together? 1. No
5A1. When did you stop living together?

ol=>
6.1A How much time has *****'s biological father spent with W e r in the past year?
pt3 6-/ A 0
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
6.1B How much time has *****'sbiological father spent with him/her prior to the past
Fr3 6-/A30 YW?
a. none
d. once a month
e. mice a month
f. once a week
g. M Y
h. other
E;- 6 . 2 Bqore he died, how much time did *****Is fmher spend with him/her in the part
year?
a. none
d. once a year
e. twice a month
f. once a week
g. daily
h. other
C/5 6- 60 6.2B Before he died, haw much time did *****Is biobgical father spend with himiher prior
to the past year?
a. none
d. once a year
e. twice a month
f. once a week
g- W Y
h. other
7. Does ***** have any children of hisher own?
Children? 2.Yes 1.No

Gender: MIF F&?fC
7.2 Name: ,d4#E2d~D.0.B

5
- 8
*-/3 D m he/she have any siblings? 2. Yes 1.No
For ea& one, I need to know their name, age, whether they are a boy or a &I,
whether they are a biological, step, foster, or adoptive sibling of ***** 3 and
whether they are still living. If ****+has siblings who have a partner or child,
negd to ask you some additional questions about them. Why don't you start
with the oldest sibling?
BROTHERS
?-#
SISTERS
partner? Y N
6
BROTHERS
cause of death:
$*dLd&7Jy. &/
d ..
f93&&S3b5
bio? step? foster? adopt? - I
biol momsname:
biol dads name:
7
BROTHERS SISTERS
f 5 b name
living: Y
cause of death:
d2Lx-&d
FK3 8 R cz 6-4
bio'l mom's name:
bio'l dad's name:
ffl
- NAP
52 5x5
parmer? Y N age: -gender: M/F
d Y=&&@t5
Children? Y N F ~ Y A ' / K &

# girls: * # boys : j=Jgd?&.%5
living: Y N age/age died:FE&%Wt%/

bio'l mom's name: d&.&Pp.dd
bio'l dad's name: 623>:&*F&
/./
8
BROTHERS SISTERS
# % name: &.Lw~/ # 7s name:
living: Y N agd&e died:&&HA, living: Y
cause of death: Mm3A cause of death:
&2&
/%BRZ?S
bio'l mom's name: dk-&?.&d bio'l morn's name:
bio'l dad's name: .d/ &De& bio'l dad's name:
dy/
- NAP
WP47S +EaP/?sF&B=-?S
.
Children? Y
# girls: .
N F&&'k/+&
.
Children? Y N ~X3@k/?.S
# boys : F W ? % & # girk:F&!%..% c # boys :f/t5@&SS

bio'l dad's m e : bio'l dad's name:
partner? Y N age: gender: M/F partner? Y N age: -gender: M/F
.
Children? Y N
# gih: .
# boys :- .
Children? Y N
# girls:- .
# boys :
- 9
Fp4 9
9. YOUmid me about (READNAMES OF SIBLINGS). Are there any
other siblings of x****, either yours or *****'s biological father's children, that you
may not have mentioned? 2.YEs 1.NO
10. Have you been married to anyone other than *****'sbiological father or lived with
F-73 YO someone else as a partner other than the relationships you have just told me about?
(CIRCLE ONE)
. ......
1OA. How many other relationships have you had?

# of relationships
1OB. For each of the people you had a relationship with, I need to know their first
1. Gender: M/F

F&/o/s ~ d /la married-still involved- 2a never married-still involved
2c never married, partner died
?.#
Id widowed .
fo/3~3
FJ la married-still involved 2a never married-still involved
F&/OA/?~~ la marrieed-st3.I involved 2a never married-still involved

1d widowed 2c never married, partner died
1
first name
\ F X ~ A O L la
~N ~
married-still invo~vexi 2a never married-still involved
f& isG'43 Mt5 la married--stdl involved 2a never married--still involved
l b divorced 2b never marriedlno longer
IC married, but separated invoived
"I
F/3 7Y 11. Has *****Is biological father been married to anyone or lived with someone else as a
partner other than the relationships you've just told me about? (CIRCLE ONE)
How many other relationships has he had?

# of relatiomhips
For each of the people *****Is biological d h e r s had a relationship waul, I

first name. I alsox~eedto know whether he was married or
need to know their................................
...............
living with them ............................ a d whether he is still in the relationship]. If the
relationship has ended, I need to know if it was due to divorce, separation or
~~~~
being widowed.
1. Gender: M E .1
first name

partner died
2k don'tknow
12
2. Gender: M/F .i

2b never married-no Ionger
partner died
2k don't know
3. Gender: M/F .1

partner died
2k don'tknow
4. Gender: M/F .1
first Mile.

partner died
2k don'tknow
5. Gender:. M F .1
fmt name

partner died
2k don'tknow
13
6. Gender: M/F .1
la married-stiu involved 2a never married-still involved

Ib divorced 2b never married-no longer
partner died
2k don't know
.1
F/J ~9 la married--still involved 2a never married-still involved

Id widowed 2c never manied, either
partner died
2k don'tknow
14
Pa@. 12. - is ****+Is

What biological mother's name? DON'T KNOW
n',QQppRtc fKst name
f.3 - y. 1311 How old is she? DON'T KNOW

(years old)
13.2 How old war she when she died? DON'T KNOW
(years old)
14.1 What is your marital status with *****'s biological mother?
l b divorced
2a never married-still invoived
14.2 W h a war your marital stau.~with *****Is mother when she died?
l b divorced
Are you living together now? 1.No

2.Yes
15.2 Were you living with *****Is
biobgicai mother when she died?

?5A. Was there a time that you lived together? 1.
2. Yes Go tea.
15A1. When did you stop living together? (YW>
16.1A How much time has *****Is biological mother spent with h n h e r in the past year?
C f i f 6 - f ~ ~
a. none
d. once a month
e. mice a month
f. once a week
g.
h. other
16.1B How much time has *****Is biological motber spent with himher prior to the past
=46-f&0 year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
16
1 6 . 2 &fore she died, how m c h time did +*++*Is biological mother spend with hidher in
3 Ag-MO
e the past year?
a. none
d. once a year
e. twice a month
f. once a week
g. M Y
h. other
16.2B Before she died, how much time did *****Is biological mother spend with h i d e r
%5~6-UdAO prior to the past year?
a. none
d. once a year
e. twice a month
f. once a week
g.
h. other

75/13 / -
Children? 2.Yes 130

A .I3 C
17.1 Name:. - D.O.B Gender: M/F
17.2 Name: - , D.0.B w d Gender: MIF

17
5 3i8 18. piow I have some questions about *****'sbrothers and sisters,
biologkd, step, foster, o r adoptive Siblings.
Does he/she have any siblings? 2.Yes 1.Mo
For ea& one, I need to know their name, age, whether they are a boy or a &I,
whether they are a biological, step, foster, or adoptive sibring of *****7 md
whether they are Stiu living. If ***** has d h g s who have a partner or child, I
will need t o ask you some additional Q.s about them. Why don't you start wifi
the oldest sibling?
BROTHERS SISTERS
# l b name: k P 4 # 1s name: &e& / ~ / 3 7 a , 'S
living: Y N age/age died. Ffi7'8MY+ living: Y N agefage d i e d : M & G
cause of death: /c/3 /&AA/4 cause of death: F;r31'819;a55
/Y
A43 s/BR .S /S
~

bio'l mom's name: d e Q 5 bio'l mom's name:
- NAP - NAP
3 3 ~ 9 ~ ? / . 3 ~&/&#i& FA18p6
partner? Y N age: gender: M E
.
Children? Y N i%f&x_r#&
c # girls:
Children? Y N &&78'&~#.5
#boys : .J-x3~8%0f.!.!9 # girls:m2jZ.x. # boys : /%&??AS
# 2 b name: dd- d.
living: Y N ageiage died. M/~M+
FBAi!-9Wd5 Cause of death:
/
Fss 7iPU@EY/
bio'l dad's name: Lz%Z4&0& bio'l dad's name:
.. ..... . .. . ... . ... .
- NAP
%318&9A/3 J&&%&k3 Ffif&HZA %37P/Ws F&&P/&S FkY&P&dS
parmer? Y I? age: -gender: ME partner? Y N age: ,-gender: ME
.
Children? Y I? F&I/BXTAeS
# girh:BBG-* # boys :
Children? Y N ,%1'8kZdS
'# girls-gs # boys : & & D ~
F B &Q&AA
44
18
BROTHERS SISTERS
# 3 b name: dz$.axwd # 3s name: ,- *
living: Y N
z
age/&e died: M1'8M. living: Y N age/age died:M/8&3,
cause of death: F*4/8&334!3 cause of death:
~ ~~
E%W..?Si
/I
+
FA KPkC 305 F&&e& 3's'
*
bio'l mom's name:
bio'l mom's name:
- NAP - NAP
%'/8P?4S A5 f&fl/ss f&/&P&3 S
partner. y N age: ,-gender: ME
Children? Y N Mf8kZ36 Children? Y N F;S/8K/35
b # girlsFZ@613& # boys :fZd....D&3
#4b name: Ld.k?&?fl& # 4 name:

~ &+
living: Y N age/age died: living: Y N agerage died:BBh4'9
cause of death: /&rn9& cause of death: AgA94B-95
h
F?37'8A14A
K
f& /2?RE4S
+
bio'l mom's name: G.&e@&ed bio'l mom's name:
- NAP - NAP
%j&?rn%& /B#H4! F&f??P6 4 3 ?3/8H45 r&@?%- FX3&H4s
xrtner? Y N age: -gender: M/F partner? Y N age: gender: M/F
Children? Y N FR/&x~.L& Children? Y N FkWki.YS
19
BROTHERS SISTERS
#5b name: , I # 5s name:
living: Y N aghage died: F&/&@54 living: y N age/age died: B&&Uq
cause of death: F&f&B5A cause of death: F&&#ASS
x
FB/8R& 5L3
F&/8KS 5 S
bio? step? fosrer?
''
- NAP - NAP
r;4/8P!5h
partner. Y N age:
&%@p/~-~
.6&/&@65&
vender: MIF
%/&#37.$
partner?
&3&w55 m/Gp*ss
N age: gender: MIF
Children? Y N FA/dQW54 Children? Y N F23/BLZ55
' # girls: * # boys : &Sbs0523 fi # g i r i s $ @ 8 ~ i ~#~boys
* :F&7'&!5S
# 6 s name: fd&y?pd,
living: Y Pd ~ f l ~Y ~ N/
age/age d i e d : ~ ~ ~ living: agg&ge died:BA5@65
cause of death: BjC?HB6/3 cause of death. F&,&flA8d
&T5weawL
65
Y
,%/4?&5 6A F&/B&S
bio? step? foster? adopt? bio? step? foster? a
w d,
- NAP - NAP
.w&?AGA *@#e/623 /53@-6;4
partner? Y N age: -gender: ME
Children? Y N H18.cT645
c # girls: ' # boys :&L@mdA
-
20
BROTHERS SISTERS
#7b name: 6z&?Lzwd d 7s name: 3
living: Y N
,
living: Y N age%& died:m/8&%< agelage died: Fz3&M4L
/ r
cause of death: R3&+6-?n Cause, of death: F&/&A.e7&

/ #
B/8R17B FA-/eie2?l'
bio? step? foster? adopt? bia? step? foster? adopt?
bio'l mom's name: &+&,?$??& mom'smname:
bio'l dad's
bio'l dad's name: bio'l e:
............................................ ......................
- NAP - NAP
F&/8&9?'' Fh,&P/,?S iAXPP~?6
partner? Y N age: gender: WF
Children? Y N /?3/&KZ-7~3 Children? Y N ,+3/8,czqs
# girls: P # boys : -)@?A0323
# 8 b name: B Ss name:
cause of death: =use of death:

- NAP
...............
- NAP
) m e r ? Y N age: -gender: MfF ) m e r ? Y N age: gender: M/F
Zhildren? Y N Ihildren? Y N
*#girls: e#bOys:- b # giris: p f boys :
21
?k3 fl other siblings of *****, either yours or *****'s biological mother's children, that you
additional siblings record them on the chart on Q. 18.
F&AB 20. Have you been married to anyone other tha.n *****'s bioiogical mother or lived with
someone else as a partner other tha.n the relationships you've just told me about?
(CIRCLE ONE)
1. - NO:
2. - YES:
20A. How many other relationships have you had'?

FA3Wm
# of relationships
/=UAZ?AGs, 1. Gender: M/F .I

fxst name
F43 x;oAM f l a married-still involved 2a never married-still involved

\ IC married, but separated involved
-22

Id widowed 2c never married, parmer died
3. Gender: M/F .l . L A q g z 3 5 ~
fmt name

4. Gender: ME 1--
first name

5. Gender: M E .1

6. Gender: M E .1
fxst name

lb divorced 2b never manied-no longer
23
.1
F43 Ad647
- l a married-still involved 2a never married--still involved
-
21. HZ biological mother been married to anyone or lived with someone else as a
*****IS
p m e r other than the relationships you've just told me about? (CIRCLE ONE)
1 - DON'T KNOW
2 - NO:
3-YES:

Fh&f/$O # of relationships
21B. For each of the people *****Is biological mother had a relationship with, I
need to know their first name. I also need to know whether she was married
.......................................
or living with &em E.......s.,... ....................
j m $and whether she still the relationship].
If the relationship has ended, I need to know if it was due to divorce,
&3 &/&@vila married-stili involved 2a never married-still involved

partner died
2k don'tknow
24
2. Gender: M/F .1
frst name
BF/&
,c&~;/ la married-stili involved 2a never married-still involved
partner died
2k don't know
3. Gender: M/F .1
first name

partner died
2k don'tknow
4. Gender: M/F -1-

fmt name

partner died
2k don'tknow
5. Gender: ME .1

\
partner died
2k don'tknow
25
&B& anfl6
IC married, but separated invoIved
partner died
2k dont know
.1
FhJ,/.&//q la married-still involved 2a never married-still involved

partner died
2k dont know
[Male/Femaie]
Fxst 9 have same questions about *****'s biological mother and father.
22. W t is *+***'s biological mother's name? DON'T KNOW

fxst name
23.1 How old is she? DON'T #NOW

(years old)
(years old)
24.1A How much time has *****'s biological mother spent with m e r in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
24-13 How much time has *****' s biological mother spent with himmer prior to the past
424-f&Q YW?
a. none
C. intermittent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27
E3 L.4- A140 2 A . a Before she died, how much time did **+**I s mother spend with Rim/her in the
past year?
a. none
d. once a month
e. twice a month
f. once a week
g. daily
h. other
24.2B Before she died, how much time did *****'s biological mother spend with
t=& 24- si30 hidher prior to the past year?
a. none
d. once a month
e. twice a month
f. once a week
g. U Y
h. other

first name

(years old)
F A $6 Ia
.
26.2 How old was he when he died?
(years old)
DON'T KNOW
27.1A How much time hiis * * * * j ' s biological father spent with him in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27.18 How much time has *****'sbiological father spent with him/her prior to the past
year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27.2.4 Btfore he died, how much time did *****'s biological faher spend with
himher in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
27.23 Before he died, how much time did **=**Is biological father s p e d mkh
frim/herprior to the p a l year?

d. once a month
e. twice a month
f. once a week
'I g. daily -
h. other
--.
-
%&&J 28.1 Are *****'s biological parents living together now? 2.Yes 1. No 3.DON.T
KNOW
28.2 Were *+***'J biological parents living together when ****+'s mother&zfher
died?
29.1 What is the marital status of *****'s biological father and mother?
l b divorced
2a never manied-still involved
29.2 Wid was the marital s c m u ~of **+**Is biological father and morher when
****+Is mothergaher died?
lb divorced
2a never manied-still involved
2b never married-no longer kvolved
30
Does he/she have any siblings? 2.Yes 1.No 2. DON'T KNOW
%;oreach one, I need to h o w their name, age, whether they are a boy or a &I,
whether they are a biological, step, foster, or adoptive sibling of *****7
whether they are still living. If***** has sib- who have a partner or a d , I
a nead to ask you some additional questions about them. Why don't you start
with the oldest sibling.
'1
BROTHERS SISTERS
# Is name: .Gz%e&w&d
living: Y N
I .
agelage died: pA.WMf&/ living: Y N agelage died:F&%7&'2

cause of death: Fzc59mw3 cause of death: F&*A?Yd
.&?%-&
K
F& 30 K.2 7zs
bio'l morn's name:
bio'l dad's name: bio'l dad's name: &z?x&
- NAP
BjOpqfA ~ * ~ ~ ~ sa,-?&
g e ~ e r %jOPA/S
: WgQHdS F&>3OK/S
partner. Y N age. - partner? Y N age: gender: M E
Children? Y - N F2330kZjj3
# 2 s name:
living: Y N
# Y L_
living: Y N agelage died: ,G3XWdfi/' agefke died: F Z ~ ~ & C . ~ L

cause of death: ?0,4Bf& cause of deak
FA3 30&E&/3 ;=i3310&.~asJY

bio'l mom's name: bio'l morn's name:
bio'l dad's name: bio'I dad's name: - d
- NAP
rej@.!!Ls /?3j'&KJfLS F&@6& s
partner? Y N age: -geader: MIF
- 31
BROTHERS SISTERS
# 3 b name:
living: Y N agelage died: F 2 . w
# 3 s name:
living: Y N
+
age/age died: F&&.'&:
cause of death: /=be
aa&B3; cause of death:
& U
Y -
&+3iua.S 3 A F6 30&S 3 s
bio'l mom's name:
bio'l dad's name:
r3430PA~S f?2?x%vdS/Gg*B3S
cause of death:
P-+ .30R s 44
.3 FB30peE4S
'
6369P& 4k3 ~ i - S ~ c l a / b ; yFESQK4i5
partner? Y N age: -gender: MfF
Children? Y N FAA!o..&~~&
32
BROTHERS SISTERS
# 5 b name: Y f f
# 5s name:
living: Y N agelage died:F&-@4A5+ living: Y N age74e died:rsmms:
cause of death: &-3a'DApa5A came of death:
K
.3oa.s6-43
F
7g F A 304s 5 s
bio? step? foster? adopt? . bio? step? foster? adopt?
F&W@j523 AZ3.30&&-'3 ~2&cl&qs -3cw/LTs F&.*F+Fa-S

ME gender: M/F
C&&$-#q
partner? N age: -gender: partner. Y N age:
Children? Y N F&&W/5..
# girls: ' # boys : / - = x L % m 3
cause of death:
G23
FA ~ D R &
:
Fk330RS 6s
i3xmf-A 3UP8 6.5.

partner.. Y N %e.
.
-
e f 6 A
gender: M/F partner? Y N age: -gender:
F&s&pf6.S 2330p665
M/F
Children? Y N J5%3OXZd4
-
b # girls: # boys : ~ 9 3 0 ~ 0 0 0
33
BROTHERS SISTERS
# 7s name:
living: Y
cause of death: FA 30?2% cause of death:
x
F/3307/3RZ FA30REPS lS'
233UP&7& AgBP/?& &?d?.?MA =&jcpP.4 9 s F k J O P 6 9s

&L%m?y~
partner? Y N age: gender: M/F partner? Y N age: vender: M/F
Childreg? Y N , % ~ ~ C J ~ V ; Z A
living: Y N age/age died: living: Y N age/agedied:
bio? step? foster? adopt? bio? step? foster? adopt'?

If NAP - NAP
partner? Y N age: ,-gender: M/F partner? Y N age: gender: M/F
c # girls: * # boys : - b # girls:- # boys :
F .3f 3 1. You told me about (READ NAMES OF SIBLINGS). Are there any
2.Yes 1.No 3. DON'T KNOW
5-1/33~ 32. Do you know if either of *****Is biological parents were married to anyone else or
1 - DON'T KNOW:
......................................
2 - NO:
3 - YES:
j=& 525 A M a Bio mother: # of relationships
FA& Aft/ Bio father: # of relationships
32B. For each of the people [the biological mother/father] bad a relationship with, I need to
know their first name. I also need to h o w whether [shehe they] [were/was] married
...............................
or living with them p:m$ ...................... ] in the
a d whether [she/he/&ey] [ j ~ / a e still
Biological mother:
FA 3 L A ~ 6 j 1. Gender: M E .1 ULL$&.ZJk
\ first name
FA A M M ~ la married-still involved 2a never married-still involved

partner died
2k don'tknow
35
2. Gender: M/F .I b*&A
flrst name

ld widowed 2c never married, either
partner died
2k don't know
3. Gender: .M/F .1 +A
first name

partner died
2k don't know
4. Gender: M/F .1
first name

partner died
2k don't know
5 . Gender: M/F .1
frrst m e

partner died
2k don'tknow
/ O ~a,+,-
Z 6 la married-still involved 2a never married--still involved
- lb divorced 2b never married-no longer
partner died
2k dontknow
?#
7. Gender: M/F .I-

E43334MG ? first n a m e
f a 3~ AM#.& la married-still involved 2a never married-still involved

partner died
. 2k dont know
Biological father:
.1
first name
pfi fifi la married-still involved 2a never manied-still invoived

partner died
2k dont know
2. Gender: M E .1
fust name
E% 3 t #fi la married-still involved 2a never married-still involved

partner died
2k dont know
- 37
3. Gender: M/F .I
frst name

partner died
2k don't know
4. Gender: M/F .1
first name

partner died
2k don'tknow
5 . Gender: MA? .I
la manied-still involved 2a never married-still involved

parmer died
2k don'tknow
38
6. Gender: M/F .1
first name
la married-still involved 2a never married-still invoIved

partner died
2k dont know
7 . Gender: MIF .1
fist d e

partner died
2k dont know
Fa 33 33. How old was ***** when he/she frrst came to live with you?
Age
39
(WRITE IN RESPONSE AND CIRCLE CODES)
pc&&+*dh -*
655.34 1. biological mom died 9. biological mom hospitalized: substance use

5 . biological mom abandoned ***** 13. biological mom hospitalized: psychiatric
6 . biological dad abandoned ***** 14. biological dad hospitalized: psychiatric
7. biological mom in another country biological mom lost c u s t ~ y ( s reason)
p~~
8, biological dad in another country
L
i/iZk&3& &&qpet&
,
, 161 biological dad lost custody (specify reason)
.- J%'&h
.
I #
@ other reason (specie reason)

G/=Cd& & ~ &
/'
40
FA 33- 35. HS *+**+always lived with you since b e frst time shehe came or have there been
p e r i d during which sheme did not Iive with you? (CIRCLE ONE)
a. Always Iived with me:

b. Has not always lived wi
35A. Describe other living arrangements since ***** fxst came to Iive with YOU:
L42.&&d&.* c&a%W&
b
/
41
Now I haye some questions about the time since ****+ fmcame to live with you.
Ffi 36 36. I need to know whether you have lived with anyone as a partner while ***+*has b e n
living with you. (CIRCLE ONE)
1 -NO:
2 - YES:
F/3 3 6 A 0 36A. How many relationships have you had during this time?
# relationships
36B. For each of the people-you had a relationship with, I need to know their first
1. Gender: M/F .1 W w =
6
,
- d
first name

Id widowed 2c never manied, partner died
2. Gender: W 1
--
first m e

3. Gender: M/F .1 k &&@/'

\/5/536 436-3 first name
la married-still involved 2a never married-still i n v o i v ~

42
4. Gender: M/F .1&%?4++-eOl

first name
la married-still involved 2a never married-still invoived

IC marrid, but separated invoived
5. Gender: M/F -1 --td
- fmname

-
H3nl5Bfi 6. Gender: M/F
first name

F4 36sgw6 lb divorced 2b never married-no longer
F ~ 3 6 6+ 7. Gender: M F .1
first name
. e 3 36% la married-still invoived 2a never married-still involved

\
43
37. Does **+** regularly spend m y n i g h of the week in another household or anywhere
else? dues not include day care]
2.Yes 1.No

N = nonbiologid aunt/uncle ,
M = maternal
'd
A B C
.1 Name BorN MorP
E Other relation -
.2 Name BorN MorP
E Other relation
F Nightseachweek F/3j7-
G Nights each month: FR 3Z-AG
H Other arrangement: F& 39- ~ 5 d f
.3 Name BorN MorP
E Other relation -...
-
F Nights each week /t=/s 3J.- 3 F
G Nights each month: Fe3-3- 3s
H Other arrangement: && 37-
iF4
38 . In ****+'sentire family ..... including anyone: parents, siblings, yourself, aunts,
u n c h , grandparents, cousins, anyone.. ..
who is **+** particularly close to? You can list as many people as you want - anyone
in the family who you thrnk ***** feels close to.
grandparent, child,
P =paternal .
.1
.2
.3
.4
.5
.6
.7
.8
.9
.%.-
-10 Name B or N
.11
\
* 12 Name
* 13 Name
-14 Name
45
Check Household Composition
39. Now I need to list all the people who live in this household except for +****. For
each person who lives here, I would like you to tell me how he or she is related to *+***.
For example, I want you PO tea me if the person you list is *****'s brother or aunt o r
cousin. Even if a person who ]Lives here is not related to *****, I need you to list them
&O.
. B = biological harent, sibling,

N = nonbiological aunduncle ,
P = paternal
.2
.3
.4
.5
.6
-7
.8
.9
-10
-11
* 12
.13
Pars Il: Famiiy Health History
40. NOW,P have some questions about *****IS familys health history. I lnegd to h o w
Kb 0 if anyone in *****IS fami.iy induciing everyone that was just mentioned in interview,
has any of the following health problems. For each person you list, please tell me how he
~
or she is related to ****+ and whether he or she is a biological or non-biological Elation.

Please include youpself.
Diabetes: (circle one) 2. Yes 1.No

[Sugar Diabetes, Sugar in Blood/Urine]
k.kiQn to *****
B = biological fparent, sibling,
P = paternal self, other]
-1
.2
.3
.4
-5
.6
-7
-8
\ .9
-10
.I1
.12
-13
47
41. Egh Blood Pressure: (circle one) 2. YS 1.No

/Hypertension]

N = nonbiological auntfuncie,
A . - B C D
.3
.4
.5
.6
.7
.8
.9
48
/;3 4iG 42. Heart Sproblens: (circle one) 2. Yes 1.No

meart Anach, Coronary, Ahphnua]

N = nonbiological aunduncie,
.1
.2
.3
.4
.5
.6
.7
.8
-9
.IO
.ll
.12
\
.13
.14
I
49
?a
43 43. Stroke: ( d e one) 2. Yes 1.No

P =paternal self, other]
."=n43-5% m43- 9c
/ J
.9 Name & BorN MorP
\
. -
F&.Y3 .- 1'+5 F& 93- 1'4e
.14 Name BorN MorP
J'
50
44.Caner: (&de one) 2. Yes 1.No

( T K ~ o ~Leukemia]
s,
51
F& 45- 45. Asthma, Chronic Bronchitis or Emphysema: (&-de one) 2. yes 1.No
[Smokers Cough, Wheezing]
R) to +*t**

N = nonbioiogical aunduncie,
.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.ll
.12
\ -13
.14
..
52
F23 5.6 46. Other chronic problems (specify): (circle one) 2. Yes 1.No

N = nonbioiogical aunduncie,
P =paternal , self, other]
r 4
% A B C D
F4346-fi3 B345-/C
.1 Name BorN MorP
A B C I)
FE46-ACA F&-YL-RC
.2 Name BorN MorP
E ILLNESS (please spec@):
A B C D
F&46-3A FA4G-dC
.3 Name & BorN MorP
E ILLNESS @leasespecify):
A B C D
Kz3 %-44 F&.C/&-4f2
.4 Name BorN MorP
E ILLNESS @lease specify): -

d
A B C D
F234ii- 4% m4/6-5c
.5 Name h 2 d BorN MorP
\
E ILLNESS @lease specify): L z k f % W d
0 END OF TNTERvlEW 0 RECORD TIME,: fS*.S7.M

LEGAL HISTORY
t
Subject ID :
Interviewer ID:
FMdH RA/&
Now I'm going to ask you some more questions about all the people in *****'s/you~
1
family that you've mentioned today.
Avd 1. Has drinking ever caused any of the people mentioned to have problem with health,
family, job, or police?
R e l a to *****
M = materna! grandparent, child,
F&i- f/3 F N / - jc
.1 Name 424.4 BorN MorP Fp-r'f- 9XY-
-2 Name y - ? FM+-RA
BorN
/Ljy 1'-
F , w a
MorP
66 &v/- 3c
FM j- d55Y
.3 Name d BorN MorP F w 4 - 3%
.4 Name a& FAyf-

BorN
443 AM/-
MorP
4c /=Mi/-&%
FM/- 5
x3 SMf-5-C FM,- 5-p
.5 Name "d BorN MorP
m 7 - 6 6 FM/-dC
.6 Name -4 W f -J*
-+=
BorN MorP
F;/Y/-?& FMS/-W
.7 Name BorN MorP
l=H%-'-73 Jw;/_&z FM#-
.8 Name BorN MorP
ed. init. ed. date

2
2.W 1.NO
to n*n*n
B = biologid [parent, sibling,

N = nonbiological aunt./uncle,
P = paternai other]
A B C D
.2 Name B or N
FAfL-3&
.3 Name BorN
FMgR - 4-4
.4 Name B or N
F&A- 373
-5 Name dLe?zxxL B or N
F M a - 6-45
-6 Name B or N
.7 Name
- 8 Name
/ -
&/y&-72.x
.12 Name B or N
3
- usually do?
they
2.YES 1.NO
R- to *****
-
. P =paternal otherJ
1
133
4
FfY 4 4. Has anyone mentioned ever had frequent trouble with the iaw, often become involved in
fights, had trouble holding a job, or was a frequent discipline problem in school?
2.YES 1.NO

N = nonbiological
. P = paternal
5
5. Has anyone mentioned ever had problems with their nerves or had a nervous breakdown?
2.ES 1.NO
grandparent, child,
A B C D
&?LE-1'/4
.I Name BorN
.2 Name
.3 Name
R Y 5 - 643
.6 Name h d B or N
FfY 5-?A
.7 Name B or N
135
6
problems or problems they might have had with alcohol or drugs?
2.YES 1.NO
M = maternal
A B C D
.1 Name /d/ BorN MorP

/c,,J-.z& /=..YI&x+dte Fmg-&%
A B C D
.2Name d
& w d BorN MorP

Fw6"-36 F H 6 - 3c Fzy6- 3 s -
A B C D
.3Name d%Zdx%?&L BorN MorP
E Reason for treatment: &Aq$$UkL
,ey& 96 iH6- +if swK--+W
A B C D
.4Name dH-68 .
( BorN MorP
A B C D
SName d BorN MorP
.6 Name BorN MorP

7
FM .+ 7 . Has anyone mentioned ever been hospitalized because of emotional problem, or because
2.YES 1.NO

N = nonbiological aunt/unde,
-
,4 P =paternal .
BorN MorP
.2Name A- BorN MorP

F&f?-LA l / JF/y?- 3c F / Y 7-3w
B C D
.3 Name BorN MorP

A B C D
.4Name A d BorN MorP
E Reason for tratment:

&f&& FMZ5L Ffi-7-9W
B C D
.5 Name BorN MorP
B C D
.6 Name BorN MorP

8
Ffi 8 8. Have any of the people youve mentioned ever attempted suicide?
2.YEs 1.NO
B = biological . Cparent, sibling,

P = paternal other]
.1 Name
.2 Name
.3 Name
.4 Name
-5 Name
-6 Name
.7 Name
.8 Name
.9 Name
.10 Name
. l l Name
-12 Name
.13 Name
.14 Name
.15 Name
I38
9
#=&y 9. Have any of the people you've mentioned ever cornmined suicide?
2. YES I .NO
b grandparent, child,
h
10
9A. So, none of the people mentioned have had any problems w i t h alcohol or drugs,
(CIRCLE ONE)
1 - no one else
2 - additional family member listed
Committed suicide - page 9

Hospitalized for alcohol, emotional problems, or drugs - page 7

Talked to a counselor about drugs, alcohol or emotional problems - page 6
Nervous breakdown - page 5
F'ights, frequent trouble with law,trouble holding a job - page 4
Suffered from depression - page 3
Drug use caused problem with health, family, job, or police - page 2
Dri~kingcaused problems with health, family, job, or police - page 1
- 11
Mow I have some questions about whether there is anyone mentioned who has had
trouble with the police or who has been arrested. Please do not include routine traffic
fflfc? 10. Has anyone that you've mentioned had trouble With the police or been arrested? (CIRCLE
o w
1. NO:
2. YES ASI(lOA-10D
10A. What is his/her name and how is he/she related to *****?

/i=Af/OAa F M I D A 3 F/YfD&+
2 3 4
BorN M or P
Name Relation
&? 10B. Do you know what he/she did? (CIRCLE ONE) 2 . m 1.NO
10B1. IF YES; What did he/she do?
pfi,-Qc 1OC. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . m 1 .NO
1OC1. IFYE& What other offenses led to himher having trouble with the police?
F / Y ~ QD
S 10D. Is he/she in jail or prison now? (CIRCLEONE) 2.YES 1 .NO
12
~ / y yi 11. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
I1 11
2. YES ASlClIA-IID

F&H&L FMi4?A3 - f f W
1 2 3 4
B or N M or P
Relation
F&7ff&L;, 11B. Do you know what he/she did? (CIRCLE ONE) 2.ES 1 .NO
FflAfC 0 11C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . m 1.NO
11D. Is he/she in jail or prison now? (CIRCLE ONE) 2 . m 1.NO

/=A/& 12. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES ASKlzA-120

F#/&.4a/ F&/izA3 FMB;74
1 2 3 4
&%Q&y9-&4
/
B or N M or P
me Relation
12B. Do you know what he/she did? (CIRCLE ONE) 2.YEs 1.NO
EYJES: What did he/she do?
(CIRCLE ONE)
2 . m 1.NO
................... :<:
12C1. ...; ..................,.............
; What other offenses led to himher having trouble with the police?
190 120. Is he/she in jail or prison now? (CIRCLE ONE) 2.YEs 1.NO
14
F/Y& 13. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
o END OF INTERVIEW e RECORD TIME

I
2. YES ASK 13A- 13D
>9
1 3 ~ . What is hisher name and how is he/she related to *****9
F?f/W& Ffl/5& 5 f W 3 k .y
2 3 4
B or N M or P
Relation
,z~7p3 13B. Do you know what he/she did? (CIRCLE ONE) 2.m 1.NO
13B 1. IF YE% What did he/she do?
13C. And were there any other reasons he/she was in uouble with the police?
(CIRCLE ONE)
2 . m 1.NO
............................
13C1. @YESj What other offenses led to W e r having trouble with the police?
>::
13D. Is he/she in jail or prison now? (CIRCLE ONE) 2 . w 1 .NO

I5
F H 744 14. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES
14A. What is hisher name andhow is he/she related to *****?

M/9##& FN/4%73 FMk&
1 2 3 4
B or N M or P
Relation
F W / W 3 d 14B. Do you know what heishe did? (CIRCLE ONE) 2 . m 1.NO
14B1. ICF W.What did he/she do?
,qy ,g,c 0 14C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
.......,....; .............:..'.!(.:
14C1. What other offenses led to h W e r having trouble with the police?
&&
F&,44~0 14D. Is he/she in Jail or prison now? (CRCLE ONE) 2.YEs 1.NO
16
~ f75
i 15. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
0 END OF INTERVIEW 0 RECORD TIME
2. YES ASX1SA-15D
15A. What is his/her name and h o w 8 he/she related to *****3

F-%f;/s464 FHY-543 Ffl,si-# p
1 2 3 4
-4 B or N M or P
Name Relation
~ ~ f s h 15B.
o Do you know what he/she did? (CIRCLE ONE) 2 . w 1.NO
15B1. IF YES2 What did he/she do?
F& f9-c 0 15C. A n d were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . w 1.NO
...........................
15C1. ..................... What other offenses led to him/her having trouble with the police?
& ? .
v y
F M / s w 15D. Is he/she in jail or prison now? (CIRCLE ONE) 2.m 1.NO

17
1. NO:
2. YES

FHflgAA F&j6&'3 fP;r/&R4
1 2 3 4
B or N M or P
Relation
Do you know what helshe did? (CIRCLE ONE) 2.ms 1.NO
IFYE& What did he/she do?

d * y
d
/=,iyyb>u 16C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . w 1.NO
..,......:.:
.... ........
,,,. ...........
16C1. Il$%'EiS~What other offenses led to himmer having trouble with the police?
d F 4
m/~m
16D. Is he/she in Jailor prison now? (CIRCLE ONE) 2 . m 1.NO
- 18
~ r / /-F
/ 17. Has anyone else had trouble with the poiice or been arrested? (CIRCLE ONE)
1. NO:
I 8 END OF INTERVIEW 0 RECORD TIME
2. YES

&c%?8q
I#
./Wfl&L fH7-293
1 2 3 4
B or N M or P
. Relation
Ffi/f7&0 17B. Do you know what he/she did? (CIRCLEONE) 2 . m 1.NO

17~1.s i ? what
i did he/she do?
..................................
d d
,,,TZH{~LQ17C. And were there any other reasons he/she was in trouble with the police?
(CIRCLEONE)
2.m 1.NO
17C1. El?$=.$
......................
What other offenses led to himmer having trouble with the police?
C U
Y V
170. Is he/she in jail or prison now? (CIRCLEONE) 2 . m 1.NO

FMf-ZBL3
EMPLOYMENT & INCOME
Date: cF..P?
B&r
mm dd yy
Interviewer ID:
FIELD COPY 2 sflwcc; L4PL &#9N
PART I: Primary Caregiver/Adult Subject Employment

"9
1. Please tell me which of these statements best describes your present work situation.
For this intentiew, "full-time"is 35 or more hours each week and "part-time"is less than 35
horn each week.
- -
ed. init. ed. date
Page 2
1. Working full-time in one job ----

working Nupart-time in additional job@)

1
4. Permanent leave (disability) ---
5 . Working part-time in one job


-
11. Retired, w o r m part-time jobs
12. Retired, worlung temporary jobs
...... ..
14. Homemaker tull-time
15. Unemployed, loolung for work --

(NOTa homemaker)
17. Volunteer work only, full/part-time -GOTONEXTPAGE, on2
Page 3
zz A 2. Have you been employed in a paying position in the past 5 years? (CIRCLE ONE)
NO: t Have you done volunteer work in the past 5 years?
YES:
Working full-time in one job ------I-
Working full-time in one job AND --

On leave (temporary illness) -

Permanent leave (disability)



9. Temporary jobs, Occasional work
11. Retired, working part-time jobs ---------

12. Retired, worlung temporary jobs ---
17. Volunteer work only, full/part-time --
is 3
Page 4
. Section 1. Full / Part-timo I

- -
1. Ohd Job -
2. Two Jobs
3. Three Jobs had3AandthenGO"0@edom4
3A. Of these jobs, I want you to first tell me about the one you consider to be y o u
?Y
4. What is your job title? ,fee &d&

+y/
5. What are your main responsibilities? &%42%t5

Y Y

SZ6
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know

2.27 Y- months

6i t.9 hourdweek
If 1Job ONLY, GO TO Page 15, (part I) Question 45A.

art I) Question 9.
rob 2: And your other job?

#,'
22 7v 11. Which of these numbers best fits your salary in this job? (CIRCLE ONE)
1. less than 5,000

2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know

Y- months

hours/week
And your other job?
15. What are your main responsibilities? L/m.;dk wJ/

/ '

SZ/6 16. Which of these numbers best fits your salary in this job? (CIRCLEONE)
1. lessthan5,000
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know
g-7 17. How long have you been in this job?

Y- months
gz/ e 18. How many hours each week do you usually work?
hours/week
GO TO Page 15, (part I) Question 45A. I

Page 7
PART: I
SECTION: 2
1 Section 2. On leave/disabiIitv 1
19. How many jobs did you hold before you went on leave/disabiiity? (CIRCLE om)
1. One Job ~ T O Q u e s t h 2 0@art&

,
2. Two Jobs Resd 19A, GO TU Qtrestkur 20, IpartI).
3. Three Jobs HA, G O TU Questha 20, (part I).
'at 19A. Of these jobs, I want you to first tell me about the one you considered to be your
20. What was your job title? u-,dh
21. What were your main responsibilities? g-md&- eat5
1. YES
2. NO
22B. Which of these numbers best fit(s) your full salary in this job? (CIRCLE ONE)
1. iessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,000
8. don't know
Page 8
22A. Do you receive your full salary or part of your salary? (CRCLE ONE)
1. Full
2. Partial
22c. Which of these numbers best fit(@ your partial salary, including
1. leSsthan5,OOo
2. between 5,000 and 9,999
3. between 10,OOo and 19,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. rnorethan50,000
8. don't know
23. How long had you been in this job

Years months
hoursiweek
Years months
If 1 Job ONLY,GO TO Page 15, (part I)Question 45A.

I
Page 9
26. What was your job titie? V U c / d b M, 1
/'
~~
27. What were your main responsibilities? fl-&kA!k &-

/
//
f*d
2/ag
1. YES
2. NO

& / ' R & ~ Q 28B. Which of these numbers best fit(s) your full salary in this job? (CIRCLE ONE)
1. less than5,OOO
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,000
8. don't know
sL&?f#o 28A. Do you receive your full salary or part of your salaxy? (CIRCLE ONE)
1. Full
2. Partial
Page 10
2 2 && C U 28C. Which of these numbers best fit(s) your partial salary, including
1. less than5,OOo
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
- LCJ 29. How long had you been in this job

Y- months
6730 30. How many hours each week were you usually woriung
hours/week
22-3/ Y- months
If 2 Jobs ONLY,GO TO Page 15, (part 9 Question 45A.

If More than 2 Jobs, GO TO Next Page, (part I) Question 32.
Secondant iob 3; And your other job?
33. What were your main responsibilities? YWd&,

Y'
2 9 39 34. Do you continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO

&/ 3yao 34B. Which of these numbers best fitis) your full salary in this job? (CIRCLE ONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
34A. Do you receive your full salary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
6 ,d.YC0 34C. Which of these numbers best fit(s) your partial salary, inciudq pension
1. less than5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
'd
8. don't how
&33 5- 35. How long had you been in this job

?2 3 6 36. How many hours each week were you usually working
hours/week
gr 5 2 37. How long have you been on leave from this job?
Y= months
I GO TO Page 15, Question 45A (part I). I
.
Page 13
PART:I
SECTION: 3
38. What types of jobs have you done recently? vm'dk

* J
?'1
39; 39. About how many hours each week do you usually work? hourdweek
40. How much money have you earned from these jobs in the past year? (CIRCLE ONE)
1. less than 5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
GO TO Page 15, (part I) Question 45A. 1

Page 14
PART: I
SECTION: 4
v-2k 454- d
4
iG&4!-&ndk
43. How many h o w o you usually volunteer? (CIRCLEONE)
1. 1-2
2. 3-5
3. 6 - 12
4. -
13 20
5. > 20

2744
1 GO TO Page 15, (part I) Question 45A. I

Page 15
PART:I
SECTION: 5
primary/Only Job]
45A. Mere is your job located? (7f travefs to vanom Locaiions, record address of main ofice.)
?'4'
PW*U?k '&d
address
city State zip code
&/ 4(j-$,o 45B. How far is your work from where you live? (CIRCLEONE)
2-1to2miles -
E/ 95L-O 45C. How do you usually get to work? (CIRCLE all that apply)
1-walk 6 - carp001
2 - drive myself -
7 driven by reiative/friend
3 - budsubway -
8 commuter train
4 - bicycle
5 - other
f/ga-ao 45D. On the average, how long does it usually take you to get to work?
minutes
Page 16
[Seconuy job 21
46A. Where is your job located? (rf travels to various locations record address of main ofice.)
city State zip code

'1
7 96&0 46B. How far is your work from where you live? (CIRCLE ONE)

2 - 1 to2miles 6 - Varies according to
746 46C. How do you usually get to work? (CIRCLEall that apply)
1-walk 6-carp001
-
3 buS/sUbWay -
8 commuter train
4 - bicycle
-
5 other
39 . B Q 46D. On the average, how long does it take you to get to work?
If 2 Jobs ONLY,If there is a partner, go to Page 18, (part n)Question 1.

If there is n~ partner, go to Page 35, (part IlI), Question 1.
If More than 2 Jobs, GO TO the Next Page, (part 1) Question 47A.
Page 17
[Secondaryjob 31
47A. Where is your job located? flf traveis to various locmionr, record address of main office.)
v*a& &k?-eG&
v
address
~~
city State zip code
W,a&o 47B. How far is your work from where you live? (CRCLE ONE)
''I 0 - works at home 4 - 6 to 10 miles

1 - less than a mile 5 - greater than IO miles
2 - 1 to 2 miles 6 - Varies according to
(/&co 47C. How do you usually get to work? (CIRCLEall that apply)
1-walk 6 - ~arp001
2 - drive myself 7 - driven by relative/ffiend
4 - bicycle
5 - other
Si'4qgiy-J 47D. On the average, how long does it take you to get to work?
minutes
Page 18
PART: EI
PART II: Partner Empioyment
1. Please tell me which of these statements best describes your spouse's/partner's present
work situation:

Page 19
1. Working full-time in one job --

2. Working full-time in one job AND ----
working fapart-time in additional job(s)

'ad
4. Permanent leave (disability) -------

5. Working part-time in one job -


frompart-time job or jobs
9. Temporarg jobs, Occasional work
12. Retired, workmg temporary jobs
13. Retired,not working
14. Homemaker full-time ---


(NOTa homemaker)
17. Volunteer work only, full/part-time -- GO TO "I'PAGE, (part n)question 2
Page 20
Has your partner been employed in a paying position in the past 5 years? (CIRCLE ONE)
2. NO: Has your partner done volunteer work in the past 5 years?
1 -Yes
2 - NO
1. YES:





10. Retired, workmg full-time

Z . P3 3. How many jobs does heishe currently hold (CIRCLE ONE)?
1. One Job
2. Two Jobs
3. Three Jobs
3A. Of these jobs, I want you to first tell me about the one he/she considers to be hk/her
primary or mainjob:
4. What is his/her job title?
~~~ ~ ~~ -
5. What are his/her main responsibilities? fl&-db

Y Y
2jP6 6. Which of these numbers best fits hisher salary in this job? (CIRCLEONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. more than 50,000
8. don't know
tZd+ 7. How long has he/she been in thisjob?

Years months
S/P 8 8. How many hours each week does he/she usually work? hours/week
Page 22
If 1 Job ONLY, GO TO Page 32, (part II) Question 45A

If More than 1 Job, GO TO the Next Page,(part If) Question 9.
9. What is hisher job title? PC&*d& && I *
?'l
10. What are hisher main responsibilities?. Y-&b
I 8

s/*p// 11. Which of these numbers best fits hisher salary in this job? (CIRCLEONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
4. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know

Z I P f& Years months
How many hours each week does he/she usually work? hours/week
E,;o r3 13.
If 2 Jobs ONLY, GO TO Page 32, (part n)Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part n)Question 14.
14. What is his5er job title? l/a4&4& / /
15. What are his5er main responsibilities? Vi*&&@*
gyp f6 16. Which of these numbers best fits hisher salary in this job? (CIRCLE ONE)
1. less than5,OOo
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,939
7. more than 50,OOo
8. dont know
&pvT 17. How long has he/she been in this job?

Years months
SZX)A9 18. HQWmany hours each week does he/she usually work? hours/week
Page 24
PART: II
SECTION: 2
1Section 2. I
It ii
On leave/disabilitg
S'iP/Q 19. How many jobs did heishe hold before heishe went on leave/disability? (CIRCLEONE)
1. OneJob GU?'U@artIIl
2. Two Jobs Read H A , GO TO (part n)qUeStian30,
3. Three Jobs Read 39A, GO To (pari '19 questiOn 20.
19A. Of these jobs, I want you to first tell me about the one heishe considered to be hisher
20. What was hisher job title? /-2h d md
21. What were hisher main responsibilities? d-:d& Lx5ecy?&

/ /
c s / p ~ 22.
~ Does he/she continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO
I Hand respondent response card #2 1

Page 25
22B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLEONE)
1. less thau5,OOO
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
&?A&##O 22A. Does he/she receive hisher full salary or part of hisher salary? (CIRCLE ONE)
1. Full
2. Partial
22C. Which of these numbers best fit(s) hisher partial salary, including pension plan,
&epdye eo SSI or any benefits? (CIRCLE ONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,Ooo and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OO
8. don't know
23. How long had heishe been in this job

CUP 2 3 before he/she went on leave/disability?
Y- months
2?zP& 24. How many hours each week was he/she usually working
2Zpa 5- 25. How long has he/she been on leave from this job?
Years months
26. What was hisher job title? v m * d & &P4@?&
27. What were hisher main responsibilities? fl-2244& &a?-&$&

?'1
E/e?t& 28. Does he/she continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO

$/pj&&o 28B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
1. ltssthan5,OoO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
4+%x?A 0 28A. Does he/she receive hisher full salary or part of hisher salary? (CIRCLE ONE)
1. Full
2. Partial
Page 27
~h%.!~CO 28C. Which of these numbers best fit@)hidher partial salary, including pension plan, SSI or any
benefits? (CIRCLEONE)
1. less than5,OOO
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
l.4 7. 'more than 50,000
8. don't know

YWS months
30. How many hours each week was he/she usually worlung
Y
m months
If2 Jobs ONLY, GO TO Page 32, (part Il) Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part II) Question 32.
Page 28
And hidher other job?

32. What was hisher job title? k-%a-&,k-d& L Z
/ -
f d
33. What were hisher main responsibilities? Lca'dk &&

/ J
'.a . -
34. Does he/she continue to receive money from this position? (CIRCLEONE)
SIP 34
1. YES
2. NO
I I
~~
f/@ 39&7 34B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
1. lessthan5,OOO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. rnorethan50,OOO
8. don't know
MA. Does heishe receive hisher full salary or part of hisher salary? (CIRCLEONE)
1. Full
2. Partial
Page 29
8 1 3 ~4 ~ 0 34C. Which of these numbers best fit(s) &/her parual salary, including pension plan,
SSI or any benefits? (CIRCLE ONE)
1. less than 5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. . more than 50,000
8. don't know

a-p35 before he/she went on leave/disability? -
months

GO TO Page 32, (part II) Question 45A.

Page 30
PART: II
SECTION: 3
38. What types of jobs has he/she done recently? /-&& -

& ,
t ' / p 39 39. About how many hours each week does helshe usually work?
hours/week
Y I
~~~
40. How much money has he/she earned from these jobs in the past year? (CIRCLE ONE)
c5.P 40
1. less than 5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than 50,000
8. don't know
I GO TO Page 32, (part II) Question 45A. 1

Page 31
PART: II
SECTION: 4
42. What types of volunteer work has he/she done recently (for what organizations)?
L W * O J & &%%%&e5
?a
43. How many hours each week does he/she usually volunteer? (CIRCLE
1. 1-2
2. 3-5
3. 6 - 12
4. 13 - 20
5. > 20

Y*S months
Page 32
PART: II
SECTION: 5
Section 5 . Job Distance
IF partner has more than 1 job listed during the interview, start with the primary job, 'TEEN
mimary/Only JobJ
45i. W e r e is your partner's job located? gf rraveh to various locations, record address of main
office.)
k&<*dd& &-
ryy
&
address
city State zip code
;e;'ppj-@ 45B. How far is hisher work from where you live? (CRCLEONE)
0 - works at home
................. ..... .........
__
_. ...................... 4-6tolOmiieS
-
3 3 to 5 miles work site
How does he/she usually get to work? (CIRCLEall that apply)

s-bW57co 45C.
1-walk -
6 carp001
-
4 bicycle
5 - other
5 / P 4 S O 45D. On the average, how long does it take himher to get to work?
minutes
Page 33
[Secondary job 21
46A. Where is hisher job located? (If travek to various locmions, record address of main office.)
city State zip code
z//W6RO 4PB. How far is hisher work from where youJve? (CIRCLE ONE)

&%)46Cfi 46C. How does heishe usually get to work? (CIRCLE all that apply)
l-walk 6-wp001
-
4 - bicycle
5 - other
S/P46BO (using the mode of transportationlisted in Question 46C)
minutes
If2 jobs ONLY,GO TO Page 35, (part III) Question 1.

If More than 2 Jobs, GO TO Next Page, (part Il) Question 47A.
Page 34
[Secondary job 31
47A. Where is hisher job located? flf travels to various locat"ioiu, record address of main office.)
Jt%ac.dh
address
city State zip code
z/pQ.m4743. How far is hisher work from where you lbe? (CIRCLEONE)

3-3to5miies work site
s/pq!o 47C. How does he/she usually get to work? (CIRCLEall that apply)
1-walk 6-carp001
-
2 drive myself 7 - driven by relativehiend
3 - bushubway -
8 commuter train
4 - bicycle
5 - other
g)@ 47D. On the average, how long does it take himmer to get to work?
minutes
I GO TO NEXT PAGE, (part m) @&ion 1.

Pagk 35
PART KKI.
1. Other than h m your job, please tell me whether you received income from any of these
sources m the past tax year. Have you m x i v&....(read each choice and circle all that apply)
a. income from partner or spouse 1 . YES 2. NO

(NOT child support or alimony),combined
income or supported by p d e r
b. child support or alimony 1. YES 2. NO
C. any public assistance, such as DPA or AFDC 1. YES 2. NO
e. unemployment compensation 1. YES 2. NO

f. money from relatives (NOTpartner or spouse) 1. YES 2. NO

g- federal grant, financial aid, scholarships 1. YES 2. NO
Z. money from any other source 1. YES 2. NO

(please specify) &42&&&&- & D D d
NOWI am going to ask you some questions about your total income. First,I will ask about your
personal income, and then I w i l l ask about your total household income.
I Hand respondent response card #2

R
'7
&9fiJ 0 2A. From these sources of income AND the income from any jobs you had in the last tax year,
1. less than $5,000

2. between $5,000 and $9,999
3. between S10,OOO and $19,999
4. between $20,000 and $29,999
5. between $30,000 and $39,999
6. between $4O,OOO and $49,999
8. don't know
F&IA&Q 2B. From these choices, what was your total household income in the last tax year before taxes?
Household income includes your income and any income coming h from anyone else in the
household.
1. less than $5,000

2. between $5,000 and $9,999
3. between $10,000 and $19,999
4. between $20,000 and $29,999
5. between $30,000 and $39,999
6. between $40,000and $49,999
8. don'tknow
CONFLICT TACTICS SCALE: Partner/Spouse Introduction,

1. Are you currently involved with someone? c7-j
1. YES EYES, ASK lA, IB, IC?aWt then BEGIN inteniew.
0. NO
A. Are you married to, engaged to, or dating this person? C7.~
04
1. married
2. engaged
3. dating
B. Are you currently living with this person? C'7i/&O

1. Yes
0. No
C. How long have you been in the relationship? c7Yco
YWS months
I I
k i
BEGIN INTERVIEW

(If more than one person, select most "significant" relationship) c7#&
1. YES
0. NO
A. Were you married to,engaged to, or dating this person?

1. married
2. engaged
3. dating

1. Yes
2. No
I . BEGIN INTERVIEW I
3. Have you dated anyone at all in the past year? c7-3
1. YES If YES, regd the fallowing and BEGW interview.
"4
1
Interviewer ID:
C7..P&#/%Y
FIELD COPY 2 S"L%&?Ce
No matter how well a couple gets along, there are imes when they disagree, get annoyed wit 1
the other person, or just have fights because they're in a bad mood or tired o r for some other
...
Refer to frst month on the time line I

these responses.
I Hand respondent the response card, and read choices 1 to 6
ed. bit. ed. date

2
1A. How many times have you discussed an issue calmly? CT //xF-
0 1 2 3 4 5 6
1
1B. How many times has he/she discussed an issue calmly? C7943
0 1 2 3 4 5 6
fi
IC. HS this ever happened? ~ 7 7C
- 1 =Ycs 0 = No
2A. How many times have you gotten information to back up your side of thugs? C/A&
0 1 2 3 4 5 6
times times tima 20 times
2B. How many times has heishe gotten information to back up hisher side of things? C T,,&&
0 1 2 3 4 5 6
2C. Has this ever happened?

* -
1 =Yes O=No Q-Aek
3
c17-4 4 3A. How many times have you brought in or tried to bring in someone else to help settle things?
0 1 2 3 4 5 6
% . times times times 20 times
0 1 2 3 4 5 6
never once twice 3-5 6- 10 11-20 more than
c-73c 3C. Has this ever happened? 1 =Yes 0 = No
c 7 L/.,+ 4A. How many times have you insulted or swore at himher?
0 1 2 3 4 5 6

C746
0 1 2 3 4 5 6
c, 4c 4C. Has this ever happened? 1 =Yes 0 = No

4
C/ s# SA. How many times have you sulked and/or refused to talk about an issue?
0 1 2 3 4 5 6
5B. How many times has he/she sulked and/or refused to talk about an issue?
CIT 5-6
0 1 2 3 4 5 6
cp 5-c# 5C. Has this ever happened? 1 = Yes 0 = No
How many times have you stomped out of the room, house or yard?
764- 6A.
0 1 2 3 4 5 6
6B. How many times has hehhe stomped out of the room, house or yard?
C7-643
0 1 2 3 4 5 6
never OnCe twice 3-5 6-10 11-20 more than

C7?& 7A. How many times have you cried?
0 1 2 3 4 5 6
7B. How many times has he/she cried?
0 1 2 3 4 5 6
8A. How many times have you done or said something to spite himmer?
c7&A
0 1 2 3 . 4 5 6
How many times has he/she done or said something to spite you?
0 1 2 3 4 5 6

6
9A. How many times have you threatened to hit or throw something at himher?
0 1 2 3 4 5 6
9B. How many times has he/she t,reatened to i t or throw something at you?
0 1 2 3 4 5 6
1OA. How many times have you thrown, smashed, hit, or kicked?-
0 1 2 3 4 5 6
never O m twice 3-5 6-10 1.1-20 more than
10B. How many times has he/she thrown, smashed, hit, or kicked w?
0 1 2 3 4 5 6
never O m twice 3-5 6- 10 11-20 more than

7
11A. How many times have you thrown something at him/her?
0 1 2 3 4 5 6
%
11B. How many times has he/she thrown something at you?
0 1 2 3 4 5 6
12A. How many times have you pushed, grabbed, or shoved himher?
0 1 2 3 4 5 6
12B. How many times has heishe pushed, grabbed, or shoved you?
0 1 2 3 4 5 6

13A. How many times have you slapped himher?
0 1 2 3 4 5 6
never once twice 3-5 610 11-20 more than
0 1 2 3 4 5 6
never once twice 3-5 6- 10 1 1-20 more than
14A. How many times bave you kicked, bit, or hit himher m?
0 1 2 3 4 5 6
14B. How many times has he/she kicked, bit, or hit you u?
0 1 2 3 4 5 6

When you had an argument With your partner in the past year,
c7 ~ 9 How many times have you hit or tried to hit himher

5 ~ 15A. ?
0 1 2 3 4 5 6
@7/3-43 15B. How many times has he/she hit or tried to hit you ?
0 1 2 3 4 5 6
07?j- c 15C. Has this ever happened? 1 =Yes 0 = No
cc/
f~ A 16A. How many times have you beat m e r up?
0 1 2 3 4 5 6
C796/fj 16B. How many times has he/she beat you up?
0 1 2 3 4 5 6
CTf6 C 16C. Has this ever happened? 1 =Yes 0 = No

10
c7{/7c9 17A. How many times have you choked hidher?
0 1 2 3 4 5 6
lis!
17B. How many m e s has he/she choked you?
c7 /-7&
0 1 2 3 4 5 6

C'7fFC
18A. How many times have you threatened himmer with a knife or gun?
0 1 2 3 4 5 6
18B. How many times has he/she threatened you with a knife or gun?
0 1 2 3 4 5 6
never 0- twice 3-5 6-10 11-20 more than

11
~2-f.pfi 19A. How many times have you used a knife or fued a gun?
0 1 2 3 4 5 6
?>$
e m 4 19B. How many times has he/she used a knife or fired a gun?
0 1 2 3 4 5 6
CT /QC 19C. Has this ever happened? 1 = Yes 0 = No
C?SPd T/Y
RECORD TIME:
1
Conflict Tactics Scale: Parent-Child
FIELD COPY 2 s-ow c e
Parents and children use many different ways of trying to settle differences between
them. I am going to read a list of things that you might have done WEEN YOU HAD A
PROBLEM WITH ***** in the past year, that is, since ...
~~
Refer to first month on the timeline
I would like you to tell me how often you did each of these things in the past year, giving
one of these responses:
- -
ed.init. &.date
2
When you had a problem w i t h ***** in the past year...
G& f 1. How-many times did you discuss an issue calmly with *****?
0 1 2 3 4 5 6
c&Yjo4 1B. Has this ever happened? 1 =Yes 0 = No
k b 2. How many times did you get information to back up your side of things?
0 1 2 3 4 5 6
never OnCe twice 3-5 6-10 1 1-20 more than
C&. 2B. Has this ever happened? 1 =Yes 0 = No
C& 3 3. How many times did you bring in or try to bring in someone else to help settle things?
0 1 2 3 4 5 6
never Oljce twice 3-5 6-10 1 1-20 more than
3B. Has this ever happened? 1 =Yes 0 = No

I,ee-36
When you bad a problem with ***** in the past year...
4. How many times did you insult or swear at *****?
0 1 2 3 4 5 6
l'd
u 4.6 4B. Has this ever happened? 1 = Yes 0 = No
How many times did you sulk and/or refuse to talk about an issue?
C k 5 5.
0 1 2 3 4 5 6
6. How many times did you stomp out of the room, or house or yard?
0 1 2 3 4 5 6

C k 643
207
When you had a problem with ***** in the past year...
e&. 7 7. How many times did you cry?

0 1 2 3 4 5 6
%
.
C& 36 7B. Has this ever happened? 1 = Yes 0 = No
9-75 8 8. How many times did you do or say something to spite *****?
0 1 2 3 4 5 6
e&&& 8B. Has this ever happened? 1 = Yes 0 = No
CLt- 9 9. How many times did you threaten to hit or throw something at *****?
0 1 2 3 4 5 6
ELL 9B. Has this ever happened? 1 =Yes 0 = No

5
e& YU 10. How many times did you throw,smash, hit or kick something?
0 1 2 3 4 5 6
10B. Has this ever happened? 1 = Yes 0 = No
11. How many times did you throw something at *****?
0 1 2 3 L 4 5 6
11B. Has this ever happened? 1 = Yes 0 = NO
12. How many times did you push, grab, or shove *****?
0 1 2 3 4 5 6
never OIlCe twice 3-5 6-10 11-20 more than
.. ...... .

6
When you had a problem with ***** in the past year.. .
&
p {3 13. How many times did you slap or spank ***** ?
0 1 2 3 4 5 6
'4
i%- 93 43 13B. Has this ever happened? 1 =Yes 0 = No
~4 14. How many times did you kick, bite, or hit ***** u?
0 1 2 3 4 5 6

t;u f%L5
cu f,j- 15. How many times did you hit or try to hit ***** * ?
0 1 2 3 4 5 6

m /3-&
7
& /6 16. How many times did you beat ***** up?
0 1 2 3 4 5 6
c i ~/-? 17. How many times did you burn or scald *****?
0 1 2 3 4 5 6

CHILD BEHAVIOR CHECKLIST
Child Behavior Checklist: Ages 2-3
$,$
mL
D COPY 2
-- --
I am going to read a list of items that describes children and youth.
~~
Hand PC ResDonse Card 1
For each item that describes ***** ppw -ro .. please say "2" if the
item is or of *****. Say "1" if the item is or
true; of *****. If the item is of ***** say ''0". Please answer all items as well
as you can, even if some do not seem to apply to *****.
0 = Not "he (as far as you know)

1 = Somewhat or Sometimes T m e
2=Very'h71eorOfien'Ihre
CL3 J 0 12 1. Aches or pains (without medical cause)

Pe 0 12 2. Actstooyoung forage
e433 0 1 2 3. Ahidtotrynewthings
e43 4 0 1 2 4. Avoids looking others intheeye
e 6-5 0 1 2 5. Can't concentrate, can't pay attention for long
cC3 6 0 1 2 6. Can't sit still or restless
ed. init. ed. date
C4 ?' 0 12 7. Can't stand having things out of place

2
-
C&8 0 1 2 8. Can'tstandwaiting; wantseverythingnow
9 0 1 2 9. Chews on things that aren't edible
Cn ~ ' 00 1 2 10. Clings to adults or too dependent
C/3 f / 0 1 2 11. Constantly seeks help
@A-
/A 0 1 2 12. Constipated, doesn't move bowels
a r3 0 1 2 13. Cries a lot
-0
-14 1 2 14. Cruel toanimals
C43 f3- 0 1 2 15. Defiant
-
1-"/37 1 2
0/6 16. Demandsmustbemetimmedkitely
-0
Cay? 1 2 17,Destroyshis/herownthings
A? 0 1 2 18. Destroys things belonging to hisher family or other children
-0 1 2 19. Diarrhea or loose bowels when not sick
&3r?9
-0
C&A8 1 2 20. Disobedient
-0
&3Ji 1 2 21. Disturbed by any change in routine
C-
nJb 0 1 2 22. Doesn't want tosleepalone
CA 23 0 1 2 23. Doesn't answer when people talk to himmer
@,W 0 1 2 24. Doesn't cat well
-
R.5 0 1 2 25. Doesn't get along with other children
-0
el3 A% 1 2 26. Doesn't know how to have fun, acts like a little adult
-
C.AC;t 0 1 2 27. Doesn't seem to feel guilty after misbehaving
-0
C&&:$ 1 2 28. Doesn't want to go out of home
CE5pZ.Q 0 1 2 29.EasilyfrUsmted
~ E3J0 0 1 2
7 30. Easilyjealous
-0 1 2
C/351' 31. Eats or drinks things that are not food - don't include sweets
C&-
a,,& 0 1 2 32. Fears certain animals, situations, or places
Ck3-
33 0 1 2 33. Feelingsareeasily hurt
t23-
39 0 12 34. Gets hurt a lot, accident-prone
C& 3 5 0 1 2 35. Gets inmany fights
@-A 36 0 12 36. Gets into everything
-0 1 2
C3? 37. Gets too upset when separated from parents
-0 1 2
C&&f 38. Has trouble getting to sleep
-
a 3 9 0 1 2 39. Headaches (without medical cause)
-
0340 0 1 2 40. Hits others
-0 1 2
G3Y/ 41. Holds hisher breath
-
0 3 9 . 0 12 42. Hurts animals or people without meaning to
& ~ 3o 1 2 43. LOO^ unhappy without good reason
*d
o 1 2 ~.~ngrymoods
-
0 3 4/5- 0 1 2 45. Nausea, feels sick (without medical cause)
e53446 0 1 2 46. Nervous movements or twitchmg
-0
C&Y? 1 2 47. Nervous, highstrung, or tense
-0
CA&& 1 2 48. Nightmares
-
C&.1/$ 0 1 2 49. Overeating
0 3 3 7 0 1 2 50.Overtire-d
C.4 5-y 0 1 2 51. Overweight
C~35.30 1 2 52. Painful bowel movements
-
Ck3 53 0 1 2 53. Physically attacks people
C23 59 0 1 2 54. Picks nose, skin, or other parts of body
w3 55 0 1 2 55. Plays with own sex parts too much
-
CR56 0 1 2 56. Poorly coordinated or clumsy
-3-7 0 1 2 57. Problems with eyes without medical cause
-0 1 2
cd5& 58. Punishment doesnt change hisher behavior
C/3 52 0 1 2 59. Quickly shifts from one activity to another
-
CdSO 0 1 2 60.Rashes or other skin problems (without medical cause)
-0 1 2
c/36/ 61.Refusestoeat
-0 1 2
c436h 62. Refuses to play active games
0-
363 0 1 2 63. Repeatedly rocks head or body
-0 1 2
0369 64. Resists going to bed at night
-
Chgj5- 0 1 2 65. Resists toilet trahkg
cA66 0 1 2 66. Screams a lot
-0 1
c&6g 2 67.Seems unresponsive to affection
-
CA68 0 1 2 68. Self-conscious or easily embarrassed
-
&3 69 0 1 2 69. SelfEh or wont share
c& 7D 0 1 2 70. Shows little affection toward people
?/ 0 12 71. Shows little interest in thrngs around himmer
G&-
7A 0 12 72. Shows too little fear of getting hurt
C&?3 0 1 2 73. Shyortimid
C b -7-y 0 1 2 74. Sleeps less than most chddren during day and/or night
C/3 ?5 0 1 2 75. Smears or plays with bowel movements
C/3?6 0 1 2 76. Speech problem
m27 0 1 2 77. Stares into space or seems preoccupied
CB?& 0 1 2 78. Stomach aches or cramps (without medical cause)
-
c/3?9 0 1 2 79. Stores up things heishe doesnt need
-0 1 2
(3380 80. Strange behavior
0-
384 0 1 2 81. Stubborn, sullen, or irritable
-0 1 2
WdA 82. Sudden changes in mood or feelings
-0
C4383 1 2 83. Sulksalot
-
CnB4 0 1 2 84. Talksorcriesoutinsleep
W- B5- 0 1 2 85. Temper tantrums or hot temper
C4-
5.46 0 12 86. Too concerned with neatness or cleanliness
CAB9 0 1 2 87.Toofearfuoranxious
-0 1 2 88. Uncooperative
C&&
-
C/E,&P0 1 2 89. Underactive, slow moving, or lacks energy
C& 0 1 2 90.Unhappy sad, or depressed
& @ 0 1 2 91. Unusually loud
CA Q& 0 1 2 92. Upset by new people or situations
a 93 o 1 2 93. Vomiting, throwing up (without medical cause)
-0 1 2
a@ %.Wakesupoftenatnight
5
-
CZ5 4%- 0 1 2 95. Wanders away from home
-
c/3 96 0 1 2 96. Wants a lot of attention
0 3 9 F 0 1 2 97. whining
0- 3 98 0 1 2 98. Withdrawn, doesn't get involved with others
-0 1 2 99. worrying
u39P
Please tell me any problems your child has that were not asked about before.
3
C ' B f i A 0 1 2 100A.
G ~i/oo/3
J 0 1 2 100B.
e~ o 1 2 100~.
EXPOSURE TO VIOLENCE
I
Exposure to Violence: PC Version
I'm going to ask you some questions about violence and how it may have affected *****
or your family and friends.
1. Are you afraid ***** might be hurt by violence in your neighborhood?
1.- YES 2.- NO
2. Are you afraid ***** might be hurt your apartment building or house?
1.- YES 2.- NO
3. Are you afraid ***** might be hurt in your apartment building or house?
1.- YES 2-. NO
4. Are you afraid ***** might be hurt by violence at school or day care?
1.- YES 2.- NO
KQ. 4A.
IF
ed. init. ed. date
223
24 y#iG 4A. Does this affect where you take *****?
5. Have any of your family members been hurt by a violent act?
?1
6. Have any of your family members been killed by a violent act?
1.- YES 2 . . N O
7. Have any of your close friends been hurt by a violent act?
1.- YES 2-. NO
8. Have any of your close friends been killed by a violent act?
1.- YES 2.,-NO
9. At what age do you think a child is affected by observing violence? (circle one)
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
3
The questions 1'11be a s k you now have to do with acts of violence that ***** may have
witnessed or experienced. Please think carefully about whether shehe was actually
present during Violent acts.
24 A7 10. Has ***** ever seen or been present when somebody was shoved, kicked or punched?
1. YES
2. NO
11. When was the last time he/she saw that?
1. Within last week

2. Within last month
3. Withinlastyear
4. More than one year ago
12. Where did that happen?
1. In ****'s home
2. In hallway of ****'s building
3. In front of ****'s howelbuilding
4. In ****'s neighborhood
5. In park outside neighborhood
6. At ****'s school/day care
7. In or outside bar
25. Other (spec@) fa-hc&~% &
+
-
13. Did he/she know the person or people who this happened to?
22 sg
1. YES
2. NO
4
13A. Who was it? (MARK THAT APPLY)
1. Parent
2 .- *****
3. Friend
4. Neighbor
5.
. .
Siblmg
6. Other Relative ( S e ) ~d~yp---&
fiaLL6f'/t
25. Other (Specify)
c.--2
LzL& 'Li-&& d&:C y$zw4A
14. How badly was the person or people injured? (MARK ALL THAT APPLY)
1 . 3 0 injury
2. Knockeddown
3. Bruised
4. Cut/bleeding
5. Unconscious
6. Broken bones/fracture
7. Medical care obtained
8-. Other
15. Did ***** know the person or people who did this?
1. YES
2. NO
15A. Who was it? (MARK "HAT APPLY)
1. Parent
2-. *****
3. Friend
4. . N e i g h b o r
5.
. .
Siblmg
6. Other Relative (Specify) V L &~d'b
~ &@ypd
25. Other (Specify) vdL&&-& t
5
2.4/E ~ 16. Has ***** seen this more than once?
1. YES
2. NO
274J&i+c> 16A. How many times has ***** seen this in the past year?
<qno 16B. How many times has ***** ever seen this?
gd f.p 17. Has ***** ever seen or been present when someone was attacked with a knife?
1. YES
2. NO
1. Within last week

2. Withinlastmonth
3. Withinlastyear

279 YQ
1. In ****Is home
2. In hallway of ****Is building
3. In front of ****Is houseibuilding
4. In ****Is neighborhood
6. At ****Is school/day w e
25.
20, Did he/she know the person or people who this happened to?
1. YES
2. N O .

1. Parent
2.- *****
3. Friend
4. Neighbor
. .
5. Siblmg
6. Other Relative (Specify) JGzype&
25. Other (specify) ~*a&,c cZr&+p
/
r;%
21. How badly was the person or people injured? (MARKBLL THAT APPLY)
1.
..
No mjury
2. JCnockeddown
3. Bruised
4-. Cutlbldi
5. Unconscious
6. Broken bonedfracture
8-. Other
24 22. Did they die?
1- YES 2. NO 8 . D o n ' t Know
SAL3
1. YES
2. NO
- _ _ ~
3 ,+ 23A. Who was it? (MARK U T H A T APPLY)

1. Parent
2 .- *****
3 .- Friend
4-. Neighbor
5.
. .
Siblmg
6. Other Relative (Specify) c d k
VLMZ-.L
25 . O t h e r (Specify)
22&?@/Ld&
P
& -&-&0&#
24. Has ***** seen this more than once?

1. YES
2. NO
24A. How many t i e s has ***** seen this in the past year?
24B. How many times has ***** ever seen this?

0
r22 A 3- 25. Has ***** ever heard a gun shot?
1. YES
2. NO . .....
2& A,8 26. W h e n was the last time he/she heard that?
1. Withinlastweek
3. Withinlastyear
8
S-& .p 27. Where did that happen?
1. In ****Is home
2. In hallway of building
****IS
3. In front of ****Is househuilding

6. At ****Is school/day care
25. Other (specify) P~&&.L& LLL - ,&
Y P
28. Has ***** heard a gun shot more than once?

1. YES
2. NO
2-79 L8?4*4c 28A. How many times has ***** heard this in the past year?
S A A&8c3 28B. How many times has ***** ever heard this?
22 29. Has ***** ever seen or been present when someone was shot?
........................
1. YES
2. NO ..............
END OFINTERVIEW
RECORD TIME:

1. Within last week
3. Withinlastyear
2- .3/ 31, Where did that happen?
1. In ****Is home
6. At school/day w e
****IS
2..3& 32. Did he/she know the person or people who got shot?
1. YES
2. NO
1. Parent
2.- *****
3. Friend
4. Neighbor
5. Sibling
6.- Other Relative (Specify) f l ~ a . & d ~
25. Other (Specify) bL2&&dL.G
33. Did they die?
1.- YES 2 .- NO 8. Dont Know
34. Did he/she know the person or people who did this?
1. YES
2. NO
1. Parent
2.- *****
3. Friend
4. Neighbor
5. Sibling
6. Other Relative (Specify) ~ ~ ~ ~ d i UAa-f &
l2eaC
25. Other (Specify) G&.e@p
/*
S# 3 5 35. Has ***** seen this more than once?

1. YES
2. NO
2% 3 5 A C 35A. How many times has ***** seen this in the past year?
24 3 5 h O 35B. How many times has ***** ever seen this?
232
EASI TEMPERAMENT SURVEY
EASI Temperament Smey: PC Version
I'B
Now I am going to read some statements about what ***** might be like.
d Point to Response Scale l

For each one, try to rate ***** on a scale from 1 to 5, with 1 being uncharacteristic or
not at all like ***** and 5 being characteristic or very much like *****.
1. ***** feels happiest in familiar surroundings. 2Y f

1= Uncharacteristic (NOTat all like your child)
2= Somewhat Uncharacteristic (NOT very much like your child)
3= Neither Uncharacteristic nor Characteristic
4= Somewhat Characteristic (sort of like your child)
5 = Characteristic (very much like your child)
2. ***** often acts on the spur of the moment. 2YA

4 = Somewhat Characteristic (sort of like your child)
&.init. &.date
3. ***** is somethmg of a loner. 2,Y 3
1= Uncharacteristic (NOT at &i like your child)
2= Somewhat Uncharacteristic (NOTvery much like your child)
4. ***** sometimes does "crazy" things just to be different. 2-94

1= Uncharacteristic (NOT at all like your child)
'9
2= Somewfiat Uncharacteristic (NOTvery much like your child)
5. ***** likes to be with people. 2-Y 4-

6. ***** has trouble resisting temptation. 2~ 6

5 = characteristic (very much like your child)
7. ***** finds people more stimulating than anything else. SY 2

2 36
8. Unfinished tasks really bother *****. L;Y8

9. ***** cries easily. 2 39

"d 1= Uncharacteristic (NOT at all like your child)
10. ***** makes friends easily. 2 Y 70

5 = Cbaracteristic (very much like your child)
11. ***** tends to be somewhat emotional. 2 Y iJ;/

2 = Somewhat Uncharacteristic (NOT very much like your child)
3 = Neither Uncharacteristic nor Characteristic
12. ***** is off and running as soon as @)hewakes up in the morning. 23'1fi
4 = .Somewhat Characteristic (sort of like your child)
233
13. ***** generally seeks new and exciting experiences and sensations. SYL3
14. ***** finds self-control easy to learn. 2Y PY

15. ***** can tolerate frustration better than most. 2.919-

16. ***** often fusses and cries. 59 16

17. ***** gets upset easily. 29/+2

18. ***** tends to hop from one interest to another quickly. SY
- 2= Somewhat Uncharacteristic (NOTvery much like your child)
19. ***** takes a long time to warm up to strangers. 2-9/ 9

1= Uncharacteristic (NOT-at all like your child)
?*f
20. ***** prefers quiet, inactive games to more active ones. 29 LO

21. ***** often says the first thmg that comes into hisher head. 2.Yki
22. ***** tends to be shy. CYLn,

23. ***** tends to get bored easily. EyL 3
2 = Somewhat Uncharacteristic (NOTvery much like your child)
- 3= Neither Uncharacteristic nor Characteristic
24. Usually ***** can not stand waiting. 9

C5Yy.L:

2= Somewhat U n c b t e r i s t i c (NOTvery much like your child)
25. ***** has trouble controlling hisher impulses. 2yRD-

26. ***** is always on the go.

4 = Somewhat Characteristic (sort of like your chiid)
27. ***** is very friendly with strangers. SYYt-7

28. ***** always likes to make detailed plans before (s)he does something. EY&8
2= Somewhat Uncharacteristic (NOTvery much like your chiid)
29. ***** generally likes to see things through to the end. 2.9 A 9
'1
2= Somewhat Unchai.acteristic (NOT very much like your child)
30. ***** often has trouble makmg up hisher mind. 25.'

30
31. ***** prefers playing with others rather than playing alone. ( y 3i
32. ***** is very sociable. Sy329

33. When alone, ***** feels isolated. SY 33
34. ***** reacts intensely when upset. 2-Y 3.9

('d 2= Somewhat Uncharacteristic (NOTvery much like your child)
35. ***** is very energetic. 2s"35-

36. ***** tends to give up easily. L'Y 36'

37. When ***** moves about, (s)he usually moves slowly. 2-Y 5.9

5= Characteristic (very much like your child)
38. ***** likes to plan things way ahead of time. ZY 38
39. Once ***** gets going on something, ($he hates to stop. 2-Y 39

a4
3= Neither Uncharackristic nor Characteristic
40. ***** will try anything once. 6Y 40

IOENROFINTERVIEWO I
243
t
2 4b
Subject ID: JkA/W

Interviewer ID:
Fss/et3/m
There are 27 statements in this survey. They are statements about families. You are to
decide which of these statements are true of your current family and which are false.
You may feel that some of the statements are true for some family members and false for
others. Say True if the statement is true for most members. Say False if the statement is
false for most membexx. If the members are evenly divided, decide what is the stronger
Remember, we would like to know what your current family seems like to you. So do not
try to figure out how other members see your family.
1. T 2. F
1. T 2. F
3. Family members are rarely ordered around
1. T 2. F
ed. init. ed. date

2
F2 4. 4. Family members rarely become openly angry
1. T 2. F
F-2- 3- 5. We don't say prayers in our family
1. T 2. F
There are very few rules to follow in our family
1. T 2. F
F A - .;z 7. Family members sometimes get so angry they throw things
1. T 2. F
8. We often talk about the religious meaning of Christmas,Passover, or other holidays
1. T 2. F
e9 9. There is one family member who makes most of the decisions
1. T 2. F
10. Family-membershardly ever lose their tempers
1. T 2. F
1. T 2. F
12. There are set ways of doing things at home
1. T 2. F
Family members often criticize each other
1. T 2. F
14. ramuy mernDers nave strict l a m about what IS right or wrong
1. T 2. F
1. T 2. F
h
1. T 2. F
1. T 2. F
1. T 2. F
19. If there's a disagreement in our family, we try hard to smooth things over and keep the
P-
1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
1. T ' 2. F
4
/=& 4 24. Rules are pretty inflexible in our household
1. T 2. F
~2 a ,5 25. In our family, we believe you dont ever get anywhere by raising your voice
1. T 2. F
Family members believe that if you sin you will be punished
~g A 46.
1. T 2. F
/=g2 7 27. You cant get away with much in our family
1. T 2. F
I HAND SUBJECT RESPONSE CARD 1

F&.&f 28.- When you answered these questions, who did you have in mind?
...........
1. Siblings
2. Parent
5. m e r
/77
3. Roommate
6. Spouse/Partner
7. Childchildren
I END OF INTERVIEW I
9
PROVISION OF SOCIAL ]RELATIONS
2 SI
Subject ID: skE5/'w
Interviewer ID:
FIELDCOPY2 ,, & PS&PdeA/B+-
Time Started: @ S h %
'd
Now I would like to know something about your relationships with other people.
For each of the statements I read, please use this scale and tell me the answer that b u t
11 vergtrue
2= somewhat true
3- nottrue
1. when I'm with my fiends I feel completely able to relax and be myself.
-
1 very true
2 - somewhat true
3 - not true
2. I share the same approach to life that many of my fiiends do.
1 -verytrue
2 - somewhat true
-
3 not true
ed. init. ed. date

psp,3 3. People who know me trust me and respect me.
1 -verytme
-
2 somewhat true
-
3 not true
4. No matter what happens, I know that my f d y will always be there for me should I need
them.
-
1 very true
-
2 somewhat true
l-4 -
3 not true
PSP 3- 5. When I want to go out to do things, I know that many of my &ends would pipipy (Zzke)
doing these things with me.
1 -verytme
-
2 somewhat true
3 - not true
6. I have at least one fiiend that I could tell anythg to.
1- v q t r u e
2 - somewhat true
3 - not true
7. Sometimes I'm not sure if1 can completely (count) on my f d y .
-
1 very true
2 - somewhat true
3 - not true
8. My f d y lets me know they think I'm a ' (valuab1e)person.
-
1 very true
-
2 somewhat true
-
3 not true
9. I feel close to some of my hends.
I
1 -verytrue
2 - somewhat true
3 - not true
-
1 very true
2 - somewhat true
3 - not true
73 1 1. People in my f d y help me find solutions to my problems.
1 - very true
2 - somewhat true
3 - not true
12. People who know me think I am good at what I do.
-
1 very true
-
2 somewhat true
3 - not true
13. My friends would take the time to talk about my problems, should I ever want to.
-
1 very true
-
2 somewhat true
3 - not true
BS P /4 14. I know my family wiU always stanc by me.
-
1 very true
-
2 somewhat true
-
3 not true
15. Even when I am with my friends, I feel alone.
-
1 very true
-
2 somewhat true
3 - not true
16. I have a teacher or coach who I can rely rbount) on and talk to.
1 - very true
2 - somewhat true
-
3 not true
17. I have a grandparent, uncle, or aunt that I feel close to and who helps me out.
9
1 - very true
2 - somiwhat true
3 - not true
1 - very true
-
2 somewhat true
-
3 not true
19. There is an adult outside my f d y , for example, a neighbor or religious or

community member, who I can go to for help i f 1 need it.
1 -verytrue
-
2 somewhat true
3 - not true
20. Is there anyone in particular that you think helps you out when you need it?
1. Yes 0.No
FF Yes: What is ths person's name and what is hidher relationship to you? (Circle all that
apply)
K@AO#&
20a1. 20a2. 1 - Immediate Family (sibling, cMd, parent, partner)
irst name 2 - Extended Family
5 - School or Community Memberkeader
-
6 Other &e
PSIpdabB
20bl. 20b2. 1 - Immediate Family (sibling, child, parent, partner)
-
-
4 Church Memberkeader
5 - School or Co
-
6 Other
P O s P ~ C ~
20cl. 2Oc2. 1 - Immediate Family (sibling, child, parent, partner)
'~irstname 2 - Extended F d y
-
-
4 Church MemberLeader
5 - School or CommUnity Memberkeader
6-Other
I I
BEND OF INTERVIEW Q
RECORD TIME: fl8P27/M

Date:
mm dd g
Subject ID:
Interviewer ID:

Early Assessment of Risk of Attrition I
I 4sk questions 1-6 of the respondent I
'at 1. Are you planning on-moving/leavinghome in the next year? Y N
if "Yes,"
1a. when?
1b. where?
If employed, ask Question #2, if unemployed, go to Question #3

if "Yes,":
2a. when? (rnonthlvear) 2b. new employer?
2c. new employment address: [street)
(citv) (state) IZlD')

-
if "Yes,":
3a. when? (monthhear) 3b. employer?
If currently in school, ask Question #4
C:W MCINTOS\WPDOCS\ROANEW.FRM
___ _ _ _ ~ _ _
4. Do you plan on changing schools, or going away to school? Y N

if "Yes,"
4a. what will the new school be?
4b. new school address:: (.street)
fcitvl (state) (ZlD)
5. Do you know of any reason why you might not be able to participate in this Project in the
future? Y N
If, "Yes,"
5a. Please explain why:
l'1
6. Can you give me the names, addresses, and phone numbers of four close friends or relatives
who will always know where to find you to help us locate you in the future?
a. b.
Name:
Relationship:
Address:
CitylSt/Zip:
Phone:
C. d. -
Name:
Relationship:
Address:
CitylStlZip:
Phone:
C:\JMCI NTOS\WPDOCS\ROANEW. FRM ROA 2

~ ~~ ___
Try to make the foilowing observations at the close of the session

a.- annoyed b. nervous c. bored d. afraid
-e.- relaxed f.- interested g. neutral h. curious
1
-. cooperative j. confused?

-
Circle one:
1 2 3 4 5

10. Using the scde below, make your best assessment of the difficulty we will have in locating
Circle one: I
1 2 3 4 5
1Oa. Please explain the reason for your assessment:
C:WMCiNTOS\WPDOCS\ROAN
EW.FRM ROA 3
A
Date:
m m dd yy
Subject ID:
Interviewer ID:
YES G o t o Q 6
NO G o t o Q 2
2. Was ail or part of the assessment administered in Spanish or Polish?

NO G o t o Q 3
YES G o t o Q 5
NO GotoQ4
2. ParentlGuardian
3. SpousePamer
5. Other non-family household member
6. Other
5. How many measures were administered in a language other than English?
1. less than one-fourth

2. between one-fourth and one-half
3. between one-half and three-fourths
4. more than three-fourths
5 . all
6. How much difficulty did the SPC have in understanding the language ofthe measures? Did
he/she find it ...
?.-I 1. Very difficult

2. Fairly difficult
3. Fairlyeasy
4. Very easy
7 . Was all of the assessment administered in private- that is, no one was actively listening to any
part of the interview?
YES Go to Comments Section

NO G o t o Q S
8. Were the following measures administered in private?
If NO, enter code(s) for the party(ies) present during the assessment.
Code
1. Child Behavior Checklist YES NO a. b. c.
2. Conflict Tactics YES NO a. b. c.
3. Deviance of Peers YES NO a. -b. - c. -
4. Self Report of Offending YES NO a. b. c.
5. Substance Use YES NO a. -b. -c. -
6. Youth Self Report YES NO a. b. c.
7. Young Adult Self Report YES NO * a. -
b. c.
Coding List
1 = ParendGuardian 5 = Other Child Family Member
2 = Spousepartner 6 = Friend
3 = Sibling 7 = Neighbor
4 = Other Adult Family Member 8 = Other
Comments Section:
Id
NOTES
Date:
mm dd yy
Subject ID:
Interviewer ID:
NOTES
..
NOTES
ASSESSMENT
COHORT: 3
I. Stanford Binet
9-7453s
STANDARD AGE
RAW SCORE SCORE %
Verbal Reasoning
1 Vocabulary
6 Comprehension
KLET 7 Absurdities
inet Intelligence Scale: 14 Verbal Relations
Sum of Subtest SASS
Fourth Edition Verbal Reasoning SAS
Abstract/Visual Reasoning
Name 5 Pattern Analysis
9 Copying
Sex 11 Matrices
13 Paper Folding & Cutting
Sum of Subtest SASS
Ethnidity NA H B WlNH O/AA PI Other Abstract/Visual Reasoning SAS
9 YEAR MONTH DAY
Quantitative Reasoning
Date of Testing 3 Quantitative
12 Number Series
Birth Date
15 Equation Building
Age Sum of Subtest SASS
Quantitative Reasoning SAS
School
Short-Term Memory
Grade 2 Bead Memory
4 Memory For Sentences
Examiner
8 Memory For Digits
Fathers Occupation: 10 Memory For Objects
Sum of Subtest SASS
Mothers Occupation:
Short-Term Memory SAS
*
Sum of Area SASS
FACTORS AFFECTING TEST PERFORMANCE COMPOSITE
Overall Rating of Conditions SCORE
Test Composite . . . . .... . . . . . . . .... . . . . ... .

Optimal Good Average Detrimental Seriously Partial Composite . . . . . . . . . . . . . .
detrimental Partial Composite based on
1 2 3 4 5 * B e sure that all Standard Age Scores

Attention (SASS) are based on t h e tables in t h e Guide
Easily distracted w i t h t h e n u m b e r 9-74502on the cover.
a) Absorbed by task I I I I I I
Reactions DuringTest Performance

a) Normal activity level 1 I I I I I Abnormal activity level
b) Initiates activity I I I I I I Waits to be told
c) Quick to respond I I I I I J Urging needed
Emotional Independence
a) Socially confident I I I I I I Insecure
b) Realistically self-confident I I I I I I Distrusts own ability
c) Comfortable in adult company I I I I I I Ill-at-ease
d) Assured I I I I I I Anxious
ProblemSolving Behavior
a) Persistent I I I i I I Gives up easily
b) Reacts to failure realistically I I I I I I Reacts to failure unrealistically
c) Eager io continue I i I I I I Seeks to terminate
d) Challenged by hard tasks I I I I I I Prefers only easy tasks
Independence of Examiner Support Needs constant praise and
a) Needs minimum of commendation I I I I I I encouragement
Expressive Language The Riverside Fublshing Company
a) Excellent articulation I I I I I I Very poor articulation
Robert L. Thorndike
Receptive Language Elizabeth P. Hagen
a) Excellent sound discrimination I I i l I I Very poor sound discrimination Jerome M. Sattler
W
Was it difficult to establish rapport with this person?
Easy 1 I I I i I Difficult
Q 1986 The Riverside PublishingCompany All rlghls reserved
N PROFILE ANALYSIS
t
4*
~
VERBAL REASONING ABSTRACT/VISUAL REASONING SHORT-TERM MEMORY
NTANDARD
AGE Verbal Pattern 'aper Folding Equation Bead Memory for Memory for Memory for
SCORE Vocabulary mprehension Absurdities Relations Analysis Copying Matrices and Cutting Building Memory Sentences Digits Objects
74
72
70
68
66
64
62
60
58
56
54
52
50
48
46
44
42
40
38
36
34
32
30
28
< 26 -
Fill in the examinees responses on the lines below. Record a P or F for each item attempted.
Picture Vocabulary
Age Level
2 A
3 B
6. scissors $
,: , L- .- : b-4 6
4 D P /:E
E
P /(fJ 10. bat
5 F P / F 11. shovel 2/;4 7Y

P / F 12. road
6 G P / F 13. bridke
P I F
Oral Vocabulary
7-8 P / F 15. dollar i./4fa-
P / F 16. enveloue PA A5-
9 P / F 17. DmOt
P I F 18. roar P A /$
10-11 P / F 19. soldier VA fy
- - P IF 20. fake L/A A0
3
12-13 K P I F 21. factory VA dv
14-15 L P I F 23. fade v/4 R3
P I F 24. lend &+

h
16+ M P I F 25. incapable Pi4 As-
P I F 26. promotion PA A , 6
N P I F 27. urge \ PA A 7
P I F 28. mortal VA Ax?

0 P I F 29. priceless VA A 9
P I F 30. falsehood
P P I F 31. prompt v4 d/
P I F 32. incision pi% 4/&
Q P I F 33. rouse FA 6.3
P I F 34. divert VA 59
4
Level item
R P / F 35. prophecy b'/ 33-
P / F 36. credible I"A 36
S P I F 37. prologue bH dp-
*
,P I F 38. docile PA 3$
T P I F 39. incandescent v% 35'
P I F 40. philanthropy &"A 9c

U P I F 41. charlatan k.'A P/
P I F 42. retroactive v?4!Y A
u P I F
P I F 44. tentative
W P I F 45. testator
P I F 46. untoward PA 46
Enter item number of highest item administered. + (Use this number to enter the chart on the back of the record
(minus) ___ Enter total number of attempted items failed. booklet.)
(equals) ___ Raw score (highest item minus total failed)
.5
TEST 2: BEA EMORY (item Book 2, Page 3)
i
Entrv Level Samolo Item I
Record a P or F for each item attempted. The sample items are not counted in the raw score.
Level Item Level Item Level Item

H P I F 11. R P I F 27.
P I F 12. P I F 28.
I P I F 13. S P I F 29.
P I F 14. P I F 30.
J P I F 15. T P I F 31.
P I F 16. P I F 32.
K P I F 17. U P I F 33.
A-C P I F 1. P I F 18. P I F 34.
P I F 2. L P I F 19. v P I F 35.
D P I F 3. P I F 20. P I F 36.
P I F 4. M-N P I F 21. W P I F 37.
E P I F 5. P I F 22. P I F 38.
P I F 6. 0-P P I F 23. x P I F 39.
F P I F 7. P I F 24. P I F 4.
P I F 8. Q P I F 25. Y P I F 41.
G P I F 9. P I F 26. P I F 42.
-
P I F 10.
Enter item number of highest item administered.

(minus) - Enter total number of attempted items failed.
(equals) - Raw score (highest item minus total failed)
6
TEST 3: QUA TITATBVE (item Book 1, Page 79)
I Entrv Level SarnDle Item ~ ~ 1I

-4-Q Na Sample I
Fill in the examinees responses on the lines below. Record a P or F for each item attempted.
Level Examinees Response Answer
A-C P I F 1. Matching (1) face
P I F I,#
rn
Matching (6) face
D P / F 3. Matching (3) face
P I F 4. Counting (2)face
E P / F 5. Counting (5) face
P I F 6. Matching 2-1
F P / F 7. Matching 5-2
P / F Matching 6-4
G P I F 9. Adding 1 +1+1
P I F 10. Adding 2 + 4 + 3
H P / F 11. Adding2 + 4
P I F 12. Series 1 , 2 , 3 , 4 ,_
5 ,_
6
I P I F 13. (3)
P I F 14. (4)
J P I F 15. a 3 c d
P / F 16.
K P / F 17.
P I F 18. a b C d
L P / F 19.
P / F 20.
M P / F 21. a B c d
P I F LL.
QUANVJTATBVE-2
Level Examinees Response Answer
N P I F 23. (71)
0 P I F 25. (24)
P I F 26. (51
P P I F 27. a B
P, I F 28. (18)
$,
Q P I F 29. (0.4)
P I F 30.
R P I F 31. ($120)
P I F 32.
S . P I F 33.
P I F 34. (10)
T P I F
P I F
35.
36.
Y)
(175)
U P I F 37. ($5.80)
P I F 38. (4Years)
V P I F 39. (50 minutes)

(equals) Raw score (highest item minus total failed)
8
WY FOR SENTE CES QltemBook 1, Page 1339
I Entrv Level Samole Item Paae I
Record a P or F for each item attempted. The sample items are counted in the raw score.
Level item
Tony chased the dog.

The string on my kite broke.
A P I F 1. Big horse.
P I F 2. Drink milk.
B P I F 3. Look at me.
P I F 4. Cars go fast.
C P I F 5. Trees are big.
P I F 6. I went home.
D P I F 7. Go to the store.
P I F 8. See the funny clown.
E P I F 9. Pat has two dogs.

P I F 10. The circus came to town.
F P I F 11. Kim made a new friend.

P I F 12. Sarah likes her new bicycle.
G P I F 13. The little child would not stop crying.
P I F 14. The sun is shining through my window.

H P I F 15. It is time to go to sleep.
P I F 16. Ken painted a picture for his mothers birthday.
I P I F 17. Lee did not want to leave before the movie was over.
P I F 18. Going to the ball game is not Daves idea of fun.

J P / F 19. They were unable to see the airplane because of the smog.
P I F 20. Georges sister gave him a shirt with red and white stripes.
K P I F 21. Running for a bus, the man slipped and sprained his ankle.
P / F 22. Although the ocean looks safe, it can be dangerous for swimmers.
rr
L P I F 23. Ruth fell in a puddle and got her clothes all muddy.
P I F 24. The airplanes engines sputtered, then stopped, forcing an emergency landing.
9
MEMORY FOR SEMTENCESP
Level item
M P I F 25. It snowed last night, so this morning the children built a snowman.
P I F 26. Sensing defeat, the fighters manager threw the towel into the ring.
N P I F 27. Chris chased the dog around the house but did not catch it.
P I F 28. The birds were flying and singing when Lynn got up this morning.
0 P I F 29. It was raining this morning, so the children carried umbrellas to school.
P I F 30. Undetected by the sleeping guard, a thief slipped into the unprotected factory.
P P I F 31. The home team was ahead when a sudden rain forced postponement of the game.
?4
P I F 32. The warm, humid weather that occurs in late summer tends to make many people feel irritable.
Q P I F 33. Due to their foresight and planning they were able to budget their money effectively.
P I F 34. Because he repaired the window before his father returned, Sam was never punished.
R P I F 35. The ship left port an hour early, leaving Scott stranded on the empty pier.
P I F 36. The truck was clearly out of control as it swerved wildly down the hill.
S P I F 37. The most difficult task of the long, lonely journey was overcoming the boredom that filled her day.
P I F 38. The weather was hot and dry all summer, so that by September the drought had reached critical
proportions.
T P I I= 39. As athletes get older they generally find it more and more difficult to keep themselves in top physical
condition.
P I F 40. To the best of my knowledge, the river has never gotten anywhere near this high within the past twenty
years.
U P I F 41. When children are small it is easy to find gifts that they will like, but as they grow up it becomes harder
and harder.
P I F 42. Most people change their minds about the type of work they are interested in a number of times as
they grow up.

-
(minus) Enter total number of attempted items failed.
10
I Entrv Level SamDle ltem Paae
-7 I
I
Record a P, F, RF, or TF for each item attempted. Examiner has the option to fill in the examinees incorrect
responses. Thdskube patterns are shown from the examiners view. The sample items are not counted in the raw score.
View Facing Examinees

Level Item Score Time Examiner Response
D-E Sl. P F RF TF
(NoLimit)
F-l s2. P F RF TF m
EB
(No Limit)
J-L s3. P F RF TF
rm
(No Limit)
5
M-0 s4. P F RF TF
(No Limit)
P-Q SS. P F RF TF
(NoLimit)
A 1. P I F
/ova/
(No Limit)
P I F
(No Limit)
B P I F
(No Limit)
P I F
(No Limit)
C 5. P I F
(NoLimit)
6. P I F
(No Limit)
D 7. P F R F TF
(30)
8. P F RF TF
(30)
E 9. P F RF TF
(30)
10. P F RF TF
(30)
F 11. P F RF TF
(30)
11
PATTERN ANALYSIS-2
View Facing Examinee's
F 12. P F RF TF
(30")
G 13. P F RF TF
(30")
14. P F RF TF
. (30") r n
H 15. P F RF TF
(30")
16. P F RF TF
(30")
m
I 17. P F RF TF
(30")
18. P F RF TF
(30")
J 19. P F RF TF
(45")
20. P F RF TF
(45")
K P F RF TF
(45")
22. P F RF TF
(4")
L 23. P F RF TF
(6")
24. P F RF TF
(45")
M P F RF TF
(30")
26. P F RF TF
(30")
N 27. P F RF TF
(30")
un
28. P F RF TF
(30")
un
0 29. P F RF TF
(30")
un
30. P F RF TF
(30")
P- 31 P F RF TF
P F RF TF
(45")
12
PATTERN ANALYSIS3
View Facing Examinee's
Q 33. P F RF TF H
H
(45")
34. P F RF TF
EH
(45")
Ea
R 35. P F RF TF
(45") .
36. P F RF TF
9 (45")
S 37. P F RF TF
(60")
38. P F RF TF
(60")
T 39. P F RF TF
(90")
40. P F RF TF
(90")
U 41. P F RF TF
(90")
42. P F RF TF
(90")
~ __ Enter item number of highest item administered.

(minus) ~ Enter total number of attempted items failed.
BEST 6 : COMPWEHENSlON (Item Book 1, Page 247)
I Entrv Level Sam& Item I
Record a "P" or "F" for each item attempted. Fill in the examinee's responses on the lines below for Items 7-42. (An asterisk
indicates that two responses are required.)
Level Item
A P I F 1. . ..nose
P I F 2. ...mouth
B P I F 3. . . .hair
P I F 4. . . .leg
c P I F 5. . ..chin
6. . ..thumb
D P I F 7. . ..umbrella
13
Level Item
D P I F 8. . . .hungry
E P I F 9. . . .stoves
P I F 10. . . .thirsty
F P5#l F 11. . . .street
P I F 12. . . .scissors
G P I F 13. ...ears
P I F 14. . . .baths or showers
H P I F 15. . . .comb their hair
P I F 16. . . .buy food
I P I F 17. . ..shots
P I F 18. . . .read newspapers
J P I F 19. . . .traffic sians
P I F 20. . . .farmers needed
K P I F 21. . . .garbage
-P I F 22. . . .light-colored clothing
14
Level Item
L P I F 23. . . .fire drills
P I F *24. . . .rather have a car
M P I F 25. . . .doctors
'.a
P I F 26. . . .could not sue11
N P I F 27. . . .more than one newsuaDer
~ ~ ~~~~
P I F 28. . . .paper recycled
0 P I F 29. . . .public education
P I F 30. . . .houses in the city
P P I F "3 1. . . .teleuhone
P I F *32. . . .electric lamps
P I F 33. . . .school board
J
P I F 34. . . .have a license to drive
15
R P I F 35. . . .inventions
P I F *36. . . .smallcars
S P''r F 37. ...loans
P I F 38. . . .citizens'rights
T P I F 39. . . .constitution
P I F 40. . . .limitedtime periods
U P I F "41. . . .laborunion
P I F "42. . . .commercials
__ Enter item number of highest item administered.

16
- Envy Level Sample Item Fage
~ -1
A-3
I
C-L
Circle the examinees responses for Items S1-4. The letter of the correct response is capitalized. Fill in the examinees responses
on the lines below for Items 5-32. Record a P or F for each item attempted. The sample item is counted in the raw
score.
Level Item
&-0 P I F
P I F
,.

SI. Treeupside-down
1. Boy combing hair with spoon
a
a
B
b
P I F 2. Bentknife A b
P I F 3. Cap upside-down a B
P I F 4. Duck with bunny ears A b
P I F 5. Drinking from a baby bottle
P I F 6 . Square bicycle wheels
P I F 7. Writing with fork
P I F 8. Cat in cage
P I F 9. Reading blindfolded
P I F 10. Eating soup with knife
P I F 11. Sweeping with broom tip
P I F 12. Walking fish on leash
P I F 13. Combing bald head
P I F 14. Putting pants on upside down
17
Level Item
H P I F 15. Riding bicycle on water
P I F 16. Stamp misplaced
I P I F 17. Saw uvside-down
P EsF 18. Penguin flvina
J P I F 19. Writing backwards
P I F 20. Jumr>ingover house
K P I F 21. Shadows in different directions
P I F 22. Rabbit running into dog
L P I F 23. No Sundays
P I F 24. Rooster sitting on nest
M P I F 25. Bubbles going down
P I F 26. Unequal weights balanced
N P I F 27. Wind blowing in different directions
P I F 28. Wake in wrong direction
0 P l F 29. Thumb on wrong side of hand
18
Level item
0 P I F 30. North America and South America reversed
P P I F 3 1. Fulcrum in wrong place
P I F 32. Flag waving o n the moon
i Enter item number of highest item administered.

1
TEST 8 : ME Y FOR DIGITS (litem csok 3, Page 73)
I Entrv Level Samole Item Paae I
Record a P for each series repeated in correct order without error. Record an F for each series that is repeated incorrectly.
The sample items are not counted in the raw score. Turn the page to administer Memory for Digits Reversed.
Level Item Digits Forward Level Item Digits Forward

I-Q P I F 31. 5-8 P I F 7. 2-8-3-5-9-4
I-Q P I F S2. 3-9 P I F 8. 7-1-9-5-4-3
1. 5-7-8 P I F 9. 3-5-9-6-8-4-7
P I F 2. 4-9-2 P I F 10. 2-8-5-1-4-6-9
3. 2-7-6-9 P I F 11. 7-3-9-4-8-1-4-2
4. 5-1-8-4 P I F 12. 2-8-1-7-3-5-9-4
5. 3- 1-8-5-9 P I F 13. 8-1-7-4-9-3-2-6-5
6. 4-8-3-7-2 P I F 14. 5-7-4-2-6-1-3-9-8
___ Enter item number of highest item administered.

__ Enter total number of attempted items failed.
___ Raw score (highest item minus total failed)
19
Level Item Digits Reversed Level ltem Digits Reversed
I-Q F I F SI. 2-4 S P I F I. 8-1-3-7-9
I-Q P I F 52. 7- I P I F 8. 4-2-5-8-1
I-K P IF 1. 6-3 T P I F 9. 4-8-7-2-1-5
P I F 2. 4-9 P I F 10. 6-2- 5- 9- 3- 8
L-Q P I F 3. 2-9-5 U P I F 11. 1-842-5-9-3
P I F 4. 8-1-6 P -1 F 12. 4-7-3-94-1-2
R 7/ 5. 8-5-2-6
P I F 6. 4-9-3-7
Enter item number of highest item administered. ____ Total raw score
(minus) ___ Enter total number of attempted items failed. (Digits Forward & Digits Reversed)
BEST 9: COPYING (hem esok 3, Page 85)
Record a P or F for each item attempted. For Items 13-28, turn to pages 29-36 in the record booklet and then place the
record booklet in front of the examinee.
Level Item Level Item
Block Designs A P I F 1. H P I F 15.
PIF 2. P I F 16.
B PIF 3. I PIF 17.
P I F 4. P I F 18.
C P I F 5. J PIF 19.
P I F 6. P I F 20.
D P I F 7. K P I F 21.
PIF 8. P I F 22.
E PIF 9. L P I F 23.
PIF 10. P I F 24.
F PIF 11. M P I F 25.
P IF 12. P I F 26.
Copying Designs G P I F 13. N P I F 27.
- PIF 14. P I F 28.
(minus) ___ Enter total number of attempted items failed.
20
I Entrv Level SarnDle Item Paae I
Record the examinees choices by sequentially numbering the order of the examinees responses in the space provided after each
word. The words in bold type list the Stimulus Card objects in the same order as they are presented. The other words list the
distraction objects that appear on the Response Cards. If the examinee points to the correct objects in the correct order, record
a P below. The sample items are not counted in the raw score.
Level Item
Sp0CSn __ h t t @ d J-

Stars- Tree- Duck-
Flower - Chimpanzee__
Hat __ Telephone __ Bird -
P I F 1. hoe.-- Horse-.-
Car- Plane- Bed-
P I F 2. Clock- Elephant -
Bus- Clown- Eggs-
P I F 3. Owl- Sanla- Table-

Box - Bills- Horn- Cup-
P I F 4. Giraffe- SS~SSQ~- Eye-

Key - Girl- Rabbit- Rock-
P I F 5. Deer- Knife- Soitcase- Dress-

Moon - Coins - Tracks - Strawberry -
P I F 6. Puzzle- Flag- Bear- Gate-

Book - Umbrella __ Stove __ Hammer __
$ I F 7. Goat-.- Wheel- Emvebpe- Rope- Vacuum-

Shell ~ Rocket I_ Shovel __ Castle __
P I F 8. Dmm- Snake- CQW....- pi&.- Watch-

Police Officer - Kangaroo __ Road __ Cage __
P I F 9. Skate- Leaf- Squirrel- Fly __ Rooster __ Kettle __

Knife - Bench - Barrel __ Train __
P I F 10. Skunk- Pot- Turkey- Web- Cane- StaflsR-

Lamp __ Hive ___ Feather __ Tomatoes -
P I F 11. Nag- L a m Mower __ Girl __ Flower - Chicken __ Fostball -
Foot __
Bee- Tiger- Gorilla- House- Crib-
21
MATRICES-2
Lwei Item Level item

.Q P I F 17. a B c d e
P I F 18. a b c D e
1of record
a P I F 19. a b c d E booklet
P I F 20. a B c d e
P I F 24.
S P I F 21. a b c d E
P I F 22. a B c d e
4 U P IF 25. See page 38

> of record
booklet.
(equals) ___ Raw score (highest item minus total failed) P IF 26.
TEST 12: ~~~~~~ SERIES (Item Book 4, Page 65)
I Entry Level Sample Item Page I

-7
67.69
I
! 1-Q SI, s2
Record a P or F and examinees response for each item attempted. The sample items are not counted
in the raw score.
Level Answer Examinees Response
I-Q P IF S1. 5,6
I-Q P I F S2. 1,2
I P I F 1. 18,20
P I F 2. 8.7
J P I F 3. 13,15
P / F 4. 3,3
K P I F 5. 15,lO
P I F 6. 9e, lOf
L P I F
7. I 2
54 >
P I F 8. 7,3
M P I F 9. 29,33
P I F 10. + , + E l >
N P IF 11. 7 , 4
P I F 12. 3 , s 9
23
NUMBER SERIES-2
Level Answer Examinees Response
0 P I F 13. ;,
P I F 14. 9, 8
P P I F 15. 7 , 6
P I F 16. 1 0 , l l
Q P I F 17. 10b + 6c, 12b +7c

P I F 18. 27,26
R P I F 19. 35,47
P 1% 20. 7 , 6
S P I F 21. 65,129
P I F 22. 22,22
T P I F 23. 64,88
P I F 24. 18, 17
U P I F 25. 14,48
P I F 26. 84,82
Enter item number of highest item administered

Enter total number of attempted items failed.
Raw score (highest item minus total failed)
24
Circle the examinees responses for Items S1-18. The letter of the correct response is capitalized. Record a P or F for each
item attempted. The sample items are not counted in the raw score.
Level item Level item I
a b C d e R P I F 11. a b c d E
a b c d E P I F 12. A b c d e
M P I F 1 . a b C d e S P I F 13. a B c d e I
I
P I F 2 . a b c D e P I F 14. a b c D e
N P I F 3. a B c d e T P I F 15. a b c d E
P I F 4 . a B c d e P I F 16. a b C d e
0 P I F 5 . A b c d e U P I F 17. A b c d e
P I F 6 . a b c D e P I F 18. a b c d E
P P I F 7 . A b c d e
P I F 8. a B c d e
Q P I F 9 . a b C d e
P I F 10. a B c d e

25
Entrv Level Samole Item Paae
Fill in the examinees responses on the lines below. Record a P or F for each item attempted. The sample item is not
counted in raw score.
Level Item
M P I F 1. scarf . . .
P / F 2 . butcher.
~ ~ ~
N P / F 3. elbow. . .
P / F 4. peel.. .
0 P I F 5. gold.
P I F 6. vise.. .
P P / F 7. agree.. .
P I F 8. Tom.. .
Q P I F 9. robin., .
P / F 10. bass.. .
26
Level Item
P I F 11. elf.. ,
PIF 12. emerald.. .
PIF 13. sight. . .
%
PIF 14. silk.. .
PIF 15. creed.. .
PfF 16. mire..
P I F 17. filly.. .
PIF 18. scurvy.. .

(minus) ___ Enter total number of attempted items failed.
I I
~~ ~~
Entrv Level Sample Item Paae
Fill in the examinees responses on the lines below. Record a P or F for each item attempted. The sample items are not
-
counted in the raw score.
Level Item
2 2 7 3 x + =
P I F 1. 1 2 2 3 3 f + x =
P I F 2. 0 2 4 8 ~
-
P I F 3. 3 4 4 5 6 + - -
P I F 4. 1 2 4 5 + - =
P I F 5. 2 4 5 1 0 x f =
P I F
P I F 7. L L L f =
6 3 2
P I F 8. 2 3 3 3 6 x x + =
~- ~
9. 21 . 3 6 ~ ~
P I F
A : + - =
P I F 10. 2-
1
z1 4 4
P I F 11. 2 2 3 4 + x =
P I F 12. i 2 4 8 - x ( ) =
P I F 13. 1 2 4 8 X +- =
P I F 14. 3 5 6 7 - ~~~
X O =
P I F 15. 1 3 4 5 1 3 + + - =
P I F 16. 2 4 5 6 9 + - X =
1
P I F 17. 7 3 5 1 0 - + =
18. ~1 1 4 6 - + =
P I F

28
f
Item number
Item number
29
Item number
item number
30
item number
Item number
31
Item number
I
Item number
32
Item number
33
Item number
,
1'
!
I
i"
i
I
Item number
1
34
_ -
Item number
item number
35
Item number
;i'
d:
Item number
1
i i
36
23.
24.
37
25.
26.
38
39
Entry-Level Chart
Highest Pair of items Administered
on the Vocabulary Test
3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19-20 21-22 23-24 25-26 27-20 29-30 31-32 33-34 35-36 37-38 39-40 41-42 43-44 45-46
2-0to2-5 A A A A B B C C D D
2-6to2-11 A A A B B B C C D D E E
3-0to3-5 A A B B C C C D D E E F F
3-6to3-11 A B B C C D D D E E F F G G
4-Olo4-5 B 6 C C D D E E E F F G G H H
4-6to4-11 B C C D D E E F F G G H H I
5-0to5-5 B C C D D E E F F F G G H H I
5-6to5-11 C C D D E E F F G G G H H I I
6-0to6-5 C C D D E E F F G G H H I I J
6-6to6-11 C D D E E F F G G H H H I I J
7-0to7-5 C D D E E F F G G H H H I I J J
7-6107-11 C D D E E F F G G H H I I J J K K
8-0to8-11 C D D E F F G G H H I I J J K K L L
9-0to9-11 C D D E F G G H H I I J J J K K L L
IO-0io10-11 C D D E F G H H I I J J K K K L L M M
11-0to11-11 C D D E F G H I I J J K K L L L M M N N
12-0to12-11 C D D E F G H I I J J K K L L L M M N N 0
13-0to13-11 C D D E F G H I J J K K L L R/1 M M N N 0 0 P
14-0to14-11 C D D E F G H I J J K K L L M M N N 0 0 P P
15-0to15-11 C D D E F G H I J K K L L M M N N N 0 0 P P
16-0to16-11 C D D E F G H I K K L L M M N N 0 0 0 P P Q
17-0to17-11 C D D E F G H I K K L L M M N N 0 0 P P Q Q
18-0andover C D D E F G H I K L L M M N N 0 0 P P P Q Q
Directions: The entry level is found at the intersection of the exarmnees chronological age (C.A.) and the highest pair
of items adrmnistered on the Vocabulary Test. For example, an examinee whose C.A. is 4-2 and whose highest pair of
items administered on the Vocabulary Test is 13-14 would begin the remaining tests at Level D.
C.A. is recorded in years and months. The C.A. for a child who is 9 years 5 months and 16 days would be 9-6. The
C.A. for a child who is 9 years 5 months and 15 days would be 9-5.
ASSESSMENT DEBRIEFING
Date:
m m dd yy
Subject ID:
Interviewer ID:
k
ecify languag
3. In what language(s) was the assessment conducted? . .
1.
2. ParentlGuardian
3. SpousePartner
-.
6. Other
5 . How many measures were administered in a language other than English?

5. all
6. Hoytmuch difficulty did the SRC have in understanding the language ofthe measures? Did
he/she find it ...
1. Very difficult
2. Fairly difficult
3. Fairly easy
4. Veryeasy
7. Was all of the assessment administered in private- that is, RO one was actively listening to any

NO GotoQS
Code
2. Conflict Tactics YES NO a. -b. c.
3. Deviance of Peers YES NO a- -b. c.
4. Self Report of Offending YES NO a. -b. c.
5. Substance Use YES NO a. -b. c.
6. Youth Self Report YES NO a- -b. c.
7. YoungAdultSeifReport YES NO ' a. b. c.
Coding List
1 = ParentlGuardian 5 = Other Child Family Member
2 = SpousePartner 6 = Friend
Comments Section:

NOTES
NOTES
HARVARD SCHOOL OF PUBLIC HEALTH

ASSESSMENT
PRKMARY CAREGIVER
COHORT: 6
FIELD COPY #2
TABLE OF CONTENTS
Age: 6(PC)

2. Home
3. School Screen: 3-6
4. Health Screen
5. Family Structure & Health History
1$ 7. Employment & Income
9. Conflict Tactics Scale: PartnerKhild
a
First,I will ask you about where you and ***** have lived during the past five years;
were born;
Third, I ask about different languages you might speak;
Fourth, I will ask for some general descriptive information about yome&
Fifth, I =-going to ask about your school background; and
Fdy,I will ask &out your etbnic and digious background
Lets start w i t h chedthg that I have your current address recorded correstly.
I
2
Your current address is (readfrom contm sheet): Is that right?
atux-e/vr 1. Yes-
0. NO-
ue"dh
Street address // apt. #
city State zip code

'.r
1. DO you: (read choices)
1. rent your home

2. own your home
4. live with someone o.oUr parents, guardians or partner) who rents this home
5. live with someone (yourparents, guardians or partner) who owns this home
1A. How long in years and months have you l i e d here? - -

Y- months
2. Please teU me all the other addresses you have had in the past five years, starting with
2A1. Why did you move from this address [2A]? [circle up to three]

3 = moved off-campus 10 = found a better ap&ent/house
6,= moved in w/someone due to finances 13 = on vacatiodgraduated from school
7 = living quarters too s d f o u n d bigger apartmenthome
25 = other ~JL?M&Z&L~-
/ /
&
2A2. How long did you live at this address [2A]?
YWS months
Years months
MLd?LiL&& -6 t?dJ
(street address) 1.
(city) (state) (*cQw
2B 1. Why did you move from this address [2B]? [circle up to three]

2 = evicted 9 = could no longerafford rent
7 = living quartem too s d f o u n d bigger apartmenthome
2 =other V~~~LL&LZ d
/
4
Years months
Y- months
3
4
V d d h LZAi%?&d
2C1. Why did you move from this address [2C]? [circle up to three]

3 = moved off-campus 10 = found a better apartmentmouse
5 =c@ange in marital/romantic status 12 = roommates left (had to move)
6 = moved in w/someone due to'finances 13 = on vacatiodgraduated from school
25 =
2C2. How long did you live at this address [2q?

Y- months
Y- months
2D. And where did you live before iiving here?
v k d h ls%fz.q?&
(street address) (city) (state) (zip d e )
2D1.~Why did you move from this address [ZD]?[circle up to t h e ]

i 4 4 ~
6 = moved in w/someone due to f m 13 = on vacation/graduated from school
7 = living quarters too smaWfound bigger apartmenthome
25 =
h 3 LBL 2D2. How long did you live at this address [ZD]?
Y'ears months
....
....
Y- months
4
5
2E. And where did you Iive before living here? .
&&&&&-&2&9-& A&*-&+
(street address) i (Ciry) (state) (zip code)
2E1. Why did you move from this address [2E]? [circle up to three]

4 = fxe/other hazardous condition 11 = wanted to Iive away from parents
5, = change in maritaVromantic status 12 = roommates left (had to move)
6 = moved in w/ someone due-to finances 13 = on vacation/graduated from school
7 = living quarters too smalVfound bigger apartmenthome
25 = other f i G % d & d ~WH&

Years months
.vc%e&?&& *&&
(street addras) (city) (state) (zip code)
2F1. Why did you move from this address [2F]? [circle up to three]

3 = moved off-campu 10 = found a better apartmenthouse
4 = fue/other hazardous condition 11 = wanted to live away from parents
5 = change in maritallromantic s t a t u 12 = roommates left (had to move)
6 = moved in w/someone due to finances 13 = on vacatiordgraduated from school
==other ~ab&fk
-6 p.,
/a*
2F2. How long did you live at this address [2q?

Years months
Y- months
6
(street address) (state) (zip code)
2G1. Why did you move from this address [2G]? [circle up to three]

3 = moved off-campus 10 = found a better apartmendhouse
5 9 change in marital/romantic status - 12 = roommates left (had to move)
6 = moved in-w/ someone due finances . 13 = on vacation/graduated from school
25 = other lvaa4.4h
/ I

Y- months
.. . . .... ... . ....

Y- months
2H1. Why did you move from this address [2HJ? [circle up to three]

3 = movedoff-campus 10 = found a b e a r apartmenthouse
5 = change in mariml/romantic status 12 = rooll~atesleft (had to move)
6 = moved in w/someone due to fhmces 13 = on vacatiordgraduated from school
7 = living quarters too smaWfound bigger apartmenthome
25 =other & / ~ d k r;
b
2H2. How long did you live at this address [2a?
Y- months
r
b.
7
21. And where did you live before iiving here?
#!~d&&>*&[~d . t d ic
- -
Y Y
211. Why did you move from this address [2rJ? [circle up to three]

5* = change in marital/romantic status 12 = roommates left (had to move)
6 = moved in wl someone due'to f a c e s 13 = on vacation/graduated from school
7 = living quarrers too small/found bigger qartment/home
25 =other ~ a ' d k&

&
212. How long did you live at this address [21]?

Years months
-
- --
271. W h y did you move from this address [a?
[circle up to three]

3 = moved offcampus 10 = found a better apartmenthouse
6 = moved in wl someone due to finances 13 = on vacation/graduated from school
7 = living quarters tD0 s d f o u n d bigger apartmenthome
25=
272. How long did you live at this address [q?

YWS months
Y= months
3
8
3. Has ***** had any different addresses than you in the past five years?
0. NO
1. YES
months
ue
4. Please tell me all the addresses ***** has had in the past frve years, starting with the most
4A.
4A1. Why did **I*** move from this address [4A]? [circle all that apply]
1 = change in custody/shared custody 7 = child hospitalii (medical)

3 = parent was in prison 9 = foster plactment/adopted
4 = parent abandoned chiid
6 = parent was hospitalized (emotiomllbehavioral) or in drug treatment
25 =other ~-'dib
/ p
4A2.How long did ***** live at this address [4A]?

Y- nibnths
9
Yw?&d& c _
- -u
f Y
(street address) (city> (state) (zip code)
4B1. Why did ***** move from this address [4B])? [circle all that apply]

, 5 = child hospitalized (emotionalhehaviod) or in residential treatment
6 = parent was hospitaliied (emotionalhehavioral) or in drug treatment
25 = other Y ~ ~ ' L G L F . ~* e b
rpv
4B2. How long did ***** live at this address [4B]?
Y- months

YL&&L&&% %d d _c c- -
(street address) (city) (sate) (ZiP~e)
4C1. W h y did ***** move from this address [4q? [circle all that apply]
3 = parent was in prison 9 = foster phment/adopted
25 =other v='d&--
4C2. How long did ***** live at this address [4C]?
Y- months
Y- months
10
40. . And where did ***** live before living here?-
4D1. Why did ***** move from this address [4D]? [circle all that applyJ
2 =_lived with another family member 8 = parent was hospitalized (medical)
9 5 = child hospitalized (emotional/behavioral) or in residential treatment
6 = parent was hospitalized (emotiod/behavioral>or in drug treatment
4D2. How long did ***** live at this address [4D]?
Y- months
4E1. Why did ***** move from this address [4E]? [circle all that apply]
5 = child hospitalized (emotionavbehavioral) or in residential treatment
6 = parent was hospitalized (emotionalkhavioral) or in drug treatment
25=other 4ehe.dJ ' &

4E2. How long did ***** live at this address [4E]f '
11

A. city B.State d4%f%W&.!. C. Country
5A. When did ***** come to live in the USA? year: 19

8. Don't Know
5B. How old was ***** when he/she came to live in the USA? age:
8. Don't Know
c. country
6A. When did you come to live in the USA? year: 19-
~
8. Don't Know
8. Don't Know
7. Is your mother still living'? 1. Yes 0. No 8. Don't Know

- c.,
12
A. City B. State c
c.counny -
A. City B. State
- c. country -4
1;;413 940 q% 9A. When did she come to live in the USA? year: 19
8. Don't Know
rn &A0 9B. How old was she when she came to live in the USA? age:
8. Don't Know
10. Is your father still living? 1. Yes 0. No 8. Don't Know

-
A. City B. State c.country
..
A. City B. State
- c. Country
7
A. City B. State - c. country -
i
j&, 12A. When did he come to live in the USA? yea&&19 I
8. Don't Know
* 72230 12B. HQWold was he when he came to live in the USA? age:
8. Don't Know
13
Are you a U.S. citizen?

. . ..... ... ....
0. NO
1. YES
13A. Are you (read choices) 1. currently applying, # To

2. planning to apply, or Q* 14
13B. Are you registered-tovote in the U.S.? 0. NO 1. YES
LpQ&&c&/&& -
14. number? --- -
Dont Know Donthave one Refused
L;&3 f5j 15. What is your marital status? Are you (Read all choices):
rn 7a-A-o 15A. Are you currently living with a partner?
1. Yes.
0.No
% a ~ & d o 15AA. Are you currently living with your spouse?

1. Yes
0. No i=,
B75 / F f l & # 15AA.1 Are you living apart because you.. are . not getting along or for some other

14
* 75434 1SB1. Is your partnerhpouse the biological parent of *-***?

1. Yes
0.
1932. How long have you lived with your partnerlspouse?

Y5Rre
/5ARM
years months
h

p.r mm dd yy
as 17. What was the frrst language you learned?
4. Spanish
5. German
6. Lithuanian
11. English AND another language (quem;)
12. Two other languages (spew:)

A.
B.
18. What is your primary language now?
4. Spanish 10. Other language (spem;)
5 . German
6. Lithuanian
11. English AND another language (spem:)
b
1
12. Two other languages (specifj:)

15
19:
It II
Please note: Insert the M ~ of

X the language (s) provided in response to Q. I 7 and 18
whenever rhe term /lanpuage(s)] appears in the text in Q . 19
I'd Like to know what h g u a g e you use in your m y activities. After each question please
tell me whether you use English only, mostly English, both English and [language(s)]
e q d y , mostly b w g e t s ) l , or Ilanguage(s)l only.
1. English only 4. Mostly Ilanguage(s)]

2. Mostly Engiish 5 . Ilanguage(s)l only
3. Equally
19B. What language (doidid) you speak with your mother?
1. English only 4. Mostly ~anguage(s)]

2. Mostly English 5. [language(s)l only
3. E@Y
19C. What language (doidid) you speak with your father?

2. Mostly English 5. [mP%e(s)l only
3. W l Y

3. Equally
IS
16
1. English only 4. Mostly Elanguage(s)]

2. Mostly English 5. tbP?ml OdY
3. Equally
1. English only 7 4. Mostly [language(s)]

2. Mostly English 5. [l=guage(s)l only
3. Equaily 7. NAP (Not in school or in a job)

2. Mostly English 5- (?anguage(s)l only
3. Equally
1. English only 4. Mostly Ilanguage(s)]

2. Mostly English 5- Ilanguage(s)l only
3. W Y
191. Do you consider your Ilanguage(s)] to be .-.(read choices).
1. VeryGood
2. PrettyGOod
3. Fair, or
4. Notgoodat all
19J. Do you consider your English to be.... ( r e d choices)
1. very Good
2. Pretty God
3. Fair, or
4. Not good at all
19K. How often has it been hard for you to get along with others because ydi 'don't
speak English well? Would you say.. . ( r e d cfroices)
1. Never
2. Sometimes
3. Often, or
4. Always
17
tQL0 problems understanding English? Would you say.. .(read choices)
1. Never
2. Sometimes
3. Often,or
4. Always
Have you attended school in another 'country, this country (the US), or both?
J
20.

2. usonly
3. another country and US-
0. NO
1. YES
..... __.,__.
20C1. What degree did you receive? ., . .
"Qz;z
.................
.....................
.....
E.
.........Dx
Did you f h h high school?
0. NO
1. YES
0. NO
1. YES
-Years months
p ~a
d 21A2. What is the highest degree you have reached?
1. No degree
4. Master's degree
5 . Doctoral degree (J.D.,M.D.,Ph.D., DDS., DO,Ed-D.)
6. Other &#&Ak2
* rnR7-3 21A3. Are you currently in school?

.....&
& ......$
...$
...
0. NO :,,.,..............
q+4
-1. YES Q&Z
21B1. Are you still in high school?
0. NO
1. YES
21C. Have you gotten a GED or bad any other schooling or training since then?
0. NO
1. YES
21C1. What have you receked? 1. GED

2. other &gree/certificatt:
0. NO
1. YES
22. What country(s) best represents your ~ t i o n aorigin

l or ancestry?
3.
19
$3 23. Do you identrfy with an ethnic group?
0. NO
1. YES
24. Which group(s) do you identrfy with?
1. V&ak&h *dld
Yfl
Y. 2.
s 3.
4.
L4.z&!&i2.&&~ .~-=L.=-
24B. Which of these groups do you primarily or mainly identify with?
In Q.24, circle the number ofthe 'primav'ethnic group.
25. How American or [ethnic group] are your customs? Would you say ...(read choices)
*ci&5
1. Very American
2:Mostly American
3. Mostly [ethnic group], or
4. Very [ethnic group]
1. never
2. sometimes, or
3. often
J% 6 26. Are you Latino or Hispanic?
0. NO
1. YES
I 7 II
Hand "CARD2: LATINO/HISPANIC" to the remondent II
20
j& &,$IO 26A. Which of the following represents your origins?
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
7. Other
-I II
yourself?
1. Asian
2. Pacifk Islander
4. Caucasian / white
5. Native American
6. Other -d
28. How oftendo people dislike you because of your ethnic group or race? l say.. .(read
W o ~ you
choices)
1. never
2. sometimes, or
3. often
29. How often are you treated unfairly at school or work bemuse of your ethnic group or race?
1. never
2. sometimes, or
3. often
30. How often have you seen friends treated badly because of their ethnic group or Would
&3 30 you say.. .(read choices)
1. never
2. sometimes, or
3. often
21
& 3.3 33. Do you follow or are you a member of any of the churches or religions listed here?
- 0. NO
1. YES
3x6 53 CHr' 1. Buddhist

2. Catholic
3. Church of Christ
9.
4. Evangelical
5. Hindu
6 . Islamic
3 3 CPJL8. Jewish
a. orthodox
b. Conservative
c. Reformed
d. Other
9. Mormon
10. Pentecostal
$ha;r3 35#5,#5/,311. Protestant
a. Anglican
fi43 5 3 C # y b. Baptist
3; National Baptist Convention
5. Other Baptist
c. Episcopalian I f
35 w.5 d. Lutheran
3 3 C+'L e. Methodist
1. Episcopalian
5. Other Methodist Churches
5 3 c+.+ f. Presbyterian
2. United Presbyterian Church in the U.S.A. , .
3. Other Presbyterian Church & P , d
g. Seventh Day Adventis
12. Other dk-~da A
21
22
34. Would you say your religion provides you with.. .(Read choices)

2. quite a bit -of guidance
35. How often do you attend religious seririce? Do you attend... (Read choices)

a a few times -a year
3.
4. almost never, or
5. never
This imewim QQ&S NOT end here.

Answer the f o W n g Questionr yourself undf o K w the hslmcti0n.sprovided:
I A. IS the PC mum*&or living with a pruner?
Yes ->
NO ->
B. Have you obtained informarion about the b-hg,;al father?
Yes ->
NO ->
22
23
36. What is hisher fxst name? -

4 Y
37. What is [Partnerl's age?

2. 20 to 29 years 5.50 to 59 years
8. Don't Know

mm YY
38. Where was @ m e r ] born?
A. city &#&. i
B. State
h
C. Country
L
3&)3.ap 38A. When did shehe come to live in the USA? year: 19
8.'Don't Know
m 55&# 385. How old was shehe when shehe came to live in the USA? age:
8. Don't Know
1
m3 39 39. Is [partner's] mother still living? 1. Yes 0. No 8. Don't Know
c. country
,
- rc-
A. city B. State

- -

-
I-c-
-rc
24
24
4zB:
A%3&jm 41A. When did she come to live in the USA? year: 19
8. Don't h o w
41B. How old was she when she'came to live in the USA? age:
mw40
8. Don't Know
h
42. Is [partner's] father still living? 1. Yes' 0. No 8. Don't Know
%5 425

-
c. country -
A. City B. State
-
c. collntry -
.
B. State - -
A. City c. country

3% .Cr.e;4-0 8. Don't Know
8% 3'r/&O 8. Don't Know
74
25
-43- 45. Has [partner] attended school in another country, this country (the US), or both?
.. . . .. ....
1. another country only A

2. US only
45A. How many years of school did [parmer] have? years (1 - 20)
45B. At what age did [pamier] stop attending school? years old
45C. Did Iparmer] receive any type of degree?
0. NO
1. YES
45C1. What degree did [partner] receive? Go to

4.47
0. NO
1. YES
46A. Has Ipartner] done any studying beyond h@ school? -

0. NO
1. YES
1. No degree
4. Master's degree h
5. Doctoral (J.D., M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other .
46A3. Is [p&er] currently in school? 0. NO

1. YES p
.,... . ...
. .'..
..
..- .,., - ... . . .

26
/f% -Y6&0' 46B. What is the last grade [parmer] completed? (1 - 12)
46B 1. Is [partner] still in- high school?
0. NO
1. YES
46C. Has [partner] gotten a GED or any other schooiing or training since then?
..
0. NO
.
1. YES
'LI
M4./6CY 46C1. what has mer] received? 1. GED
2. other degredcertificate:
3. othe6%hooling:
46C2. Is [parmer] currently in school or trainhg? 0. NO

1. YES
Q&Z
......_.. .......
>: .......
_i_
47. ~ dor ancestry?

What country(s) best represents Iparmer's] ~ t i origin
1.
2.
3.
48. Does [partner] identify with an ethnic group?

0. NO
1. YES
48A. Which group(s) does helshe identify with? ;pr

1.
27
3.33 49 49. Is [partner] Latlno or Hispanic?
NO
.. .....
0.
1. YES
.... ..
333 ,Y@HO 49A. Which of the following represents hisher origins?
1. Cuba
2. Mexico
3. PuertoRiw
4. Spain
5. South America
7. Other
3: RACE/ETHNICllY" to the respondent I

50. If you were asked to put [partner] into only one of these groups, in which one would you
place himiher?
1. Asian
2. Pacific Islander
4. Caucasian /white
5 . Native Ameri
6. Other
28
This interview MBy or MBy NOT end here.

Answer the following questions yourself and follow the instmaions provided:
-
A. Have you obtained informrrtion about BOTH the biological mother and
biological father?
-r
B. Have you obtained i@ormation about the biological father?
Time stopped:
I
a
29
Now some questions about *****'sfather:
51. What is his first name? Don't Know
$-A. 52. Is he stiU living? 1. Yes

0. No
8. Don't

8. Don't know
&3 3-3 ,A 53.2 What was [*****'s fatherl's age Quen ..,e died?
. . .
2.20 to 29 years 5.50 to 59 years
8. Don't know
53A. When was [*****IS father] born?

mm
54, Where was [*****Is father] born?
A. city+ , B. State
_L
c.country -
55.1 Where does he live now? 4
A. cityd
-
, B. State - C. Country
-

-A. City B. State 3)--c
C. Country
-
8. Don't Know
8. Don't Know
Is fatherl's mother still living? 1. Yes 0.No

rti4 56 56% [*****IS 8. Don't Know

c -
c.country
.-.
A. city B. State
- c. -country
-
58.2. Where 'did she h e when she died?
-
A. City B. State c. country
I_
-
. .
. . . ........
......
S A . When did she come to live in the USA? ycar: 19.-,

8. Don't Know
58/30 8. Don't Know
rn 59 59. Is [*****'s fatherl's father still living? 1. Yes 0. No
Where was he born?
*
60.
A. city eo! B. State - C. Country
-
31
A. City B. State
c
c. country
-
-
5 A. City B. State C. Country

-

8. Don't Know
61B: How old was he when he came to live in the USA? age:
8. Don't Know
Has [*****Is father] attended school in another country, this country (the US), or both?

2. usonly
~ US
3. another m u n and
0. NO
1. YES
62C1. What degree did he receive?
31
32
63. Did [*****'s father] finish high school?

%563
-
0. NO
1. YES
,&A 6 3 63A. And has he done any studying beyond high school?
0. NO
1. YES
B i 6 3 S 9j 63A1. How many years of studying beyond high school
'<y
-. y- -
, months
Am 6 8 63A2. What is the highest degree he has reached?
1. No degree
4. Master's degree
5. Doctoral degree (J.D.,M.D., Ph.D., D.D.S., D.O.,Ed.D.)
6. Other d
63A3. Is he currently in school? 0. NO
1. YES
63 63B. What is the last grade he completed? (1 - 12)
*/3 6 3 /35/ 63B1 Is he stiU in high school?
0. NO
1. YES
63 CQ 63C.' Has he gotten a GED or any other schooling or training since then?
0. NO
1. YES
63Cl. What has he received? 1. GED

h
3
436 3 Cf ' late:
m6 5 C f Oj 9 2. other degree/certX
-
2
Y '
3. other schooling:
L3r
h e&w&
.... :. ......
63C2. Is he currently in school or training? 0. NO
1. YES Q&4
32
64. What counuy(s) best represents [*****'s fatherf's national origin or ancestry?
1. *d
VC-i-R-c'dk
65. 5 Does [*****'s

~ 9 5 ~ father] identify with an ethnic group?
0. NO
1. YES
1.
2. -
66 66. Is [*****'s father] Latino or Hispanic?
0. NO
1. YES
&;EM 66A. Which of the following represents his origins?
1. Cuba
2. Mexico
3. PuertoRiw
4. Spain
5. South America
7. Other
34
6 7 67.
-
If you were asked to put him into only one of these groups, in which one would you piace
him?
-
.................................
...............
. I . Asian
:.;.>:.;.....:.:........
2............... 3:.......3%
2. Pacific Islander
:.:.:.

qq 4. Caucasian /White -
5 . Native American
6. Other k%ka-e'aBb
This interview MAY or M Y NOT end here.

Answer the fouoWng Questions yourself and f o W the irzstnrctionrprovided:
A. Have you obtained informmion about the biological mother?
Yes ->
NO ->
3Y
35
Now some questions about ***+*Is mother
68. What is her first name? Don't Know

0. No
8. Don't Know

8. Don't know
70.2 What was [*****Is motherl's age when she died?

3.30 to 39 years 6. 60 or above
8. Don'tknow-
70A. When was [*****Is mother] born?
71. Where was [*****'s mother] born?
c. country
.7
F-
-
-
4
-
+
*.d B. State -
*. c. counay
-.
40 72A. When did she come to Iive in the USA? year: 19
8. Don't Know
&3
' ?ii&-AO 72B. How old was she when she came to Iive in the USA? age:
8. Don't Know
73. Is [*****Is motherl's mother still living? 1. Yes 0. No 8. Don't Know

k
-
c. country
75.1 Where does she Iive now?
A. City B. State. - c. country -
A. city - B B ~ B. State - C. Country

-
+6#0 75A. When did she come to live in the USA? year: 19
8. Don't Know
ps-r3 -f5&C> 8. Don't Know
h
76. Is [*****Is mother]'^ father still living? 1. Yes 0. No 8. Don't Know
?S
c. country
-
37
B. State c. country
7
A. City
rc-
Where did she live when she died?
-
78.2
A. City B. State
- c. country
I
B.
8. Don't Know
8. Don't Know
f%3 p.9 79. Has [*****Is mother] attended school in another country, this country (the US), or both?

2. usonly
3. another wuntry and US
79A. How many years of school did [*****Is mother] have? years (1 - 20)
0. NO.
1. YES
79C1. What degree did she receive? - d =a3 t.,
33
~
38
80 80. Did [*****Is mather] finish hgh school?
. .
NO
..
0.
1. YES
80A. And has she done any studymg beyond high school?
0. NO
1. YES
p y a s -, months
80A2. What is the highest degree she has reached?
1. No degree
4. Masttr's degree
5. Doctoral degree (J. Ph.D., D.D.S.,D.O., Ed.D.)
6. Other
80B. What is the last grade she completed? (1 - 12)
80B1 Is she still in high school?

0. NO
1. YES
h.
0. NO
.l. YES
80C1.What has she received? 1. GED
x
2. other degredeertifkate:
3. other schooling:
39
8OC2. Is she currently in school or training?
NO.
................
...........
0.
1. YES
81. What country(s) best represents *****Is mother's national origin or ancestry?
2.
I_
3.
82. Does *****IS mother identify with an ethnic group?
0. NO
1. YES
82A. Which group(s) does she identify with?
1. tJc*.%dk **d
3.
-
83. Is [*****'s mother] Latino or Hispanic?
0. . NO
1. YES
1. Cuba
2. Mexico
3. PuertoRico .
4. Spain
5. South America
7. other hd I
34
40
ir It
84. If you were asked to put her into only one of these groups, in which one wouid you place
her?
1. Asian
2. Pacific Islander
y$ 5. Native American
6. Other Y-d&
Y
=4
HOME
43
FIELD COPY # 2
SUBID TIME
STARTED
BOW. Inventorv: A g e6,

Introduction; Now I'd like to get an idea of what *****'s days are like and what some of the
things are that you and ***** do together. A good way to start is for you to
describe a typical day, like yesterday and then I'll ask a few more questions.
~ ~ W I Winventory:
L
-
OBS SCALE I. IN THE HOME?
EMOTIONAL and VERBAL RESPONSMTY
#C 5/- 1. PC talks with subject mice during visit a. YES

(beyond introduction and correction). b. NO
2. PC answers a of the subject's questions or a. YES
flc 4 - A requests verbally. b. NO
3. PC encourages subject to contribute to the a. YES
conversation during visit by getting M h e r b. NO
74c r - 3 to relate an experience OR by taking time to
listen to M h e r relate an experience.
7% A4 OR sets up the situation that allows the
subject toshow off during visit.
** 5. PC spontaneously praises subject's qualities a. YES
- or behavior p i c e during the visit. b. NO
**
-
6. PC uses some term of endearment or some
diminutive for subject's name when talking
about or to the subject during visit. -
I a. YES
b. NO

- conveys positive feelings. b. NO
7
nnr;e during the visit. b. NO
- to praise of subject offered by interviewer. b. NO
** 11. PC initiates verbal interchanges with the a. YES
spontaneous comments.
** 12. PC expresses ideas freely and easily and uses a. YES
- conversation.
-
** 13. PC appears to readily understand the a. Y I ~
7
w I- y3 interviewer's auestions. b. NO
I n v a o n : A&
-
Introduction: Now I'd like to ask you about some of the different experiences ***** may
OBS SCALE II. IN THE HOME? School/

-
*
VARIETY OF STIMULATION
1. Home has a pet.

/CIRCLE om1
a. YES
Day Care
Do you have a pet?

b. NO
2. Family visits or receives visits a. YES

mice a. b. NO
How often do you Visit with
3. Subject eats meal per day, a. YES
on most days, with PC and
How do you handle mealthes?
separately? (Who does heishe eat
with?)
uQmU=k. b. NO
Does *****'s father (or father
figure) spend time with m e r ?
(About how often?)
5 . PC or other family member a. YES
.-
member(@? (About how often?)
reads stories to subject
s weekly. b. NO
Do you get a chance to read to
*****? (About how often)?
SCALE II.
-
IN THE HOME? School/
VARIETY OF STIMULATION [CIRCLE ONE] Day Care

member on one outing a
other. b. NO
Does ***** go on outings with
any family members? (What
kinds of things do they do; about
how often?)
S/Cd- 8A to go to a scientific, historical, b. NO b. NO
art, or cultural museum within If NO,
79Cd-86 ttuasu=* Has ***** donethis at
to go on a trip more than 50 b. NO
miles from home &K&&G
Dast-

to take a trip on a plane, train b. NO b. NO
(NOTsubway), or bus within
rlhmwwu.
Has ***** been on a plane, train
or bus this vear?
11. Family has arranged for subjed a. YES a. YES
organizational membership to b. NO
support subject's talents
rhumU=*
lessons, arr, dance, or music
lessons)
Does ***** belong to any clubs 01
4%
SCALE II. INTHEHOME? I -School/
I I
.
VARIETY OF STIMULATION [CIRCLE ONEJ Day Care

(biking, walking, playing in b. NO
park, playing ball, swimming,
checkers, puzzles)
hobbies? Does ***** join in on
s ~
Home Inventorv Ape 6
Introduction Now I'm going to ask you about some of the things that ***** likes to play with
and some of the things that hdshe may be learning about. Maybe you could
start by telling me about any toys and/or books heishe may have.
~ ~
OBS SCALE III. IN THE HOME? SchooY

- *
DEVELOPMENTAL ADVANCE [CIRCLE ONE] Day Care
1. Subject has access to toys, a. YES a. YES

games, or books to learn
colors. b.NO b. NO
games that teach colors?
* 2. Subject has access to toys, a. YES a. YES

games, or books to learn
rn sizes. b.NO b.NO
games that teach sizes?

ec3- 34 games, or books to learn e
two shapes. b.NO b.NO
#C 4-3/5 D.oes ***** have any toys, games
or books that teach shapes?
* 4. Subject has access to ~WQ a. YES a. YES

toys, games, books or resources
to learn numbers. . b.NO b. NO
Does **a** have any toys, games
or books that teach numbers?

games, or books to learn animal
names and behavior. b. NO b.NO
Does ***** have any toys, games
-
or books that teach about animals?
'SQ
OBS SCALE III.
DEVELOPMENTAL ADVANCE
IN THE HOME?
[CIRCLE ONE1
School
Dav Care
6. Subject has access to toys, a. YES a. YES

#C 3- 6B games, or books to learn the
HC 3 - 66 alphabet. b. NO b. NO
Does ***** have any toys, games ENO,
or books that teach letters? Does ***** trave this at
hidhersehuaYdaycare?
* 7. Subject is encouraged to learn to a. YES a. YES
read a few words.
Have you tried to teach ***** to b.NO b. NO
read any words?

games, or books to learn spatial
relationships. b. NO b. NO
(upidown, under/over, bigAittle,
idout)
Does ***** have any toys, games
or books that teach up/down,
ovedunder, bighittle, idout?
* 9. Subject has access to ~ e or e a. YES a. YES
- gf? mxs puzzles.
Does ***** have any puzzles? b. NO b. NO
?yc3- 9 6 (About how many?)
* 10. Subject has access to real or toy a. YES a. YES

musical instrument.
Does ****a have anything he/she b.NO b. NO
likes to make music with?

games, books, records, or other
resources to learn patterned b.NO b. NO
speech.
(mrsery rhymes, prayers, songs,
TV commercials)
Does ***** know any songs or
nursery rhymes? (Howdid he/she
learn them?)
-
-
-
OBS SCALE m. IN THE HOME? School/

DEVELOPMENTAL ADVANCE /CIRCLE ONE1 Day Care
* 12. Subject has access to two toys or a. YES a. YES

games permitting free
expression. b. NO b. NO
( C h , p i a y h g h , crayons,
jirigerpamts. sand and water)
Does ***** have anything that he
/she uses to make or draw things?
* 13. Subject has access to two toys or a. YES a. YES
games necessitating refined
(hand) movements. b. NO b. NO
(paint by number, dot-to-dot
booh, coloring books, crqons,
beads and strind
* 14. Subject has access to a record, a. YES a. YES
CD, or tape player and &
children's recorddCDdtapes. b. NO b. NO
Is there a record player, CD,tape
player that ***** can use? Does
hdshe have any of hisher own
tapes or records? (About how
many?)
* 15. Subject has access to a. YES a. YES
children's books.
Does ***** like to read? Does b. NO b. NO
hdshe have any books hdshe can
read in the house? (About how
many?)
* 16. Subject has or mpcle books a. YES

of hidher own.
Does ***** have any books of b. NO
hisher own? (About how many?)
6
Introduction: Now, I'd like to ask you some questions about scheduling, rules you may have
-
OBS
and how you handle discipline.
SCALE IV. M THE HOME^

SUPERVISION [CIRCLE ONE]
1. Subject has a set time [curfew] to be home on a. YES

school nights.
Does ***** have a certain time he/she has to be b. NO
home on school nights?
2. Subject routinely obeys curfew on school nights. a. YES
Does ***** usually obey that rule?
b. NO
weekend nights.
How about on weekends? Does ***** have a b. NO
certain time to be home?
4. Subject routinely obeys curfew on weekend nights. a. YES
b.NO
5 . PC requires subject to sleep at home on school a. YES
nights.
Does ***** have to sleep at home on school nights b. NO
or can hdshe stay with friends?
6. When PC is not available to subject at home, a. YES
reasonable procedures have been established for
himher to check in with PC, or their designee, on b. NO
weekends and after school.
When you aren't at home, does ***** check in with
you or anyone else?
7. After school subject goes somewhere that adult a. YES
supervision is provided.
Where does ***** go after school? Are there any b. NO
adults there?
8. PC establishes rules for subject's behavior with a. YES
peers and asks questions to determine whether they
are being followed. b.NO
Do you have any rules about what ***** does with
hisher friends? Do you talk to ***** about what
hdshe is doing?
53
-
9. PC has had contact with two of the subject's fiiends a. YES

1~ the last week.
Hc4- 9 Do you ever get to talk with *****'s friends? (About b.NO
I-
how often?)
10. Subject is not allowed to wander in public places a. YES
without adult supervision for more than 1 hour.
How much time can ***** spend in public places b. NO
without an adult?
1 1. PC talks daily with subject about hidher day.
Do you get to talk with ***** every day about
hisher day? b: NO
12. PC has visited the school or talked to the teacher or a. YES
counselor
. . the last 3 months.
Do you ever go to *****'s school or talk with the b. NO
teacher or counseior there? When was the last
time?
~~~ ~ ~~
13. Family has TV, and it is used judiciously, not left a. YES
on continuously.
(No TV requires an automatic NO) b. NO
Do you generally keep the TV on or do you turn it
on for specific programs?
14. Subject is taken regularly to a doctor's office or a. YES
(once). b. NO
Has **a** been to a doctor or clinic for a check-up
during the past year?
15. Family has a fairly regular and predictable daily a. YES
schedule for subject.
(meals, day care, bedtime, how much W, b. NO
homework)
Are things like bedtimes, mealtimes, daycare done
about the same time everyday?
54
16. PC sets limits for subject and generally enforces a. YES

them.
(curfay, homework before P, cleaning up, other b. NO
regulations)
Other than the rules that we've already talked
about, are there any other rules you have for
*****'s behavior? (Do you usually try to get
himher to follow them?)
Do you have similar rules for the other members of b. NO
the family? (Do you usually try to get them to follow
them?)
- OBS
~ ~
SCALE V.
ROME Inventorv: -4ee 6
IN THE HOME?
AVOIDANCE OF [CIRCLE ONE]
-
**
RESTRICTION AND PUNISHMENT
1. PC does not shout at subject during the visit. a YES
b NO
**
~~
2. PC does not express overt annoyance with or
**
-
** 4. PC does not scold or criticize or put down the
* 5 . Subject is allowed to express negative feelings

toward PC or can disagree with PC without harsh
*
reprisal.
SCALE VI.
MODELING
1 INTHEHOME?
[CIRCLE ONE/
* 1 At least &Q books are present and visible in the a. YES
home. (Ifnot seen, Ask:)
Do you get a chance to read? Do you have a place b. NO
you keep books?
** 2 PC does not violate rules of common courtesy a YES

b NO
** 3 PC introduces interviewer to subject. a. YES
b.NO
* 4. Some delay of food gratification is demanded of a. YES
the subject.
(there are planned meaVsnack times and subject b. NO
ISgenerally required to wair)
Does ***** eat whenever hdshe wants or do you
have specific times to eat?
* 5. PC teaches subject some simple manners. a. YES
(to say please, thankyou, sorry)
Has ***** learned things like please, thank-you, b. NO
sorry? (How did hdshe learn?)
6. PC or other family member buys a newspaper a. YES

daily and reads it.
Does anyone in the house get a chance to read the b. NO
7. PC or other family member subscribes tohuys a. YES
Does anyone in the house buy or subscribe to any b. NO
magazines?
Are you involved in any religious or community b. NO
activities?
9. PC participates in child oriented organitation. a. YES
How about any organizations that do things for
children? b.NO
s7
OBS I SCALE VI. 1 INTBEHOME?
MODELING /CIRCLE ONE/
10. PC has not cried or been visibly upset in subject's a. YES

presence more than once dun= uast week.
#C 6-7 0 When you feel unhappy or sad, do you let ***** b. NO
see how you're feeling or do you try to hide your
feelings? Have you cried or been very upset in
front of ***** recently? (When?)
m m e Inventorv. Age 6
Jntroduction. Now I'd like to ask you about different responsibilities ***** might have.
-OBS SCALE VII.

FOSTERING INDEPENDENCE
1. Subject is permitted some choice

INTHEHOME?
fCIRCLE ONE]
a. YES
I
in lunch or breakfist menu.

Does ***** ever choose what
he/she has for breakfast or lunch?
2. PC allows subject to choose
certain favorite food products or
brands at grocery store.
Does ***** ever choose any food or
brands?
3. PC tries to get subject to help
pick up and put away toys.
Does ***** help you put hisher
a.
b. NO
YES
I
toys away?
4. PC has provided guidance to a. YES

subject vear
concerning personal hygiene. b. NO
In the past year have you given
any advice or help to ***** about
things like washing or bathing or
other aspects of personal hygiene?
5 . PC has taught subject how to a. YES

deal with health and safety
emergencies in an age b. NO
appropriate manner.
Does ***** know what to do in
emergency?
6. PC teaches subject to help with a.YES

cooking and cleaning.
Do you show ***** how to cook b.NO
and clean?
7. Subject has wee& age

appropriate household
responsibilities.
(picking up afrer himherself,
putting clothes in hamper)
Does ***** have any weekly chores
or responsibilities?
-OBS SCALE VII. I INTHEHOME? I
- FOSTERING INDEPENDENCE I
I
[CIRCLE ONE]
8. PC allows subject to visit with a.YES

fiends outside schooUday care
pnce each week. b.NO
Does ***** visit with friends
outside of school?
~ ~~ ~

hisher toydtreasures or
belongings. b. NO
Does * * * * * have a place to keep
belongings?
TIME STOPPED
FIELD COPY # 2
SUBID TIME STARTED
INTID
OBS I SCALEVIII. PHYSICALENVIRONMENT'

[INTERIOR OF HOME]
I INTHEHOME?
[CIRCLE ONE]
eC8- f
(ielevision, shouts of childen, r d o )

** 8. House or apartment is not overly noisy - from a. YES
noise outside the house. b. NO
(train, cars, people, music)
b. NO
or non-prescription drug consumption in the b.NO
UC 8-i0 home.
TIME ENDED
SCALE IX. PHYSICAL ENVIRONMENT I
I[EXTERIOR OF HOME]
Date: -- -
mm dd YY
(CIRCLE ONE)

tY hrmin
Left home: -'- AM PM

hrmin
1. Street Layout:
7
K 9- f
2. Through - curved
3. H-la y out
4. T-layout
5. L-layout
6. Cul-de-sac
7. Boulevard
8. Divided Highway
9. Other
2. How would you characterize the land use on this.face-block, based on -t -level
#C 9-R frontage?
4. primarilyindustrial
6. Primarily vacant lots and open space
9. Other
#C 9-3 3. How would you rate the general condition of
in the face-block?
of the housing units or other buildings

2. Fair condition
4. Do any of thefronts of residential or commercial units have metal security blinds, gates,
#C 9-9 or iron bars or grills?
?-4
1. None .
2. Some
3. At least half
4. Most

t?C 9-5
1. No traffic permitted
2. Very light
3. Light
4. Moderate
5. Heavy
6. Very heavy
#C 9-6 6. How would you rate the condition of the street in the face-block?

9-3. 7. Is there garbage, litter, or broken glass (except beerlliquor bottles) in the street or on the
sidewalk?

3. Yes, quite a bit
ryc 9-8 8. Are there drug-related paraphernalia, condoms, beer or liquor containers or packaging,

3. Yes, quite a bit
ffc9-9
a?
7% 9-;/o drinking, or behaving in any kind of hostile or threatening way?

3. Yes, one or two behaving in a hostile manner
11. How did you feel parking, walking, or waiting at the door in the face-block?
7% 944
1. Very comfortable: can imagine livhg/working/shopping here
2. Comfortable: it seem to be a safe and friendly place
4. I would be uncomfortable living/workhg/shopping here
5. I felt afraid for my personal safety
SCHOOL SCREEN
SCHOOL W E N : PC f34j
mm dd yy
Interviewer ID:
1. Does ***** attend school, daywe, or preschool? 6% J

(Code YES if currently on vacation, suspensibn, etc. and will return to school.)
1. YES SI3 f- .. . ..... .

a. preschool
b. daycare
c. school
d. Headstart or Headstart-type program
2. NO
4. What is the m e and address of the FTsrchoot..iZ3care ***** attends?
1. vwa-$h &&
Name of preschool/ day&e person
5. when did ***** enroll?
1. SA 5- 2. SA 5- 25
month Yf=
ed. hit. ed. date

6. How many hours per week is ***** in preschool/ daycare?
SA3 6
- hours per week
7. Is this preschool/ daycare a home-based or center-based program? (circle one)
1. home-bzised -
S6 7
2. center-based
qI
8. What is the name and address of the school ***** currently attends?
1. vaRt2b lA?tZ@@ d
Name of school
3. 4. 5.
1. Sh9-f 2. SA 9-R.
month Y W
10. What is *****Is school ID number?
11. What type of school is it? sfi ff
1. Public
2. Catholic
3. homeschool
4. Private, non-Catholic
5. Otherbieasespecitjt) -v d h da?wd
3
13. what grade is ***** currently in? s/313

(Ifduring summer break and *****

grade
~4 74 14. In the past year, was ?**** ever truant (skipped school without an excuse)?
$4
. 1.YEs - , .I
2.NO
15. On the average, how often was ***** truant? (Cicle one)
SA 15 '

b. once a week
d. once a month
SA &A 22. . Has ***** ever skipped a grade? 1. YES 2.. NO .,', -
23. Has ***** ever repeated a grade? 1. YES 2: NO
SA A3
4
24, Mmy students receive special teaching or help in school. At any point in *****Is
e d u d o q has she received any help or special teacfung in any of the following
areas?
(Read aloud - circle all that apply.)
1. YES 2. NO
b. Special remediation clasdtutorhg program 1. YES 2. NO

c. Learning problems 1. YES 2. NO

d. Class/ program for developmentally 1. YES 2. NO
e. English as a Second Language or 1. YES 2. NO

Limited English speaking
E Speech therapy classes 1. YES 2. NO

handicapped, hearing problems,
sight problems
b Emotional or behavior problems 1. YES 2. NO
i. Special music or art school 1. YES 2. NO
j. Special science program 1. YES 2. NO

I
I
5 I
,
~
sa ~5 25. IS +++**routinely involved in extracumcuiar activities directly connected with

Wer school, such as school sports teams, school clubs, music groups, etc.
1. YES
2. NO
Sa A6 ,t
1.1 '
SAA7 27. What kind of program is this? (Circle all that apply)
I .
1. Recreational (sports, garnres, crafts)

2. Artistic (music, dance, art) A
3. Academic enricfiment (tutoring, classes)
4. ~ther(pleasespecitj.) - ~ ~ i 4 ! e
//
28. Is ***** involved in any other kind of &er school program?

ShA8 (Ths may be at *****Is school, but is more of an &er school program rather than
extra&daraCtivity.)
1. YES
2. NO
&f3A9
SA 30
1. k e a t i o n a l (sports, games, crafts)
3. Academic enrichment (tutoring, dasses)
4. Other(p1easespecify) w b &e daopped
/ /
6
31. What schools bas **+** attended in the past?
a. Davcarfl
SchooY person's name
1.
/J
3.
*
&
4.
5.
+&
7
-
2 Catholic
3 - home school
3/ b. Elementary School (incluchg Kindergarten)

I I I i
8
32. How often do you attend scheduled parent/ teacher conferences? (Read choices.)
1. almost always
2. often
3. seidom
4. never
sfi 33 33. How often do you attend PTA meetings, locd school council meetings or any school
'144
1. almost always
2. often
3. seldom
4. never
34. How would you describe the education ***** is receiving in his/ her current school?
s/334 (Read choices.)
a excdknt
b. good
c. fkir
d. poor '
,
HEALTH SCREEN
HEALTH SCREEN: PC Version
m m dd yy
Subject ID: sw3/2f

Interviewer ID:
f / L 7WRA /w
1 FIELDCOPY2 SQLU ce
Time Started:
Now I have some questions about *****'s health.
1. Would you say that in general *****Is health is excellent, very good, good, fair, or poor?
1. excellent
2. verygood
3. good
4. fair
5.. poor
2. Now t h b h g about *****Is physical health, including being sick or injured, for how m a y
i '7A days during the past 30 days was *****Is physical health not good?
number of days
3. Now t h k h g about *****Is mental health, which includes stress, depression, and
747-3 problems with emotions, for how many days during the past 30 days was *****Is mental
health not good?
number of days
ed. init. ed. date

4. During the past 30 days, for about how many days did poor physical or mental health keep
***** from doing [hidher] usual activities, such as self-care, work, or recreation (play)?
END OF INTERVIEW
RECORD TIME:
FAMILY STRUCTURE &
HEALTH HISTORY
mmdd yy
Interviewer ID:
F.fl7YBe#/W

I, '4
n from the Demographic
Now 1 would like to ask some questions about *****'s family. This year I w i l l only be
getting a general outline of who is in the family. Next year we w i l l come back to this
information and we w i I l draw out a tree to complete it.
F h t , let me review a few details.
1.A You told me earlier that you are *****Is:

7/40 (READ AMD CIRCLE APPROPRIATE CHOICE)
a. biological mother d. stepmother g. adoptive mother

c. femalecousin f. sister i. other ~ ~ M L /""e
L
l.B You told me d e r that you are *****k
/=E3 I B O (READ AND CIRCLE APPROPRIATE CHOICE)

c. malecousin f. brother i. other P a a L . ' d b -d
&i%+lpI
Is that right? Y N
2. What is *****Is biological fathers name? DONT KNOW
fmt name
3.1 How old is he? DONT KNOW

(years old)
a*I- 3.2 How old was he when he died? DONT KNOW

&ears old)
4.1 what is your marital status with *****IS biological father?
la married-still invoived
1b divorced
2a never mar~ied-still involved
4.2 whar was your marirol stanrr wilh ****+Is r f when he died?
l b divorced
5.1 Are you living together now? 1.No

2.Yes
5.2 Were you living wirh*****s

biobgicaifather when he died?
I
3
5A. Was there a time that you lived together?
yes ;&h<Q:3B
........................................
............................
5A1. Wh did you stop living gether?

orear>
6.1A How much time has *****'s biological father spent with m e r in the past year?
a. none
than once a month)
c. intermittent at set times (less
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
6.1B How much time has *****'s biological father spent with himmer prior to the past
year?
a. none
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
4
6.U &fore he died, how m h time did +*+*+Is faher spend With himher in the p a
year?
a. none
d, o m a year
e. twice a month .
f. once a week
g- M Y
L
h. other
6.2B B#ore he died, haw much time did *****Is biohgical faher spend with himlher prior
to the part year?
a. none
b. intermittent a d unpredictable (less than once a month)
d. once a year
e. twice a month
f. once a week
g.
h. other

A B C
7.1 Name: D.0.B *$~'d Gender: M/F R3ZfCd
7.2 Name: .d&.j%S& D.0.B Gender: M/F F h 3 - a
. Gender: MIF Fp?-3 ti

5
ing
,=& d Does he/she have any sibiings? 2.Yes 1.No
For ea& one, I need to h o w their name, age, whether they are a boy or a &I,
whether they are a biological, step, foster, or adoptive sibling of *****9 a d
whether they are Stiu living. If ***** has sibhgs who have a partner or child, I
- w i l l need to ask you some additional questions about them. Why don't you start
#;? with the oldest sibling?
BROTHERS SISTERS
- NAP
cause of death:
/. 1'
H3 &e 2 6
bio'l mom's name: he?-&
bio'l dad's name:
- NAP
6
I
7
f
BROTHERS SISTERS
#9 m e : & ~ , ~ : ~ ~ . & /
8Li 3-43 living: Y N ag&&e died:W%%%/
cause of death: F&&&F&3

bio'l morn's name:
bio'l dad's name:
: - NAP
%&H5& ;&PP&-& j=&&&f??3A&
parmer? Y N age: -gender: M/F
Children? Y N F&&k'/T&
living: Y N age/age died:FM?c9i/
bio'l dad's name:

... . ..
BRQTHERS
# 7 b name: hm*& # 7s name:
1iving:Y N age//&edied:&&%?4 living: Y
cause of deatix 2?&fim9& cause of death:
f Y
d u
FA8REFS -
e !
ffiBRS.A
bio'l mom's name: bio'l mom's name: -
bio'l dad's name: dfk% Ya
fW& bio'l dad's name:
- NAP
wm7s s&$?i+ys F238P69S
Children? Y N #%&k/3& Children? Y N FABx/?.S
'# girls: -. b # boys :~Ekf23iS43 b # girk&%W% # boys :i%@&
cause of deatfi:

partner? Y N age: gender: M/F partner? Y N age: -

gender: M/F.
# girls: b # boys : b # girls: b # boys :
bfromAge to
- 9
i
j
Fa5 9 9. YOUtold me about (READ NAMES OF SIBLINGS). Are there my

other siblings of r****, either yours or *****'sbiological father's children, that you
10. Have you been married to anyone other than biological father or lived with
/C/s 98
*****IS
(CIRCLE ONE)
1. - NO:
2. -YES:

F25 .m#o # of relationships
1OB. For each of the people you had a relationsfiip with, I need to know their first
name. I ais0 need to know whether you were married or living with them and
whether you are still in the relationshrp. If the relationshrp has ended, I need to
1. Gender: M/F d
first name

\
F&rDr3M' Ib 2b never married-nolonger
F&~Q& la married-still involved 2a never married-still involved
-
1$
Id widowed ~
myo&d~/3 la married-still involved 2a never married-still involved

F&+oh#v la married-still involved 2a never married-still involved

6 5 5. Gender: M/F 1
first Dame
\ F A . ~ ' D A Hla~ married-stiu involved 2a never married-still involved

IC married, butseparated involved
ld widowed 2c never married, partner died
.... . . . . . . .. . . ..
. ~ . . . . -
11
frsr name .

lb divorced 2b never maniedLno longer
11. Has *****Is biological father been married to anyone or lived with someone else as a

# of relationships
11B. For each of the people *****'s biological fithers had a relationship with, I
need to know their.........fmt
.
W e . I also-needto lcnow whether he was married or
.. ..... ......
living with them f I @ ! jand whether he is still in the relationship]. If the
$
:.>% *
<V
,
relationshrp has ended, I need to know if it was due to divorce, separation or

being widowed.
1. Gender: M/F .1 -4
first name

IC married, but separated .involved
Id widowed 2c never married, eitber
partner died
. 2k don't know
90
,. .... .. . . . . , .... . ._...... .
12
2. Gender: M/F .1
la married-still , ~ o l v e d 2a never married-still involved

partner died
2k don't know
-
3. Gender: M/F .1

partner died
2k don'tknow
4. Gender: M/F .1
first name-

partner died
2k don'tknow
5. Gender:. M/F .1
first name

partner died
2k don'tknow
91
13
++fidyd: la married-still involved 2a never married-stdl involved

panner died
2k don't know
q
.-
. '4
3 , y ~ la married-still involved
~ / //& 2a never married-still involved
partner died
2k don'tknow
\
.. . . .. . .., . . ....... . . . . . .. . - , . ,.. .. . .. -. - .-.-..--
14
w. - is *+**+'s biological mother's name? DON'T KNOW

*/&
12. What
fmt .name
/% -
f3 i'.- 13:l .Howold is she?
'- . Q.ean old)
DON'T 'KNOW
a.
,qs%
13.2 How old was she when s& d i d ? DON'TKNOW

(years old)
14.1 what is your marital status with *****Is biological mother?
la marrid-still involved
l b divorced
14.2 what was your marital sf mu^ with *****Is mother when she died?
lb divorced
2b never manied-no longer involved

2.Yes
15.2 Were you living with *****Is

biologicd-motherwhen she died?
...................... . . . . . . . . . . . . . . . ..,. . . . . . . ...
... .
15
F& 15- 40 !SA. Was there a time that you lived together? 1.
15Al. When did you stop living together? (Ya>
16.1A How much time has *****'s biological mother spent with M e r in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g.
h. other
16.1B How much time has *****'s biological mother spent with himmer prior to the past
year?
a. none
b. intermittent and uqredictable(1ess than once a month)
d. once a month
e. twice a month
f. once a week
g* daily
h. other
34
16
1624 Beore sfre died, how m c h time did *****'.Tbiological mother spend with himlher in
the past year?
a. none
d. once a year
e. twice a month
. f. once a week
g. M Y
I$. h. other
16.2B Before she died, how much time did *****'s biological mother spend with h i d e r
prior to the past year?
a. none
d. once a year
e. twice a month
f. once a week
g. M Y
h. other
17. Does ***** have any children of bisher own?
children? 2.Yes 1.No
F .f7- fC0
D.0.B Gender: ME FA/?- & C O
17.3 Name: D.0.B Gender: M E

Y *
53
FB /*a 18. Now I have some q u d o n s about *****'sbrothers and &en, ~&WU
biological, step, foster, or adoptive &lings.
For each one, I need to h o w their name, age, whether they are a boy or a el,
wj&her they are a biological, step, foster, or adoptive sibring of **#*, a d
whether they are still living. IT ***** has SU&Swho have a partner or child, I
will need to ask you some additional Q.s about them. Why don't you start w - i t l ~
- .e'? the oldest &ling?
-
BROTHERS
#lb m e :

bio'l mom's m e :
d - 5
bio'l dad's name: @k.46W
- NAP
**rn//3 /C.ie&/& /%3/8J-'~
Children? Y N ,%78x_~/43 Children? Y N F&Y8XZ/.S
#girls: #boys : Mf8'1/~ * # gkls:&g/f-* # boys : / s s A B ~ l l S
#2b name:
living: Y N age?age died:
cause of deatk FA78HWAL.5 cause of death:
/
FAss?eEd
- NAP
Children? Y N FR~u-&&
4 6
18
-
BROTHERS SISTERS
# 3 b name: Ji?%&xw& # 3 s name:
living: Y N age&e died: Mt8M23 living: Y N agelage died:&&%?$
Cause of death: M /8&3& cause of death: mAf?4!!3
45&ea4w&
//
FAA.8&S3& Fk-/8&?3/S/
e
- NAP
F/3/8m+S &;r8xy.3g fAieP'3s
partner. Y N age: gender: M/F
Children? Y N R3/8H3B Children? Y N F;sr'BX/35
living: Y N age/age did=*+

# 4 name:
~
living: Y N
&
+
ageLigedicxi:~~~~
-
mj&m& cause of death: F&M?#mkS
:
cause of death:
:
F~%7'8AI9?3 P i/8RS-Q.S
*+

Children? Y N F&r'&XT4% Cmciren? Y N FJW'U.~/S
19
BROTHERS SISTERS
living:Y N age/agedied:A%&%Wi+
cause of death: FiMBj'S
FB/8R& 5a
Y
F/3/8RS5-S
bio? step? foster? adopt? bio? step? foster? adopt'?
~AZFS L23/8!5S Fs/GsP&5s

N age:- gender: M/F
Children? Y N f/3&&-5S
Children? Y N K&&'A/5.3
'# girls: P # boys : -/8&3TA w # boys : / c ; c 3 j & S
# girk&W'~/~S*
from Age to =/B# 5-4
#~bname:
living:Y N age/agedied:Fw!@
cause of death ?%/8HBcG4 cause of death.
Y Y
,G%/8&56A
bio'l dad's name:
q,
- NAP
?3/gPAfg;9 M H G A
Children? Y N
. ..
. . .... . .... . . ..
20
l
i 0.18 Continued l
BROTHERS SISTERS
d 7s name: .'I
living: Y N agef&e d i e d : m W q living: Y N agbage died: F M # Z
#
cause of death: m&flAw3 &Use of death: Fk???&.wd
H/&RS+A / y
bio'l morn's name:
e?.=
~
b # boys :=JYA?OAs
#8b name: # & name:

living: Y N age/agedied: Living:Y N agdagedied:
cause of death: cause of deatk
bio? step? foster? adopt? bio? step? faster? adopt?

- NAP - NAP
parmer? Y N age: gender: M/F partner? Y N age: -gender: M/F
children? Y N Children? Y N
*#giris: .#boys:- b#giris: .#boys: .
21
19. You told me about (READ NAMES OF SI3LMGS). Are there any
F23 79 other siblings of *****, either yours or +****'sbiological mother's children, that you
20. Have you been married to anyone other than *****Is biological mother or lived with
someone else as a partner other thm the relationships you've just told me about?
(CIRCLEONE)
1. - NO:
2. - YES:

X of relationshqs
20B. For each of the people you had a relationship with,I need to know their first
1. Gender: ME .1
first name

...
... .. . . .. .
-22
2. Gender: M/F .l *eJL

first name
la married-still involved 2a never marriet-still involve;

3. Gender: M/F .1
first name

-
4. Gender: M/F .1
first name
la ma~ried-stiu involved 2a never married-stdl involved

IC married, but separated hNOlVed
F43d.OA6 5 5. Gender: M/F .1

. firstde
'la married-still involved 2a never married-stiU involved

*
ld widowed
6. Gender: h4.F .l
first name
la married-stitl involved 2a never married-still involved

23
~6 6.7 7. Gender: M/F .I
A-OkW6:
- la married-still invoIved 2a never married-stitl involved
Id widowed 2c never married, p m e r died
-
F&&# 21. Has *****Is biological mother been married to anyone or lived with someone else as a
1 - DON'T KNOW
2 - NO:
3-YES:
2.1A. How many other relationshys has she had?

F
23U w j a - 0
# of relationships
21B. For each of the people *****'s biological mother had a relationship with, I
need to know their first...,<name.
....................
I also need to know whether she was married
- $ ____,. and whether she is still in the relationship].
or Iiving with &em ~-<...-.-:c..:dA,.........,.
-
If the relationship has ended, 1.need to know if it was due to divorce,
e3/?t57%3iw 1. Gender: M/F .1

first name
F&&/'+9j la married-still involved 2a never married-still involved

partner died
\ 2k don'tknow
24
,~&pzd la married-still involved 2a never married-sm involved

partner died
2k don't know
-
5;.1
3. Gender: M/F
~=r4&{/3&3 - .1-
first name
FA j 3
~,i,f la married-still involved 2a never married-still involved
lc married, but separated involved
partner died
2k don'thow
-
-AS/B/YL/ - la maniexi-still involvexi 2a never married-still involved
partner died
2k don't know
E;4A/AS5 5. Gender: M/F .1

fit &e
5M la marrie.ci-still invoiveci
~fi~.s/d3 2a never married-still involved
\ lb divorced 2b never married-no longer
partner died
2k don't know
25
,Ffi&jZ3Gb 6. Gender: M/F .lA&yYp-d
firstname
F&AmN6
. la married-sull involved 2a never married-stili involved
partner died
2k d o n ' t h o w
.1
kied-still involved 2a never married-still involved

divorced 2b never married-no longer
married, but separated involved
widowed 2c never married, either
partner died
2k don't know
26
22. what is *****IS biological mother's name? DON'T KNOW

fmr name
23.1 How old,&she? DON'T KNOW

(years old)
23.2 Haw old was she then she died? DON'T KNOW
(years old)
24.1A How much time has *****'s biological mother spent with m e r in the past year?
a. none
-
c, intermittent at set h e s (less than once a month)
d. once a month
e. twice a month
f. once a week
$* M Y
h. other
24-13 How much time has *****'s biological mother spent with himmer prior ta the past
year?
a. none
b. brerxnittent and qredictabie (less than once a month)
d. once a month
e. twice a month
f. onceaweek
g- M Y
h. other
27
I
24.2.4 B q i m she died, how much time did *****Is mother spend with him/her in the
post year?
a. none
d. once a month
e. twice a month
f. once a week
g. daily
h. other
24.23 &$ore she died, haw m h time did *+***'s bioibgicd mother spend wizh
hindher prior to the past year?
a. none
d. o m a month
e. twice a month
f. once a week
g- M Y
h. other
25. What is ****+'s biological fither's name? DON'T KNOW

first Dame
F&.&6 -/ 26.1 Howold ishe? DON'T KNOW

(years old)
FA ZG -. .L . 26.2 How old wus he when he died?

(years old)
DON'T KNOW
1-06
28
HOW much time ha *****Is biological father spent with him in the past year?
a. none
d. om:: a month
e. twice a month
f. once a week
g.
h. other
How much time has *****IS biological father spent with him/her prior to the past
year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
2 7 . 2 Before he died, haw much time did *****'s biological faherspend with
him/her in the past year?
a. none
c. intermittent at set times (less than a c e a month)
d. once a month
e. twice a month
f. once a w e k
g.
h. other
. . . ..
. .. . . ... - ~ . . , . ..,~....
. . ,, .. .... . . . -
29 I
2 7 3 Before he died, how much time did +****'s biologicalfather s p e d wirfr

hidher prior to the p a s year?

d. once a month
e. twice a month
f. once a week
g, M Y -
h. other
28.1 Are *****'s biological parents living together now? 2.Yes 1. No 3.DON'T
KNOW
28.2 Were *****Is biological parents living together when ****+Is motherflarher
died?
29.1 What is the mvital status of *****'s biological father and mother?
la married-still involved ,
l b divorced
2a never married-stiU involved
29.2 Wut was the marital s c a f u ~of *****Is biological faher and mother when
*****Is mt?ier@aherdied?
lb divorced
2b never married-no longer*iuvolved
30
Does he/she have any siblings? 2.Yes 130 2. DON'T KNOW
For each one, I need to h o w their name, age, whether they are a boy or a girl,
whether they are a biolo@d, step, foster, or adoptive Sibfine of *****, and
whether they are still living. If***** has siblings who have a partner or child, I
w i l l need t o ask you some additional questions about them. Why don't yon start
BROTHERS SISTERS
#Ib name: Ldk%&!wd # Is name: .R$c&?@&
agelage died: !%&?&9/9
I '
*
living: Y N living: Y N age/age died:F&39MA
~p423!xv/& cause of death: B$OAB+i
k
B30&2?/5
bio? step? foster? adopt?.
bio'l mom's name: bio'I mom's name:
""53opq' b m*wfAge%er: ~ M/F

partner. Y N age. -
Q P ~ M
Children? Y N FZ33O%TP43
#2s name:
living: Y N
I Y w
agelage died:i%3&fq living: Y N agehge died: p Z 3 5 W L

cause of deatk Ffi 30HB;/A cause of death:
F A 30ueEoZA
- NAP - NAP
- 31
0. 30 Continued I
BROTHERS SISTERS
living: Y N agglage died: F%%.?&:
I
agekge died: 6
4- living: Y N
cause of death: .3&3B3S cause
- of death:
&W
Y -
m3Das 3 6 jGf33sles3s
bio? step? foster? bio? step? foster? adopt?
- NAP
ts430pAr3s 4233%%43s R330K.S
partner? Y N age: zender: M/F
Children7 Y N 6 6 3 0 R / 3 ~
.
' #FB306/3s
glJls; # boys : H U D ! s
f r O z A p 2 to &OQd5735
c
cause of death: =%m3v.S
FBdOCeS4S
bio'l mom's name:
bio'l dad's name:
=A&7&l4 ~A*/4.s eL3=3s4s

partner? Y N age: -gender: MfF
Children? Y N Fi3O*es
w # [fi$o"'*" c # boys : F h a a 4 !
fro~#$&gF% to 5 3 Q D A 4 S
32
BROTHERS SISTERS
age/& d i e d : ~ & a c ~ ~ 5living:
4.
living: Y N + Y N
5
F & S O ~ S # g cause of death:
' FA.30leE543
FA 5Lbz.5 35.5
cause of deatk
J
F;/330~.56 s
bio? step? .foster? adopt?
- NAP
Q. 30 Continued 1
BROTHERS SISTERS
# 7b nam-e,: # 7s m e :
living: Y N agejage diedj%mAq& living: Y x
cause of death: Ffi -3m943 cause of death:
/L/ - -
F@Sof/Sm5 FA 3 0 R S S S
bio'l mom's name:
bio'l dad's name: bio'l-dad's name:
2330PAr.7A /=/3BH. FA%&&

Y N C=.A30,e"i?S
# 8 b name: #as name:

living: Y N age/age died: living: Y N agehgedied:
cause of death: cause of de&:

NAP - NAP
partner? Y N age: gender: M/F partner? Y N age: zender: M/F
Children? Y N . Children? Y N
b # girls: b # boys : - b # girls: b # boys :
34
I
3j 3 I. You told me about @EAD NAMES OF SIBLINGS). Are there any
2.Yes 130 3. DON'T KNOW
F - ~ A 32. Do you know if either of *****Is biological parents were married to anyone eke or
1 - DON'T KNOW
2 - NO:
3 - YES:
32A. How m y other relationships has he/she had?
FA 3A A M a Bio mother: # of relationships
FA&&AW Bio father: # of relationships
32B. For each of the p p l e [the biological mother/father] had a relatiodup with, I need to
m m
know their first name.
...............I......also
............need
.... to h o w whether [shehe they] [were/was] married
or living with them 1
. .... and whether [she/he/they] [=/are] in &e
relationshq]. If the relationship bas ended, I need to know if it was due to divorce,
.%.A
A
,,
..\
,....'
Biological mother:
F j 3 3i5/3&7+6/ 1. Gender: M E .1 v w - d h
\ first name
FA h/it~l la married-still involved 2a never married-still involved

partner died
2k don'tknow
35
2. Gender: M E 1
first name

.ld widowed 2c never married, either
partner died
2k don't know
-
3. Gender: -M/F -1
la nprried-still involved 2a never married-still involved

partner died
2k don't know
4. Gender: MIF .1
first name
la married-still involved 2a never married-still ixwolved

partner died
2k don't know
5. Gender: hUF

partner died
2k don't know
36
~ h s & , &- y6~ la married-stiil invoived 2a never married-still involved

l b divorced 2b never married-no longer .
IC \married, but separated involved
partner died
2k dontknow
- -
&
v
F& 3~ la married-still involved 2a never married-still involved

partner died
2k dont know
I Biological fathe= I
fmt name
F,+ 3~ A B ,qd la married-still involved 2a never married-still involved

p m e r died
2k dontknow
2. Gender: ME 1
fmt name
B%3 t 68Nfi la married-stiU invoived 2a never married-still involved

IC married, but separated imroived
Id widowed. 2c never married, either .
partner died
2k dontknow
- 37
3 . .Gender: M E ,I
- first name
la married-stiU involved 2a never married-still involved

- partner died
2k dont know
4. Gender: WF .1
la manid-still involved 2a never married-still involved

partner died
2k dontknow
5. Gender: MfF .1
la married-still involved 2a never married-& involved

partner died
2k dont know
.1
frrs-tname

partner died
b
2k don't know
7. Gender: M/F .1

partner died
2k don't know
e
333 33. How old was **+**when he/she fmt came to live with you?
Age
\
39
34. What circumstances led to ***f+ living with you?

v-db
- .
1. biological mom died 9. biological mom hospimlized: substance use

7. biological mom in another country m
( 15;) biological mom lost custody(specify reason)
a. biological dad in another country - i/bZ&dh&&ppf3&
&6) biological dad lost custbly (specify reason)
ve&A.a&5 &&2#g&&

@ oher reason (specify reason)
40
s5- 35. Has **fs.* always lived with you since the fxst time shehe came or have there been
perids during which shehe did not live with you? (CIRCLEONE)
a. Always lived with me:

b. Has not always lived w
35A. Describe other l i v h arrangements s k c e ***** first came to live with you:
6?ki%w&
>
/b&%-dL&
1.?'.1
\
41
Now f have some quedions about the time since *++**f

m m e to Eve w i you.
~
,qfi 36 36. I need to know whether you have b e d with anyone as a p m e r while ***t+* has been
1 -NO:
2 - YES:
How many relationships have you had during this time?

- # relationships
i;.r
3m. For each of the people-you had a relationship with, I need to know their first
name. I also need to h o w whether you were married or living with them and
1. Gender: M/F -1
*
first name

2. Gender: M/F -1-

first name

IC married, but separated involved -.c
3. Gender: M/F .l
first name

42
4. Gender: M/F --1 first name

la married-stitl involved 2a never married-still involved
IC marrikd, but separated involved
5. Gender: M/F 1
--
~ firstname

F& 36-& 5 lb divorced . 2b never married-no longer
6. Gender: M/F 1.-

first name
l a marrid-still ~llvolved 2a never married-still invoived

7. Gender: M/F .1
first name
la xnarried-still invoived 2a never married-still involved

ld widowed 2c never married, parmer died
-.
43
A43 3-5 37. Does ****+regdarly spend any nights of tbe week in another household or anywhere
else? does not include day care]
2.Ye 1.No

N = nonbioiogical auduncle ,
M =maternal* grandparent, child,
-
1 .I
=d
m33-ix =&zyc Fis37, #/Ev
A B C D
.1 Name BorN MorP
E Other relation I
.2 Name-- BorN MorP
E Other relation
\
.3 Name BorN MorP
E Other relation .-
F Nightseachweek FE.3J-3F -
G Nights each month: FR3J- 36
- H Other arrangement: F& H- 3H
+t
38 . In *+s*+s entire family..... including anyone: parents, siblings, yourself, aunrs,

uncles, grandparents, cousins, anyone....
who is **+**particularly close to? You can list as many peopie as you wmt - anyone
in the family who you think ***** feels close to.
to *****
B = biological * . Iparent, sibling,
P =paternal . other]
A B c I)
.1
.2
.3
.4
.5
.6
.7
-8
.9
\
45
39. Now I need to list all the people who live in this household except or *+***, For
each w o n who Eves here, I would like you to tell me how he o r she is related to **+*f.
For example, I want you t o teU me if the person you k t is **+**Is brother or aunt or
cousin. Even if a person who lives here is not related to *****, I need you to list thm
also.
'?4?q
. B = biological [parent, sibling,

N = nonbiological
, M=mated grandparent, child,
P = paternal
A B c D
/%3&9-1%5 F&39- fC
.1 Name BorN MorP
r /
F#39-&A m339-ac
.2 Name dkUmzw4 2 5 BorN MorP
H39-3/3 FA39-3C
.3 Name BorN MorP
F A 39- 923 FR39-4c
-4 Name BorN MorP
#Jsg-5& -39-
.5 Name B o r N MorP
F/339-6& -39-
.6 Name BorN MorP
/ q 3 3 9 - J / 3 A%39- ?C
.7 Name BorN MorP
FA59d33 ,4339-BG
.8 Name BorN MorP
Fh3g-9fA H 3 P -
.9 Name-. BorN MorP
P/s3$?-/&3 F?3 3!?-/oc
.10 Name BorN MorP
m39-//4 F i 3 9 ,
-11 Name BorN MorP
F&39-/ea e5g-/2: c
-12 Name BorN MorP
R339J3A *39-/3
-13 Name BorN MorP
46
Part Ip: F d y Ed& moq

40. WOW, I have some questions about *****'s family's health histow. I n e d to h o w
if anyone in *****Is d y hduding everyone that was just mentioned in this h t h e w ,
has any of the following health problems- For each person you list, please tell me how he
or she is related to ***** and whether he or she is a biological or non-biologd &tion.
Please include yourself.
Diabetes: (circleone) 2. Yes 1.No

- [Sugar Diabefes, Sugar in BbodlUrine]
*d
to *****
B = biological @arent, sibling,
N = nonbiological aunthncie,
M = matelpal grandparent, child,
A B C B
.2
Y C
/=/3&7-3& M 4a3c
.3 Name BorN MorP
.4
.5 -
.6
.7
-8
.9
.10
.ll
,.12
- -13 Name 7B o r N MorP c L t a j ? ?
47
G
r3 41. BIood P r m : (cirrle one) -2. Yes 1.NO
flypertension]
to *****
N = nonbioiogical auduncle ,
P = paternal . self, other]'
A . . B C D
F&4%3A
.3 Name- &+@-e@ c B or N
%&- 4
23
.4 Name B or N
4%6%
.5 Name h BorN
.6
.7
.8
-9
.10
-
-11
.12
\ .13
Y'
4L 7?2c-
I -
/Q3 &/-
.14 Name h d BorN MorP
48
to *****
B = bioiogical @arent, sibhg,
N = nonbiological aunduncie,
M=matemal grandparent, child,
P = paternal sec, other]
.l
.2
.3
-4
.5
.6
.7
.8
.9
.10
-11
.12
\
-13
-14
I24
49
m 43 43. Stroke: (circle one) 2. Yes I.NO

M = maten grandparent, child,
P =paternal ~ 1 self, other]
.A . B C 13
.1
.2
.3
.4
.5
-6
.7
.a
-9
F&4?3 -fQ&
I 8
F&3-*
.10 Name BorN MorP
w 3 - H A A393 - H C
-11 .Name BorN MorP
F.43- fm?/33.43-%5c
.12 Name BorN MorP
\ r -
Fk5.93- w?3.-=&93-14T,
-14 Name BorN MorP
J
. ..... .... -_ . . .,, . , .. , , . ..- . . . .. . ... .i ..... .. . .. ~ - ,..
.. ,. . ,.... ,. ..~..
/: .
50
B = biological [parent, sib&,

N = nonbiologid aunt/uncie,
*
A -B C D
x44-16 F& -W-fC
-1 Name d w BorN MorP b r n d
/=A 44- L A F444-LC
.2 Name 4 BorN MorP
f=/3&&- 3k3 l=e44- JC
-3 Name ed BorN MorP -&
r43 44-4% se5 44- 4c
.4 Name BorN MorP
F& 44-5n ~ & 4 43--e
.S Name BorN MorP .detQ#Wd
43 F2349-6-C
m3.444- 6
.6 Name W L BorN or^
Fk3 4//-923F / s 4!-7C
-7 Name B o r N MorP 3 4
F/5 44- 84 Fa&&- BC
/ Y
.8 Name -3& BorN MorP

A43 Y.-P& Ff344- 9c / *
.9 Name B o r N MorP
ii3474-104 &44/.-/0c JJ
.10 Name * ? & B o r N MorP L&
FF3 44- /!A F/3 #-+//e
. l l Name- or^ M O ~ P
/=/5 &&.-/&& fi3 44-f.25 c P
.12 Name *d BorN MorP
m 4-4/34 FA&-
\ .13 Name &2& B or N Mor
Fh44- /&A F A 4 4
.14 Name &Wd.2 L a d BorN MorP
51

M=mater~l grandparent, child,
P = paternaI self, other]
.1
.2
.3
.4
.5
.6
-7
.a
.9
.10
.ll
.12
\ .13
-14
, ,. , .
, . . , . . . . . . . .
..>L,.- . .. ..2,2 .... . . . . . . , . . . . -. . . . . . . .
52
46. mer chronic problems bpedy): (circle one) 2. Yes I.NO

. .
B = bioiogical [parent, sibling,

N = nonbiological auntfuncle,
P =paternal , seif, other]
7.
$4 A B C D
j=&-&.-fA --4G-/C
.1 Name B or" Mor P
A B C D
1' F . - L A F64d-RC
.2 Name BorN MorP
E ILLNESS (please specify): Y Y
A B C D
h946--3A m9z=.3c
.3 Name BorN MorP

A B C D
/=E3 M - 4 3 F&&-&e
.4 Name BorN MorP
E IUNESS (piease specify):

Yp'
A B C D
F& 44 - 6~ 5e-
m~z
.5 Name h#d BorN MorP
\
E ILLNESS (please specify): Ld&%wd

FAMILY MENTAL HOEALTH &
LEGAL EUSTORY
. .
Family Mental Health and Legal History
Interviewer ID:
FHHHRR/JB)
,44 Now I'm going to ask you some more questions about all the people in *****'s/yow
family that you've mentioned today.
f=Md 1. Has drlnklng ever caused any of the people mentioned to have problems with health,
family,job, or police?
2.YEs 1.NO
B = biological [parent,sibling,
N = mnbiological audmle,
P = paternal other]
A B C D
/ '
FMf- 523 FMJ-SC F/41,- 55y
.5 Name -& BorN MorP
ed-init. ed. date
I 3.3
2
family,job, or police?
2.YES 1.NO
B = biological fparent, sibhug,

N = nonbioiogical auduncle,
M = maternal
A B
F&jZ- /A
.1 Name d w B or N
.2 Name
FMd-3&
.3 Name BorN
F M . 4 - 4fi
.4 Name B or N
.5 Name a FML-
FMd -
s.
B or N
g&2
.6 Name B or N
A=W2 -9.4
.7 Name B or N
/ /
F#L -A
-8 Name / /
B or N
P . A - 9&
.9 Name ktt%%U%& BorN
.10 Name
. l l Name
/ -
.12 Name
3
FM.3 3. Has anyone mentioned ever suffered from depression, that is, they have felt so low for a
period of at least two weeks that they hardly ate or slept, or couldnt work or do whatever
they usually do?
2.YES 1.NO
t* *****
. P =paternal
- other]
I
4
F44 4. Has anyone mentioned ever had frequent aouble with the law,.often become involved in
fights, had trouble hoiding a job, or was a frequent discipline problem in school?
2.YES 1.NO
to *****
M = maternai grandparent, child,
. P = paternal other]
I316
5
FM.5 5. Has anyone mentioned ever had problems with their nerves or had a nervous breakdown?
2.YES 1.NO
to *****
N = nonbioiogical - aunt/uncie,
P = paternal other]
A B C D
BorN MorP
.6 Name BorN MorP F M 5 - 6x3-
.10 Name BorN MorP

6
2.YES 1.NO

N = nonbioiogical auntluncie,
P = paternal other]
BorN MorP

#qyd-.z& FMd-Jdc F/yG_R*
A B C D
.2Name d BorN MorP
-3 Name BorN MorP

FMLC-+~ /crRl'fi_+e i/41~",~+
-4 Name BorN MorP

/eM8"-5-& 6-e
J=+.6- F/Y6- 3-s-
B c D
.5 Name BorN MorP

Fwg-d& -6- 6-C FMd- 6;9"
.6 Name BorN MorP

7
k=fi ? 7. Has anyone mentioned ever been hospitalized because of emotional problem, or because
2.YES 1.NO
to *****
B = biological . @rent, sibling,
P =paternal -
,=p,yr_f/3
' other]
jtwf_~e F&+--L%-
- -
A B c D
.1 Name BorN MorP
.2 Name BorN MorP

FM?-z_& v uF W j - 3c F . 9 F-3W
B C I)
.3 Name BorN MorP
.4 Name BorN MorP
.5 Name BorN MorP
.6Name BorN MorP

8
/cT/./ 8 8. Have any of the people you've mentioned ever attempted suicide?
2.YEs 1.NO
B
to *****
B = biological . @rent, sib-,
P = paternal other]
9
F,g 9. Have any of the people you've mentioned ever cornmined suicide?
- to *****
2.YEs 1.NO

N = nonbiologid auntluncle, .
P = paternal other]
10
9A. So, none of the people mentioned have had any problems with alcohol or drugs,
J
(CIRCLE ONE)
1 - no one eke
Committed Suicide - page 9

Attempted Suicide - page 8

Fights, frequent trouble with law,trouble holding a job - page 4
Suffered from d e p d o n - page 3
Drinking c a u s e d probpemS with health, family,job, or police - page 1
- 11
trouble w i t h the policg or who has been arrested. Please do not include routine M i c
f&' A9 10. Has anyone that you've mentioned had trouble with the police or been arrested? (CIRCLE
o w
1. NO:

FMfoAA fMfDA 3 F'jD,q+
1 2 3 4
B or N M or P
'Name Relation
/=fl
fQ 10B. Do you know what heishe did? (CIRCLE ONE) 2. YES 1.NO
10B1. :Em$
......................
.............................. What did he/&
............
.,
:.
do?
FAfS/DC0 1OC. And were there any other reasons he/she was in trouble with the police?
(CIRCLEONE)
2 . m 1.NO
F / Y ~0 10D.
Q ~ Is heishe in jail or prison now? (CIRCLEONE) 2.YEs 1.NO
-
12
i-'iy Yf 11. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
1
2. YES

f&ff/dL FMfX4S Mff.9
1 2 3 4
B or N M or P
Relation
/cNA'&7 11B. Do you know what he/she did? (CIRCLE ONE) 2. YES 1.NO
11~1. Whatdidhe/shedo?
FflHCO 11C. And were there any other reasons helshe was in trouble with the police?
(CIRCLE ONE)
2 . w 1.NO
11D. Is he/she in jail or prison now? (CIRCLE ONE) 2 . w 1.NO

FMJ& 12. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES

pM/A&& F./&A3 Ew&!A&
1 2 3 4
&e4&7pd
4
B or N M or P
fime Relation
................ .....*....
@
.....
- ...... ....,.
.......v., %
...
What did he/she do?
12B1.
//
(CIRCLEONE)
2.m 1.NO
....._,.
12C1. ;Emi What other offenses led to him/her having trouble .with the police?
.>..A-.,y<.:
F#/,& Bo 120. Is heishe in jail or prison now? (CIRCLE ONE) 2.YEs 1.NO
14
FH/i.!i 13. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
0 END OF INTERVIEW 8 RECORD TIME 1

2. YES
1 3 ~ .what is hisher name and how is he/she related to *****9

/w/3.4& FZM5.43 m/3> 9
2 3 4
B or N M or P
Relation
~ ~ 1 ' 3 13B. Do you know what he/she did? (CIRCLE ONE) 2.m 1.NO
FHA3 Ct3 13C. And were there any other reasons hdshe was in trouble with the police?
(CIRCLEONE)
2.m 1.NO
............ ,.......,.,
13C1. I@@@%
What other offenses led to hidher having trouble with the police?
13D. Is he/she in jail or prison now? (CIRCLE ONE) 2.m 1.NO

15
F H /4 14. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
tI 0 END OF INTERVIEW 0 RECORD TIME
2. YES
14A. What is his/her name and-how is he/she related to *****7

Bvj94L F#&%73 /r/yYdi4
1 2 3 4
B or N M or P
Relation
i w f % Z d 14B. Do you know what heishe did? (CIRCLE ONE) 2 . m 1.NO
14B1- J&+*;
.._....;.
.;.:z
.*. .
... i* what did he/she do?
:
,qy f4c 0 14C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
14C1. tJoar"3trrrsz
..,..,. E
3.i- d
........
other offenses 1 4 mer
have the
YJ
F N ~ ~ B O14D. Is heishe in jail or prison now? (CIRCLEONE) 2.YEs 1.NO

16
FM /s 15. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
8 END OF INTERvlEW 8 RECORD TIME
2. YES
15A. What is hisher name and how% he/she related to *****?

my54.45 Fe7-323 FM/5-&k
1 2 3 4
B or N M or P I
Relation
15B. Do you know what he/she did? (CIRCLEONE) 2.m 1.NO
15B1. l'E&2&What did he/she do?
(CIRCLEONE)
2 . m 1.NO
gJ"!!!@:
.,.-......
1SC1. What other offensesled to him/her having trouble with the police?
......a ?..A 7.:
1533. Is he/she in jail or prison now? (CIRCLEONE) 2.YEs LNO

17
FM /6 16. Has anyone else had trouble with the police or been arrested? (CIRCLEONE)
1. NO:
.....
2. YES

/#6Ab FH7643 FMf644
1 2 3 4
B or N M or P
Relation
, C M ~ ~ A O16B. Do you know what helshe did? (CIRCLEONE) 2.YEs 1.NO

1. what .did do?
............
..................
_.._.... >.
16C. And were there any other reasons helshe was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
.................... <...
16C1. $!$$- What other offenses led to m e r having trouble with the police?
w / ~ m16D. Is he/she in jail or prison now? (CIRCLE ONE) 2.YEs 1.NO
1
- 18
~ / t /f7
' 17. Has anyone eke had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
e END OF INTERVIEW e RECORD TIME
...... ........
2. YES
9.
'1 ' 17A. What is hisher name and how is he/she related to *****?
-f=WH%!L FN&%53 FNfl.34
2 3 4
BorN M or P
~ Relation
FM7V&O 17B. Do you know what he/she did? (CIRCLEONE) 2.YEs 1.NO
1* m j m What did he/&

...........,....... -+.,..,
...v.&&> < ... ....<..>?
-.:-
do?
/t/tif/yeD 17C. And were there any other reasons heishe was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
17C1. What other offenses led to himmer having trouble with the police?
~ / Y f ? B O17D. Is he/she in jail or prison now? (CIRCLEONE) 2 . m 1.NO
I5Q
EMPLOYMENT & INCOMX
..
hployment & Income Interview
Interviewer ID:
S&P?&#/w
PART I: Primary CaregivedAdult Subject Employment

For this interview, is 35 or more hours each week and "part-time"is less than 35
hours each week.
- -
ed.init. &.date
- 1. Working full-time in one job

working Wpart-time in additional job@)
Page 2
,+
4. Pwmanent leave (disability)


7. On leave temp^^^^ illness)

9. Temporgy jobs, OccBSiOnal work
-
1 1. Retired, working part-time jobs
12. Retired, w o r m temporaryjobs
14. Homemakertnll-time

(NOTa homemakcr)
Page 3
d?z,& 2. Have you been employed in a paying position in the past 5 years? (CIRCLE ONE)
2Z&/Vl 2. NO: Have you done volunteer work in the past 5 years?
1 -Yes
2-NO
&&,-&&
1. YES: .....................................
'*r
''4 1. Working full-time iri one job

working Wpart-time in additional job(s)


7.' o n leave (temporary illness)


11. Retired, workmg part-time jobs ..................

. . . _" .
Page 4
PART: I
SECTION: 1
3. How many jobs do you currently hold? (CIRCLEONE)

1. One Job.
2. Two Jobs
3. Tbree Jobs
3A. Of these jobs, I want you to frst tell me about the one you consider to be your
primary or mainjob:
,.;.I
4. What is your job title? YC&"d&
5. What are your main responsibilities? a'4L-45
I
~~
6. Which of these numbers best fits your salary in this Job? (CIRCLE ONE)
1. lcssthan5,o0O
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
7. more than50,OOO
8. don't know
7. How long have you been in thisjob?

Y- months

hours/week
If 1 Job ONLY,GO TO Page 15, (part I)Question 45A.

.
If More than 1 Job, GO TO Next
r
Page (part I) Question 9. r
Page 5 1
w:
And your other job?
9. What is your job title? uae-'dL& I' 4
10. What are your main responsibilities? v-*db
b 1
8L H 11. Which of these numbers best fits your salary in this job? (CIRCLE ONE)
1. lessthan5,Ooo
3. between 10,ooO and 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
7. rnorethan50,OOO
8. don't know

Y- months

hours/week
If2 Jobs ONLY,GO TO Page 1

Page 6
lob 3; And your other job?
15. what are your main responsibilities?

1. lessthan5,OOo
2. betwtcn 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. betwttn 40,OOO and 49,999
7. morethan50,OOO
8. dontknow
How long have you been in this job?
How many hours each week do you usually work?

hours/wetk
i 54-
Page 7
PART: I
SECTION: 2
6/ s/9 19. How many jobs did you hold before you went on leave/disability? (CIRCLE ONE)
1. One Job
2. Two Jobs
3. Three Jobs .
(4 19A. Of these jobs, I want you to first tell me about the one you considered to be your
20. What was your job title? u a d h
21. What were your main responsibilities? y-*dk

/v
22. Do you mntinue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO

22B. Which of these numbers best fit(s) your full salary in this job? (CIRCLEONE)
1. lessthan5,Ooo
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. dont know
22A. Do you receive your full salary or pan of your salary? (CIRCLEONE)
1. Full
2. Partial
22c. Which of these numbers best fit(s) your partial salary, inClu&g
1. lessthan5,OOO
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. more than 50,000
8. don'tknow
23. How long had you bees in this job

before you went on leavddisability?
24. How many hours each wcek were you usually working
hours/week
Y- months
If More than 1 Job, GO TO Next Page, (part I) Question 26.

Page 9
26. What was your job title? V W d h -

,/ J
27. What were your main responsibilities? fl-kd&-

,
//
-1
>4
1. YES
2. NO

28B. Which of these numbers best fit@)your full salary in this job? (CIRCLE ONE)
1. ltssthan5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. bemeen 40,000and 49,999
7. morethan50,OOO
8. dont know
Shm40 28A. Do you receive y o y full salary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
_. .. .. . . . . . . . . .. .. ... . . . . . ., .-.. ,., . , , .....,. . .
Page 10
&Z A?C O 28C. Which of these numbers best fit@) your partial salary, includmg-
1. lessthan5,Ooo
2. between 5,000 and 9,999
3. between 10,000.and 19,999
4. betwen 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than 50,OOO
8. don't know .

Y- months
hours/week
3 1. How long have you been on leave from this job?

Y- months
If2 Jobs ONLY,GO TO Page 15, @art I)Question 45A.

If More than 2 Jobs, GO TO Next Page!, (part I)Question 32.
Page 11
iob 7. And your other job?
32. What was your job title? Y&'dz&

Y W
33. What were your main responsibilities? .l&&

Y"
''4i
!
34. Do you continue to receive money from this position? (CIRCLEONE)

1. YES
2. NO

34B. Which of these numbers best fit(@ your full salary in this job? (CIRCLE ONE)
1. less than5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,000
8. don't know
1. Full
2. Partial
Page 12
6 1 34/cO 34C. Which of these numbers best fit(s) your partial salary, including pension
1. less than 5,000

2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
..d.' 7. more than50,000
8. don't h o w
2.735 35. How long had you been in this job

Y- months
&I36 36. How many hours each week were you usually working
hourslweek
Y-
-
months
I GO TO Page 15, Ques&'on 45A (part I). I

Page 13
PART: I
SECTION: 3
tion 3. T e m p o r a r y W
38. What types of jobs have you done recently? VL?kQAdk
39 39. About how many hours each week do you usually work? hours/week

40. How much money have you earned from these jobs in the past year? (CIRCLEONE)
1. less than5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than5d,OOO
8. don't know
I GO TO Page 15, (part I) Question 45A.

1
Page 14
PART: I
SECTION: 4
I
n- ~ Y
Section 4. Volunteer work
42. What types of volunteer work have you done rccently (for what organizations)?
t/Q-&&*&
43. How many hours usually volunteer? (CIRCLEONE)
1. 1-2
2. 3-5
3. - 6 - 12
4. 13-20
5. > 20

Y- months
c

Page 15
PART:1
SECTION: 5
[Primary/Only Job]
45A. Where is your job located? (7f travels to various kationr, record address of main ofice.)
i>t
%
L/tz;aL;db
address
city State zip code
45B. How far is your work from where you live? (CIRCLEONE)

2-1to2miles -
6 Varies accofding to
45C. How do you usually get to work? (CIRCLEall that apply)
l-walk -
6 ~arp001
2 - drive myself -
7 driven by relative/friend
-
3 bdsubway -
8 commuter train
4 - bicycle
5 - Other
45D. On the average, how long does it usually take you to get to work?
minutes
fb6
I
Page 16
[Seconay job 21
46A. Where is your job located? (zf travels fo various locmiOnr record address of main m c e . )
Y&&*dh
address
!
State zip code
46B. How far is your work from where you live? (CIRCLE ONE)
0 - works at home .... 4-6tolOmiles

-
.
1 less than a mile 5 - greater than 10 miles

2 - 1 to2miles -
46c. How do you usually get to work? (CIRCLEall that apply)
1-walk 6-c~p001
-
2 drive myself 7 - driven by relativehiend
-
3 bus/SUbway -
8 commuter train
-
4 bicycle
-
5 Otkr
46D. On the average, how long does it takc you to get to work?
minutes
If 2 Jobs ONLY,If them is a partner, go to Page 18, (part n)Question 1.

If there is M partner, go to Page 35, (part m),Question 1.
-
Page 17 I
[Secondary job 31
47A. Where is your job located? flf travek to various locmiom, record address of main ofice.)
Y-aL eQe/
address
city stafe zip code
+ 0 - works at home
1 - less than a mile
, 4-6tolOmiles
5 - greater than 10 miles
47C. How do you usually get to work? (CIRCLE all that apply)
1-walk 6-
-
2 drive myself 7 - driven by relative/friend
4 - bicycle
-
5 other
47D. On the average, how long does it take you to get to work?
minlltcs
"
If the= is a partner, go to Page 18, (part II) Question 1.

1 L
Page 18
PART II: Partner Empioyment
1. please tell me which of these statements best describes your spouse's/partnerlspresent

work situation:

., ... ..............
~. . . . .............. ,
Page 19 I
I
I
I
1. Working full-time in one job -4
2. Working f'ull-time in one job AND -

.......................................................

y;' from full-time job or jobs



-

(NOTa homemaker)
Page 20
&/Pa -
2. Has your parmer been employed in a paying position in the past 5 years? (CIRCLE ONE)
...
g/PJ#d 2- No: .................. Has your partner done volunteer work in the past 5 years?
1-Yes
2-NO
1. yEs: & &E&
................
........................
T'
;.:,:.:,:.:<.:.
8.Powo 2A. Which of these statements best describes your partner's recent employment?
q, .'4
-3. . . . . .
1. Working fidl-time in one job

working fulypart-time in additional job(s)
3. ,On leave (temporary illness)

4. Pexmanent leave (disability)


9. Temporaryjobs, occasional work
17. Volunteer work only, full/part-the -

Page 21
PART: II
SECTION: 1
a . 3 3. How many jobs does he/she currently hold (CIRCLE ONE)?

1. One Job
2. Two Jobs
3. Three Jobs
'**4
Of these jobs, I want you to fust tell me about the one heishe considers to be hidher
I
3A.
,I>$ '
5. What are hisher main responsibilities? PzM&db
1. less than5,OOO
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know

8 . f Y- months
8. How many hours each week does he/she usually work? hours/week
- .... . . .. . ,.
Page 22
If 1 Job ONLY,GO TO Page 32, (part n)Question 45A

If More than 1Job, GO TO the Next Page,(part Ill Question 9.
w: And hisher other job?
9. What is hisher job title? Y-dk
Q
10. What are hisher main responsibilities?- V W L &
#
I Hand rcsnondent resDonse card #2 I

11. Which of these numbers best fits hisher salary in this job? (CIRCLE ONE)
1. less than 5,000

2. between 5,000 and 9,999
4. bctwe!.cn 20,000 and 29,999
5. between 30,000 and 39,999
7. morcthan50,OOO
8. don't know
12. How long has hdshe been in this job?
I f f 2 Jobs ONLY, GO TO Page 32, (part 11) Qwstion 45A.

If More than 2 Jobs, GO TO the Next Page, (part n) 'on 14.
, .
.
Page 23
ob 3; And hisher other job?
14. What is hisher job title? Y

&&
/ d
15. What are hisher main responsibilities? .6ffQ5G2'd&

I
16. Which of these numbers best fits &/her salary in this job? (CIRCLEONE)
1. less than5,Ooo
2. between 5,000 and 9,999
3. betwen 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,W
6. between 40,000 and 49,999
7. more than50,000
8. don'tknow
17. How long has helshe been in this job?
18. HQWmany hours each week does heishe usually work? hours/week
art n)Question 45A. I

Page 24
PART: II
SECTION: 2
I Section i. leave/disabii 1
~Frio/Q 19. How many jobs did he/she hold before he/she went on leave/disability? (CIRCLE ONE)
1. One Job
2. Two Jobs
3. Three Jobs
19A. Ofthese jobs, I want you to first tell me about the one he/she considered to be hisher
20. What was hisher job title?
2 1. What were hisher main responsibilities? k4i%z?ir2a& + ? !
&,I,@J& 22. Does he/she continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO

Page 25
~ Which
~ ~ P A R22B. o of these numbers best fit($ hidher full salary in this job? (CIRCLEONE)
1. less than5,OOO
2. between 5,000 and 9,999
. .
4. between .20,000and 29,999

5. between 30,000and 39,999
6. between 40,000and -49,999
7. morethan50,OOO
8. don't know
%
";
&?J&#O 22A. Does he/she receive his/her full salary or part of his/her salary? (CIRCLEONE)
1. Full
2. Partial
22c. Which of these numbers best fit@)hisher partial salary, including pension plau,
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than 50,OO
8. don't know
23. How long ,.ad he/she been in this job

SZP Fz3 before he/she went on leave/disability?
Y- months
&%)A& 24. How many hours each week was he/she usually working
S5Q;ztj- 25. How long has he/she been on leave from this job?
YWS months
Page 26
Secondary job 2: And &/her other job?
26. What was hisher job title? .442&dk &app&

J /
27. What were hisher main responsibilities? fl-k-d& &&B&

/ -
%
1. YES
2. NO

28B. Which of these numbers best fit@) hisher N1salary in this job? (CIRCLE ONE)
1. lessthan5,Ooo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don'tknow
Fh%c5s A 0 28A. Does he/she f his/her salary? (CIRCLEONE)

1. Full
2. Partial
Page 27
28C. Which of these numbers best fit($ hidher partul salary, including pension plan, SSI or any
-
1. less than5,OOO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and-29,999
5. between 30,000 and 39,999
-4 6. between 40,000 and 49,999
9 - 7. .more than 5 0 , W
8. dont know

before he/she went on leave/disabiiity?
Years months
before he/she went on leave/disabiiity? hours/week
Y
m months
If 2 Jobs ONLY,GO TO Page 32, (part II) Question 45A.

Page 28
lob 7: And hisher other job?
32. What was hisher job title? &-/t

1 '
33. What were hisher main responsibilities? J-.dk &J&

/ J
t,>@
c9P 34 34. Does he/she continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO

I
fie34r4e) 34B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
c
1. lessthan5,000
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don't know
34470 34A. Does heishe receive hisher full salary or part of hisher salary? (CIRCLEONE)
1. Full
2. Partial
Page 29
3 4 ~ 0 34C. Wluch of these numbers best fit(s) hislher partial salary, including pension pian,
1. less than 5,000

2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
$? 7.. more than 50,000
8. don't know

&Z@35 before he/she went on leave/disability?

before heishe went on leave/disability? hourslweek
37. How long has heishe been on leave from this job?
Y- months
age 32, (part n)Question 45A.

I
Page 30
PART: EI
SECTION: 3
1'
38. What types of jobs has he/she done recently? p-&& -
,
&'/p 39 39. About how many hours each week does he/she usually work?
hours/week

40. How much money har helshe earned from these jobs in the past year? (CIRCLEONE)
F/p 40
1. less than5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
7. morethan50,OOO
8. don't know
I GO TO Page 32, (part n)Question 45A. I

Page 31
PART: II
SECTION: 4
r c
rl
k i o n 4.
-OV
42. What types of volunteer work has heishe done recently (for what organizations)?
U&*d& -/3 %
e&,
&/P 93 43. How many hours each week does he/she usually volunteer? (CIRCLE ONE)
1. 1-2
2. 3-5
3. 6 - 12
4. 13 - 20
5. > 20

SZ?&& months
Page 32
PART: II
SECTION: 5
IF partner has more than 1 job listed during the interview, start with the primary job, THEN
-/Only Job]
45i. Where is your partner's job located? (If traveh to various locations, record address of main
once.)
fw'db
address
city
~ ~~
State zip code
& ' , l p y ~ - 45B.

~ How far is hisher work from where you live? (CIRCLEONE)
. .
0 - works at home ., ._ .... . ... . 4-6tolOmiies
- -
,
1 less than a mile 5 greater than 10 miles

e"/P&b-ci)
1-walk -
6 carp001
-
3 bushubway 8 - commuter train
-
4 bicycle
-
5 other
$/P4no 450. On the average, how long does it take himmer to get to work?
minutes
If 1Job ONLY, GO TO Page 35, (part m) Question 1.

l a r t II) Question 46A.
i 533
Page 33
[Secondary job 21
46A. Where is hisher job located? @f travelr to various locations, record address of mn office.)
city State zip code
&/p34/6k30 4%B. How far is hisher work from where youJve? (CIRCLE ONE)
c/@+?.ScC,46C. How does he/she usually get to work? (CIRCLEall that appfy)
1-walk 6-c~p001
-
2 drive myself 7 - driven by reiative/fiiend
-
-
4 bicycle
-
5 other
46D. On the average, how long does it take him/her to get to work?
8/446%0 (using the mode of transportation listed in Question 4 6 0
minutes
If 2 jobs ONLY, GO TO Page 35, (part m)Question 1.

If More than 2 Jobs, GO TO Next Page, (part ]OD Question 47A.
Page 34
[Secondary job 31
47A. where is his/her job located? (If trave& to various loc~&ons, record d r e s s of main office.)
Ji%Wd&
address
city State- zip code
~ / , o y 4f q~4 - is hisher work from where you b e ? (CIRCLEONE)

How far
0 - works at home .. . _.
..___ 4 - 6 to 10 miles
6iP40 47C. How does he/she usually get to work? (CIRCLEall that apply)
1-walk 6-r.up001
3 - bushbway -
8 commuter train
4 - bicycle
5 - other
,&a ~ On the average, how long does it take him/her to get to work?
q g , ~47D.
(using the mode of transportationlisted in Question 4 7 0
minUteS
GO TO NEXT PAGE, (part IU)Question 1. 1
I
Page 35
PART III.
1. Other than from your job, please tell me whether you received income from any of these
Have you received....(read each choice and circle all that apply)
sourtes in the past tax year.

(NOT child support or alimony),combined
income or supported by parher

f. money from relatives (NOT partner or spouse) 1. YES 2. NO

g* federal grant, financial aid, scholarships 1. YES 2. NO

(please specify) b-z%-&ka& &PdJ
. , .. . , . . .. . ..
Now I am going to ask you some cpeshs about your total income. First,I will ask about your
p e r s o d income, and then I will ask about your total household income.

1,)
2A. From these sources of income AND the income from any jobs you had in the last tax year,
1. less than $5,000

2. between $5,000 and $9,999
3. between $lO,OOO and $19,999
4. between $20,000and $29,999
5. between $30,000and $39,999
6. between W , OO and $49,999
O
7. more than$50,000
8. don'tknow
23. From these choices, what was your total household incom- in the las tax year before taxes?
household.
1. lessthan$5,OOo
2. between $5,000 and $9,999
3. between $lO,OOo and $19,999
4. between $20,000 and $29,999
5. between $30,000and $39,999
6. between $40,000and $49,999
8. don't know
I
i
rsg
CONFLICT TACTICS SCALE: Partner/Spouse Introduction,
Now, I have some questions ahout your relationships.

1. Are you currently involved with someone? CT f
1. YES W.
0. NO g ~ 2~
..........................................
F'.
~ : ~ ; ~
..............................
A. Are you married to, engaged to, or daring this person? C 7 ~0 4

1. married
2. engaged
3. dating
B. Are YOU currently living with this person?

1. Yes
0. No
C. How long have you been in the relationship? oveo
I BEGIN INTERVIEW I
(If more than one person, select most " s i ~ i c a n trelationship)
" C7A
1.
0. NO
A. Were you married to, engaged to, or dating this person?

1. married
2. engaged
3. dating

1. Yes
2. No
\
I BEGIN INTERVIEW I
I s4
3. Have you dated anyone at all in the past year?
1. YES
For this interview,I would like you to think of all your dating
0. NO .
1
Interviewer ID:
C/SPk?#/S
FIELD COPY 2 SQdiXCeS
reason. They also ise many different ways of trying to settle their differences. I'm going to
...
Refer to fmt month on the time line
these responses.
Hand respondent the response card, and read choices 1 to 6 I
ed. init. ed. date

2
1A. How many times have you discussed an issue calmly?
0 1 2 3 4 5 6
never OIU% twice 3-5 6-10 11-20 more tan
f,%
4.
1B. How many times has he/she discussed an issue calmly?
0 1 2 3 4 5 6
1 =Yes 0 = No
2A. How many times have you gotten information to back up your side of things?
0 1 2 3 4 5 6
2B. How many times has he/she gotten information to back up hisher side of things? r&&
0 1 2 3 4 5 6
. . ..... . ...
2C. Has this ever happened? 1 =Yes O=No a-bck

3
34 3A. How many times have you brought in or tried to bring i

n someone else to help settle things?
0 1 2 3 4 5 6
11.4
. times times times 20 times
0 1 2 3 4 5 6
c73c 3C. Has this ever happened? 1 =Yes 0 = No
c7-L& 4A. How many times have you insulted or swore at him/her?
0 1 2 3 4 5 6
0 1 2 3 4 5 6
4C. Has this ever happened? 0 = No

C . 7 4c 1 =Yes
4
C/ 54 5A. How many times have you sulked andor refused to talk about an issue?
0 1 2 3 4 5 6
+
5B. How many times has he/she sulked andor refused to talk about an issue?
67t5-d3
0 1 2 3 4 5 6
C T 5-c 5C. Has this ever happened? 1 =Yes 0 = No
c7-64- 6A. How many times have you stomped out of the room, house or yard?
0 1 2 3 4 5 6
C.T.643
0 1 2 3 4 5 6

C i 6C
5
7A. How many times have you cried?

0 1 2 3 4 5 6

0 1 2 3 4 5 6
never once twice 3-5 610 1 1-20 more than
8A. . How &y times have you done or said something to spite m e r ?
0 1 2 3 . 4 5 6
0 1 2 3 4 5 6
8C. Has this ever happened? 1=Yes 0 = No

6
C'T 9 . 9A. How many times have you threatened to hit or throw somethug at himher?
0 1 2 3 4 5 6
?*>#
9B. How many times has he/she threatened to hit or throw something at you?
c79.43
0 1 2 3 4 5 6
9C. Has this ever happened? 1 = Ye3 0 = No
1OA. How many times have you thrown, smashed, hit, or kicked somethrng?
m j o /;t
0 1 2 3 4 5 6
10B. How many times has helshe thrown, smashed,.hit, or kicked w?

0 1 . 2 3 ' 4 5 6
0 -7 NO
CTro c 1OC. Has this ever happened? 1 =Yes
7

0 1 2 3 4 5 6
0 1 2 3 4 5 6
11C. Has this ever happened? 1 =Yes 0 = NO
12A. How many times have you pushed, grabbed, or shoved him/her?
0 1 2 3 4 5 6
0 1 2 3 4 5 6

c7f3 4 13A. How many times have you slapped him/her?
0 1 2 3 4 5 6
0 7 3 43 13B. How many times has he/she slapped you?
0 1 2 3 4 5 6

e743 c
C7fXu 14A. How many times have you kicked, bit, or hit m e r w?
0 1 2 3 4 5 6
C ~ { q / 4 14B. How many times has he/she kicked, bit, or hit you w?
0 1 2 3 4 5 6
never O m twice 3-5 6-10 11-20 more than
0-7Wc 14C. Has this ever happened? 1 =Yes 0 = No

9
15A. How many times have you hit or tried to hit hidher ?
0 1 2 3 4 5 6
.a,t
0 1 2 3 4 5 6
16A. How many times have you beat himmer up?
0 1 2 3 4 5 6
16B. How many times has he/she beat you up?
0 1 2 3 4 5 6
16C. Has this ever happened? 1 = Yes . O= N o

10
When you had an argument w i t h your partner in the past year,
C7//7/7 17A. How many times have you choked him/her?
0 1 2 3 4 5 6
1.;'"
How many times has he/she choked you?

c7 /?A 17B.
0 1 2 3 4 5 6
Has this ever happened? 1 = Yes 0 = No

c777c 17C.
cn=%4 18A. How many times have you threatened himmer with a knife or gun?
0 1- 2 3 4 5 6
c7-&=3 18B. How many times has heishe threatened you with a knife .or gun?
0 1 2 3 4 5 6
never 0- twitx 3-5 6-10 11-20 more than

O / @ C '
11
19A. How many times have you used a knife or fired a gun?
0 1 2 3 4 5 6
never once twice 3-5 - 6-10 1 1-20 more than
Y.;9
19B. How many times has he/she used a knife or fired a gun?
0 1 2 3 4 5 6
1%. Has this ever happened? 1 =Yes 0 = No

1
Conflict Tactics Scale: Parent-Chiid
Subject ID:
Parents and children use many different ways of trying to settle differences between
them. I am going to read a Iist of things that you might have done YOU HAD A
Refer to fust month on the timeline
U Hand respondent response card and read choices 1 to 6 I
ed. init.
-
ed. date
2
1. H o w - i y times did you discuss an issue calmly with *****?
0 1 2 3 4 5 ' 6
'I..
4'.r. - . -
2. How many times did you get information to back up your side of things?
0 1 2 3 4 5 6
times times tima 20 times
2B. Has-this ever happened? 1 =Yes 0 = No
3. How many times did you bring in or try to bring in someone else to help settle things?
0 1 2 3 4 5 6
never * orice twice 3-5 6-10 11-20 more than

W 3 6
3
CL'L 4 4. How many times did you insult or swear at *****?
0 1 2 3 4 5 6
ta'.a
&'?5 46 4B. Has this ever happened? 1 = Yes 0 = No
How many times did you sulk andor refuse to mlk about an issue?
e& 5 5.
0 1 2 3 4 5 6
5B. Has this ever happened? 1=Yes 0 = No

G k 4-4
C& 6 6. How many times did you stomp out of the room, or house or yard?
0 1 2 3 4 5 6

C k 64
4
c&-7 7. How many times did you cry?

0 ' 1 2 3 4 5 6
ci45 96 7B. Has this ever happened? 1 = Yes 0 = No
C& 8 8. How many times did you do or say something to spite *****?
0 1 2 3 4 5 6
ea84 8B. Has this ever happened? 1=Yes 0 = No
C& 9 9. How many times did you threaten to hit or throw something at *****?
0 1 2 3 4 5 6

cu- 943
ON = 0
s a q oz
mxp aJom
9
ON =0
=woz
q a~om
9
ON = 0
.
-................... . .
samn 02
ump aiom
9
s
6
&& ~3 13. How many times did you slap or spank ***** ?
0 1 2 3 4 5 6
never once twice 3-5 . 6-10 1 1-20 more than
I$
L%L f3 4 13B. Has this ever happened? 1 = Yes 0 = No
+,q 14. How many times did you kick, bite, or hit ***** &h a fist?
0 1 2 3 4 5 6

f4k3
f3- 15. How many times did you hit or try to hit ***** * ?
0 1 2 3 4 5 6

& y3-43
7
& /6 16. How many times did you beat ***** up?
0 1 2 3 4 5 6
c& /6A 16B. Has this ever happened? 1 = Yes 0 = No
cdb j
? 17. How many times did you burn or scald *****?
0 1 2 3 4 5 6
17B. Has this ever happened? 1=Yes 0 = No

&I%-
1
Date: ---
mm dd yy
Subject ID: s&/s/W

n
Interviewer ID:
ITime Started: 1
I am going to read a list of items that describe children and youth.
I Hand PC Response Card 1 1

For each item that describes ***** now or within the past 6 mon t hs, please say "2" if the
item is very true or often true of *****. Say "1" if the item is Somewhat or sometimes true
of *****. If the item is not true of *****, say "0". Please answer all items as well as you
can, even if some do not seem to apply to *****.
0 = Not True
1 = Somewhat True
2 = Very True
CC f o 1 2 1. ~ c t too
s young for h i h e r age
CCA o 1 2 2. Allergy
CC3 o 1 2 3. Arguesalot
cc4 0 1 2 4. Asthma
cc 5 0 1 2 5 . Behaves like opposite sex
cc 6 0 12 6. Bowel movements outside toilet
ed. intl. ed. date

CC?O 1 2 7. Bragging, boasting
CCP 0 1 2 8. Can't concentrate, can't pay attention for long
cc9 0 1 2 9. Can't get hidher mind off certain thoughts; obsessions
CCsr.0 1 2 10 Can't sit still, restless, or hyperactive
n ccr/ 0 1 2 11. Clings to adults or too dependent
CCf4 0 1 2 12. Complains of loneliness
7
cc1'3 0 1 2 13. Confused or seems to be in a fog
CCf. 0 1 2 14. Cries a lot
ccr5 0 1 2 15. Cruel to animals
C1'6 0 1 2 16. Cruelty, bullying, or meanness to others
ccr? 0 1 2 17. Day-dreams or gets lost in his/her thoughts
ec& o 1 2 18. Deliberately harms self or attempts suicide
CCf'O 1 2 19. Demands a lot of attention
cc;wo 1 2 20. Destroys his/her own things
CCJi 0 1 2 2 1. Destroys things belonging to his/her family or others
cczz 0 1 2 22. Disobedient at home
23. Disobedient at school
24. Doesn't eat well
25. Doesn't get dong with other kids
26. Doesn't seem to feel guilty after misbehaving
27. Easily jealous
28. Eats or drinks things that are not food- don't include sweets
29. Fears certain animals, situations, or places, other than school
30. Fears going to school
3 1. Fears he/she might think or do something bad
32. Feels he/she has to be perfect
33. Feels or complains that no one loves himmer
34. Feels others are out to get him/her
2 i.9
3
a 3 5 0 1 2 35. Feels worthless or mferior

0 1 2 36. Gets hurt a lot, accident-prone
0 1 2 37. Gets in many fights
0 1 2 38, Gets teased a lot
0 1 2 39. Hangs around with others who get in trouble
0 1 2 40. Hears sounds or voices that aren't there
IJ0 1 2 4 1. Impulsive or acts without thinking

0 1 2 42. Would rather be alone than with others
0 1 2 43. Lying or cheating
0 1 2 44. Bites fingernails
0 1 2 45. Nervous, highstrung, or tense
0 1 2 46. Nervous movements or twitching
0 1 2 47. Nightmares
0 1 2 48. Not liked by other kids
0 1 2 49. Constipated, doesn't move bowels
0 1 2 50. Too fearful or anxious
0 1 2 51. Feels dizzy
0 1 2 52. Feels too guilty
0 1 2 53. Overeating
0 12 54. Overtired
CC 550 1 2 55. Overweight
56. Physical problems without known medical cause:
cc 56a 0 1 2 a. Aches or pains (not headaches)
C C 3-66 0 1 2 b. Headaches
-0
ccLT6c 1 2 c. Nausea, feels sick
CC 564 0 1 2 d. Problems with eyes
CC 5-6e 0 1 2 e. Rashes or other skin problems
CC 569 o 1 2 f. Stomach aches or cramps
CC550 1 2 g.Vomiting, throwing up
4
*I
CCS64 o 1 2 h. Other physical problems without known medical cause
cc5z 0 1 2 57. Physically attacks people
-0 1 2 58. Picks nose, s h , or other parts of body

-0 1 2 59. Plays with own sex parts in public
0 1 2 60. Plays with own sex parts too much
-0 1 2 61. Poor school work
-
9 0 1 2 62. Poorly coordinated or clumsy
-0 1 2 63. Prefers being with older kids
-0 1 2 64.Prefers being with younger kids
-0 1 2 65. Refuses to talk
0 1 2 66. Repeats certain acts over and over; compulsions
-0 1 2 67. Runs away from home
0 1 2 68. Screams a lot
0 1 2 69. Secretive, keeps things to self
-0 1 2 70. Sees things that aren't there
0 1 2 71. Self-conscious or easily embarrassed
-0 1 2 32. Sets fires.
-0 1 2 73. Sexual problems
-0 1 2 74. Showing off or clowning
-0 1 2 75. Shy or timid
-0 1 2 76. Sleeps less than most kids
-0 1 2 77. Sleeps more than most kids during day and/or night
-0 1 2 78. Smears or plays with bowel movements
-0 1 2 79. Speech problem
-0 1 2 80. Stares blankly
-0 1 2 81. Steals at home
-0 1 2 82. Steals outside the home
cc83 0 1 2 83, Stores up things he/she doesn't need
cc& 0 1 2 84. Strange behavior
-0 1 2 85. Strange ideas
I - 0 1 2 86. Stubborn, sullen, or irritable
I1 -- O 1 2
O 1 2
87. Sudden changes in mood or feelings
88. Sulks a lot
0 1 2 89. Suspicious
I, 0 1 2
g--.
d/ -0 1 2
90.Swearing or obscene language
91. Talks about killing self
-0 1 2 92. Talks or walks in sleep
-0 12 93. Talks too much
0 1 2 94. Teases a lot
0 1 2 95. Temper tantrums or hot temper
-0 12 96. Thinks about sex too much
0 1 2 97. Threatens people
-0 1 2 98. Thumb-sucking
-0 1 2 99. Too concerned with neatness or cleanliness
0 1 2 100. Trouble sleeping
-0 1 2 101. Truancy, skips school
-0 1 2 102. Underactive, slow moving, or lacks energy
0 1 2 103. Unhappy, sad, or depressed
0 1 2 104. Unusually loud
-0 1 2 105. Uses alcohol or drugs for nonmedical purposes
-0 1 2 106. Vandalism
-0 1 2 107. Wets self during theday
0 1 2 108. Wets the bed
-0 1 2 109. whining
-0 1 2 110. Wishes to be of opposite sex
-0 1 2 111. Withdrawn, doesnt get involved with others
cc7z4 0 1 2 112. Worries
6
cc H3 0 1 2 113A.
0 1 2 113B.
0 1 2 113C.
END OF INTERVIEW
RECORD TIME:
...
Subject ID: .S&A/W
1. Are you afraid ***** might be hurt by violence in your neighborhood?
1.- YES 2 . 2 0
2. Are you afraid ***** might be hurt your apartment bujldq or house?
1.- YES 2 . 2 0
3. Are you afraid ***** might be hurt in your apartment building or house?
1.- YES 2 . . N O
1. YES 2.- NO
ed. init. ed. date

2
4A. Does this affect where you take *****?
1- YES 2.- NO
1 .- YES 2.- NO
1.- YES 2. NO
7. Have any of y o u close friends been hurt by a violent act?
1 .- YES 2 . N O
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
The questions I'll be asking YOU now have to do with acts of vioience that ***** m a y have
present during violent acts.
22 f0 10. Has ***** ever seen or been present when somebody was shoved, kicked or punched?
1. YES
2. NO
1. Withinlast week
3. Withinlastyear
1. In ****'s home
3. In front of ****'s househuilding
6. At ****'s schooyday care
25. other (speclf~) ~-.*CL&&
1. YES
2. NO
2.20
4
s4 J3& 13A. Who was it? (MARK BLL THAT APPLY)
1. Parent
2.- *****
3. Friend
4.,Neighbor
5.
. .
Siblmg
6. Other Relative (Specify) t.&&Le
25. -
Other (Specify) L ~ ~
Vd
tCtje ~
&
-
14. How badly waS the person or people injured? (MARK THAT APPLY)
1. N o injury
2. Knockeddown
3.Bruised
4. Cutmleeding
5. Unconscious
6. Broken bones/fracturt
8-. Other
SA / F 15. Did ***** know the person or people who did this?
- . 1. YES
2. NO

1. Parent
88888
2-.
3. Friend
4. Neighbor
5.
. .
Slbllng
6. Other Relative (Specify
25. Other (Specify)
5
2% - 16. Has ****+ seen this more than once?
....
1. YES
2. NO
2-4
fB&O 16A. How many times has ****? seen this in the past year?
CsP4 fqao 16B. How many times has ***** ever seen this?
&'$ y+ 17. Has ***** ever seen or been present when someone was attacked with a knife?
....
1. YES
2. NO
2?& /8 18. When was the last time he/she saw that?
1. Withinlastweek
2. Withinlastmonth
3. Withinlastyear
229 & 19. Where did that happen?
1. in ****'s home
6. At ****'s schoollday care
25. Other (specify))
222
6
1. YES
1. Parent
2.- *****
3. Friend
4. Neighbor
. .
5. Sibirng
6. Other Relative (Specify) ~ ~ ~ & zx
+ ~d k
25. Other(Specify) P&LLL-&Q ,&a-& /
21. How badly was the person or people injured? (MARK&THAT APPLY)
1. No injury
2. J(nockeddown
3.Bruised
4. Cut/bleeding
5. Unconscious
6 . - B r o k e n bones/fracnue
7. Medicalcareobtained
-8. Other
22. Did they die?
1 .- YES 2 . , N O 8. Don't Know
SAL3
1. YES
2. NO
7
242 3 Y+ 23A. Who was it? (MARK BLL THAT APPLY)
1. Parent
2 .- *****
3. Friend
4. Neighbor
5.
. .
Siblmg
6. Other Relative (Specify) ~ ~ ' c w ? f d e
25. Other (Spec@) Va7Ct^d& L-GG.7p-
7),
2.A4 24. Has ***** seen this more than once?

1. YES
2. NO
259 &L/AO 24A. How many times has ***** seen this in the past year?
25. Has ***** ever heard a gun shot?
... .. .
- 1. YES
2. NO
26. When was the last time hehhe heard that?
1. Withinlastweek '

3. Withinlastyear
22Y
8
2-4
#&p 27. Where did that happen?
1. In ****'s home
3. In front of ****Is hornelbuilding
6. At ****Is schml/day care
25. Other(specify) / ~ e + z o d &
Y *
28. Has ***** heard a gun shot more than once?
'1. YES
2. NO
2-79 fwm 28A. How many times has ***** heard this in the past year?
28B. How many times has ***** ever heard this?

2% Ai? A 0
s4 L F 29. Has ***** ever seen or been present when someone was shot?
1. YES
2. NO ... ..
I END OF INTERVIEW I
I RECORD TIME: I
1. Withinlastweek
3. Withinlastyear
9
Where did that happen?
1. In ****Is home
****IS
,3. In front of ****Is househuilding

; 4. In ****ISneighborhood
6. At ****Is school/&y care
' 25. Other (specify) v u ' & & & 4
Did he/she know the person or people who got shot?
1; YES
2. NO
32A. Who was it? (MARKAIL THAT APPLY)
1. Parent
2.- *****
3. . F r i e n d
4. Neighbor
5. Sibling
6. Other Relative
25. Other (Spec@)
2.4 3 3 33. Did they die?
1 .- YES 2.- NO 8. Don't Know
34. Did he/she know the person or people who L-- this?
1. YES
2. NO
226
10
1. Parent
2 .- *****
3. Friend
4. Neighbor
5.
. .
Siblrng
6. Other Relative (Specify) vak-d& & R J ~
25. Other (Specify) Az?z&'d& &&k##p&
/
35. Has **?** seen this more than once?

1. YES
2. NO
35A. How many times has ***** seen this in the past year?
I RECORD TIME: I
EASI Temperament Survey: PC Version
For each one, try to rate ***** on a scale from 1to 5, with 1 being nncharactwistic or
not at all like ***** and 5 being characterjstic or very much like *****.
1. ***** feels happiest in familiarsurroundings. 2Y f

4 = Somewhat characteristic (sort of like your child)
2. ***** often acts on the spur of the moment. 2YA

.-
3. ***** is somethrng of a loner. 2-93

1= Uncharacteristic (NOTat a2 like your child)
4 = Somewhat characteristic (sort of like your child)
5 = Characteristic (very much Iike your child)
4. ***** sometimes does crazythings just to be different. 294

?-
I
% 2= Somewhat Uncwteristic (NOTvery much like your child)
5. ***** likes to be with people. 5-

2.9.
5 = Characteristic (very much like your chiid)
6. ***** has trouble resisting temptation. 2 ~ 6

5 = characteristic (very much like your child)
7. ***** finds people more stimulating than anything eke. zY2

1= uncharacteristic (NOT at all like your child)
230
8. Unfinished tasks really bother *****. 2Y8
9. ***** cries easily. E9 9

Uncharacteristic (NOTat all like your child)
4q>;
1=
10. ***** makes friends easily. SY YO

11. ***** tends to be somewhat emotional. 2.9if.

12. ***** is off and running as soon as (&he wakes up in the morning. 231a
1 = Uncharacteristic (NOTat all like your child)
13. ***** generally seeks new and exciting experiences and sensations. G943
14. ***** finds self-control easy to learn. 2-y/L/

15. ***** can tolerate frustration better than most. s.919-

16. ***** often fusses and cries. ZY /6

17. ***** gets upset easily. 29/;z

18. +++**tends to hop from one interest to another quickly. S Y A!?
1. = Uncharacteristic (NOTat all like your child)
19. ***** takes a long time to warm up to strangers. s-9i 9

qd 1= Uncharacteristic (NOT-at all like your child)
Somewhat Uncharacteristic (NOTvery much like your child)
9 -
2=
20. ***** prefers quiet, inactive games to more active ones. 29 LO

21. ***** often says the frst thing that comes into hisher head. 29 &.
22. ***** tends to be shy. s9&z

2 33
23 ***** tends to get bored easily. 2YL.3
4= Somewhat characteristic (sort of like your child)
24. UsuaIly ***** can not stand waiting. SY.459

1
3 '
% 2= Somewhat Uncmteristic (NOTvery much like your child)
25. ***** has trouble controlling hisher impulses. 29455-


1 = Uncharacteristic (NOT at ail like your child)
27. ***** is very friendly with strangers. SYLT

28. ***** always likes to make detailed plans before (s)he does something. EYi8
29. ***** generally likes to see t h u g s through to the end. S9A9
t2 1=
2=
Uncharacteristic (NOTat all like your child)
Somewhat Uncharacteristic (NOTvery much like your chiid)
30. ***** often has trouble making up hisher mind. s .30

31. ***** prefers playing with others rather than playing aione. 2'9'
3/
32. ***** is very sociable. S93D

233
33. When alone, ***** feels isolated. ZY 33
1= Uncharacteristic (NOT at all like your chiid)
34. ***** reacts intensely when upset. 29 34

12;
2= Somewhat Unclxqcteristic (NOTvery much like your child)
3= Neither Uncharacteristic por Characteristic
35. ***** is very energetic. SY35

36. ***** tends to give up easily. 5536

37. When ***** moves about, (s)he usually moves slowly. 2 3 57

38. ***** likes to plan things way ahead of time. c5-Y 38
39. Once ***** gets going on something, (s)he hates to stop. 39

2-9
1= Uncharacteristic (NOT at all like your child) ,
7%'a# 2= Somewhat Uncharacteristic (NOT very much like your child)

3 3= Neither Uncharackristic nor Characteristic
40. ***** will try anything once. 2-940

8 END OF INTERVIEW e
Famiiy Environment Scale: Short Version
Interviewer ID:
FSSRA/S
There are 27 statements in this survey. They are statements about f e e s . You are to
You m a y feel that some of the statements are true for some family members and false for
fake for most members. If the members are evenly divided, decide what is the stronger
overall impression and answer accordingly.
1. T 2. F
1. T 2. F
1. T 2. F
&.init. ed. date
F.2 4 4. Family members rarely become openly angry
1. T 2. F
5. We dont say prayers in OUT family
1. T 2. F
1. T 2. F
Family members sometimes get so angry they throw things
1. T 2. F
8. We often talk about the religious meaning of Christmas, Passover, or other holidays
1. T 2. F
9. There is one hmiiy member who makes most of the decisions
1. T 2. F
1. T 2. F
11. We dont believe in heaven or hell
1. T 2. F
1. T 2. F
1. T 2. F
3'
Fs /'g 14. Family members have strict ideas about what is right or wrong
1. T 2. F
15. There is a saong emphasis on following rules in our family
1. T 2. F
16. Family members sometimes hit each other .
1. T 2. F
17. We believe there are some thrngs you just have to take on faith
1. T 2. F
18. Everyone bas an equal say in family decisions
1. T 2. F
19. If there's a disagreement in our family, we try hard to smooth thmgs over and keep the
P-
1. T 2. F
fEao 20. In our family each person has different ideas about what is right and wrong
1. T 2. F
1. T 2. F
1. T 2. F

1.' T. ' 2. F
4
Fs 2 4 24. Rules are p r e q inflexible in our household
1. T 2. F
~2 a 5 25. In our family, we believe you don't ever get anywhere by raising your voice
1. T 2. F
FlJ6
1. T 2. F
Fc 2 7 27. You can't get away with much in our famiIy

1. T 2. F
r
I
1
I HAND SUBJECT RESPONSE CARD
F&A% 28.- When you answered these questions, who did you have in mind?
1. Siblings
2. Parent
5. other
fF
3. Roommate
6. SpouseRartmr
7. Childchildren
.1. .. . __
.
Provision of Sociai Relations
1= verytrue
2= somewhat true
3= nottrue
1. When I'm with my fiends I feel completely able to relax and be myself.
1 -verytrue
-
2 somewhat true
-
3 not true
2. I share the same approach to life that xnmy of my fiends do.

PSPA
1 -verytrue
-
2 somewhat true
-
3 not true
ed. init. ed. date

/Q.rp
3 3. People who know me trust me and respect me.
-
1 very true
-
2 somewhat true
-
3 not me
PSP -9 4. No matter what happens, I know that my f d y will always be there for me should I need
them.
1 -verytrue
2 - somewhat true
3 -nottrue .
5. When I want to go out to do things, I know that many of my fiends would MiQy (like)
PSP 5- doing these things with me.
1 -vexytrue
2 - somewhat true
-
3 not We
6. I have at least one fiend that I could tell anything to.
1 -vexytme
2 - somewhat true
-
3 not true
7. SometiImesI'm not sure ifl can completely (count) on my fan\ilv.

1 -vcrytrue
-
2 somewhat true
-
3 not true
8, My f d y lets me b o w they think I'm a (vahab2e)person.
1 -vexytrue
-
2 somewhat true
-
3 not true
2y6
9. I feel very close to some of my &ends.
1 -verytrue
2 - somewhat true
3 -not true
1 - very true
2 - somewhat true
3 - not true
=t
People in my family help me find ~olutionsto my problems.
1-
4 11.
-
1 very true
2 - somewhat Vue
3 - not true
-
1 very true
-
2 somewhat true
3 - not true
13. My fiiends would take the time to talk about my problems, should I ever want to.
1 -verytrue
-
2 somewhat true
-
3 not true
14. I know my f d y will always stand by me.
1 -verytrue
-
2 somewhat true
-
3 not true
15. Even when I am with my fiiends, I feel alone.
1 -verytrue
2 - somewhat true
3 - not true
Psp /G I have a teacher or coach who I can & i,ounl) on and talk to.
1 - very true
-
2 somewhat true
3 - not true
I have a grandparent, uncie, or aunt that I feel close to and who helps me out.
-
1 very true
-
2 somewhat true
3 - not true
I have a brother, a sister or a cousin who listens to me and understands my problems.
1 -verytme
2 - somewhat true
3 -not m e
There is an adult outside my family, for example, a neighbor or religious or

community member, who I can go to for help if1 need it.
1 -veryme
-
2 somewhat true
-
3 not true
PSP 20. Is there anyone in particular that you think helps you out when you need it?
1. Yes 0. No
PP.Yes: What is t h s person's name and what is hidher relationship to you? (Circle all that
20a1. d d 20a2. 1 - Immediate Family (sibling, child, parent, partner)

'girst name 2 - Extended F d y
-
-
6 - Other
#QssO&ob~
20bl. v d 20b2. 1 - Immediate F d y (sibling, child, parent, partner)
2,k.d First name -
2 Extended Family
-
5 - School or Co
-
6 Other
PsPmca
20cl. 20~2. 1 - Immediate F d y (sibhg, child, parent, partner)
name 2 - Extended F d y
'FKs~
4 - Church MernberLeader
6-other
I8 END OF INTERVIEW 8
RECORD TIME: BJ@@S7/riJ

I
PROJECT O N J3%3L&V DEVELOPMEhT I SCHlCAGO xEIGHBORBOODS
1. Are you planning on rnovingeaving home in the next year? Y N

if"Yes,'I
1a. when? (mon W e a r )
lb. where? fstreet)
(citv) f state) f 2iD.J

i"Yes,":
2a. when? (monthhrear) 2b. new employer?
2c. new eqloynent address: meet)
/citvl (state) (2iU.I
3. Do you think it is likely you will obtain work m the near fitme? Y N
if 'Yes,":
3a. when? (montbht car) 3b. employer?
3c. new employment address: /set)
fcitv) (state) IZiD)
4. Do you plan on changing schools, or gomg away to school? Y N

if"Yes,"
4b. new school address:: (street)
C:\WPWINGO\CHIP\DOC\ROANEW.FRM
future? Y K
Yes,
5a. PIease explain why:
6. Can you give me the names, addresses, and phone numbers of four close fiends or reiatives
who will always know where to find you to help us locate you in the future?
a. b.
Name:
1 Relationship:
Address:
Phone:
c. d.
Name:
Relationship:
Address:
City/St/Zp :
Phone:
C:\WPWINGO\CHIP\DOC\RO
ANEW.FRM ROA 2
a. annoyed b. nervous c-. bored d. &aid
e.- relaxed f- interested g. neutral h. curious
i cooperative I.- confUsed7
8. Please note any other observations about the respondents demeanor

-4
9. Using the scale below, make your best assessment of the pdcipants likelihood of
Circle one:
1 2 3 4 5

10, Using the scale below, make your best assessment of the d.i.6- we wlil have m locating this
individual next year:
Circle one:
1 2 3 4 5
Great dficulty Little dficdq

inlocating in locating
loa. Please explain h e reason for your assessment:
C:\WPWINGO\CHIP\DOC\ROANNV.FRM ROA 3

. ...... . ...... . .
1 . Research Assistant
2. Parent/Guardian
3. Spouse/Partner
6 . Other

2 . between one-fourth a d one-half
5. all
6. How much difficultydid the S/PC have in understanding the language of the measures? Did
heishe find it ...
1. Very difficult
2. Fairly difficult
3. Fairly easy
4. Veryeasy
7 . Was all of the assessment administered in private- that is, no one was actively listening to any
EYES, enter code(s) for the party(ies) present during the assessment.
Code
3. Deviance of Peers YES NO a. b. c.
4. SelfReportofOffending YES NO a. b. c.
5. Substance Use YES NO a. b. c.
6. Youth Self Report Y E S NO a. b. c.
7. Young Adult SelfReport YES NO a. b. c.
Coding List
1 = ParentIGuardian 5 = Other Child Family Member
2 = Spouse/Partner 6 = Friend
Comments Section:
PLEASE RECORD ANY ADDITIONAL COMMENTS
53
NOTES
2 56
NOTES
NOTES
I

I

ASSESSMENT
SUBJECT
COHORT: 6
FIELD COPY #2
TABLE OF CONTENTS
Age: 6 (Subject)
1. Vocabulary: WISC-R
2. WRAT: Reading
WISC-R
1
WISC-R
Only ask the following questions of subjects who speak either Enghsh or Spanish. Do not
administer this measure to subjects whose primary language now is any other language.
You should answer the next set of questions in the language you know the best, that is, the
language you know the most words in.
1. Which language do you know the best?

2
Vocabulary (WISC-R)
Subject ID: g&/p

Interviewer ID :
w;sc &A/Z
-
Write down exactly what the child says in response to these questions. If the child does not give
a correct answer, ask M e r "Explain what you mean." or "Tell me some more about it." and
write a (Q), indicating that you have queried this answer, on the answer sheet after hidher
original answer, but before the query. If the child provides more information but it is not a
clearly correct answer, write a (Q) on the answer sheet, query the response again, and record
hidher answer. In general, if an answer is not clearly correct, query it, but do not make more
than 2 queries to any item. If an answer is clearly incorrect or ifthe child does not know the
word, go on to the next item. 5 c-ub
.ve- . are-
I am going to say some words. Listen carehlly and tell me what each word means. What
does mean?
1. KNIFE
Correct Query Incorrect

Something you cut with To hunt with Play with it
Tostabwith Sharp Put itinyourpocket
Aweagon It can kill people I have one
Has a blade and a handle Made of steel
Can peel an apple with it Can eat with it
It's sharp and can hurt someone
Taken from the Wechsler InteIlbence

- -
Scale for Children Revl'sed, New York
Psychological Corporation, 1979.
ed. init. ed. date

~
7. Alphabet
lm?
im 8. Donkey
V A8
9. Thief vb 9
10. Join
I
1 1 . Brave
1/14ff
12. Diamond
~
&z3/a
!
. :.
13. Gamble
u3 13
14. Nonsense
! YA i.L/
15. Prevent Y A6
16. Contagious %% 16
17. Nuisance
I v.45
v i /8
~
18. Fable
19. Hazardous
~~ ~
m j9
20. Migrate
Vh#
21. Stanza LAdf
22. Seclude VhAX
23. Mantis /Ad3
24. Espionage Y Aa4
25. Belfry ma5
26. Rivalry v.;Zs
27. Amendment v//322
28. Compel dw8
29. Affliction . Vb.29
30. Obliterate @530
31. Imminent @3/
32. Dilatory 1/A&
Max.=64
Total
L
4
8. OBJECT ASSEMBLY Give entire test to all children.
2. Horse 150"
76-180 51-75 36-50 1-35

4. Face 180" y2: 0 1 2 3 4 5 1 6 7 8 91
PERFECT ASSEMBLY
I
'Round half-scores upward. IMax.=BC
Toial
I
~~
9 . COMPREHENSION Discontinue after 4 consecutive failures.

score
2,l,or0
1. Cut finqer
2. Find wallet I I
*3. Smoke
*4. Policemen
5. Lose ball
6. Fight
' 7 . Build house ~~~~~~

I I
* 8. License plates
*9. Criminals
10. Stamps
1 I . Inspect meat
*12. Charity
13. Secret ballot
* 14. Paperbacks I I
1
~ ~~~~
15. Promise
'16. Cotton I
* 17. Senators I I
U
'If the child replies with only one idea, ask him for a second response. Rephrase the test item appropriately, saying, "Tell me Max.=34
.."
another thing to do (reason why, advantage of). .
Total
I 10. CODING I Time I Score I

(0-93)
8 (for children 8 8, older) 120"
5
WRAT
.~..
i
5
4-
6
1 Aver age:
5 20% of 120 =
-33
1 33- 7.96
x30.8
24,18,21,26, 17
1- Ans:
+2- Ans:
2
Factor:
Write as a decimal: _3 -- %
1
I
(-5)(+9) = 8.2)62.703
1 1 8 - ir;
r2 -lOr+25= I
5 2 ~ % = ,LA
Ans: Ans:
-_ .._ ,.,
----".- -
7 -
;-l >
,
1
----.-1"11111--lllr-.-
Solve: Find interest on

( 1
' 7-(6+8)
7
&=6
$1200 at 6% per
i4 2
- 6 ~ 3 - z
8 X= year for 2 years
cornpounded
i annually:
1 Ans:
I
i
Ans:
3
Photocopying of this test is a violation of copyright law. Page 3

I
- I
1
ered milk
I
3 +Was !
red milk wuz
1
Y
/jar .,?letter <city I
jahr let-& sit-ee i
j -+cliff stalk :grunt i
klif stawk grunt
I__--
i
plot ssour humidity i
i
J
plot sowr hyoo-mid-i-tee

_ _ _ _ _ _ _ ~
iI
,:residence
rez-i-dzns
curge
UrJ
1; rancid
ran-sid
.-I
i
i-------
-1
' conspiracy ?:deny 12quarantine 1. deteriorate

ken-spir-;-see di-nr kwor-zn-teen di-teer-i-;-ray t
i .t rudimentary 1 mosaic 2; rescinded 22 audacious

: roo-di-men-tz-ree moh-my-ik ri-si nd -ed aw-dav-shEs
I i
:Q protuberance :. lon-jev-i-tee
longewity ;predilection
;
1I
i
proh-too-bcv-rks
-~ pred-i-lek-sh& _ _ .
-, 1
f
~
bealify ,::internecine .;o regicidal i

bi-at-i-h in-t&-nee-seen, -nes-een rei-i-sT-dd 1
,- /
I
-e
1 :;puerile .:->factitious :td lucubration
I pyoo-e-ril
B
fak-tish-Cs loo-kyuu-bray-shh
I -----
lepithalamion -> inefjicac io us :synecdoche
ep-i- thg-lay-mi-& in-e f-i-ka y-sh;s si-nek-dz-kee
>"
OBSERVATIONSIREMARKS:
.._..----. -r-.
*y
Photocopying of this Past is a violation of copyright law.

COPYRIGHT 0 1993 bv Jastak Associates
\
-
4 DIVISIONOF WIDE RANGE, I N C
: 411 rights reserved Printed in U.S.A.
1937 1946, 1965, 1976, 1978, 1984, 1993 Page 4 WIDE -GE
__
15 Ashley Place.Sulte I A , Wilmington, DE 19804-1314
PROJECT ON B7JiVIApd DEVELOPMENT IN CHICAGO NEIGEBORBOODS
I
1. Are you planning on moving/leaving home in the next year? Y N
if'Yes,"
1a. when? (monthhrear)
lb. where? (*et)
/citv) (state)
.
I
I
2. D o you plan on changing jobs m the near fixture? Y N

if 'Yes, ":
2a when? Irpontidvear) 2b. new employer?
2c. new employment address: f street)
fdw) (**I
3. Do you think it is likely you will obtain work m the nearfuturc? Y N

if'YeS,":
3a when? (month/vear) 3b. employer?
3c. new employment address: f-t)
fdw) (stare)

if'Yes,"
4b. new school address:: { m t )
C:\WPWINGO\CHIP\DOC\RO
ANEW.FRM
5. D o you h o w of any reason why you might not b e able to paniapate in b s Project in &e
%me? Y W
I$ "Yes,"
6. Can you give me the names, addresses, and phone numbers of four close fiends or relatives
*
who win always h o w where to find you to help US locate you in the future?
*
a. b. -_
Name:
Relationshq:
Address:
city/st/zIp:
Phone:
c
Name:
Relationship:
Address:
city/st/zip:
Phone:
C:\WPWINGO\CHIP\DOC\ROANEW.FRM ROA 2
a.- annoyed b. nemous c.- bored d. &aid
e.- relaxed E interested g. neutral h. &ous
i cooperative j. confUsed?
participating next year
Circle one:
1 2 3 4 . 5
Little likelihood
of prrticipating
9a Please explain the reason for your assessment:
10. Using the scale below, make your best assessnent of the we wiIl have in locating this
Cirde one:
1 2 3 4 5
Great disculty Littie dif~icrrtty
,-
inlouting . in louting
10a Please explain the reason for your assessmeat:
ROA 3
Date:
mm dd
Subject ID:
Interviewer ID:
YES GOtqQ6
NO G o t o Q 2
YES Go to 4-2 Specify language

NO. G o t o Q 3
YES-GO.toQ 5
NO G o t o Q 4
1.
2.
2. ParendGuardian
3. SpousePartner
6. Other

5 . all
6. How much difficulty did the SRC have in understanding the language of the measures? Did
he/she find it ...
'
1. Very difficult
2. Fairly difficult
3. Fairly easy
4. Veryeasy
7. Was all of the assessment administered in private- that is, no one was actively listening to any

NO GotoQ8
Code
2. Conflict Tactics YES NO a* -b. c.
3. Deviance of Peers YES NO a* -b. c.
4. SelfReportofOffending YES NO a. -b. c.
5. Substance Use YES NO a. -b. c.
7. YoungAdultSelfReport YES NO ' a. b. c.
Coding List
1 = ParentIGuardian 5 = Other Child Family Member
2 = SpouseRartner 6 = Friend
Comments Section:
PLEASE RECORD ANY ADDITIONAL,COMMENTS:

Date:
mm dd yy
Subject ID:
Interviewer ID:
5
HARVA SCHOOL OF PUBLIC HEALTH
'1'

ASSESSMENT
SUBJECT
COHORT: 9
FIELD COPY #2
F CONTENTS
Age: 9 (Subject)
I. Vocabulary: WISC-R
* 2. Deviance of Peers
3. gubstance Use: 6-9
4. WRAT: Reading
5. Health Screen
6. Pubertal Development
8. Self Report o f Offending
-
WISC-R
WISC-R
Only ask the following questions of subjects who speak either English or Spanish. Do not
administer h s measure to subjects whose p n m q language now is any other language.
YQUshould answer the next set Qf quesltiom in the language you h o w the best, that is, the
langnage you know the most words in.

2
Vocabulary (TW3C-R)
Date: pg'/sc m7e

mm dd y~
Subject ID : Le/&
Interviewer ID : H15C R A / D
FIELD COPY 2 &!&%&-~
I Time Started:
i
a correct answer, ask him/her "Explain what you mean." or "Tell me some more about it." and
write a (Q), indicating that you have queried this answer, on the answer sheet after hisher
clearly correct answer, write a (Q) on the answer sheet, query the response again, and record
hisher answer. In general, if an answer is not clearly correct, query it, but do not make more
than 2 queries to any item. If an answer is clearly incorrect or if the child does not know the
. .
word, go on to the next item. D i s c o d e t e m after 5 consecutive items are EIven cl&
ancorrect or 'Don't-knowwswers,
I am going to say some words. Listen carefilly and tell me what each word means. M a t
does mean?
1. KNIFE
Correct Quew Incorrect

Something you cut with To hunt with Play with it
6.2
To stab with Sharp Put it in your pocket
A weapon It can kill people I have one
Can peel an apple with it Can eat with it
It's sharp and can hurt someone
Taken from the Wechsler IntelIiPence Scale for Children - Revised, New York
Psychological CQrpQratiOn,1979.
ed. init. ed. date

1 . Knife
1//37
2. llmbrella lh3 k
3. Clock
v/s 3
4. Hat -
L/3 d/
5. Bicycle -
u/3 3-
6. Nail
733 e5
7. Alphabet
P A9
8. Donkey
.&3 8
9
9 . Thief
Y43 9
10. Join
/& /o
11. Brave
v/3//
12. Diamond l!43/&
13. Gamble Y43 /3
I 14. Nonsense
Y& 141
15. Prevent PA 13-
16. Contagious L//3 A5
17. Nuisance Yh /?
18. Fable i//3 4f
19. Hazardous Pi3 /P
21. Stanza I/& 2)
23. Mantis
-.
PBa3
24. Espionage UdCzq
25. Belfry v.!23-
27. Amendment .
28. Compel L/n -5CP

29. Affliction L9
30. Obliterate 83-59
31. Imminent b%%
32. Dilatory N33&
Max.=h4
4
CE PEERS
Deviance of Peers
Date: BOPBA 76
FIELD COPY 2
1
I r ii
Time Started:
9
Now I am going to ask you some questions about your friends and people you spend time
with. All of these questions are about things these people have done in the past year,
that is since...
Refer to first month on the time line.
Hand Subject response card #1
During the past year, how many of the people you spend t h e with have done each of the
following things. Choosing from,
3. Au ofthem
2. Some of them
1. None of them
1A. Are any of your friends and/or people you spend time with in school? BP7.40
1. YES
2 . NO
During the past year, how many of the people you spend time with ...
1. Have been involved in school activities, not including sports? Would you say ... B,Df&
3 2 1
AU of them Some of them None of them
ed. init. ed. date

2
Deviance of Peers
D m the past year, how many of the people who you spend t h e with.. .
2. Have been involved in school athletics/sports?
3 2 1
All of them Some of them None of them
3. How many have gotten along well with teachers and adults at school? BP3
3 2 1
4. How many have been thought of as a good student? BPY
3 2 1
5. How many have obeyed school rules?
3 2 1
6. How many have skipped school without an excuse?
3 2 1
7. How many have gotten into trouble at school?
3 2 1
3
Deviance of Peers
During the past year, how many of the people who you spend time with...
8. Have been involved in community activities, like sports, scouts, girls and boys clubs,
done volunteer work, or other things like that?
_I
BP s
3 2 1
9. How m y have been involved in religious activities or church groups? BP 9

3 2 1
10. How many would be considered to be good citizens?
3 2 1
All of them. Some of them None of them
11. How many have taken part in their own family activities?
3 2 1
12. How many have gotten into trouble at home?
3 2 1
13. How many have been generally honest and told the truth?
3 2 1
4
Deviance of Peers ---
During the past year, how many of the people who you spend time with.,.
14. Have lied, disobeyed, or talked back to adults, such as parents, teachers or others?
3 2 1
15. How many have purposely damaged or destroyed property that did not belong to them?
,. I$
3 2 1 .. 3
All of them Some of them None of them ..
.16. How many have stolen something worth $5 or less? BP 7

'
6
3 2 1
17. How many have stolen something worth more than $5 but less than $500? ap f f
3 2 1
18. How many have stolen sometlung worth more than $500?
3 2 1
19. How many have gone into or tried to go into a building to steal something? B P / 9
- 3 2 1
5
Deviance of Peers
D&g the past year, how anmy of the people who you spend time with.. .
20. Have taken a motor vehicle, such as a car or motorcycle, for a ride or drive wihout b e
owner's permission?
BPfl
i'$
3 2 1
2 1. How many have gotten into physical (fist) fights with schoolmates/co-workers or B,OJ /
friends?
3 2 1
22. How many have hit someone with the idea of hurting them?
3 2 1
23. How many have attacked someone with a weapon with the idea of seriously hurting 3
them?
3 2 1
24. HOW many have used a weapon or force to get money or things from people? BNA+
3 2 1
25. How many have sold drugs, such as heroin, cocaine, crack, or LSD (other than p ~ 5
marijuana).
--
3 2 1
6
Deviance of Peers
During the past year, how many of the people who you spend t h e with...
26. How many have used marijuana or pot? BPA?6
3 2 1
27. How many have used any form of alcohol, including wine, liquor, or beer? WJT
3 2 1
28 D How many have used drugs, such as heroin, cocaine, crack, or IS14 (other than a p J 8
marijuana)?
3 2 1
29. How many have used tobacco? BPA9
3 2 1
30. How many have had sexual intercourse?

(Record " don't understand" if applicable)
3 2 1
~~

7
Deviance of Peers
D m the past year, how often have people you spend time with done the following?
Chooshg from (I) Never, (2) QncdTwice, (3)Several %es or (4) Often.
31. How often have they asked you to go drinking with them? Would you say,. ..
"#
1 2 3 4
Never Once/Twice Several Times Often
32. How often have they put pressure on you to drink?
1 2 3 4
33. How often have they said that you have to get drunk to have a good time?
1 2 3 4
Never OncefI'wice Several Times Often
34. How often have they offered (gave or sold) marijuana or pot to you?
1 2 3 4
Never OnceA'wice Several Times Often
35. How often have they said that you have to get high on drugs to have a good time?
BP35--
1 2 3 4
Never OncdTwice Several Times Often
36. How often have they put pressure on you to use drugs?
W36
1 2 3 4
1
i
0 END OF INTERVIEW Q
SUBSTANCE USE
Substance Use Interview
[6 & 9 Year Old Subjects]
FIELD COPY 2
li
Now I have some questions about using cigarettes, alcohol, marijuana and other drugs.
Remember, at the beginning of the study, I told you about the special protection to
ensure your privacy? The Federal Certificate of Confidentiality makes it illegal for
anyone, even your parents or people at school, to see or find out what your answers are
in this study. No one except our research staff will ever see them. Your answers can
never be seen by police, the courts, your parents, or anyone else.
If YSU don't know the me- of a word just ask me.
For each of the drugs I ask you about, I want you to tell me how many times you have
used them in your entire We-choosing from one of these choices. ..
These are the choices for telling me how many times you have used alcohol or a drug in
your whole life. The choices are: 0. Never, 1. 1-2 Days, 2. 3-5 Days, 3. 6-11 Days,
4. 12-24 Days, 5. 25-50 Days, 6. 51-99 Days, 7. 100-199 Days, or 8. 200 or more Days.
ed. init. ed. date

Page 2
For each of the drugs I ask you about, I also want you to tell me how many times you
have used them in the past year, that is since.. ..
Refer to f
m month on the time line.
In thinking about the past year, the choices are the same, however, there is some extra
information to help you figure out your answer:
0. No use in the past year

1. 1 - 2days
2. 3 - 5 days
3. 6 .1 1 days.............meansevery other month
4. 12 - 24 days...........means 1 or 2 times each month
5. 25 - 50 days...........means several times each month
6. 51 - 99 days...........means 1 or 2 days each week
7. 100 - 199 days........means 3 - 4 days each week
8. 200+ days.............meam almost every day
have used them in the past month, that is since....
Refer to point one month ago on the time line.
In thinking about the past month, the choices are a little different and here is some extra
0. No use in past month

1. 1 - 2 days
2. 3 - 5 days..............means once each week
3. 6 - 9 days..............means twice each week
4. 10 - 14 days...........means three times each week
5. 15 .20 days...........means four times each week
6. +
21 days............. .meansalmost every day
Page 3
Section I: Substance Use
The first questions are about cigarette smoking.
I
(CIRCLE ONE ANSWER) SLZ#40
NO. . . . . . . . . , . . . . 0 -
Doesn't Understand. . . 5 -
Yes. . . . . . . . . . . . . . 1
1B. About how old were you when you first smoked a cigarette? SK I% 0
Years Old
How many days have you smoked cigarettes...

(CIRCLE ONE ANSWER FOR EACH ROW)
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

Days Days Days Days Days Days 199 Days
Days
1C. Ever in 1 2 3 4 5 6 7 8
your whole life?
1D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
If never
Never 1-2 3-5 6-9 10-14 15-20 21+

Days Days Days Days Days Days
SA5 ?@so
1E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 4
1F. During the past 30 days, about how many cigarettes did you usually smoke in one day?
-1
(CIRCLE ONE ANSWER)
1 - Less than one cigarette a day
2 - 1 - 5 cigarettes a day
3 - About 1/2 pack a day (6-15 cigarettes)
4 - About 1 pack a day (16 - 25 cigarettes)
5 - More than 1 pack a day (over 25 cigarettes)
1G. How did you get any cigarettes you smoked during the last 30 days?
1-Did you use what was in the house?. .................................... 1. Yes

2-Did you buy it from friends, family, or other people you know?... 1. Yes
3-Did you buy it from a store?............................................... 1. Yes
4-Did others share it with you? ............................................... 1. Yes
5 -Did others give it to you? .................................................. 1. Yes
6 -Did you trade things for it? ................................................ 1. Yes
8 -Did you steal it?............................................................. 1. Yes
10-Did someone else buy it for you?......................................... 1. Yes
Page 5
1H. During the past 12 months, when you smoked cigarettes, what have been your m ~ s r
for d o l n g ?
1 - Was it for fun, kicks, or excitement?..................................... 1. Yes

2 - Was it to relax or relieve tension? .... ................................... 1. Yes
3 - Was it to feel good or get high?............................................ 1. Yes
4 - Was it to have a good t h e with your friends?.......................... 1. Yes
5 - Was it to fit in with a group you like?................................... 1. Yes
6 - Was it to get away from your problems or troubles?.................. 1. Yes
7 - Was it because of boredom, nothing else to do? ....................... 1. Yes
8 - Was it because of anger or frustration?.................................. 1. Yes
9 - Was it to help yourself fall asleep?....................................... 1. Yes
10 - Was it to help yourself stay awake?..................................... 1. Yes
11 - Was it to help manage your weight? .................................... 1. Yes
12 - Was it to help get rid of a hangover?................................... 1. Yes
15 - Was it for any other reason? (specify:) ............................... : 1. Yes
Page 6
2A. Have you EVER taken or used smokeless tobacco? Other names for smokeless
tobacco are snuff, plug, dipping tobacco, and chewing tobacco..
(CIRCLE ONE ANSWER)
NO.. . . . . . . . . . . . . O -
Doesnt Understand. . . 5 -
1
Yes. . . . . . . . . . . . . .1
2B. About how old were you when you first used smokeless tobacco?
Years Old
How many days have you used smokeless tobacco.. .

Never 1-2 3-5 6-11 12-24

Days Days Days Bays
2C. Ever in
your whole life?
1 2 3 4
5 1 6 1 7 1 8
2D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

Days Days Days Bays Days Days
2E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 7
How did you get any smokeless tobacco you used during the last 30 days?
1-Did you use what was in the house?..................................... 1. Yes 0. No

2-Did you buy it from friends, family, or other people you know?... 1. Yes 0. No
3-Did you buy it from a store?............................................... 1. Yes 0. No
4-Did others share it with you? ............................................... 1. Yes 0. No
*-Did others give it to you? .................................................. 1. Yes 0. No
6 -Did you trade things for it? ................................................ 1. Yes 0. No
8 -Did you steal it?............................................................. 1. Yes 0. No
10-Did someone else buy it for you? ......................................... 1. Yes 0. No
During the past 12 months, when you used smokeless tobacco, what have been your mpst
I?
1 .Was it for fun, kicks, or excitement?..................................... 1. Yes 0. No

2 - Was it to relax or relieve tension?........................................ 1. Yes 0. No
3 .Was it to feel good or get high? ............................................ 1. Yes 0.No
4 - Was it to have a good time with your friends?.......................... 1. Yes 0. No
5 - Was it to fit in with a group you like?................................... 1. Yes 0. No
6 - Was it to get away from your problems or troubles?.................. 1. Yes 0. No
7 - Was it because of boredom, nothing else to do? ....................... 1. Yes 0. No
8 .Was it because of anger or frustration? .................................. 1. Yes 0. No
9 - Was it to help yourself fall asleep?....................................... 1. Yes 0. No
10 - Was it to help yourself stay awake?..................................... 1. Yes 0. No
11 - Was it to help manage your weight?.................................... 1. Yes 0. No
12 - Was it to help get rid of a hangover?................................... 1. Yes 0. No
15 - Was it for any other reason? (specify:) ................................ 1. Yes 0. No
Page 8
The next questions are about drinking alcohol, including BEER, WINE, WTNE CQQEW,
and LIQUOR, like scotch, gin, vodka.
3A. Have you EVER had a drink of beer, wine, wine cooler, or hard liquor - not just a
sip or taste? (CIRCLE ONE ANSWER) SLq5AO
No... . . . . . . . . . . . O -
Yes. . . . . . . . . . . . ..l
3B. About how old were you when you first drank alcohol?
Years Old
Not including sips or tastes, how many days have you drank alcohol?
:1 1 1111
Never 1-2 3-5
Days Days
Everin
our whole life?
During the
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

Days Days Days Days Days Days - a
i
3E. D-wing the 0 1 2 3 4 5 6 S&3LO
last 30 days?
Page 9
3F. During the last 30 days how many times have you had 5 or more drlnks in a row? Would
you say.. .
0 - None
1 -Once
2 - Twice
3 - 3-5 times
4 - 6-9 times
5 - 10 or more times
3G. During the past 12 months, about how many times have you gotten drunk or very high on
alcohol?
Number of times drunk or very high in the past 12 months

__
Page 10 . ..,
The next few questions are about beer only. -7
I
4A. Have you EVER had a drink of beer - not just a sip or taste?
(CIRCLE ONE ANSWER)
NO... . . . . . . . . . . . O -
DoesntUnderstand. . . 5 -
Yes. . . . . . . . . . . . . .1
4B. About how old were you when you first drank a can of beer -- not just a sip or a taste? s b4 8 0 .
Years Old
How many days have you drank beer - not just a sip or taste.. .
r
(CIRCLEONE ANSWER FOR EACH ROW)
I 1
- ~-
. .,
Never 1-2 3-5 6-1 1 12-24 2004-
Days Days Days Days Days
-
K: Ever in 1 2 3 4 8
our whole life? -
During the 1 2 3 4 8
last 12 months? -
4
Never 1-2 3-5 6-9 10-14 15-20 21+
Days
4E. Duringthe 0 1
last 30 days?
l2 months, Go t o Q. 41
Page 11
4G. On those days when you drank beer, about how many drrnks did you have? stc+%i,
Usual number of bottles or cans per day on the
days you drank in the past 30 days
How did you get any beer you drank durikg the last 30 days?
1;Did you use what was in the house?..................................... 1. Yes 0. No

tt
2-Did you buy it from friends, family, or other people you know? ... 1. Yes 0. No
4-Did others share it with you?............................................... 1. Yes 0. No
5 -Did others give it to you? .................................................. 1. Yes 0. No
6 -Did you trade things for it?................................................ 1. Yes 0. No
41. During the past 12 months, when you drank beer, what have been your
. .
?-

2 .Was.it to relax or relieve tension?........................................ 1. Yes 0. No
3 .Was it to feel good or get high?............................................ 1. Yes 0. No
4 .Was it to have a good time with your friends?.......................... 1. Yes 0. No
5 .Was it to fit in with a group you like?................................... 1. Yes 0. No
6 .Was it to get away from your problems or troubles?.................. 1. Yes 0. No
7 .Was it because of boredom, nothing else to do?....................... 1. Yes 0. No
8 - Was it because of anger or frustration?.................................. 1. Yes 0. No
10 - Was it to help yourself stay awake?. .................................... 1. Yes 0. No
11 .Was it to help manage your weight?.................................... 1. Yes 0. No
Page 12
-
The next few questions are about wine and wine coolers only.
5A. Have you EVER had a drlnk of wine or wine coolers - not just a sip or taste?
(CIRCLE ONE ANSWER) SL3-90
NO... . . . . . . . . . . . 0 -
Doesnt Understand. . . 5 -
Yes. . . . . . . . . . . . . .1
5B. About how old were you when you first drank a glass of wine or wine cooler -- not just a sip
or a taste? -
Years Old
How many days have you drank wine or wine coolers .not just a sip or taste...
:1 1 1 1 1 1 1
~ Days Days
Everin
our whole life?
~
During the
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

5.s
5E. Duriagthe 0 1 2 3 4 5 6 5&52?0
last 30 days?
Page 13
On those days when YOU drank wine or wine coolers, about how many drlnks did you have?
Usual number of glasses per day on the

SLL 5-60
How did you get any wine or wine coolers you drank during the last 30 days?
1 9 i d you use what was in the house?..................................... 1. Yes 0. No

4-Did others share it with you? ............................................... I. Yes 0. No
During the past 12 months, when you drank wine or wine coolers, what have been your
for
. . ?
1 - Was it for fun, kicks, or excitement?..................................... 1. Yes 0. No

2 - Was it to relax or relieve tension?........................................ 1. Yes 0.No
3 - Was it to feel good or get high? ............................................ 1. Yes 0. No
6 .Was it to get away from your problems or troubles?.................. 1. Yes 0.No
7 - Was it because of boredom, nothing else to do? ....................... 1. Yes 0. No
11 .Was it to help manage your weight? .................................... 1. Yes 0: No
Page 14
The next few questions are about hard liquor. Hard liquor includes scotch, gin, vodka and
mixed drinks like rum and cokes, gin and tonics and screwdrivers.
I I
6A. Have you EVER had a drink of liquor - not just a sip or taste?
shM40
(CIRCLE ONE ANSWER)
NO. . . . . . . . . . . . . . 0 -
Yes. . . . . . . . . . . . . .1
6B. About how old were you when you first drank a mixed drlnk or shot of hard liquor -- not just a
sip or a taste?
Years Old shb6/3*
How many days have you drank hard liquor - not just a sip or taste...
i
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

If never i
>
Never 1-2 3-5 6-9 10-14 15-20 21+ p*

Ske620
6E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 15
6G. On those days when you drank liquor, about how many mixed drinks or hard liquor did you
Usual number of drrnks per day on the

* 6H. How did you get any liquor you ~ a n during

k the last 30 days?
'>
SLL 6fe 1-bid you use what was in the house?..................................... 1. Yes 0. No
8 -Did you steal it? ............................................................. 1. Yes 0. No
10-Did someone else buy it for you? ......................................... 1. Yes 0.No
SA bsc/a
61. During the past 12 months, when you drank liquor, what have been your
. .
reasons?.
1 - Was it for fun, kicks, or excitement?................................. :... 1. Yes 0.No
2 - Was it to relax or relieve tension? ........................................ 1. Yes 0.No
3 - Was it to feel good or get high?............................................ 1. Yes 0. No
4 - Was it to have a good time with your friends?.......................... 1. Yes 0.No
5 - Was it to fit in with a group you like? ................................... 1. Yes 0.No
7 - Was it because of boredom, nothing else to do?....................... 1, Yes 0. No
8 - Was it because of anger or frustration?.................................. 1. Yes 0.No
11.- Was it to help manage your weight? .................................... 1. Yes 0. No
Page 16
The next questions are about other drugs.

- 3
7A. 1. Do you know what marijuana or hashish is? Other names are grass, pot, hash and hash oil. ___
No ....0
Yes.. .1
7A.2. Have you EVER used marijuana or hashish? (CIRCLE ONE ANSWER)
NO.........0 -
Yes ........1
33. About how old were you when you used marijuana or hash, even once?
Years Old
How many days have you used marijuana or hash...

100-
199
Days
7
If A.1
Never 1-2 3-5 6-9 10-14 15-20 21C

7E. Duringthe 0 1 2 3 4 5 6
last 30 daw?
Page 17
7F. How did you get any marijuana that you used during the last 30 days?

3-Did you buy it from a dealer?.............................................. 1. Yes 0. No
4-Did others share it with you? ............5 . . ................................ 1. Yes 0. No
6. -Did you trade things for it? ................................................ 1. Yes 0. No
7G. During the past 12 months, when you used marijuana, what have been your
for so-?
1 .Was it for fun, lucks, or excitement?..................................... 1. Yes 0. No

2 .Was it to relax or relieve tension?........................................ 1. Yes 0. No
6 .Was it to get away from your problems or troubles?.................. 1. Yes 0.No
7 - Was it because of boredom, nothing else to do?....................... 1. Yes 0. No
10 .Was it to help yourself stay awake?..................................... 1. Yes 0. No
12 - Was it to help get rid of a hangover? ................................... 1. Yes 0.No
Page 18
8A. 1. Do you know what cocaine is? Other names for cocaine are: coke, snow, crack,
freebase, or cocoa paste.
No.. .O S M A4
Yes.. 1
I
-.-.
.
8A.2. Have you EVER used Cocaine or Coke in any form, such as powder (or Snow),
.,
crack, freebase, or cocoa paste? (CIRCLE ONE ANSWER)
No.. ..O
Yes ...1
8B. About how old were you the first time you used cocaine, in any form?
Years Old
How many days have you used any form of cocaine -- powder cocaine, crack, freebase or cocoa
paste..
1$I I 1Everin
our whole life?
During the
last 12 months?
Never 1-2
Days
51-99
Days
6
100-
199
Days
7
7
200+
Days
Never 1-2 3-5 6-9 10-14 15-20 21+

8E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 19
8F. How did you get any cocaine that you used during the last 30 days?

4-Did others share it with you? ............;... ............................... 1. Yes 0. No
. .
6;-Did you trade things for it? ................................................ 1. Yes 0. No
7
8 -Did you steal it? ............................................................. 1. Yes 0. No
[()-DidSomeone else buy it for you? ......................................... 1. Yes 0. No
8G. During the past 12 months, when you used cocaine, what have been your
for d o j l l g ? .

3 .Was it to feel good or get high? ............................................ 1. Yes 0. No
8 .Was it because of anger or frustration?.................................. 1. Yes 0.No
9 .Was it to help yourself fall asleep?....................................... 1. Yes 0. No
12 .Was it to help get rid of a hangover? ................................... 1. Yes 0. No
Page 20
These questions are just about crack. Crack is cocaine in a sock OF chunk form.
NO..........................
Doesnt Understand.. ...5 -
Yes .........................
0-
1
I
9B. About how old were you when you first used crack even once?
Years Old sec 9 6 0

How many days have you used crack.. .
Never 1-2 3-5 6-9 10-14 15-20 21+

9E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 21
How did you get any crack that you used during the last 30 days?
I-Did you use what was in the house?..................................... 1. Yes 0. No

2-Did you buy it from friends, family, or other people you know?. .. 1. Yes 0. No
4-Did others share it with you? ............ ;. ................................. 1. Yes 0. No
Id
During the past 12 months, when you used crack, what have been your
for dorng?...
1 .Was it for fun, lucks, or excitement?..................................... 1. Yes 0. No

2 .Was it to relax or relieve tension?........................................ 1. Yes 0.No
6 - Was it to get away from your problems or troubles?.................. 1. Yes 0.No
7 - Was it because of boredom, notlung else to do?....................... 1. Yes 0. No
12 .Was it to help get rid of a hangover?................................... 1. Yes 0. No
JLL 96&- 15 - Was it for any other reason? (specify:) ................................ 1. Yes 0. No
Page 22
10A. Have you EVER W e d or sniffed anything like glue, gasoline, paint or markers to
get high? (CIRCLE ONE ANSWER)
NO...........................
..................
0-
Doesn't Understand.. ......5 -
Yes ........................... 1
""
10B. About how old were you when YOU first lnhaled or sniffed a spray, liquid or anything else to
get high, even once?
How many days have you dialed or sniffed anything to get high.. .
Never 1-2 3-5 6-9 10-14 15-20 21+

10E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 23
IOF. How did you get any of these things that you sniffed during the last 30 days?
5~2 1-Did you use what was in the house?...................................... 1. Yes 0.No
SLd f o F L 2-Did you buy it from friends, family, or other people you know? ... 1. Yes 0.No
SL2 3-Did you buy it from a store?............................................... 1. Yes 0. No
/ O F 4 4-Did others share it with you? ................................................ 1. Yes 0. No
&*~ifEk-5- 5 -Did others give it to you? .................................................. 1. Yes 0. No
5~ fc,c6- 6.,,-Did you trade things for it? ................................................ 1. Yes 0. No
1
loF 8 8 -Did you steal it?............................................................. 1. Yes 0. No
5k /oF-j/o10-Did someone else buy it for you? ......................................... 1. Yes 0. No
10G. During the past 12 months, when you sniffed these things, what have been your m ~ s t
?-
$.& 1 .Was it for fun, kicks, or excitement?..................................... 1. Yes 0. No

S u ;1%162 2 - Was it to relax or relieve tension?. ....................................... 1. Yes 0. No
S& ;/os 3 3 - Was it to feel good or get high? ............................................ 1. Yes 0. No

su +o6 ,+ 4 - Was it to have a good time with your friends?. ......................... 1. Yes 0. No
su f ~ 56 5 .Was it to fit in with a group you like?................................... 1. Yes 0. No
sa /o66 6 - Was it to get away from your problems or troubles?. ................. 1. Yes 0. No
.So ;/o 67 7 - Was it because of boredom, nothing else to do? ....................... 1. Yes 0. No
K /Q E # 8 - Was it because of anger or frustration?. ......:. ......................... 1. Yes 0. No
yu 9 9 - Was it to help yourself fall asleep?....................................... 1. Yes 0. No

92 fQ6/0
11 - Was it to help manage your weight? .................................... 1. Yes 0. No
S& f o g / /
SLL fOk'/L
15 - Was it for any other reason? (specify:) ................................ 1. Yes 0. Nu
40G/.3--
Page 24
--.
11A. Have you EVER used any other h d s of drugs to get high or change the way you
feel? This includes drugs you may have used on your own, that is, without a
I doctor's prescription, or drugs that were prescribed for you but you used them
I just to get high. (CIRCLE ONE ANSWER) -.-
No .......................... 0 - Go to Section ZI, page 26 _-
Doesn't Understand.. ..-5 - Go to SectiOn E, page 25

Yes ......................... 1
11B. About how old were you when you first used any of these other kinds of drugs?
How many days have you used other kinds of drugs.. .

Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

Days
11C. Ever in 1 2 3 4 5 6 7 8
your whole life?
11D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months? *
Never 1-2 3-5 6-9 10-14 15-20 21+

11E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 25
11F. What types of other drugs have you taken to get high?
Page 26
Section 11: Perceptions of Drug Risk
These questions are about how much YOU think people might h a themselves when they smoke
cigarettes, drink alcohol, or use drugs.
On each one, I want you to think about how much a person might hurt themselves if they do different
things - Do you think that: they wopf,' hurt themselves,
they Drobablv WQef I hurt themselves,
they hurt themselves, or
they definitelv wjJl hurt themselves?
S&99
1. How much do you thmk a person would hurt themselves if they smoke one or more packs of cigarettes
each day? Do you think that they definitely won't hurt themselves, they probably won't hurt themselves,
they probably will hurt themselves, or they definitely will hurt themselves?
1 2 3 4
definitely probably probably definitely
won't won't will will
..
abo- S A &A
2. How much do you think a person would hurt themselves if they try marijuana once or twice? Do you
thlnk that they definitely won't hurt themselves, they probably won't hurt themselves, they probably will hurt
themselves, or they definitely will hurt themselves?
1 2 3 4-
def d t e ly probably probably definitely
won't won't Will will
3. How about if they smoke marijuana every now and then? Would you say they.. .(read choices) SA5 4 3
1 2 3 4
4. How about if they smoke marijuana regularly (pretty ofren)? Would you say they.. .(read choicq) S A 8 4'
1 2 3 4 _.
definitely probably probably defrnitely
won't won't WiII will
-. "
Page 27
are about uhaknk- S&A5
5. How much do you thlnk a person would hurt themselves if they try inhalants once or twice? Do you thmk
that they definitely won't hurt themselves, they probably won't hurt themselves, they probably will hurt
themselves, or they definitely wiIl hurt themselves?
1 2 3 4
definitely probably probably definite1y
6. How about if they use lnhaiants regularly (pretty often)? Would you say they.. .(read choices) SlC A6'
s 7
1 2 3 4
won ' t won't will will
are a b o m S&AZ
7. How much do you think a person would hurt themselves if they try cocaine once or twice? Do you thmk
1 2 3 4
8. How about if they use powder cocaine every now and then? Would you say they ...(read choices) S& *a8
1 2 3 4
9. How about if they use powder cocaine regularly @retry open)? Would you say they.. .(read choices) Sie A3
1 2 3 4
def ~ t ey l probably probably definitely
out crack. gLL4Vo

10. How much do you think a person would hurt themselves if they try crack once or twice? Do you think
themselves, or they defrnitely will hurt themselves?
-
1 2 3 4
Page 28
11. How about if they use "crack" cocaine every now and then? Would you say they.. .(read choices) s&A if-?
1 2 3 4
won't won't - will will
12. Use "crack" cocaine regularly @refly often)? Would you say they.. .(read choices) sk,8
1 2 3 4
definitely probably probably defrnitely
are about alcohal-.- or IQ 1'& 5'LC A7/3

13. How much do you thlnk a person would hurt themselves if mey have one or two drinks of alcohol nearly
every day? Do you think that they definitely won't hurt themselves, they probably won't hurt themselves,
1 2 3 4
defrnitely probably probably definitely
14. How about if they have four or five drinks of alcohol nearly everyday? Would you say they ...(read
choices) S& 4 f9
1 2 3 4
15. How about if they have five or more drinks of alcohol twice a week? Would you say they ...(read
choices) S& p i9-
1 2 3 4
definitely probably probably definitely #-*
won't won't wili will
Now I am going to ask you some questions about how easy or hard it would be for you to get alcohol or
drugs if you wanted to. For each one, I want you to decide if it would be very easy to get, pretty easy
t o get, very hard to get, or probably impossible to get.
16A. How easy or hard would it be for you to get cigarettes? Would it be probably impossible to get, very
hard to get, pretty easy to get, or very easy to get? sf&Waffo
1 2 3 4
Probably Very Pretty Very
Impossible Hard &Y k Y
16. How about beer, wine, or liquor? Would it be. ..(read choices) SzL&/'6
1 2
Probably Very
Impossible Hard
17. How about Marijuana? Would it be.. .(read chpices) 5&&q.
* 1 2
Probably Very
Impokible Hard
18. How about LSD? Would it be ...(read choices) /8

1 2
Probably Very
Impossible Hard
19. How about PCP? Would it be ...(read choices) S& A /Q

1 2 3 4
Probably Very Pretty Very
Impossible Hard b Y &Y
20. How about Cocaine or "crack"? Would it be ...(read choices) &-& 4 @
1 2 3 4
Probably very Pretty very
Impossible Hard b Y M Y
21. How about Heroin? Would it be.. .(read choices) SA A Z /

1 2 3 4
Probably very Pretty Very
Impossible Hard b Y EUY
22, In the past month, has someone tried to sell you drugs? Yes 1
Sic:Ad,& No 0
WRAT
CAUTION: EXAMINER USE ONLY!
A B O S E R T H U P I V Z J Q
I: milk &was
milk wu 2
7 letter t city
Iet-Zr sit-ec
. ~ ..~ ~ ~ - . __ ~
;:stalk i: grunt
stawk grunt
___ ~ . _ _ ____ ... ..
'2 sour :i. humid it y

sowr hyoo-mid-i-tee
- c' urge rancid

I.:
urj ran-sid
..: quarantine ;4 deteriorate

kwor-&-teen di-teer-i-Z-rayL
27 rescinded
ri -sind -cd
:--mitosis 2; protuberance 2i longevity c;:predilection

rnytoh-sis proh-too-b;-r&s Ion-jev-i-tee pred-i-lek-shon
regime 3; beatify - 5 internecine

-- c
: regicidal
-7
-
rF-zheem bi - B t -T-fT in-tZr-nee-seen. -nes-een rei - i-si -dal
--.__ __-
;-puerile - 1 - c factitious
-. 2" lucubration
pjoo-e-ril fak-tish-us loo-ky u u - b r a y - s h z n
__ - _ _ -~
:. epithalamion inef_ficacious synecdoche Word Reading +

e p- i - ti1 a-Ioj - rn I 4n In -e f- 1- kag-s h us
___ --
si - n e k -d& kee
Total
5/10R U L E S Reading
Page 4 \H$ WIDE RANGE

HEALTH SCREEN
EIXALTH SCREEN: S
..
Interviewer ID:
7&7#fiArn
Time Started: 1 #!/-flS7py
Now I have some questions about your health.
1. Would you say that in general your health is excellent, very good, good, fair, or poor?
1. - excellent
2. verygood
3. good
4. fair
5. poor
2. Now thinking about your physical health, including being sick or injured,
.
for how many
days during the past 30 days was your physical health not good?
79s 2 5
number of days
.-
3. Now thtnkjnn about your mental health, which includes stress, depression, and problems
with emotions,for how many days during the past 30 days was your mental health not
good?
number of days
ed. init. ed. date

you fiom doing your usual activities, such as self-care, work, or recreation (play)?
#S 4 '
number of days
END OF LNTERVIEW
RECORD TIME: #LWP?Y

PUBERTAL DEVELOPMENT
Pibertd Development Scale
Subject LD: s . / r
NOW,I'm going to ask you some questions about physical development.
1 Would you say that your growth in height has not yet begun to spurt, has barely
started, is definitely underway, or does growth seem completed? (if asked, spurt =
more growth than usual)
1 2 3 4
NO Yes (Barely) Yes (Def~tely) Development Completed
2. And how about the growth of body hair? Would you say that your body hair has not
yet started growing, has barely started growing, or does growth seem completed? (if
asked, body hair = underarm or pubic hair)
1 2 3 4
NO Yes (Barely) Yes (Definitely) Development Completed
ed. init. ed. date
Adapted from Pubertal Development Scale; Petersen, Crockett, Richards, & Boxer (1988).
A self-report measure of pubertal status: Reliability, validity and initial norms.
- m,
m, 117-133.
3. Have you noticed any slun changes, especially pimples? 3
1 2 3
No Yes (Barely) Yes (Definitely)
POYS OdYI
4. Have you noticed a deepening of your voice?
1 2 3 4
rSOYS
5.
only1
Have you begun to grow hair on your face? m5
1 2 3 4
No Yes (Barely) Yes (Definitely) Development Completed
[Girls only]
6. Have your breasts begun to grow?
1 2 3 4.
[Girls only]
7. Have you begun to menstruate (get your period)?
1 2 3
NO Yes (Barely) Yes (Definitely)
7a. What was the date of your first period: PB?dO# m ?my mzAQ
month year
c,
7al. If you dont h o w the date, how old were you?
3 3 ?Ai
age ~~~-~~~~~ --
8. --Howtall are you?

feet inches
9. How much do you weigh? pounds
10. Do you thlnk your development is earlier or later than most other boys/giris y o u age?
1. much eariier
2. somewhat eariier
3. about the same
4. somewhat later
y
5. much later
1 RECORD TIME 1
i
.--
_.
1
Exposure to Violence: Subject Version
Subject ID: LSh/3/iT

Interviewer ID:
FIEm COPY 2 SOARC e 271/PRA/af
2 /vrs 7//v
I
Time Started:.-
I'm going to ask you some questions about violence and how it may have affected you or
your family and friends.
Are you afraid you might be hurt by violence in your neighborhood?

1.
22 !
1.- YES 2. NO
2. Are you afraid you might be hurt your apartment building or house?
SAX/
1. YES 2. NO
3. Are you afraid you might be hurt in your apartment building or house?
1. YES 2. NO
4. Are you afraid you might be hurt by violence at school or work?
I. YES 2. NO
ed. init. ed. date

2
4A. Does this affect where you go?
1. YES 2. NO
1.- YES 2. NO
1.- YES 2. NO
1. YES 2. NO
1. YES 2. NO
9. At what age do you think a child is affected by observing violence? (circle one) &A Q
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
h
3
The questions I'll be asking you now have to do with acts of violence that you may have
witnessed or experienced.
10. Have you ever seen or been present when somebody was shoved, kicked or punched?
2
74 3fl7
'I 1. YES
2. NO
11. When was the last time you saw that?
1. Within last week

3. Withinlast year
1. In your home
2. In your hallway or building
3. In front of your househuilding
4. In your neighborhood
6. At your schoollday care
25. Other (specify) v&4+-o-4fk & d K % i i
13. Did you know the person or people who this happened to?
2A 2 3
1. YES
2. NO
13A. Who was it? (MARK ALL THAT APPLY)
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
6. Other Relative (Specify) -
/
25. Other (Specify)
14. How badly was the person or people injured?

(MARK THAT APPLY) 2.4 7v
1. No injury
2. Knocked down
3. Bl-UiSed
4. Cutmleeding
5. Unconscious
8. Other
15. Did you know the person or people who did this?
1. YES
2. NO
15A. Who was it? (MARKBLL THAT APPLY)
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
6. Other Relative (Specify)
25. Other (Specify) a&mwci//
5
16. Have you seen this more than once?
1. YES
2 . NO
16A. How many times have you seen this in the past year? GAf6t;LO
!Y
16B. How many times have you ever seen this? 2.4Y6k3 0
17. Have you ever seen or been present when someone was attacked with a knife?
1. YES ( A 7fs
2. NO
18. When was the last t h e you saw that?
1. Within last week

3. Withinlast year
1. In your home
6. At your school/day w e
25. Other (specify)
6
20. Did you know the person or people who this happened to? - ( A 20
1. YES
2 . NO

Y
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
6. Other Relative (Specify
25. Other (Specify) ' i t

(MARKBIf, THAT APPLY)
1. No injury
2. Knocked down
3. Bruised
4. Cut/bleeding
5. Unconscious
6. Broken bones/fkacture
7 . M e d i c a l care obtained
8. Other
22. Did they die?
1. YES 2. NO 8. Don't Know '(A A5 2
23. Did you know the person or people who did this? 2-4a 3
- 1. YES
2. NO
7
23A. Who was it? (MARK & THAT APPLY) s4&3&Q

1. Parent
2.- *****
3. Friend
4. Neighbor
. .
5. Siblmg
25. Other (Specify)
24. Have you seen this more than once? SAA4
1 . YES
2. NO
24A. How many times have you seen this in the past year? zk7J44 0
24B. How many times have you ever seen this? .&4 A-9
25. Have you ever heard a gun shot?
1. YES
2. NO
26. When was the last time you heard that?
1. Withinlastweek
3. Withinlast year
8
27. Where did that happen?.
1. In your home
6. At your school/day care
25. Other (specify)
28. Have you heard a gun shot more than once?
1. YES
2. NO
28A. How many times have you hearL this in tue past year? 22 2584 0
28B. How many times have you ever heard this? 24 & 8 & 0
29. Have you ever seen or been present when someone was shot? CFd A 9
1. YES
2. NO
END OF INTERVIEW
RECORD TIME: L
.
._
r
9
30. When was the last time you saw that? ,XA3 0
1. Within last week
3. Within last year
?#, 3 1. Where did that happen?
1. In your home
25. Other (specify)
32. Did you know the person or people who got shot? 24 3J5
1. YES
2. NO
32A. Who was it? (MARK BLL THAT APPLY) 2*43A&O
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
25. Other (Specify)
10
33. Did they die? 24 33 --
1. YES 2. NO 8. Don't Know
34. Did you know the person or people who did this? 2-A 3-9
,--. .
1. YES
i
2. NO
i .
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
25. Other (Specify)

EA 3 5
1. YES
2. NO
35A. How many times have you seen this in the past year? 2A35-Bo - -
35B. How many times have you ever seen this? 2/43 5 - 6 0
"A*
END OF INTERVIEW
SELF-REPORT OF OFFENDING
Self-Report of Offending
Subject ID:
This interview asks about things that people sometimes do. Remember, at the beginning
of the study, I told you about the special protection to ensure your privacy? The Federal
Certificate of Confidentiality makes it illegal for anyone, even your parents or people at
school, to see or find out what your answers are in this study. No one except our
research staff will ever see them. Your answers can never be seen by police, the courts,
your parents, or anyone e k .
I am going to describe some things that people do. M, tell me if you have f4~stdone
any of these things. Then I will ask how many times you have done-the thing during the
last year or last 12 months, that is since...
Refer to firstmonth on the time line.
Please give me your best estimate or guess of the of times you've done each
thing in the last year.
ed. init. ed. date

1
SRO
SECTION I.
You you
awav o v m
m
ve vou ever;
1A. Run away from home and stayed away 1C. How old were you
overnight? s/c / A 0 you did this? S Z SC 0
1. Yes -
0. N O -
-,
1D. Whenwas- * you did

1B. HOWmany times have you done this this?
12 months? s& --
SZflB/Y S&i;&Y
month year
# of times
1E. Were you alone or with others?

$& Y.SQ
1. alone
2. with others
1F. Did the police talk to you a b h t

this? 6 2 TF.0
1. Yes
0. No
2
SRO
2 Are you still in grade school/high You w o u had bee-

school? SA2 ol- w L T ~the past:
1. Yes -
'1 0. NO -
2A3. How old were you
ve vou ev- you did this? 34 & A 5
2A1. Absent from school without an excuse?
S&AAf
1. Yes - 2A4. Whenwas- YOU
0. NO - were absent from school without
an excuse?
2A2. How many times have you done this --
SkL%W& s&U4y
e?
SRJA#& month year
# of times
1- 2B3. How old were you

2B 1. Absent from gradehigh school without you did this? 5&A435
an excuse? seZA5/
1. Yes -
0. N O -
2B4. Whenwas- YOU
were absent from grade/~igh
2B2, HOWmany times in your W school without an excuse?
did you do this? ,EBczd3&~ sAJB&g
month year
SA&&&
# of times
3
SRO
voud- a hidden
3A. Carried a hidden weapon? 3C. How old were you

S& 3AO you did this? S ,3~ 0
1. Yes-
0. N O -
3B. How many times have you done this 30. When was & last time YOU
12 mQ.&s ? carried a hidden weapon?
SR 3/30
523B. s43;b5p
# of times month year
P,
4
SRO
ve vou ever;
4A.il Caused trouble in a public place so that

people complained about it, such as
being loud or disorderly? 4c, How old were you
SA 440 you did this? 4-22 4 C 0
1. Yes -
0. NO-
4B. How many times have you done ths 4D. When was you did
m?
S& 4/30
this?
S 2 4 3 N &&+PBY
month year
# of times
4E. Did the police talk to you about

this? $4 +so
1. Yes
0. No
5
SRO
e vou ever;
5A. Purposely damaged or destroyed

that did not belong 5C. How old were you
to you? (for example, breaking, cutting you did this? S& 5 C O
or marking up something)
S& 5 - 0
1. Yes-
0. N O -
5D. Whenwas- you did
this?
5B. HOWmany times have you done this J&.GZii?Y
SZ?~z?&L
V? month year
Sdz tW30
#of times

S& 3-20
1. alone
2. with others
5F. Did the police talk to you about

this? sie 5 7 0
1. Yes
0. No F.2
6
SRO
6A. Purposely set fire to a house, building, 6C. How old were you
w, or vacant lot? $4 6/40 you did this? SR 6-cO
1. Yes -
0. N O -
6D. When was & last t

hyou did
v? S& 6 6 0 J26;OM SA6a.9
month year
# of times

S& 6SO
1. alone
2. with others

this? .g)z, 6 F Q
1. Yes
0. No
7
SRO
7A. Entered or broke into a building to steal 7C. How old were you
something? SR- 740 you did this? SR jc0
1. Yes -
0. N O -

?- SR.?L&C) --
LS6e-zM SR-72Y
month year
# of times

SP, 7 0
1. alone
2. with others

thLs? S& J F O
1. Yes
0. No L,
-__--
-
SRO
You
em-
ax$
8C. How old were you
8A. Stolen something from a store? you did this? &@ 8 C O
SR 8/90
1. Yes -
0. N O -

?-
SA &B0
s&?a/Y J z & A y
month year
# of times
8E. What was the total cost of the

items you stole? .5&&eo
$-,------
8F. Were you alone or with others?

8FO
1. alone
2. with others
8G. Did the police or store security

guards taik to you about this?
Ge 860
1. Yes
0. No
9
SRO
You you
vou e v E
9A. Taken something that did not belong to 9c. How old were you
you from any member of your you did this? SR vco
household? SR QAO
1. Yes -
0. NO-
9B. When wa ShLk & you did
this?
9B. HOWmany times have you done this 5..9B/Y F(je9aY
?- month year
sk?9430
# of times

9-60
1. alone
2. with others

this? SX?PFO
1. Yes
0. No
10
SRO
did not
- b
10. Have you ever had a job? past;

5'84 5
90
'I
1. Yes - 1OC. How old were you
0. N O - you did this? &Z #oCO

*
10A. Taken something that did not belong to this?

you from your place of work or your S&?i/D;s/l/s&t?~g
employer ? month year
SR 7.0.40
1. Yes -
0. N O -
10E. Were you alone or with others'?
JX Y Q 2 U
10B. HOWmany times have you done this 1. alone
?- 2. with others
J.2- / D A D 10F. Did your supervisor find out
# of times about this? SL / O F 0
10G. Did he/she call the

police? -p'o 60
1. Yes
0. No
11
SRO
vou e v a
11A. Snatched someone's purse or wallet or 11C. How old were you
picked someone's pocket? you did this? J& ,
y
[
o
SR
1. Yes -
0. N O -
11D. Whenwas- . you did

V? J& //AN sx7?/2w
sbf2 7v.430 month year
# of times
1IE. were you alone or with others?

s i 7?20
1. alone
2. with others
11F. Did the police talk to you abou

this?
1. Yes
0. No 8.i
12
SRO
You 1
to vpu
12A. Taken something that did not belong to 12C. How old were you
you from a car? $22 9 A f f O you did this? Sk /ACO
1. Yes -
0. N O -
12D. When was you did

~3 the past 12 d? SiZfAAw Se/AW
SA?/.A 430 month year
# of times

S& A560
1. alone
2. with others

this? SA? f 4 F Q
1. Yes
0. No
13
SRO
ve vou ever;
13A. Knowingly bought or sold stolen goods? 13C. How old were you
C . /3AO you did this? S& f 3 C O
1. Yes -
0. N O -
13B. HOWmany times have you done this 13D. Whenwas- you did
17. m? this?
S'R f 3 450 &22/3BM SMf3W
month year
# of-times

SR f 3 S Q
1. alone
2. with others

this? S& f 3 F O
1. Yes
0. No h
14
SRQ
ve vou ever:
-!
14A. Stolen a car or motorcycle to keep or 14C. How old were you
sell? %5A &h40 you did this? ~4~4
1. Yes -
0. N O -

V? 5&5/4B& sbZ/+3y,
SA ;/L//30 month year
# of times

J 2 7.920
1. alone
2. with others

this? JZ/&FO
1. Yes
0. No
15
SRO
You evou . .
v'to wv for
ve vou ever;
15A. Used checks illegally to pay for 15C. How old were you
something? SP, f5.90 you did this? && f3-c~
1. Yes-
0. N O -
15D. Whenwas- ' you did

15B. How many times have you done this this?
V? --
s.2A3-a
Csk?725-&Y V
.
s
e2 Y5AO month year
# of times

this? Sk 73-so
1. Yes
0. No
16
SRO
~~
vou
ds
. . .
e-
16A. Used credit or bank cards without the 16C. How old were you m
owners permission? Sd .-/BAD did this? f6C0
1. Yes - Age
0. N O -

u)the past 12 months? - 5&&BY
S&ir6/i3/4/ -
Sbe / 6 / 3 0 month year
# of times
16E. Did the police talk you about

this?
P6@ /&SO
1. Yes
0. No
17
SRO
17A. Sold marijuana or pot? f7&o 17C. How old were you
you did thu? sg /?CO
1. Yes -
0. NO-
17B. HOWmany times have you done this

V? 17D. When was you did
S& 77430 this?
--
sg7$z-wy cs.&/zDY
month year
# of times

Jv Y72B
1. alone
2. with others

this? &e 97F-0
1. Yes
0. No
18
SRQ
t vou c o c m
ve YOU e v a
i ,#
18A. Sold cocaine or crack? - / s @ ~18C. How old were you

sg ~ R C Q
J - ~
you did this?
1. Yes -
0. N O -
18B. HOWmany time have you done this in 18D. When was you did
this?
L.r& +&BO $2/8A&' Sk?f&%Z/
month year
# of times

S& .A8250
1. alone
2. with others

this? 98 /aFo
1. Yes
0. No
19
SRO
ever L
19A. Sold heroin? 222 et40

1. Yes - you did this? SR i@c0
0. NO-
19B. How many times have you done this

SPQ this?
sk!a- -
J 2 ? Sk?/Q8Y

s-z f9SO
1. alone
2. with others

this? sk??@L9dj=u
1. Yes
0. No
P$
20
SRO
ve vou ever;
? 20C. How old were you
20A. Hit someone * with you did this? $4
the idea of hurting them?
S&WRO
1. Yes -
0. N O - 20D. Whenwas- you did
this?
--
csg&uBM S&20B.y
20B. HOWmany times have you done this month year
1~ the p t 12 d?
s&2&!30
# of times 20E. Who did you hit? c u d 0
(CIRCLE ALL THAT APPLY)
1. sibling 2. mother
3. father 4. child
5. partner 6 . roommate
7. other (specify):
a. Sk Lf?/DR
b. SleOsLaA
c. se -e
20F. Was anyone you hit hurt
seriously enough to see a
doctor? sg.Lo-
1. Yes
0. No
20G. Did the police talk to you about

this?
1. Yes
0. No
-.
21
SRO
... .
You siid VOU -one
t live with the
ou ever;
21C. How old were you the first time
you did this? gg j c o
1
21A. Hit someone with vou W t live

with the idea of hurting them?
$&UciAO
1. Yes - Go to Q. 21B
-
0. N o - G ~ r n Q . 2 2 A 21D. Whenwas- you hit
someone with the idea of hurting
them?
2 1B. How many times have you done this C&AfWY JA4/BY --
?- month year
SRBMO
Of this
# of times 21E. Who did you hit? S L G g f ~ B
(CIRCLE ALL THAT APPLY) , . -,
3. father 4. child
5 . partner 6 . roommate
7. friend 8. neighbor
9. acquaintance
10. gang member 11. stranger
12. other (specify):
a. JZ?ee res04
b. S& L f S D b
C. sue &fEOC
21F. Was anyone you hit kzrt
seriously enough to see a 4
doctor? G e &7vx)
1. Yes
0. No

*...A
this? S& A / G O
1. Yes
0. No
22
SRO
You vou
with a w m the
you did this? g~
224. Attacked someone with a weapon?
S&&JA.O
1. Yes -
0. N O - 22D. When was you did
this?
L.3&2B@ S0eALBY
ast 12 months?
last
S.A&AO
22E. 1, Who did you attack? Sk?A L E/
# of times (CIRCLE ALL THAT APPLY)
3. father 4. child
5 . partner 6 . roommate
9. acquaintance
10. gang member 1 1. stranger
a. S R &zaE;/OA
b. SRXS Sf043
C. sje 6ur722e:
22E. Were you alone or with others
1. alone SA?AJSl
2. with others
22F. Was this person hurt seriously

enough to see a doctor?
1. Yes SRL-GFO
0. No

this?
1. Yes ~ b & # & 6 0
0. No
23
SRO
23A. Used a weapon or force to get money or 23C. How old were you
things from people? S&J3&0 you did this? s2 R3
1. Yes -
0. N O -
23D. When was J;hp last timg you did
this?
23B. HOWmany times have you done this --
S & 5 3 ~ !sk?232y
?- month year
S& A 3 A 0
# of times
23E. Where did this occur?
1. school
2. playground
3. street
4. business
5 . bar
6 . car
7. other ~X~5350

$4 06 3FO
1. alone
%
2. with others
23G. Did the police taik to you about

this? SRR34O
1. Yes
0. No
24
SRO
24A. Thrown objects, such as rocks or bottles,

$$

at people (other than events you have you did this? sg A&CQ
already mentioned)? g& ~4.4 0
1. Yes -
0. N O -
'
this?
24B. HOWmany times have you done this J&J&mY si24ay
V? month year
SpeJ4y3s
# of times

sz a920
1. alone
2. with others

this? SI$A YFC3
1. Yes
0. No
25
SRO
beebvolved in a
dw i w
25A. Been involved in a gang fight in which 25C. How old were you
someone was hurt or threatened with you did this? ~ ~ - ~
harm? SdQL5AO
1. Yes -
0. N O -
this?
25B. HOWmany times have you done this JZ&3-.fl sz'd5-.y
?- month year
J2?&5k30
# of times
25E. Were weapons used?

S42560
1. Yes
0. No
25F. Was anyone hurt seriously

sz?a5-Fo
1. Yes
0. No
t-6
26
SRO
You avou have had or
e vou ever; 26C. How old were you

you did this? 0
26A. Had or tried to have sexual relations
with someone against their will?
Jl A 6 40
1. Yes - 26D. When was you did
0. NO- this?
S @ < X D f l SZ=&5~Y
month year
1JI the ? 26E. Were you alone or with others?
~Li%23o 1. done -94?Z6SO
2. with others
# of times
this? g&aZt5+/=0
1. Yes
0. No
26G. Did you know this person?

1. Yes S&26&0
0. No
26H. Was this person the opposite sex

or same sex? gig ~ 6 ~ 0
1. same sex
0. opposite sex
261. Did you physically harm or

threaten to hurt this person to
get them to have sex with you?
1. Yes S&A6/0
0. No
27
SRO
be- bv s m
the past;
ve vou ever;
27A. Been paid by someone for having sexual you did this? sg 2 7 ~ 0
relations with them? X ~ ?J r 0 ~
1. Yes -
0. N O -
this?
27B. HOWmany times have you done this J z 2 g B M SP2ZJAY
month year
# of times
27E. Did the police tallc to you about

this? sle U2;zGO
1. Yes
0. No
28
SRO
You & vou used a

to trv to -bo
not m d to 111 the past;
28A. Used a false name or alias to try to

"' obtain something you were not entitled
to, such as a job or bank loan?
you did this? s&agci;,
1. Yes -
0. N O -

this?
28B. HOWmany times have you done this .J@&?;wr G'e -4aa.3
V? month year
SL &&3/30
# of times
28E. Did the police or a government

agent taik to you about this?
S& ~ C ? S O
1. Yes
0. No
29
SRO
ve vou e v K
29A. Given false mformation (other than a 29C. How old were you
false name) on an application for a job, you did this? ~4A qc 8
a tax form, or an application for a loan
or bank account? Sk?'&Q#AO
1. Yes -
0. N O - 29D. When was you did
this?
Sp,.&.sBN @ . z P m
13. months?
'Je&.gAo
# of times
agent talk to you about this?
S&C920
1. Yes
8. No
30
SRO
d welfare -b
t vou w e not
30A. Obtained welfare benefits or

i'funemployment checks that you were not 30C. How old were you
entitled to? 223 3 D 4 0 you did this? J -3
- ~ ~ 0
1. Yes -
0. N O -

~3 the past 12 months? -
J&?dQB/y ~4?3L?BY
SA2 3u/5 0 month year
# of times

s-be SOLO
1. Yes
0. No
31
SRO
vou be-
. .
t for a c l r i v m the pilsf;
3 1A. Been given a ticket for a driving

offense'? s6??3 / 4 0 3 1C. How old were you
you did this? s& 3/c0
1. Yes -
0. N O -
31B. HOWmany times has this happened in 31D. Whenwas- . this

?- S& 3/'AO happened?
L
Sz 3/'3& s i 3/yog;/
month year
# of times:
3fBf. 31E. Have you had your driver's

license revoked or suspended?
sg 3 / 2 0
31B1. Did any of these driving offenses involve 1. Yes
alcohol? 0. No
3/&i
1. Yes
0. No
32
SRO
YOUtaht- v o d driven
when vou n-oet a
e or & you 11c-
ve YOU ever;
32A. Driven a motor vehicle when you did not 32C. How old were you
you did this? j d 3~
-t
have a driver's license or after your
driver's license had been suspended?
Sk.940
1. Yes -
0. N O -

.JZ3&Xw ~~~~
month year
# of times

thB? s6e ac0
1. Yes
0. No
1 1
If any initial question = Yes, Return to Go To Question 33

appropriate follow-up questions in the right hand
column.
33
SRO
SECTION II
33. How old were you the first time in your whole life that you were in trouble with the
police: (Circle Never or record age) -
0. Never S&33AO
34. As a result of any police contact in your life, have any of the followin things ever
happened to you?
34.1. Were you ever warned and released? 0. No 1. Yes S g 34-

34.2. Were you held in jail for some time? 0. No 1. Yes sk 34- a
34.3. Were your parents ever told? 0. No 1.yes S& 34- 3
J.862 $9- 4
34.4. Were school officials ever told? 0. No 1. Yes
34.5. Were you ever referred for counseling? 0. No 1. Yes 5'&34- 5-
34.6. Were you ever sent to a treatment program? SA?k3 4 - 8'

0. No
1. Yes
34.6A. What treatment programs have you been sent to?

k. $
1.
2.
3.
4.
34.7. Did you ever go to juvenile or adult court after being in trouble with the police?
S& 3 4 - ?
0. No
1. Yes
34
SRO
34.7. . Were you ever on probai in? 0. No 1. Yes
34.7B. Have you been fined money? 0. No 1. Yes
34.7C. Did you ever have to make restitution?

(pay them back)? 0. No 1. Yes
'7
34.7D. Have you had to do community service? 0. No 1. Yes
34.7E. Have you lived in a juvenile or correctional center?
O.NO -
1. Yes -
34.7F. How many times have you lived in a juvenile or correctional s& 3+- ,?FO
center?
1. Only once
2. More than once
34.76. What juvenile or correctional centers have you lived in?
1.
2.
3.
4.
5.
35. Of the contacts you have had with the police over the past 12 months, on how many
occasions were you arrested or charged with an offense?
&e 3 5-
# of times
36. For each time you were arrested or charged in the past year, please tell me what you
did, when and where it happened and whether you went to court.
35
SRO
36.1A.What did you do?
h what month and year did this happen? $A 36.-/BO

36.1B. month (circle one): 1. Jan 4.Apr 7. Jul 10. Oct
2 . Feb 5. May 8. Aug 11. Nov
3. Mar 6. Jun 9. Sep 12. Dec
36.1C. year (circle one): 2 . 1995 3. 1996 sit?36- yL.0
In what city and state did this happen?
36.1D. city: 1. Chicago

2. Other:
36.1E. state: 1. Illinois

2. Other: 36- A50
36.1F. Did you go to court because of this? 22e 3 6 - y F o

O.NO -
1. Yes -
36.1G. What type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffk
5 . Other S& 3 6 - 760
h
36.1H. Have you been arrested or charged for anything else?
S& 3-6- 7wQ
O.NO -
1. Yes -
36
SRO
In what month and year did this happen? 5-4 3 6 - - d B Q

d
36.2B. month (circle one): 1. Jan 4. Apr 7. Jul 10. Oct
2. Feb 5. May 8. Aug 11. Nov
36.2C. year (circle one): 2. 1995 3. 1996 r

# Z3 6 - +&co

2. Other: ry&? 96 -2 2
30

2. Other: S2q?6-2sO
36.2F. Did you go to court because of this?
0. N O -
1. Yes -
36.26. What type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffic
5 . Other SA3 3 6 - A GO

s&5 6 - A H 0
O.NO -
1. Yes -
37
SRO
Id what month and year did this happen? sz 36.- 3 h O

3. Mar 6.Jun 9. Sep 12. Dec
36.3C. year (circle one): 2 . 1995 3. 1996 S& 3 6 - 3 C O

2. Other: sg 36-38-0
2. Other: J-k?36- 3x3

d;e 36- 3 F O
c

2. Adult
3. Family
4.Traffic
5 . Other SA 36- 3 6 0
4
38
SRO
~~
In what month and year did this happen?

?l
S&36-- 460 2. Feb 5. May 8. Aug 11. Nov
3. Mar 6 . Jun 9. Sep 12. Dec
36.4C3.year (circle one): 2 . 1995 3. 1996 S&?38-

2. Other: &-&? 36-

2 . Other: 36- 4so
36.4F. Did you go to court because of this? Sic! 36-

O.NO -
1. Yes -
36-46. What type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffic
5 . Other Jie $6--4e7
36.4H. Have you been arrested or charged for anything else? SiE 36- 4Nz,
O.NO -
1. Yes -
39
SRO
what month and year did this happen?

SR 3 6 - 5-40 2. Feb 5 . May 8. Aug 11. Nov
36.5C. year (circle one): 2. 1995 3. 1996 S'R 36-"-5cCa

2 . Other: CAZ3 6 - 5-&0

2. Other: SA?36- 5ZC3
36.5F. Did you go to court because of this? 6-Az 36- 5-F-c)

O.NO -
1. Yes -

2. Adult
3. Family
36.5H. Have you been arrested or charged for anythmg else?
. >.
40
SRO
Zn what month and year did t h ~ shappen?

L#
S& 3 6 - 6430 2 . Feb 5 . May 8. Aug 11. Nov
36.6C. year (circle one): 2 . 1995 3. 1996 s&?

36 - d'co

2. Other: S&.j-W- 623-0

2. Other: J&'36--6&
O.NO -
1. Yes -

2. Adult
3. Family
4.
5.
36.6B. Have you been arrested or charged for anything else? J& 3 6 - 6 M
0. NO - G t i ~ Q ~ ~
1. Yes - G i 5 t i i " Q x A
*-e
41
SRO
-_
--"
Irr what month and year did this happen? _.
36.7B. month (circle one): 1. Jan 4. Apr 7. Jul 10. Oct J% 36- 745-a.
2 . Feb 5 . May 8. Aug 11. Nov 3
3. Mar
n-
6. Jun 9. Sep 12. Dec
36.7C. year (circle one): 2 . 1995 3. 1996

-1
36.70. city: 1. Chicago __

2. Other: SZ?36-7B-o
36.7E. state: 1. Illinois - 2
2. Other: J436- 3.2?0
36.7F. Did you go to court because of this? sk?&L-z-/=c7

0.NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5 . Other &C 36"-7GO

C&?36 - 7W
O.NO -
1. Yes -
. .-
42
SRO
36.8A What did you do?

36.8B. month (circle one): 1. Jan 4.Apr 7. Jul 10. Oct SA336-k%o
2. Feb 5 . May 8. Aug 11. Nov
36.8C. year (circle one): 2. 1995 3. 1996 J-+e3 6 - 8 ,

I

2. Other: s&36-&?m
2. Other: SA2 36-
36.8F. Did you go to court because of this? SA? 36- i!?FQ

O.NO -
1. Yes -

2. Adult
3. Family
36.9H. Have you been arrested or charged for anything else? S& 36--epM
O.NO -
1. Yes -
43
SRO
_.
36.9A.What did you do? 1-
I6what month and year did this happen?
4.Apr SZ36- 9230

-,
36.9B. month (circle one): 1. Jan 7. Jul 10. *ct

2. Feb 5. May 8. Aug 11. Nov 7-3
36.9C. year (circle one): 2. 1995 3. 1996 SL36-
36.91). city: 1. Chicago

2. Other:

2. Other:

Sg36- 27*
0.NO - Eo%&QH
1. Yes - m G

2. Adult
3. Family
4. Traffic
5 . Other S& 3 6 - 9so
O.NO -
1. Yes -
44
SRO

9 4.Apr 7. Jul 10. Oct S& 36-/Q43
36.10B. month (circle one) 1. Jan
36.10C. year (circle one): 2. 1995 3. 1996 J-2236- /oc


2. Other: SA?36'- / D W

2. Other: S&36 - /ot
O.NO -
1. Yes -
36.1OG. What type of court did you go to? 1. Juvenile

2. Adult
3. Family
37. In the past year have you gone to court for any other reason?
1. Yes -
O.NO -
Ir 1
37. For each time you went to court please tell me the reason for your appearance and what
type of court you went to. s-k? 3.3-
37.1A.Why were you in court?
37.1B. What type of court did you go to? 1. Juvenile SE3-3- 7930
2. Adult
3. F d y
4. Traffic
5 . Other Sce s-
/no
Have you been in court in the past year for anythmg other than what you've already told me
about?
1. Yes -
s4? 3?- 25
O.NO -
RECORD TIME: s a Z7/N
37.2A.Why were you in court? P
37.2B. What type of court did you go to? 1. Juvenile r e 37- 2/30
2. Adult
3. Family
4. Traffic
5 . Other SK,.SJ- 223 0
46
SRO
Have you been in court in the past year for anything other than what you've already told me
about? 3?- 3
1. Yes -
0. NO -
1
7
37.3B. What type of court did you go to? 1. Juvenile PA?3-7- 3/30
2. Adult
3. Family
4. Traffic
5 . Other S& 39 - 3/30
+-
about? 5&3;,a-
1. Yes -
O.NO -
37.4B. What type of court did you go to? 1. Juvenile A&$?- +A0
2. Adult
3. Family
4. Traffk
5 . Other J& 32- w 3 Q
47
SRO
about? J2Z 3?- 5
1. Yes - Go to Q.37.5A
0. NO - End.intercfiew
37.5B. What type of court did you go to? 1. Juvenile 3-A-3?- 5-80
2. Adult
3. Family
4. Traffic
5 . Other Cjke 3?- 5-230
about?
1. Y e s -
. ... .......... . sa3.7- 6
O.NO -
37.6B. What type of cow? did you go to? 1.

2.
3.
4.
5.
Have you been in court in the p a t year for anything other than what you've already told me
about?
1. Yes - Go tu 4.37.7A
0. No - Endinterview
1 II
37.7B. What type of court did you go to? 1 . Juvenile

2. Adult
3. Family
4. Traffic
5. Other se 3?- 7 B O
about?
1. Yes -
O.NO -
37.8B. What type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffic
5. Other S& 3 7 - 2 m
END INTERVIEW. mcoRD TIME: s&og7/&

,

Provision of Sociai Relations
mm dd yy
Subject ID: sm/*

Interviewer LD:
PSRS&AF
Time Started: 1 PSKSS7.M
Hand Respondent the Response Card and Read Choices
1= verytrue
2= somewhat true
3= nottrue
1. When I'm with my fiends I feel completely able to relax and be myself pss f
1 - very true
2 - somewhat true
3 - not true
1 -verytrue
2 - somewhat true
-
3 not true
ed. init. ed. date

3. People who know me trust me and respect me. PSS 3
1 - very true
2 - somewhat true
3 - not true
4. No matter what happens, I know that my family will always be there for me should I need
them.
PSS Y
1 - very true
2 - somewhat true
3 - not true
5. When I want to go out to do things, I know that many of my fnends would &(like)
1 - very true PSS 5-

2 - somewhat true
3 - not true
6. I have at least one fiiend that I could tell anything to. PSS6
1 - very true
2 - somewhat true
3 - not true
7. Sometimes I'm not sure if I can completely rely (count) on my family. pSS 7
1 - very true
2 - somewhat true
3 - not true
8. My family lets me know they think I'ma d w h i l e (vaZuabZe)person.

pss 8
1 - very true by,
2 - somewhat true
3 - not true
9. I feel very close to some of my mends. PSS 9
1 -verytrue
2 - somewhat true
3 - not true

5
1 - very true
I
Y
2 - somewhat true
3 - not true
11 People in my family help me h d solutions to my problems.
1 - very true
2 - somewhat true
3 - not true
1 - very true
2 - somewhat true
3 - not true
13 My fiends would take the time to talk about my problems, should I ever want to.
1 - very true PSS Y.3

2 - somewhat true
3 - not true
14. I know my family will always stand by me.

PSS /+
1 - very true
2 - somewhat true
3 - not true
15. Even when I am with my fiends, I feel alone.
1 - very true
2 - somewhat true
3 - not true
IF a 8ubject, To Q. 16
IF a primary caregiver, GO TU Q. 20
16. I have a teacher or coach who I can rs;ly (counr) on and talk to. PSS /6
1 - very true
2 - somewhat true
3 - not true
17. I have a grandparent, uncle, or aunt that I feel close to and who helps me out. pss /i7
1 - very true
2 - somewhat true
3 - not true
1 - very true pass 1.8

2 - somewhat true
3 - not true
19. There is an adult outside my family, for example, a neighbor or religious or

community member, who I can go to for help $1 need it.
pss 19
1 - very true
-
2 somewhat true
3 - not true
1. Yes 0. No
IFYes; What is this persons name and what is hdher relationship to you? (Circle all that
apply)
20al. 20a2. 1 - Immediate Family (sibling, child, parent, partner) p s s J,oA&

6 - Other
20b 1. 20b2. 1 - Immediate Family (sibling, child, parent, partner) ,dsS @A&
6 - Other
20cl. 20c2. 1 - Immediate Family (sibling, child, parent, partner) pss @c h

6 - Other
ASSESSMENT DEBFUEFING
Date:
mm dd yy
Subject ID:
Interviewer ID:
To bekornpieted by the Research Assistant at the conclusion of the assessment.
I. Was the entire assessment administered in English?

YES GotqQ6
NO G o t o Q Z

NO G o t o Q 3
2.
4. who assisted with the translation?
2. ParentlGuardian
3. SpousefPartner
- 5. Other non-family household member
6. Other

5. all
6. How much diEiculty did the S/PC have in understanding the language of the measures? Did
he/she find it ...
1. Very difficult
2. Fairly difficult
3. Fairly easy
4. Veryeasy

NO GotoQS
Code
1. Child Behavior Checklist YES NO a. -b .- c. -
7. YoungAdultSeIfReport YES NO ' a. b. c.
Coding List
1 = Parent'Guardian 5 = Other Child Family Member
2 =~ p o u s e ~ ~ e r 6 = Friend
Comments Section:

NOTES
Date:
mm dd yy
ID:
Interviewer ID:
NOTES
HARVARD SCHO L OF PUBLIC HEALTH

i?
ASSESSMENT
PRIMARY CAREGIVER
COHORT: 9
FIELD COPY #2
TABLE OF CONTENTS
Age: 9(PC)

2. Home
-6. Employment & Income
8. Conflict Tactics Scale: ParentKhild
Demographic & Cultural Information
Demographic and Cultural Information Interview: PC
Subject ID: CM/W

Interviewer ID:
Time Started: I %-wos7-//Y
First, I will ask you about where you and ***** have lived during the pas five years;
were born;
Third, I will ask about different languages you might speak;
Fourth, I will ask for some general descriptive information about youme&
Hfth, I am going to ask about your school backgrouna and
Einally, I will ask about your ethnic and religious background.
Lets start with checking that I have your current address recorded correctly.
ed. init. ed. date

2
J4.L+zR&
\
r
street address
-
'
apt. #
-
city state zip code
#
1. Do you: (read choices)
1. rent your home

2. own your home
5 . live with someone (your parents, guardians or partner) who owns this home
1A. How long in years and months have you lived here? ah-
720
Y=
-
months
2. .Please tell me all the other addresses you have had in the past five years, starting with
.-
3
I .
2A.
- - -
2A1. Why did you move from this address [2A]? [circle up to three] QB 2f i I
n
25 = other

Yf=S months
Y- months

.- - -
(strwt address) (city) (state) (zip code)
2B 1. Why did you move from this address [2B]? [circle up to three] 0 8z \
7 = living quarters bigger apartmenthome
25 = other
..
i 2B2. How long did you live at this address [2B]? &&& A5
_.. Years months
. .. .... ..... .
4

UOr,Q?A -.-L- -
(street addess) (city) (SUE) (zip code)
2C1. Why did you move from this address [2C]? [circle up to three] p82cl
6 = moved in w/ someone due to frnances 13 = on vacationlgraduated from school
25 = other O.PqgeJ
2C2. How long did you live at this address [2C]?
Ye= months
-
- -
2D1. Why did you move from this address [2D]? [circle up to three] P@ 2 D1
3 = movedoff-campus 10 = found a better apartmenthouse
25 = other OmVPeJ
2D2. How long did you live at this address [2D]? i m g a
Y=s months
Ye= months
5
2E. And where did you live before living here? .
Qr.P?d .- - -

3 = moved off-campus 10 = found a better apartmentlhouse
6 = moved in wl someone due to finances 13 = on vacation/graduated from school
25 = other h 4 W

Years months
Yf=S months
2F1. W h y did you move from this address [2F]? [circle up to three] 132'FI
4 = fire/other hamdous condition 11 = wanted to live away from parents
5 = change in maritaVromantic status 12 = roommates left (had to move)
6 = moved in w/ someone due to fiaances 13 = on vacation/graduated from school
25 = other n*
2F2. How long did you live at this address [2F]? B o w -
Years months
Ye- months
6
-
DflBPlzd -
n
(street addr2ss)" (city) (state) (zip code)
2G1. Why did you move from this address [2G]? [circle up to three] DE5 2 $1
6 = moved in w/ someone due to finances 13 = on vacationlgraduated from school
7 = living quarters too small/found bigger apartmendhome
25 = other fifl Q @64

2G2. How long did you live at this address [2G]? JzL7t?Ga/
Years months
. ..
Ye= months

1
2H1. Why did you move from this address [2H]? [circle up to three] 13132#!
5 = change in marital/romantk status 12 = roommates left (had to move)
6 = moved in w/ someone due to finances 13 = on vacationlgraduated from school
eipd
2H2. How long did you live at this address [2H]? &?3 GZAcL
Years months
Y- months
7
Dfl@QPJ v
.- - --z
(street addrdss) (city) (state) (zip code)
211. Why did you move from this address [21]? [circle up to three] 82 11
7 = living quarters too small/found bigger apartmenvhome
25 = o t h e r f l f i p p
212. How long did you live at this address [21]? MaZ&
Y- months

- / c _
(street addes;) (city) (state) (zip code)
2J1. Why did you move from this address [2Jl? [circle up to three] Qg2
3 = movedoff-campus 10 = found a better apartmentlhouse
6 = moved in w/someone due to finances 13 = on vacatiodgraduakd from school
25 = other
w J7.2
v
2J2. How long did you live at this address [q?

YMS months
8
3. Has ***** had any different addresses than you in the past five years? PB3
NO
1. YES
months
4. . Please tell me all the addresses ***** has had in the past five years, starting with the most
-
4A.
w
-
4A1. W h y did ***** move from this address [4A]? [circle all that apply] p 8 tfil
2 = lived with another f d y member 8 = parent was hospitalized (medical)
3 = parent was in prison 9 = foster placementhlopted
5 = child hospitalized (emotional/behvioral) or in residential treatment
6 = parent was hospitalized (emotionalhehavioral)or in drug treatment
25 = other h
.99
0
4A2. How long did ***** live at this address [4A]? &+An/
Years months
Ye= months
9
P.,o)Lq2&j
1
- _.
(street addred) (city) (state) (zip code)
4B1. Why did ***** move from this address [4B])? [circle all that apply] D'i3 4- I
1 = change in custodyhhared custody 7 = child hospitalized (medical)
5 = child hospitalized (emotionallbehavioral) or in residential treatment
25 = other cmvsed
4B2. How long did ***** live at this address [4B]? b 3
Years months

m+yd
(street address) (city)
- c,
(state)
-
(zip code)
4C1. W h y did ***** move &om this address [4C]? [circle all that apply] D!3 c1
2 = lived with another famiiy member 8 = parent was hospitalized (medical)
25 = other &Q&
V Y
4C2.How long did ***** live at this address [4C]? I> 9

Years months
10
4D. And where did ***** live before living here? .

.
A m
J l X Q Qy3f)A
(street aculdress) (city) (state) (zip code)
4D 1. Why did ***** move from this address [4D]? [circle all that apply] 9D!
25 = other
4D2. How long did ***** live at this address [4D]? 13 4- p z

YWS months
Y- months

ppd - - -
4E1. Why did ***** move from this address [4E]? [circle all that apply] D@4 1
25 = other
4E2. How long did ***** live at this address [4E]? 0 f$E 2
Years months
. ...
Ye- months
11
. -
-r"i
B. State C. Country I e----
5A. When did ***** come to live in the USA? D854I year: 19
8. Don't Know
5B. How old was ***** when he/she came to live in the USA? PET@\ age:
8. Don't Know
A. City D m p Q e $ B. State - C. Country

. .
6A. When did you come to live in the USA? v 6A year: 19

8. Don't Know
6B. How old were you when you came to live in the USA? DB 6 age:
8. Don't Know
7. IS your mother still living? D B-7 1. Yes 0. No 8. Don't Know

I
A. city
, - , B. State -/
C. Country -
12
A. City [Q 9g-J-p
U '
B. State -c--
C. Country -+
A. city B. State uc C. Country -
9A. When did she come to live in the USA? DQ Qo year: 19

8. Don't Know
9B. How old was she when she came to live in the USA? D@4 age:
8. Don't Know
10. IS your father still living? D 18 1. Yes 0: No 8. Don't Know
A. City B. State C. Country -

A. city T>~o W Y B. State C. Country -

B. State C. Country
.. . . .
year: 19
'''
8. Don't Know
8. Don't Know
13
13. Are you a U.S.citizen? DB 1

3
0. NO
1. YES
13A. Are you (read choices) 1. currently applying,
D W 3 Q8 2. planning to apply, or
13B. Are you registered to vote in the U.S.? 0. NO ''l..: YES

DB 13 Bo
pqv
Y
e,rJ -
~,..
---
(NW
15. What is your marital status? Are you (Read all choices): "p 15
15A. Are you currently living with a partner? 15 23 0

1.. Yes
0. No
15AA. Are you currently living with your spouse? og15 A fl
1. Yes
0. No
15AA.1 Are you living

- apart
- because you are not getting along or for some other
reason? %iat is the reason?

4.0therJwQm.A
14
15B1. Is y o u r - / s p o u s e the biological parent of *****? iDG15Bl
0.
15B2. How long have you lived with your partnerhpouse? 1

5 2
17. What was the frst language you learned? 1-?-
5. German
6. Lithuanian

A.
B.
?og18
y/
5. German
6. Lithuanian
11. English AND another language (specify:)
12. Two other languages (spec@.-)

A.
B.
15
tell me whether you use English only, mostly English, both English and panguage(s)]
equally, mostly [language(s)l, or [language(s)l only.
19A. What language do you speak with your children? IY

1. English only 4. Mostly [languagefsll
2. Mostly English 5. [lang=ge(s)l only
3. Equally
19B. What language (do/did) you speak with your mother.7 pr3NBS
3. Equally
19C. What language (do/did) you speak with your father? pBZYC0
1. English only % 4. Mostly [language(s)]
2. Mostly English 5 . [langua%e(s)lonly
3. Equally
19D. What language do you speak with your partner. .pgiWQ

3. Equally.
16
19E. What language do you speak with friends? P I Eo
3. Equally
19F. What language do you speak with people at work or school? "0 glq F6
1, English only 4. Mostly [language(s)]
19G. In what language are television programs you watch? Dl3 T Y W

3. Equally
19H. How about the radio stations you listen to? DB\9W J
<
' .\
1.English only 4. Mostly [language(s)]

3. Equally
191. Do you consider your [language(s)] to be ... (read choices). gg\qro

1. Very-
2. Pretty Good
3. Fair,or
4. Notgoodatall
19J. Do you consider your English to be.... (read choices) '0$~01ss

1. Very Good
2. Pretty Good
3. Fair,or
4. Not good at all
speak English well? Would you say.. . (read choices) p 1q 'IC0
1. Never
2. Sometimes
3. Often,or
4. Always
17
1. Never
2. Sometimes
3. Often, or
4. Always
20. Have you attended school in another country,this country (the US), or both? pg2 0
1,. another country only
2.: us only
'3. another country and US
20A. How many years of school did you have? - -years (1 - 20) 0B20po
20B. At what age did you stop attending school? years old P gzo
2OC. Did you receive any type of degree?
Z j
2OC1. What degree did you receive?

\/:-
@ZSCl
21. Did you finish high school? DB2r

.9.' NO
1. YES
21A. And have you done any studying beyond high school? PB21
0:; NO
1. YES
2 1Al. How many years of studying beyond high school have you done?
m21
-years months
18
21A2. What is the highest degree you have reached? D 8 2 1A 2
1. No degree
4. Master's degree
6. Other 0821A Z O
21A3. Are you currently in school? PBU33

.......... ........
@#) jfjg
0. NO
i....
................
YES
jiiS
1. . $2 ........
21B. What is the last grade you completed? (1 - 12) D@221130

21B1. Are you still in high school? 'oB2I f.31
0. NO
1. YES
21C. Have you gotten a GED or had any other schooling or training since then?
0132ICO
0. NO
1. YES

DE21 Cl 2. other degredcertificate:
3. other schoa,l'
VcaN I 3 le olro d
pk7-e.
21C2. Are you currently in school or training? on2' 2
0. NO
1. YES
/
2.
c__
3.
19
23. Do you identify with an ethnic group? OB23
NO
....
0..
1. YES
24. Which group@)do you identify with?
1.
2.
Lc_
c-r
3.
CI-
4.
ch of these groups do you primarily or mainly identify with?
R In Q. 24, circle the number of the 'primary' ethnic group.
25. How American or [ethnic group] are your customs? Would you say. ..(read choices)
1. Very American
2. Mostly American
25A. How often have you hac problems with your family because you prefer a e r i c a n
customs? Would you say. .(read choices) Pg25AO
'1. never
-2. sometimes, or
3. often
26. Are you Latino or Hispanic?

pn26
. .. . .....
0. NO
1. YES
20
26A. Which of the following represents your origins?
1. Cuba
2. Mexico
3. Puerto Rico
4. Spain
5. South America
6. Other Central Am r i m
7. Other o.ro~~e%
yourself? PBij
1. Asian
2. Pacific Islander
5. Native
6. Other
28. How often do people dislike you because of your ethnic group or race? Would you say...(read
choices) 082g
1. never
2. sometimes, or
3. often
29. How often are you treated unfairly at school or work because of your ethnic group or race?
Would you say.. .(read choices) Dl324
1. never
2. sometimes, or
3. often
you say.. .(read choices) PG.30
1. never
2. sometimes, or
3. often
Please note that Questions 31 - 32 have been intentionally omitted. Y

21
33. Do you follow or are you a member of any of the churches or religions listed here?
DB33
0. NO
1. YES
1. Buddhist D B 3 3 CHI-
2. Catholic
3. Church of Christ
4. Evangelical
5 . Hindu
6. Islamic
8. Jewish on33C-H-2
a. Orthodox
b . Conservative
c. Reformed
d. Other
9. Mormon
10. Pentecostal
11. protestant PI3 3 3 C H 3
a. Anglican
b. Baptist DG33 ur
4. SouthemBap
5. Other Baptist
c. Episcopalian
d. Lutheran D E 3 3 c tt's-
e. Methodist 3 3 *c 6
1. Episcopalian
5 . Other Methodist Churches
f. Presbyterian pr333 ct-s7
1. Presbyterian Church in the U.S .A.
2. United Presbyterian Church in the U.S.
t
g. Seventh Day Adve tist
12. Other J W Q O ~ Q
22
34. Would you say your religion provides you with.. .(Read choices) D 3 4.
35. How often do you attend religious service? Do you attend... (Read choices) pgss
4. almost never, or
5. never
This interview NOT end here.

Answer the folkwing questionS yourself and f o h the inmuetions provided:
A. Is the PC married or living with a pamrer?
Yes ->
NO ->
B. Have you obtained ir@ormationabout the biological father?
Yes ->
NO ->
23
36. What is hisher first name? LDm9loer) U '
37. What is [partnerl's age? DQ'37

1 . Under 20 years 4; 40 to 49 years
2. 20 to 29 years 5 . 5 0 to 59 years
3 . 3 0 to 39 years 6. 60 or above
8. Don't Know
37A. When was [partner] born? .@fi'L

mm dd yy
Where was [partner] born?
-
38.
A. city ,(b
bfic c!
'1 B.State - C. Country
38A. When did shehe come to live in the USA? D@38 R1 year: 19
8. Don't Know
38B. How old was shehe when shehe came to live in the USA? age:
P B 3 %131 8. Don't Know
39. IS [~artner's]mother still living? OS34 I. yes 0. No 8. Don't Know
A. city Y)*dy?ed B. State C. Country . ' -'-I
A. city c! B. State -.-- C. Country

-
41..2 Where did she live when she died?
A. City B. State C. Country .Lc,

24
IA and 41&
41A. When did she come to live in the USA? P if I year: 19

8. Don't Know
41B. How old was she when she came to live in the USA? 0 age:
8. Don't Know
42. Is [partner's] father still living? D8'4(2 1. Yes 0. No 8. Don't Know
A. city W\73e i l
B. State
/
C. Country
-
A. City (2 - B. State - c.country -

J I
-
A. City \@ B. State - c.country
44A. WhendidhecometoliveintheUSA? os94-fiO year: 19,-,

8. Don't Know
44B. How old was he when he came to live in the USA? 4 4-@ 0 age:
8. Don't Know
25
45. Has [partner] attended school in another country, this country (the US), or both?
OGi-t-5
2. US only
45A. How many years of school did [partner] have? years (1 - 20) P 13ltsnu
45B. At what age did [partner] stop attending school? years old PB gg 0
45C. Did [partner] receive any type of degree? 0\3 $5 C 0
. ...
0. NO
1. YES

DB"uC1 Q. 47
46. Did [partner] finish high school? 'D @-f-&

0. NO
..- YES
I
l.,,
-
46A. Has ipartner] done any studying beyond high school? 9W6W
0. NO
l..' YES
46A1. How many years of studying beyond high school has shehe done? D896n1
months
46A2. What is the highest degree Ipartner] has reached? D@q6A T

1, No degree
4. Master's degree
5. Doctoral (J.D., M.D., Ph.D., D.D.S., D.O., M.D.)
6. Other
46A3. Is [partner] currently in school? QB?h pi3 0. NO Gu to

..1. YES Q. 47
26
OB 9-6
46B. What is the last grade [partner] completed? (1 - 12)
46B1. Is [partner] still in high school? DL3 96 1
0. NO
1. YES
............ 'L>G$6c 0
0. NO
1. YES
46C 1. What has [partner] received? 1. GED

m3r6 CI
3. other schooling:
...................
.............:::.
46C2. Is [partner] currently in school or training? 0. NO
:Q$m
...... :.......5.....
......................... ..
DG!lt6 c 2 1. YES .
.......
m.:.....
47. What country(s) best represents Ipartner's] ~ t i o n aorigin

l or ancestry?
48. Does [partner] identify with an ethnic group? '0 9

0. NO
1. YES
1.
3 "1
- 'D
/---
2.
3.
27
0. NO
1. YES
49A. Which of the following represents hidher origins?

Pacts I30
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
7. Other r W n 4~ >A
Hand "CARD 3: RACE/ETHNICITY"to the respondent
50. If you were asked to put [partner] into only one of these groups, in which one would you
place himher? DES-0
1. Asian
2. Pacific Islander
28
This .nterview M B y or MAY NOT end here.

Answer the following questions yourself and follow the instructions provided:
A. Have you obtained information about BOTH the biological Mother and
biological father?
....
Yes -->
NO -->
B. Have you obtained information about the biological father?
.. . ...
Yes -->
NO ->
A Time stopped:
29
Now some questions about *****Is father:
51. What is his first name? t b B b 7 p ,

* . < Don't Know
52. Is he still living? p 8 s2 1; Yes

,---I_*
0. No
8. Don't Know
53.1 What is [*****Is fatherl's age? r) 5341

1. Under 20 years "4 -140 to 49 years
L...*
2 . 2 0 to 29 years 5.50 to 59 years

8. Don't know
53.2 What was [*****Is fatherl's age when he died? "OB 53-2
3 . 3 0 to 39 years 6. 60 or above
8. Don't know
53A. When was [*****Is father] born?

mm dd yy
54.
A. city
Where was [*****'s
\D/uo Q ~ C J
2
father] born?
B. State
_ I
- C. Country 7
A. city, - - B. State - C. Country _1
A. city B. State
- C. Country
-
30
55A. When did he come to live in the USA? p G scr)o year: 19

8. Don't Know
55B. How old was he when he came to live in the USA? 13 %ss'@o age:
8. Don't Know
56. Is [*****Is fatherl's mother still living? 1. Yes 0. No 8. Don't Know

tr 0esG
A. city X')-ms~d B. State :.-.?- C.Country -,
A. city Dfi\pLi?~J, B. State -.

C. Country -
58.2 Where'did she live when she died?
A. city D*p~(lrl, B. State .-

c. country
58A. When did she come to live in the USA? 13135 % flo year: 19
8. Don't Know
58B. How old was she when she came to live in the USA? '0 age:
8. Don't Know
59. Is [*****Is fatherl's father still living? 1. Yes 0. No 8. Don't Know

9r3.S-q
A. City B. State .-
C. Country -
31
If
if
A. City B. State - C. Country *-
B. State C. Country
-2-
-/
61A. When did he come to live in the USA? '0 t36lRO year: 19
'
8. Don't Know
61B. How old was he when he came to live in the USA? oa 618 age:
8. Don't Know
62. Has [*****'s father] attended school in another country, this country (the US), or both?
Or3 62
3. us only
62A. How many years of school did [*****'s father] have? years (1 - 20)
DE3 b2PO
62B. At what age did he stop attending school? years old 6 62Go
62C. Did he receive any type of degree? "ObzeO
0. NO
1,. YES
62C1. What degree did he receive?

0%6 2 c i
32
63. Did [*****Is father] finish high school? D 63
0. NO
1. YES
63A.And has he done any studying beyond high school? 63

0. NO
1. YES
63A1. How m y years of studying beyond high school "1
63A2. What is the highest degree he has reached? 0156332 i

I
1. No degree
4. Master's degree
5. Doctoral degree (J.
6. Other ~4 .fo ppe
1 r
8 .,M.D., Ph.D., D.D.S., D.O., Ed.D.)
$&#&
63A3. Is he currently in school? 0x363n3 0. NO QgM
................ .../.
1. YES
i...
63B. What is the last grade he completed? (1 - 12) 0G.63I30

63B1 Is he still in high school? Dl363gi
0. NO
1. YES
63C. Has he gotten a GED or any other schooling or training since then? 0 63 *
0. NO
1. YES

D963C\ 2. other degreekertificate: (3g6 3 c\ 61
3. other schooling:
$rapped
63C2. Is he currently in school or training? 0. NO Go to
r>G63c:2 1. YES Q* 64
33
64. What country(s) best represents [*****Is fatherl's national origin or ancestry?
I '
2.
3.
-.cq-
65. Does [*****'s father] identify with an ethnic group? DB6c

0. NO
,'
*-,.9
1. YES
1.
-rc-
3.
66. Is [*****'s father] Latino or Hispank? 0866

0. NO
YES
.
d
'
1.
Hand "CARD 2: LA"INO/HI$PANIC" to the,respondent
66A. Which of the following represents his origins?
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
6. Other C mal Ameri
7. other dmyper
34
67. If you were asked to put him into only one of these groups, in which one would you place
him? PI3 67
1. Asian
2. Pacific Islander
3: African American / Black
5. Native
6. Other m y a e d
This interview M Y or M Y NOT end here.

Answer the folroWing questtom youme& and foUow the iitstnrctionS provided:
A. Have you obtained irzfonnationabout the biological mother?
Yes ->
NO ->
35
Now some questions about *****Is mother
68. What is her first name? (h cl Don't Know
D@ 601
.. . . . .... .. . .
69. Is she still living?
70.1 What is [*****Is motherl's age? D97 0-1

1. Under 20 years 4 , 4 l to 49 years
2 . 2 0 to 29 years 5 . 5 0 to 59 years
8. Don't know
70.2 What was [*****Is motherl's age when she died? D@ 7 0-2
2. 20 to 29 years 5 . 5 0 to 59 years
8. Don't know
70A. When was [*****Is mother] born?

mm
-
mpd
dd yy
71. Where was [*****'s mother] born?
A. City B. State
~..
-%- .'e- C. Country -

-.a
B. State .- C. Country
" -
A. City 1
m
5 !
B. State
_c
C. Country -
I
36
72A. When did she come to live in the USA? DG472RO year: 19
8. Don't Know
72B. How old was she when she came to live in the USA? DB72a 0 age:
8. Don't Know
73. Is [*****Is motherl's mother still living? D B 7 3 1, Yes 0. No 8. Don't Know
If
If
A. City c3 mp&J B. State - C. Country -

A. city Odwod B. State - c. country L
75A. When did she come to live in the USA? 0 7 560 year: 19
8. Don't Know
75B. How old was she when she came to live in the USA? D s-go age:
8. Don't Know
76. IS 6 1. yes
[*****'s motherl's father still living? ~137 0. No 8. Don't Know
A. City B. State I_ C. Country -

37
A. City
J'J
B. State - C. Country -
A. city 0O \ ~ ? X J B. State /
C.Country
c _
78
78A. When did she come to live in the USA? D g 7 get) year: 19
8. Don't Know
78B. How old was she when she came to live in the USA? 103-78B0 age:
8. Don't Know
79. Has [*****'s mother] attended school in another country, this country (the US), or both?
-77
i 2 . us only
I*-
Or37
79B. At what age did she stop attending school? yearsold P ~ ~
79C. Did she receive any type of degree? "fgG74

0. NO
1. YES
79C1. What degree did she receive? DlC7e.d

38
80. Did [*****'s mother] finish high school? 0 yo
0. NO
...
YES
'
1.
80A. And has she done any studying beyond high school? 10'13 %o A
NO
.......
0.
1. YES
-years months
80A2.What is the highest degree she has reached? D@ OQ2
1. No degree
4:' Master's degree
, M.D., Ph.D., D.D.S., D.O., Ed.D.)
UI
80A3. Is she currently in school? go
0&? /?i3
#.&@
0.
1.
NO
YES
........L.......
Q@&.J
...........
80B. What is the last grade she completed?

-
(1-12) DWiwO~
80B1 Is she still in high school? 0 3 go E31
0. NO
1. YES
80C. Has she gotten a GED or any other schooling or training since then? Pi2 YUC 0
0. NO
1. YES
80C1. What has she received? 1. GED

oggoc\ 2.
3. other schdlibg:
39
80C2. Is she currently in school or training? 0Q 'd 0c '2
0. NO Ga to
1. YES Q. %I
81. What country(s) best represents *****Is mother's national origin or ancestry?
0
1. I\row;d~CzJ~&V, 4 -+-.*w " ~~
82. Does *****Is mother identify with an ethnic group? pg 2

0. NO
1. YES
82A. Which group@)does she identify with?
__
2.
3.
83. Is [*****'s mother] Latino or Hispanic? P 6 b '3

:-04 NO
1. YES
83A. Which of the following represents her origins? D 8 g?~rf0

1. Cuba
2. Mexico
3. Puerto Rim
4. Spain
5. South America
7. Other c h ~ ~ e A
I
40
84. .".these groups, in which one would you place

If you were asked to put her into only one of
her? PBq-
X "
1. Asian
2. Pacific Islander
5. Native American
6. Other
H End Interview and Record Time.

I
I -Time Stopped: "D E M O - r \ M
F-
'i
HOME
FIELD COPY # 2
SUBID TIME
STARTED
INTID DATE ---
Now I'd like to get an idea of what *****Is days are like and what some of
the things are that you and ***** do together. A good way to start is for you
to describe a typical day, like yesterday and then I'll ask a few more
questions.
I I
~~~
OBS SCALE I. INTHEHOME?
to relate an experience OR by taking time to
fQ\-'ct
accomplishment of subject during interview

conveys positive feelings. b. NO
during the visit. b. NO
to praise of subject offered by interviewer. b. NO
~~~
. PC initiates verbal interchanges with the

oductinn; Now Id like to ask you about some of the different experiences ***** may
-
OBS
*
SCALE 11.
VARIETY OF STIMULATION
1. Home has a pet.

I
IN THE HOME?
[ClRCLE OAE
a. YES
School/
Day Care
Do you have a pet?

b. NO
2. Family visits or receives visits ,*a. YES
b. NO
How often do you visit with
/1
3. Subject eats meal per day, i a. jYES
on most days, with PC and ?-*-

separately? (Who does he/she eat
with?)
UaYumAs. .b. NO
Does *****Is father (or father
figure) spend time with himher?
(About how often?)
5 . PC or other h i l y member a. YES

* -

member(s)? (About how often?)
OBS IN THE HOME?
-
SCALE 11. School/
VARIETY OF STIMULATION [CIRCLE ONE] Day Care
6. Subject has gone with a family -

a. YES
member on one outing
other. b. NO
Does ***** go on outings with
any family members? (What
kinds of things do they do; about
how often?)
7. Family member has taken a; YES a. YES
to go to a scientific, historical, b. NO b. NO
art, or cultural museum
lwusU=*
to go on a trip more than 50 b. NO b. NO
miles from home
nast.
vear? ~
9.Family member has taken a. YES a. YES

subject, or arranged for subject to
. . train (NOT
take a trip on a plane,
subway), or bus
b. NO b. NO
YeaL
Has ***** beem on a plane, train
or bus this year?
l0.Family member has taken a. YES a. YES
to attend some type of live b. NO b. NO
musical or theater performance
Has ***** seen a live musical or

any type of theater performance
this past year?
OBS SCALE II. IN THE HOME? School/
VARIETY OF STIMULATION /CIRCLE ONE] Day Care
11. Family has arranged for subject a. YES a. YES
organizational membership to b. NO b.NO
support subject's talents within
.-
lessons, art, dance, or music
lessons)
Does ***** belong to any clubs or

family's recreational hobby.
@king, walhng, playing in b. NO
park, playxng ball, swimming,
checkers, puzzles)
hobbies? Does *****join in on
them?
13. Subject has accompanied PC or a. YES

other family member on a
commercial family venture 3-4 b.NO -
. .
t i m e s w a s t vea~,
(mechanidgarage,
tailor/clothing shop, appliance
repair shop, bank)
Does ***** ever go with you on
errands you have to do?
-
Inventorv:
Introduction: These questions are about what kinds of activities ***** might be involved in.
- OBS
*
SCALE 111.
1. Subject has access to

IN THE HOME?
[CIRCLE ONE]
a. YES
School/
Day Care
a. YES tD3- 1A
record/CD/tape player or radio
and fire records/CDs/tapes. b. NO b. NO
Is there a record/CD/tape player
that ***** can use on his/her
own? Does he/she have any of
hislher own tapes or records?
(About how many?)
*
- 1
2. Subject has access to real ./ YES

:a. a. YES
musical instrument.
@iano, drum, ukelele, guitar, b. NO b. NO
trumpet, clarinet)
Is there a musical instrument in
the house?
* 3. Subject has access to &Q @YES a. YES

appropriate board games. t03..3F1
Does ***** enjoy playing any b. NO b. NO
I03 -3B
board games? Are there any in
the house? (How many?)
* 4. Subject has access tom age

appropriate books.
Does ***** like to read? Are there
am b. NO
a. YES
b. NO
any books in the house he/she can
read? (Howmany?)
5 . Subject has access to a desk or

other suitable place for reading P a. YES
or studying. b. NO b. NO
Does ***** have any homework?
Where does he/she do it?
-
OBS
*
SCALE 111.
6. Subject has access to a

IN THE HOME?
[CIRCLE ONE]
4p
YES
School/
Day Care
dictionary in the home.

Is there a dictionary in the house? b. NO
* 7. Subject has access to a library

card and PC arranges for
subject to go to library
month.
Does ***** have a public library
card? Does he/she ever go there?
- (About how often?)
* 8. Subject is encouraged by PC to YES
read on his/her own.
Does ***** read on hisher own or b. NO
- do you encourage himher to read?
* 9. Subject has k e e or more books I D S
of hidher own.
Does ***** have any of hisher b. NO
own books? (About how manv?)
* 10. PC or other family member 'PES
encourages subject to develop
or sustain hobbies. b. NO
Does ***** have any hobbies? If
yes, Did you encourage this? If no,
Are there any you have
- encouraged him/her to have?
* 11. PC helps subject to achieve
advanced motor skills.
Has ***** learned to ride a bike
or play ball or any activities like
that?
(How did he/she learn them?)
Introduction: Now, Id like to ask you some questions about scheduling, rules you may
have and how you handle discipline.
SCALE IV. IN THE HOME?

1. Subject has a set time [curfew] to be home on @YES

school nights.
Does ***** have a certain time he/she has to be b. NO
2. Subject routinely obeys curfew on school nights. @ YES
b. NO
3. Subject has a set time [curfew] to be home on @YES
weekend nights.
How about on weekends? Does ***** have a b. NO
certain time to be home?
4. Subject routinely obeys curfew on weekend @YES
nights.
Does ***** usually obey that rule? b. NO
5. PC has established rules about homework and {gYES
i\
checks to see if homework is done.

Do you have any specific rules about homework? b. NO
Do vou check to see if it is done?
6. PC assisted subject with homework and school CpES
assignments cvery during current or
most recent school year. b. NO
Do you ever help ***** with hisher homework?
(About how often?)
7. PC requires subject to sleep at home on school ;*
nights.
Does ***** have to sleep at home on school nights b. NO
or can helshe stay with Mends?
8. When PC is not available to subject at home, +@YES
him/her to check in with PC, or their designee, b. NO
on weekends and after school.
When you arent at home, does ***** check in
with you or anyone else?
9. After school subject goes somewhere that adult a. YES
Where does ***** go after school? Are there any (3
/7
NO
adults there?
I 10. PC establishes rules for subject's behavior with I O
i
>ES
peers and asks questions to determine whether
they are being followed. b. NO
Do you have any rules about what ***** does with
his/her friends? Do you talk to ***** about what
he/she is doing?
without adult supervision for.-
How much time can ***** spend in public places 0 0
without an adult?
12. PC has had contact with two of the subject's
friends w t we&. IC J E S
Do you ever get to talk with *****Isfriends? b. NO
(About how often?)
13. PC talks daily with subject about his/her day. G
JkS
-
Do you get to talk with ***** every day about
&/her day? b. NO
14. PC has visited the
. . school or talked to the teacher O Y E S
or counselor 3 m.
Do you ever go to *****Is school or talk with the b. NO
teacher or counselor there? When was the last
time?
15. Family has TV,and it is used judiciously, not left a. YES
on continuously.
(No TV requires an automatic NO) C*O
16. PC has discussed television programs with subject rCUES
ast two weeks.
Do you talk with ***** about different programs? b. NO
(When was the last time?)
17.PC has discussed current events with subject G E S
ast two weeks,
(current events) b. NO
Do you ever get to talk with ***** about what
he/she sees on the news, or in newspapers or
magazines?
SUPERVISION [CIRCLE O m ]
18. PC has discussed the hazards of alcohol and drug

abuse with subject
During the past year have you spoken with ***** b. NO
about the dangers of alcohol and drug abuse?
19. PC denies subject access to alcohol (including a. YES
beer or wine) in the home.
Is ***** allowed to drink beer, wine, or o t k r
alcohol at home?
(<--, '2 NO
20. PC knows signs of drug usage and remains alert @YES
to possible experimentation.
Do you feel familiar with the signs of drug use and b. NO
keep an eye out for them?
21. Subject is taken regularly to a doctor's office or
@ES
6zuaUad. b. NO
Has ***** been to a doctor or clinic for a check-up
22. Family has a fairly regular and predictable daily /3YES
I
(meals, &zy care, bedtime, how much W, b. NO
homework)
Are things like bedtimes, mealtimes,daycare done
about the same time everyday?
23. PC sets limits for subject and generally enforces a2YES
i __*
them.
(cu@w, homework before TV,cleaning up, other b. NO
regulations)
Do you have rules for *****Is behavior? (Do you
usuauy try to get himher to follow them?)
24. PC is generally consistent in establishing or -
Do you have rules for the other members of the
family? @o you usually try to get them to follow
them?)
** 1. PC does not shout at subject during the visit. a. YES
6NO
** 2. PC does not express overt annoyance with or a. YES
hostility toward the subject during the visit. IT)
v
NO
** 3. PC neither slaps nor spanks subject or any other a, YES
family member during the visit. &dNO
** 4. PC does not scold or criticize or put down the a YES
sub-jectduring the visit. -
fChJO
* 5. PC has not lost temper with subject mu&ul a. YES
Dnce
Im sure ***** does things that are annoying.
* -
aNO
>2
Do you ever lose your temper with himher?
physical punishment occurred

-
-
OBS
* 1. At least
SCALE VI.
MODELING
books are present and visible in the

IN THE HOME?
[CIRCLE ONE]
'd YES
home. (If not seen, Ask:) L-
Do you get a chance to read? Do you have a place b. NO

you keep books?
** 3. PC introduces interviewer to subject.
* 4. Some delay of food gratification is demanded of a. YES

the subject.
(there are planned meal/snack times and subject b. NO
is generally required to wait)
Does ***** eat whenever he/she wants or do you
have specl'fic times to eat?
* 5. PC teaches subject some simple manners. YES
(to say please, thank you, sorry)
Has ***** learned things like please, thank-you, b. NO
sorry? (How did he/she learn?)
6. PC or other M y member buys a newspaper
daily and reads it.
Does anyone in the house get a chance to read the b. NO
7. PC or other family member subscribes tobuys a. YES
Does anyone in the house buy or subscribe to any $NO
magazines?
8. PC regularly participates in religious or
Are you involved in any religious or communify
!Pb. NO
activities?
9. PC participates in child oriented organization. @YES
How about any organizatih that do things for
children? b. NO
,- OBS I SCALE VI. I INTHEHOME?
10. PC has not cried or been visibly upset in

subject's presence ce-
When you feel unhappy or sad, do you let *****

see how you're feeling or do you try to hide your
-
Tntroductlon: Now Id like to ask you about different responsibilities ***** might have.
OBS SCALE VII. I INTHEHOME?

FOSTERING INDEPENDENCE [CIRCLE ONE1
1. PC allows subject to choose l@ES

certain favorite food products or
brands at grocery store. b. NO
Does ***** ever choose any food
or brands? I
2. PC has provided guidance to
subject
concerning personal hygiene.
In the past year have you given
any advice or help to ***** about
things like washing or bathing or
other aspects of personal hygiene?
3. PC has taught subject how to
deal with health and safety
emergencies in an age b. NO
appropriate manner.
Does ***** know what to do in an
emergency?
4. PC teaches subject to help with @YES
DOYOU Show ***** how to Cook 1
. b. NO
and clean?
5 . Subject has age @YES
responsibilities. b. NO
lpicking up Mer himherself,
putring clothes in hamper)
Does ***** have any weekly
chores or responsibilities?
-
/
6. PC expects subject to put aJYES
-1
outdoor clothing, dirty clothes,
and night clothes in specific b.
0
places.
Is ***** expected to pick up after
I
hidher toys/treasures or
belongings. b. NO
&/her toys, treasures or
TIME STOPPED &&& IF)

OBS SCALE VIII. PHYSICAL ENWRONMENT IN THE HOME?
[INTERIOROF HOME] [CIRCLE ONE]
1. House or apartment is free of potentially a. YES
dangerous structural or health hazards. b.NO
(exposed outlets, broken winhws, windows
without screens or pard, leakrng radiator,
pots hanging over edge of stove)
** 2. House or apartment has as least 100 square a. YES
feet of living space per person. b.NO
of the home are reasonably clean and b.NO
** 4. In terms of available w-, the rooms a. YES
are not overcrowded with furniture. b.NO
** 5. The interior of the house or apartment is not a. YES
dark or perceptually monotonous. b.NO
or other types of art work on the walls. b.NO
**
II 7. House or apartment is not overly noisy - ftom l
noise in the house.
(television, shouts of children, r d o )
I
I
a. YES
b. NO
** II 8.
noise outside the house.
(train, cars, people, music)
-
House or apartment is not overly noisy fiom
II a. YES
b.NO
* I 9. Household members do not use tobacco. 1 a. YES

home.
( h g p a r c p h e m l i a , beer cans, liquor
bortles)
PXTERIOR OF HOME]
Day of week: M Tu W Th F Sa su
(CIRCLEONE)
Left home: AM PM
1. Street Layout:
2. Through - curved
3. H-layout
4. T-layout
5. L-layout
6. Cul-de-sac
7. Boulevard
8. Divided Highway
2. How would you characterize the land use on this face-block, based on meet-level
frontage? y99-2
1. primariiy residential
4. primarily industrial
5. Primarily vacant houses
7. P r i i y services or institutions
8. Primarily park, playground
9. Other
3. How would you rate the general condition of of the housing units or other buildings
in the face-block? I4Snu-3
2. Fair condition
4. DO any of the fronts of residential or commercial units have metal security blinds, gates,
or iron bars or grills? HD4- 9
1. None
2. Some
3. At least half
4. Most
1. No traffic permitted
2. Very light
3. Light
4. Moderate
5. Heavy
6. Veryheavy
6. How would you rate the condition of the street in the face-block? HD9-Q

7. Is there garbage, litter, or broken glass (except beerlliquor bottles) in the street or on the
sidewalk? 'HD9-7-
3. Yes, quite a bit

3. Yes, quite a bit
H-Ylc1-4
drinking, or behaving in any kind of hostile or threatening way?
NOS -10
11. How did you feel parking, walking, or waiting at the door in the face-block?
1. Very comfortable: can imagine living/working/shopping - here

- CtO'LJ1
Comfortable: it seems to be a safe and friendly place
_ -
2.
4. I would be uncomfortable living/worlcing/shoppinghere
,-
I. .,
SCHOOL SCREEN
1
SCHOOL SCREEN: PC [9-151

Date: S C WLDFFJE
mm dd yy
Interviewer ID:
rnLDLOPY2 SOUR E rl
SCULRQlp
Does ***** currently attend school? s l31

P -
1. ,.
1. YES
2. NO
2. Why is ***** not in school? SB2
2. Dropped out
3. Expelled
4. Long term illness or injury
5. Other (please specifjl)
33 5333
<= -
3. what was the last grade ***** was in? .. *.J -
I*--
grade
~~
ed. init. ed. date

2
1. P.;,,r:C -;-'J :'d g -
3. f)ro,,QJ
v u- -"
4. - 5.
&i,:
3
City State Zip
10. What is *****'s school ID number?
11. What type of school is it? sg11

Ct Public
I
2. Catholic
3. home school
4. Private, non-Catholic
5. Other(p1easeexplain)
13. What grade is ***** currently in? sw3

(Ifduring summer break and
1.
"i
drd
j 90. Ungraded school
grade
14. In the past year, was ***** ever truant (skipped school without an excuse)? 58I9
1. YES
-
I-
15. On the average, how often was ***** truant? (Circle one) S t3 1 5
b. once a week
d. once a month
16. In the past year, did ***** ever skip classes without an excuse? S Q 1 6
1. YES
17. On the average, how often did ** ** * skip classes without an excuse? s @ 17
a. everyday
b. a few times a week
c. onceaweek
d. a few times a month
e. onceamonth
:- f. a few times a year.
LI"
I .
$,
r-'
I ,
i .:
. .
4
18. Thinking back to the last year ***** was in high schooV grade school, was
***** ever truant -- skipped school for the whole day without an excuse? s 18
..... ............ ..... .... ......

1. YES
2. NO
19. How often did ***** skip school for the whole day without an excuse? s g1
b. onceaweek
d. onceamonth
e. a few times a year.
20. Thnkmg back to the last year ***** was in high schooll grade school,did *****
ever skip classes without an excuse? s820
1. YES
2.NO
21. How often did ***** skip classes without an excuse? S E 21

a. everyday
b.afewtimesaweek
c.onceaweek
d.a few times a month
e.onceamonth
f a few times a year.
22. Has ***** ever skipped a grade? @YES

23. Has ***** ever repeated a grade? @YES
5
24. Many students receive special teachmg or help in school. At any point since
***** started hidher education has she received any help or special teaching in
any of the following areas?
-
(Read aloud circle all that apply.)
a. Gifted class 1. YES

b. Special remediation clasdtutoring program /;sIYES
(4 2. NO l;O2+l3
C. Learning problems 64
)YES 2. NO S 1 3 2 w
d. Class/ program for developmentally 1. YES
e. Enghsh as a Second Language or !??YES

4
2. NO 5t329.E
Limited En@ Speakmg
f Speech therapy classes 1. YES
8. C l a d program for physically 1. YES

sight problems
h. Emotional or behavior problems J-Y

iEs
i. Special music or art school
j. Special science program

6
25. Was/Is ***** routinely involved in extracurricular activities directly connected

with hidher school, such as school sports teams, school clubs, music groups, etc.
1. YES
93-25-
ig/Lo
26. How many hours diddoes this take place? hours per week
Si326
27. What kind of program wadis this? (Circle all that apply) S; E 2 7

3. Academic enrichment (tutoring, dasses)
4. other (please specify) VWI 42.b)e $ro wea
28. Wash ***** involved in any other kind of after school program? 513-28
(This may be at *****Is school, but is more of an after school program rather than
extracurricular activity.)
1. YES
@ NO
29. How many hours &&does this take place? hours per week
si3-2q
30. What kind of program wadiis this? (Circle all that apply) '
%30
3. Academic enrichment (tuto
4. Other (please spec@)
7
3 1. What schools has ***** attended in the past?
a. Daycarekeschool or Headstart-type program

SchooV Derson's name I Address (include city, state) Dates enrolled 1
I
3. \I II I/
4. 11 i'
I \I
.
,"
8 . ..'
For RA.s only: for Elementary and High School type, use the following codes:
1 -'Public
2 - Catholic
-
3 home school
4 - private, non-Catholic
Grades
F
9
1 Public -
2 Catholic -
-
3 home school
-
4 private, non-Catholic
C. High School
School Name Address (iclude city, state) School type Datesenrolled I Grades
2.
h
1 I/
5l33 I c3 E
I I
15. I I
10
32. How often do you attend scheduled parent/ teacher conferences? (Read choices.)
Qngt always
3 . seldom
4. never
33. How often do you attend PTA meetings, local school council meetings or any school
503 3
1. almost always
2. often ' -4
(tJ:::m ' . I
34. How would you describe the education ***** is receiving in hid her current school?
(Read choices.)
5x34
a. excellent i... J
b. good
0fair
d. poor
Y END OF INTERVIEW
.-.
r-'
FAMILY STRUCTURE &

HEALTH HISTORY
Family Structure and Health History: PC
Date: i5s DRTE
mmdd yy
Interviewer ID: F(;UI-+ R8 IO

FIEUD COPY 2 SOUr7CF
Now I would like to ask some questions about *****Is family. This year I will only be
getting a general outhe of who is in the family. Next year we w i l l come back to this
F'irst, let me review a few details.
l.A You told me earlier that you are *****Is: F t3 \no

c. femalecousin f. sister i. other O ~ Q W ,V~W \ d k
l.B You told me earlier that you are *****Is: FS1BO

(READAND CIRCLE APPROPRIATE CHOICE)
a. biological father d. step-father g. adoptive father
c. malecousin f. brother i. other Dmaoed V c t r l d l t
Isthatright? Y N
ed. init. ed. date

SECTION 1: BIOLOGICAL MOTHER
2. What is *****Is biological father's name? @.& DON'TKNOW

first name
3.1 How old is he? F63-I DON'T KNOW

(years old)
3.2 How old was he when he died? FB3-2 DON'T KNOW

(yearsold)
4.1 What is your marital status with *****ISiological father? F !3 9-I
la married--still involved
lb divorced
4.2 What was your marital status with *****Is father when he died? E? 9-2
lb divorced
5.1 Are you living together now? ~&1 i- 1 .No

2.Yes
....
5.2 Were you living with*****'s F:@ 5-2 1.No
biological father when he died? 2.Yes
3
5A. Was there a time that you lived together? W W 01. No
* yes ........................
.. .. .. . . ..........
....................
5A1. When did you stop living together? FG5731
W 6-iItsO
6.1A How much time has *****'s biological father spent with him/her in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
6.1B How much time has *****'s biological father spent with himmer prior to the past
year? F B61- IEX)
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
4
6.2A Before he died, how much time did *****Is

I336-240
faher spend with him/her in the past
year?
a. none
d. once a year
e. twice a month
f. once a week
g. daily
h. other
6.2B Before he died, how much time did ***** 's biological father spend with hidher prior
to the past year? PI3 6.,2G:O
a. none
d. once a year
e. twice a month
f. once a week
g. M Y
h. other
7. Does ***** have any children of hisher own? FB 3
Gender: M/F irg)_\Co
Gender: M/F g137-~~~

c
FB 8
J
Now I have some questions about *****Is brothers and sisters, including
Does he/she have any siblings? 2.Yes

1.No FB8
will need to ask you some additional questions about them. Why don't you start
with the oldest sibling?
BROTHERS SISTERS
#lb name: QlfloPPed
living: Y N cA'v:f
age/age died: FBgflfi\B/ I1vlng:
fl'w
a$ge died: FRQA9 IS/
LFB
FB8RE16
@ I
DIR cause of death:
"BgPEIS
rIrwQd
v
FBgAPIS
bio? step? foster? adopt? Go? step? foster?

bio'l mom's name: W P ed bio'l mom's name:
bio'l dad's name: PD e bio'l dad's name:
- NAP
E&:#%' N @dP''' &?&f:%hF
Children? Y
.
'# girls:
from Age
-
N
. # boys :FBMOlB
to n O A 1 S
#2b name: 0 mwed
living: Y N age/age died: IWJWW3/
m 2 s
cause of death:
h
V Rstep.
bio. F +oster?
Q adopt?
bio'l mom's name: &wed
bio'l dad's name: QDd
V "
6
BROTHERS SISTERS
#3b n a m e : m l p p d e
living: Y N age/age died: FBW?t23E2/ #''j1vm
f%!%@'Tge!age died: h GUWs;/
D 3 5
Ff3WDSk3
3
cause of death:
1 ,
A- PrnQPd
I '
FRXE3S
bio'l mom's name: bio'l mom's name: m p P Qd
l
bio'l dad's name: bio'l dad's name: rc~
~ ~ 5 N9&@%-He
~ 4134 iier.
Q8Bjp
.
Children? Y
# girls:
N
. #boys :Fl38803B
# 4b n a m e : , h W Q d
living: Y N age/age died: FB~AR+B/
cause of death: r=@WP()R
Omflmed
k%gg?!oste*?
bio'l mom's name:
bio'l dad's name:
- NAP - NAP
FBgf)fly FB8PA4-S F=-BBPZ+~Wf4Ct-s
FBBP\U,B F 8 P
N age: .-gen Bder:Ti% partner? Y N age: -gender: M/F
.
partner?
.
Children? Y N
'# girls: # boys :F@spOl+n
from Age to FG<O#W
BROTHERS SISTERS
living: Y N
cause of death:
agejage died:
Wrwwned
I
wt%%
FG3fG5R FBWXSS
bio'l mom's name: O m p d
bio'l dad's name: Dmp#3ed V '
- NAP
F68P$5g
partner. Y N age: -
F138PlqB fB$
tg
:
.. .
gen er:
Children? Y N
# girls:- # boys :
from Age to m O A 5 B
# name: d
living: Y N
-
'age/age died: F@WiR6@/
cause of death: F B8R06G
I
VmQQpd
v -
f=011RE6B F%'13RE_65'
bio'l mom's name: bio'l mom's name: mpPd.
bio'l dad's name:
8
BROTHERS SISTERS
#7b name: DwQPQ~CJ
living: Y N
cause of death:
age/age died:
WgY
brmpGd
Fl3BRE-lB
g y? m s
tep? foster? adopt? 1
bio'l mom's name: ' O m ~ P d bio'l mom's name: '(3mipWd

bio'l dad's name: &apipd bio'l dad's name: "Droglped
- NAP -
: NAP
FWPIJB FB P - 7 8
FB8PA'JB
partner? Y N age: - d
gen r : h I F Y
'
?
!
%
; N .-ngp17s
kge. wspG7s
gender: M/F
Children? Y N
. # girls:
from Age
.
# boys : FG (ago7 3
to FI380A713
Children? Y N FBgKmS
m?fL
#8b name:DflIQpd
living: Y N age/age died:
P d
s
Y I
F@ AES/S
bto step? foster? admt?
- NAP - NAP
9

other siblings of *****, either yours or *****Is biological father's children, that you
may not have mentioned? 2.YES 1.NO FEW
10. Have you been married to anyone other than *****'s biological father or lived with
(CIRCLEONE) FB10
1. - NO:
2. -YES:
1OA. How many other relationships have you had? -~~~~
# of relationships
1OB. For each of the people you had a relationship with, I need to know their frrst
FG\OG41
1.Gender: M/F .199Q&
first name
FB1OG'PoI~
10
first name
la
G K q M--stdl
Fmarrie - 2 involved F "'8Gt#2
2a never marrie --s involved
FB iopM3 FBPOIJrq3
la married--still involved 2a never married--stdl lnvolved
Id widowed 2c nevez married, partner died
4. Gender: ME F@1oBqy.1 uded

first name
5:I34 0 BM4-
first name
TtZlOSMS-
11
first &e
Fr3P ISM6.
la marned--stdl involved 2a never married--still involved
11. Has *****'s biological father been married to anyone or lived with someone else as a
1 - DON
FEN
2 -NO:
3 - YES:
11A. How many other relationships has he had? FBTtflO

# of relationships
11B. For each of the people *****'s biological fathers had a relationstup with, I
.,.. :.:..>....name.
need to know their..........first .......... I also need to know whether he was married or
l i v a with them [ ....f....,..... M a d whether he is still in the relationship]. If the
>.
l ........F .......*
L
:
relationship has ended, I need to know if it was due to divorce, separation or

being widowed.
1. Gender: M/F 'i%\l 'Qd; I .l-;OuDppCd,

first name
l q 3 2 \ 23 M-
partner died
2k don'tknow
12
first name
FGBI.I 2W-l'z
la marrie --still involved 2a never married--still involved
partner died
2k don'tknow
3. Gender: M/F FBlroci3 -I.

first name .
ClylW? 2a never married--still involved

partner died
2k don'tknow
\-6WM+
la marrid-still involved 2a never married-still involved
partner died
2k don'tknow
FBI\\BMS
la marrid--still involved 2a never married--still involved
Id widowed 2c never married, either .
partner died
2k don'tknow
13
\" B\\BM 6 2a never married--still involved

partner died
2k don'tknow
F4WG7
7. Gender: M/F
F$31It3w 1 2a never married-still involved

la married-stdl involved
P" lb divorced 2b never married-no longer
involved
I
ii IC married, but separated

F--
partner died
2k don'tknow
r-
i
L _2
14
12. What is *****'s biological mother's name? - , DON'TKNOW

first name
13.1 How old is she? l%(33--1 DON'T KNOW

(years old)
13.2 How old was she when she died? FB13.R DON'T KNOW
(years old)
14.1 What is your marital status with *****'s biological mother? F

L3 I$.-!
lb divorced
14.2 what was your marital status with *****Is mother when &died? !3 14-2
lb divorced
15.1 h e you living together now? ~ gg-1

l 1.No
2.Yes
Were you living with ****e's F Glg-"r

.......
15.2
biological mother when she died?
15
15A. Was there a time that you lived together?

FGS-iSO
..... ........
2. Yes
15A1. When did you stop living together? orear)

FQKAt
16.1A How much time has *****'s biological mother spent with him/her in the past year?
I 6_11?0
a. none
d. once a month
e. twice a month
f. once a week
g*
h. other
16.1B How much t i e has *****'s biological mother spent with himher prior to the past
year? r.rz16330
a. none
d. once a month
e. twice a month
f. onceaweek -
g. daily
h. other
16
16.U Before she died, how much time did *****Is biological mother spend with him/her in
the past year?
a. none
d. once a year
e. twice a month
f. once a week
g. daily
h. other
16.2B B@ore she died, how much time did *****'s biological mother spend with hidher
prior to the past year? sTS916-2BO
a. none
d. once a year
e. twice a month
f. once a week
g- dailV
h. other
17. Does ***** have any children of hisher own? ' F@1 1

A C
17.1 Name: 0 rpef' D.0.B ascpd Gender: M/F
17.3 Name:
V
j :.Qc)r! D.0.B nflppd Gender: M/F
whether they are stiU living. If ***** has siblings who have a partner or child, I
the oldest sibling?
BROTHERS SISTERS
cause of death:
6)nop"pp
-
Clc? "pmfpec!
Fio?Q'ImE1i3
step? foster? adopt?
q?%REls
bio. step? foster?
bio'l mom's name: 'omspe$ bio'l mom's name:
bio'l dad's name: @+i)'q@ bio'l dad's name: &'
- NAP
- NAP - NAP
g+gpr)2s @ rg912s G@~K=
gartner? Y N age: gender: M/F
Children?- Y N
18
BROTHERS SISTERS
cause of death: FSl 031 cause of death:
!=GISRG 3s
bio'l mom's name:
bio'l dad's name:
.......,.
gBwREY/3
io? step? oster? adopt? \
bio'l mom's name: POWw ed
bio'l dad's name: nrb~td
- NAP
19
BROTHERS SISTERS
bio'l mom's name:

bio'l dad's name:
i
20
BROTHERS SISTERS
:livmg
c a :y N - d
age/age died:FB\Qfil?T
cause of death: F4W807t3 cause of death:
YlrqpeJ DnmQd
FsrmE-713 FBlbRE7S
bio'l mom's name: P d . bio'l mom'sname:
bio'l dad's name: r)mipd bio'l dad's name:
- NAP
21
other siblings of *****, either yours or *****s biological mothers children, that you
may not have mentioned? 2.Yes 1.No Ffa9
20. Have you been married to anyone other than *****s biological mother or lived with
someone else as a partner other than the relationships youve just told me about?
(CIRCLE ONE) FG70
1. - NO:
.. .....
2. - YES:
20A. How many other relationships have you had? fl2ow

# of relationships
20B. For each of the people you had a relationship with, I need to know their frst
FB-20S5\
1. Gender: M/F F132013Ci1~ ~ ~ p pec?
fvst name

F-aq0 aN
22
2. Gender: M/FFOzogG2.1 ~ ~ P p ~ ~
first name
1a married--still involved 2a never married--still involved

\LI3zogw2
3. Gender: M/F . 1 9 ,
-FB 7 8 $3G-3 first name

F G 2 0 0 ~ 3
4. Gender: W F .l.JE3322d
Fl32 0 GG 4- first name

OGWQ
5. Gender: M E
p3zsEscis first name

W32sQM&-
6. Gender: M/F .1 QnFPd
FG0 BGb first name

F820BM6
23
7. Gender: M/F
FG-20 B G I
1a married--still dvolva 2a never man ,zd--still involved

FEZ%X3M1
21. Has *****Is biological mother been married to'anyone or lived with someone else as a
1 - DON'T KNOW:
ySc5-a
2 - NO:
3 - YES:
21A. How many other relationships has she had? FI32IRO

# of relationships
21B. For each of the people *****'s biological mother had a relationship with, I
need to know their fitst .................. I also need to know whether she was married
..........name.
or living with them E;?@............................
$...........................
-* i?i whether she is still in the relatio&ip].
1. Gender: M/F
FG2\t3G\ first name

partner died
24
2. Gender: M/F .ll3w.pd

m32mG2 first name

partner died
2k don't know
n32w-
3. Gender: M/F .1 Wppd
FQZ.2 BG3 first name

partner died
2k don't know qz g~ 1Q M 3
4. Gender: M/F .1 Dmlqlped

F9zr Bc;q- first name

partner died
2k don't know g 2 1Qlu\~+.
5. Gender: M/F
FBZl 355 first name

partner died
2k don'tknow
FT32PWl6
, .. .
25
6. Gender: M/F .1 D.sopped

Ft3-a nc, 6 first name
1a married--still involved 2a never man ,cd--still involvec

partner died
2k don'tknow
Fl321BM6
7. Gender: M/F .1 rnpped

F92185-7 first name

Id widowed 2c never married,either
partner died
2k don't know
Fl32 \G Ml
..
, .
26
[Male/Female]
First I have some questions about *****Is biological mother and father.
22. What is *****Is biological mother's name?

first namk
I AL DON'TKNOW
How old is she?

u /
23.1 DON'T KNOW

{
-r
(yearsold) F%2.-3.-\
(years old) 'F"r323-2
24.1A How much time has *****Is biological mother spent with himher in the past year?
a. none
d. once a month
e. twice a month
f. once a week
r-" M Y
hi other
r. ?,
1 - - " * _ >
24.1B How much time has *****'s biological mother spent with himher prior to the past
year?
a. none
F132+-iBD
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27
24.2A Before she died, how much time did *****Is mother spend with hidher in the
past year? F g 2 q -2RO
a. none
d. once a month
e. twice a month
f. once a week
g. daily
h. other
24.2B Before she died, how much time did *****Is biological mother spend with
hidher prior to the past year? F82Q-2QO
a. none
d. once a month
e. twice a month
f. once a week -
g. M Y
h. other
25. What is *****'s biological father's name? LA :,. , I

DON'T KNOW
first name ProPPecJ

(years old) Frnk;-\

(years old)
FG-26-2
28
27.1A How much time has *****Is biological father spent with him in the past year?
a. none
b: intermittent and unpredictable (less than once a month)
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27.1B HOWmuch time has *****'s biological father spent with him/her prior to the past
year? FI327-2W
a: none
6d intermittent and unpredictable (less than once a month)
d. once a month
e. twice a month
f. once a week
h. other
27.2A B#ore he died, how much time did *****'s biological faher spend with
him/her in the past year? Fg21-2 Q 0
a. none
c. inte!mittent at set times (less than once a month)
d. owe a month
e. twice a month
f. once a week
g. M Y
r- .-
29
27.2B Before he died, how much time did *****Is biological father spend with
hidher prior to the past year? fsK?27,2~0
a. none
d. once a month
e. twice a month
f. once a week
g. daily
h. other
28.1 Are *****Is biological parents living together now? l.'ko

2.Yes ,+- 3.DON'T
KNOW
28.2 Were *****'s biobgical parents living together when *****Is motherybther
died? F"n28',2
29.1 What is the marital status of *****'s biological father and mother?
F7324-1
lb divorced
29.2 what was the marital status of *****Is biological father and mother when
*****Is mother/farher died? F1324-2
lb divorced
30
30. Now I have some questions about *****Is brothers and sisters, including
Does he/she have any siblings? '2.iYes 1.No 3. DON'T KNOW

4'
FQ30
For each one, I need to know their name, age, whether they are a boy or a &I,
will need to ask you some additional questions about them. Why don't you start
BROTHERS
died:FG30fiR@
cause of death: F336ft01f?
sipd
F630KE iB
bio? step? foster?
bio'l mom's name:
bio'l dad's name:
v v
FG30 RE2B
bio'l mom's name: Pped
bio'l dad's name: D q P d
- NAP - NAP
. ..
. ........ ... . ... ..... .....
~ K 3 3 o f p FT330PI2g FEZQFG2t
partner. Y age: gender: M/F -
BROTHERS SISTERS
FInOL13rj'
agelage died:Fg30flfl3@
cause of death: f#D3[3
'rsmmd
v -
'f%.30CE3g
bio'l mom's name:
bio'l dad's name:
- NAP
FE30$63g %3C~Pj3g m30-3g
partner. Y N age: -
gender: M/F
32
BROTHERS SISTERS
# 5s name: Vf l p p d mous
living: Y N ige/age died:@aP#s*s
cause of death: Iza30&95-2
$mpp& Drnpped
Fg306?ES13
U '
g330REs-S
bio91 mom's name: D @ , P P ~ ~. ) bio'l mom's name: ~ O P 3P C ~
bio'l dad's name: PEd bio'l dad's name: merl
- NAP
FB330Pm3 m30p&m WUPGSB
Fl330RFG&
bio? step? oster? adopt? 1
bio'l mom's name: k%Q

bio'l dad's name:
- NAP - NAP
33
BROTHERS SISTERS
living: Y N Gelage died:Fg30flfi7@

cause of death: Ft33ofso76
PflBQ4
f=E30 s
bio'l mom's name: I k I l i P H ~
bio'l dad's name: D ~ P P G : J
V
3
NAP
F G 3 w m r Fg3clpj-7s ~ m b P c i 7 S
partner? Y N age: ,-gender: M/F
Children? Y N F1330K17S
# gklsl?R'"0(i17sb
# boys :~ ~ 3 0 1 3 m
b from Age=3"'/%? F630EF7.S
# 8s m e : FG301-1FS
l W i : Y N " age/age died:Fg3bf&R
cause of death: malpm 8s
Dm-d
F1330~~9~
bio'l mom's name: r o p d .
bio'l dad's name: OWpped
34
31. You told me about (READNAMES OF SIBLINGS). Are there any
2.Yes 1.No 3. DONTKNOW FB3 1
es sharing of living quarters for most of the time, without
32. Do you know if either of *****Is biological parents were married to anyone else or
Ff33-2
1 - DONTKNOW:
2 - NO:
3 .:- YES:
-.>
32A. How many other relationships has he/she had? g3-2RM I
Bio mother: # of relationships
Bio father: # of relationships
32B. For each of the people [the biological mother/father] had a relationship with, I need to
know their fmt name. I also need to know whether [shehe they] [werelwas] married
.....................................................
or living with &em p ................................m% and whether [she/he/&ey] [is/are] still in the
relationship]. If the relationshq has ended, I need to know if it was due to divorce,
Biological mother:
FB3Z13qlf7 1. Gender: M/F .1 Pmsiped,

first name
F~3u3~
la ~
married--still involved 2a never married--still involved
lb. divorced 2b never married-no longer
partner died
2k dontknow
35
I,s&3aBWQ 2. Gender: M/F .1 Orop??

first name
M MZ la married-still involved 2a never married--still involved

IC married, but separated - involved
partner died
2k don'tknow
3. Gender: M/F .1 P*Pd

first name
I ~ ~ 3M la Nmarried-still involved 2a never married-still involved

partner died
2k don'tknow
Fg3mMML)- la marriai-still involved 2a never married-still involved

partner died
2k don't know
F 333% M M 5 la married-still involved 2a never married--still involved

partner died
2k don'tknow
37
F637-g8 q3 3. Gender: M/F .1 WroIpPeLJ

first name
ws2'DM31a married--still involved 2a never married--still involved

lb divorced
partner died
2k don't know
) Z ~ 3 z ~ p W / married--still
ia involved 2a never married--still involved
partner d i d
2k don'tknow
F63*goW>a married--still involved 2a never married--still involved

partner died
2k don'tknow
36
I=B32Q % 6. Gender: M/F .I Q OW~

first name
Fl33aMM6 l a married--still involved 2a never married--still involved

partner died
2k don't know
FgzaMM1 la married--still involved 2a never married--still involved

IC married, but separated invalved
partner died
2k don'tknow
Biological fathec
Fg3*2aPq'1. Gender: M/F .1 Q-so@Vi!l

first name
FG3213 IpE4 I 2a never married-still involved
partner died
2k don'tknow
TG32t3DGjZ
2.Gender: M/F
first name
'g3213DM2 la married-still involved 2a never married-still involved

partner died
2k don't know
38
6. Gender: M/F
FG32'i3p4g
fist mine
married--still involved 2a never married--still involved

divorced 2b never married-no longer
married, but separated involved
widowed 2c never married, either
partner died
2k don'tknow
FB32vD@7
partner died
2k don'tknow
F@33
*
33. How old was ***** when he/she first came to live with you?
Age
39

7. biological mom in another country 15. biological mom lost custody(specify reason)
8. biological dad in another country
16. biological dad lost custody (specify reason)

40. other reason (specify reason)
40
35. Has ***** always lived with you since the first time she/he came or have there been
periods during which she/he did not live with you? (CIRCLEONE)
FB-35-
35A. Describe other living arrangements since ***** first came to live with you:
41
Now I have some questions about the time since ***** first came to live with you.
36. I need to know whether you have lived with anyone as a partner while ***** has been
living with you. (CIRCLEONE)
Fa3 6
36A. How many relationships have you had during this time?
# relationships
whether you are still in the relationship. If the relationship has ended, m e e d
F W ~ B ~ ' la marrid-still involved 2a never married-still involved

-
FG36 2. Gender: M/F

first name
F W W W a married-still involved 2a never married-still involved

c-B36BG;3 3. Gender: M/F .1~&

first name
Fg3Ge~3la married--still involved 2a never married--still involved

42
F036 $1 4. Gender: M/F .1 0TQpp
.
first name
6
FG3 y la married--still involved 2a never married--still involved
TE36 B M g 1 a married--still involved 2a never married--still involved

Fg36q3566.Gender: M/F .l,J&QE!d

first name
36 e ~ la6 married-still involved 2a never married-still involved

FG36g57
7. Gender: ME
first name
F133613 married-stiU involved 2a never married-still involved

43
37. Does ***** regularly spend any nights of the week in another household or anywhere
else? [Thisdoes not include day care]
2.Ys 1.No FB37
to *****
N = nonbiologicd auntluncle,
P = paternal other]
A B C D
.1 Name 1&!mpp,ed BorN MorP
E Other relation
F Nights each week FG37-ZF

G Nights each month: 1-"037-- 1
H Other arrangement: i=n37--1H
FB37-"zz3 F33nnc 'F=Cs37-20

A B C D
.2 N a m e D rapped
V ' BorN MorP
E Other relation
F Nights each week &Q"37-2r-

G Nights each month: F1337--2
H Other arrangement: 37 -ai
c)
F1357-38 B37-3C ~~3-37-3'13

A B C D
.3 Name!7miQ coed BorN MorP
E Other relation
I I
F Nights each week: F1337-3F
G Nights each month: !%37 -39
H Other arrangement: G 3 1 - 3~
4.4
38 . In *****Is entire family..... including anyone: parents, siblings, yourself, aunts,
uncles, grandparents, cousins, anyone.. ..
who is ***** particularly close to? You can list as many people as you want - anyone
in the family who you think ***** feels close to.
A
. I
.l Name l ~ o r& ~
rP
FSijg-2.g Fl33r-
.2 Name BorN *@orP
.3
.4
.5
.6
.7
.8
.9
.10
.ll
.12
.13
.14
45
39. Now I need to list all the people who live in this household except for *****. For
each person who lives here, I would like you to tell me how he or she is related to *****.
For example, I want you to tell me if the person you list is *****Is brother or aunt or
cousin. Even if a person who lives here is not related to *****, I need you to list them
also.
R m to ***e*
B = biological @arent, sibling,
P = paternal other]
V
F1339-613
-6 Name B or N
FG39 -3 13
.7 Name B or N
46
Part II: Family Health History

40. Now, I have some questions about *****Is family's health history. I need to know
if anyone in *****Is family including everyone that was just mentioned in this interview,
has any of the following health problems. For each person you list, please tell me how he
or she is related to ***** and whether he or she is a biological or non-biological relation.
Fwo
[Sugar Diabetes, Sugar in Blood/Unne]
R e b to **e**
B = biological jparent, sibling,

47
41. High Blood Pressure: (circle one) 2. Yes 1.No FBc\-\

/Hypertension]
h 1~

.1
.2
.3
.4
.5
.6
.7
.8
.9
10
.ll
.12
.13
.14
48
42. Heart Problems: (circle one) 2. $Yes 1.No FG4-2
Heart Attacks, Coronary, Arrhythmia] '-.. +
n to ***#I*
N = nonbiological aunduncle,
.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.ll
.12
.13
.14
49
43. Stroke: (circle one) 2. Yes 1.No

C D
.1
.2
.3
.4
.5
.6 M or P "YQppQJ
.7
.8
.9
.10
.ll
.12
FR4-3 13$3
.13 Name
I
B or N
FP43 - \+3
.14 Name B or N
50
44. Cancer: (circle one) 2. Yes FC3q-Y

~ u m o r sLeukemia]
,
to *****
.1
.2
.3
.4
.5
.6
.7
.8
.9
.10 Name
.ll Name
.12 Name
.13 Name
.14
51
45. Asthma, Chronic Bronchitis or Emphysema: (circle one) 2. Yes 1.No
[Smokers Cough, WheezingJ
Fr34.5-
-to *****
.1
.2
-3
.4
.5
.6
.7
.8
.9 Name
.10 Name
-11 Name
.12 Name
m 1
.13
.14
52
46. Other chronic problems (specify): (circle one) 2. Yes 1.No
.1
E ILLNESS (please specify): d 0,pped
.2
E ILLNESS (please specify): hpped

A
1 n
.3 Name Wf'Ved BorN MorP
E ILLNESS (please specify): $ r o ~e

?d
.4
E ILLNESS (please spec@): hpvd

A B C D
.5
E ILLNESS (please specify): dflX3pe.d

LEGAL HISTORY
Family Mental Health and Legal History
Subject ID: SvI131P
Interviewer ID:
FIELD COPY 2 SOUR C F e
M c W R l0
Now Im going to ask you some more questions about all the people in *****s/yozv
family that youve mentioned today.
1. Has drinking ever caused any of the people mentioned to have problems with health,
family, job, or police? FM.2
2.YES 1.NO
to *****
P = paternal other]
A B C D
ed. init. ed. date

2
family,job, or police? F IM-2
2.YES 1.NO
I
to *****
P = paternal other]
3
they usually do?
2.YES 1.NO

N = nonbiological
M = maternal
4
fights, had trouble holding a job, or was a frequent discipline problem in school?
2:YES
"..' 1.NO
.1 Name
.2 Name
.3 Name
.4 Name V
.5 Name
.6 Name
5
5 . Has anyone mentioned ever had problems with their nerves or had a nervous breakdown?
2.YES l,!NO
.1
.2
.3
.4
.5
.6
.7
.8
;9
F 145-1213FMS-12 C
U '
.12 Name Proppec! BorN MorP

6
2.YES 1.NO

P = paternal other]
.-
A B C D
.I N a m e D W W J BorN MorP
E Reason for treatment: "oro$pd

PM6-ZZf3 FM6-2 C F M 6-2D
B C D
.2Name odw&
A
BorN MorP
E Reason for treatment: l3-Q tsecr

FM63B F1\616,3C FM 6-3v
B C D
.3 Name y) BorN MorP
A B C D
.4 Name y)roi%d BorN MorP
E Reason for treatment: c!LQ PseJ

Mvr6-st3 FM6-5C FM6SD
A B C D
SName "grD@ BorN MorP
B C D
.6 Name BorN MorP
E Reason for treatment: d/rowd
7
7. Has anyone mentioned ever been hospitalized because of emotional problems, or because
2.YES 1.NO
FMi

M = maternal
B C D
.1 Name BorN MorP
E Reason for treatment: 4-@wed

)=/M7-2I3 lrsM1-7-2C FM7.--2 P
B C D
BorN MorP
B C D
-3 Name V BorN MorP
B C D
.6 Name dKs BorN MorP
E Reason for treatment: w PPeCJ

8
8. Have any of the people you've mentioned ever attempted suicide?
2.YES 1.NO
to *****
.1
.2
.3
.4
.5
.6
.7
.8 Name B or N
Fr/l c-4l3
.9 Name - B or N
/I I FMC-lOB
.10 Name drDppQl B or N
.12 Name B or N
FM1v1-13B
.13 Name B or N
.15 Name cJ1?lrm BorN MorP

9
9. Have any of the people you've mentioned ever committed suicide?
i
2. YES LNO
,' En 4
RAiUQDto *****
P = paternal other]
C D
"Fq -6%
.6 Name h p p d B or N
'r=owq-7 B
.7 Name $rO& B or N
FM4-9I3
.9 Name B or N
.
10
(CIRCLE ONE)
1 - no one else
-
Committed Suicide page 9

Fcghts, frequent trouble with law,trouble holding a job - page 4
Drinldng caused problems with health, family, job, or police - page 1
11
trouble with the police or who has been arrested. Please do not include routine traffic
10. Has anyone that you've mentioned had trouble with the police or been arrested? (CIRCLE
ONE)
FMlO
1. NO:
_"
2. YES
1OA. What is his/her name and how is he/she related to *****?

FM10#2 FwlOfi3 FMlOW+
'2 3
B or N Mor P
----
Name Relation
1OB. Do you know what heishe did? (CIRCLE ONE) 2 . m 1.NO

............. ..... ..... ...........
.
.ij...,,
F M 10130
1OB1. ..... What did he/she do?
1oc. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE) FM loco
2.YEs 1 .NO
locl.
10D. Is he/she in Jail or prison now? (CIRCLE ONE) 2.YES 1 .NO

FjvllODQ
12
1. NO:

pWfl2 FMW3 FmilAy
2 3 4 1
&4ppe$ zs-/or N Mor
..-... P
Name Relation
11B. Do you know what he/she did? (CIRCLE ONE) 21YES

llBl
.. What did he/she do?
..:
~~
......5K.3
.__..............,
.....:...*
:
P
, * ' i'
(CIRCLE ONE)
2.m 1.NO
11C1. $@ =
What other offense led to himmer having trouble with the police?
11D. Is he/she in jail or prison now? (CIRCLE ONE)

13
1. NO:
f=M 1
7
, 2. YES
- - ~

FpnIcLA2 m1-3 ~ u 2 ~ 4
2 3 4
dY&&! BorNb M or P
Name Relation
12B. Do you know what he/she did? (CIRCLE ONE) .2.YES 1.NO
......................
:...................... ~ What did $ do?
~ he/she
12B1.
(CIRCLE ONE)
2.w 1.NO
d
12D. Is he/she in jail or prison now? (CIRCLE ONE)

14
1. NO:
2. YES -
ASK 13A 13D

fM13cn FMl33y
FF=ln3Rz2 3 4
B or N M or P
Name Relation
13B. Do you know what he/she did? (CIRCLE ONE) 2.YES

....................
1331. 1[3F
......................
....................... What did he/& do?
(CIRCLE ONE) FMK3CO
2.m 1.NO
13D. Is heishe in jail or prison now? (CIRCLE ONE)

15
1. NO:
2. YES ASK 144 - 14D

FV14-112 Fla1,l33 FMlit.W+
2 3 4
&&eJ B or N M or P
Name Relation
14B1 W - .................. .........,...

..%.m ..............S
................
..... ::*: what did he/&e do?
FIvl14l30
14C. And were there any other reasom he/she was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
..................:.....
.......c:> .... ....... ....... What other offenses led to M e r having trouble with the police?
14C1. W;%@5$ i.
14D. Is he/she in jail or prison now? (CIRCLE ONE) 2.YEs I .NO

FMl4Do
16
1. NO:
15A. What is his/her name and how is he/she related to *****3

PW1SR2 FMM1SA3 FJvllf;lsy
2 3 4 I
B or N M or P
Name Relation
15B. Do you h o w what he/she did? (CIRCLE ONE) 2.YEs 1 .NO
(CIRCLE ONE)
2.m 1.NO
15C1. l&@#f&What other offenses led to himmer having trouble with the police?
15D. Is he/she in jail or prison now? (CIRCLE ONE) 2.YES 1 .NO

r-
17
1. NO:
II II
2. YES

FMI6RZ pM16A-3 FMl6A4
2 3 4
B or N M or P
Name Relation
16B. Do you know what he/she did? (CIRCLE ONE) 2.YES 1.NO
.......................
16B1. W :$j;.w
................ ;*
:.........;......2 what did he/& do? ~ ~ 1 6 g O
8-7
;, :
is?
(CIRCLE ONE) FMlb@
2 . w 1.NO
.,. ..,.. >...
16C1. E
Fm What other offenses led to himmer having trouble with the police?
..A Y A. A,.:
.....A, ............. I

1
. .
I ..~
16D. Is he/she in jail or prison now? (CIRCLE ONE) 2.YEs 1.NO
I L.,
~hN6)30
F
L .
18
1. NO:
2. YES

!=M\-JW FW7l-33 FMI7fllf
&bPd
2 3 4
B or N M or P
Name Relation
17B. Do you know what he/she did? (CIRCLE ONE) 2.YEs
17B1. ; E mWhat did he/&e do?

............................
.....................
(CIRCLE ONE) Flvr17 e0
2.YEs 1.NO
..,.....,.. ..... .......
17C1. What other offenses led to himher having trouble with the police?
f
v.............. n
17D. IS he/she in Jail or prison now? (CIRCLE ONE) 2.YEs

T'
-.
EMPLOYMENT & INCOME
r
.- .
..
I "
Subject ID: 6UQ31P
tz
Interviewer ID:
MPLRFa I D
PART I: Primary CaregivedAdult Subject Employment

For this interview, "full-time1'is 35 or more hours each week and "part-time"is less than 35
hours each week.
ed. init. ed. date

- ET1
1. Worlring full-time in one job -----------------
2. Working full-time in one job AND ----------
Page 2
3. On leave (temporary illness) -------------------

4. Permanent leave (disability) ---------------

6. Working part-time in two or more jobs -----
7. On lave (temporary illness) ---------

from part-timejob or jobs

9. Temporary jobs, occasional work --
-
10. Retired, worlung full-time
11. Retired,workmg part-time jobs
12. Retired, worlung temporary jobs -

13. Retired,not workmg ----
14. Homemaker N1-time - I-
15. Unemployed, lookmg for work -----
16. Unemployed, not lwkmg for work ----

(NOTa homemaker)
17. Volunteer work only, full/part-time ------
Page 3
2. Have you been employed in a paying position in the past 5 years? (CIRCLEONE)
............... E12
2. NO:
................
A$&
.......................... Have you done volunteer work in the past 5 years?
ElzJv1
1 - Yes
2 - NO
mK*:
1. YES: ........................
..................
(CIRCLE RESPONDENT'S CHOICE) F12RO
1. Working full-time in one job -------- --------
2. Working full-time in one job AND ----------
3. On leave (temporary illness) -----------------

4. Permanent leave (disability) --------

...
5. Working part-time in one job ----

. .

8. Permanent leave (disability) --

. . . . .
9. Temporasg jobs, occasional work -----
10. Retired, working full-time u-
11. Retired, working part-time jobs --

12. Retired, working temporary jobs -----
17. Volunteer work only, full/part-time ------

Page 4
PART: I
SECTION: 1
3. How manv iobs do vou currentlv hold? (CIRCLE ONE) E n

1 . OilJob
2, Two Jobs
3. Three Jobs
L.
'
4. What is your job title? V&&J&-"<h ped.

5. What are your main responsibilities? ,y

6. Which of these numbers best fits your salary in this job? (CIRCLEONE) E16
1. lessthan5,000
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know

Y- months
E17
hours/week E-TQ
If 1Job ONLY,GO TO Page 15, (part I) Question 45A.

Page 5
rob 2: And your other job?
-
10.
-
What are your main responsibilities?
1. less thaa5,000
2. between 5,000 and 9,999
"3.".between 10,000 and 19,999
-4
4. between 20,000 and 29,999

5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
12. How long have you been in this job? E1 1 2 / *

(&")
Y- months
13. How many hours each week do you usually work? ET r3

hours/week
If2 Jobs ONLY, GO TO Page 15, (part I) Question 45A.

Page 6
lob 3; And your other job?
U Hand respondent response card #2 I

16. Which of these numbers best fits your salary in this job? (CIRCLEONE) E7 16
c
1. less than5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know

Years months
E117
18. . How many hours each week do you usually work?
hourdweek

Page 7
PART: I
SECTION: 2
19. How many jobs did you hold before you went on leave/disability? (CIRCLEONE)
ET 14
1. One Job
2. Two Jobs
3. Three Jobs
19A. Of these jobs, I want you to first tell me about the one you considered to be your
20. What was your job title? b p p d
21. What were your main responsibilities? $rOpp@
22. DO you continue to receive money from this position? (CIRCLE ONE) ET 2-2-
1. YES
2. NO
22B. Which of these numbers best fit(s) your full salary in this job? (CIRCLE ONE) E1zzg('J
1. less than 5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than 50,OOO
8. don't know
Page 8
... . .... . ... ....... . .... ..
EZZ280
1. Full
2. Partial
22c. Which of these numbers best fit(s) your partial salary, including
pension plan, SSI or any benefits? (CIRCLEONE) E-L-22W
1. less than5,000
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. more than50,OOO
8. dontknow

before you went on leave/disability? E123
Y- months
hours/week
25. How long have you been on leave from thisjob?

Y- months
1 If 1Job ONLY,GO TO Page 15, (part I)Question 45A. 1

1 If More than 1 Job, GO TO Next Pane, (part I) Question 26. 1
~~
Page 9
.s--
-
27. What were your main responsibilities?
E l - 2 5r
1. YES
2. NO
28B. Which of these numbers best fit@)your full salary in this job? (CIRCLE ONE) x2k80
E
1. less than 5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
28A. Do you receive y o y full salary or part of your salary? (CIRCLE ONE)
ETZfiO
1. Full
2. Partial
Page 10
. _
-.
28C. Which of these numbers best fit(s) your partial salary, including
pension plan, SSI or any benefits? (CIRCLEONE) ETz%co
1. less than5,OOO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don'tknow

hourdweek
31. How long have you been on leave from this job? E I31
Y- months
If 2 Jobs ONLY,GO TO Page 15, (part I) Question 45A.

If More than 2 Jobs, GQ TO Next Page, (part I) Que!& *OD 32. L
Page 11
bol- 3 ; And your other job?
32. What was your job title? hppd
33. What were your main responsibilities? &Q\Op&l
34. DOyou continue to receive money fiom this position? (CIRCLE ONE) E13 4-
1. YES
2. NO
1 Hand respondent response card #2, I

34B. Which of these numbers best fit@)your full salary in this job? (CIRCLE ONE) E234-gfJ
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
1. Full
E239430
2. Partial
..
Page 12
.-
34C. Which of these numbers best fit(s) your partial salary, including pension -3
plan, SSI or any benefits? (CIRCLEONE)

EI3Ctco
1 . less than 5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know

before you went on leaveldisability?
hourdweek
E136
1 GO TO Page 15, Question 45A (paxt I). I
' L
Page 13
PART: I
SECTION: 3
38. What types of jobs have you done recently? pQd

1
39. About how many hours each week do you usually work? hourdweek
=EFl
.
.
~..
~. 40. How much money have you earned from these jobs in the past year? (CIRCLEONE)
1. less than5,OOO
2. between 5,000 ~JXI
9,999
4. between 20,000 and 29,999
5. betweem 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don'tknow
Page 14
PART: I
SECTION: 4
j,dAIeM P ~
43. How many hours each week do you usually volunteer? (CIRCLE ONE) E J3-3
--r'
1. 1 --2
2. 3-5
3. 6 - 12
4. -
13 20
5. > 20
~ ~- ~
GO TO Page 15, (part I) Question 45A.

Page 15
PART: I
SECTION: 5
[Prima,ry/OnlyJob]
45A. Where is your job located? (If travels to various locationS, record address of main ofice.)
address
city State zip code
45B. How far is your work from where you live? (CIRCLEONE)

2-lto2miles 6 - Varies auxrdmg to
l-walk 6 - carp001
3 - bdSUbWay 8 - commuter train
4 - bicycle
5 - other
minutes
If 1 Job ONLY, If there is a partner, go to Page 18, (part n)Question 1.

Page 16
' __li
[Secondary job 21
46A. Where is your job located? (If travels to various locations record address of main office.)
address
city State zip code
46B. How far is your work from where you live? (CIRCLE ONE) ET 4-6E O
0.-'works at home 4-6tolOmiles
"*I

1-walk -
6 carp001
2' - drive myself 7 - driven by relative/friend
I
4 - bicycle
5 - other
~s46m
minutes
If 2 Jobs ONLY, If there is a partner, go to Page 18, (part n)Question 1.

If there is pp partner, go to Page 35, (part m),Question 1.
CONFLICT TACTICS SCALJ3: Partner/Spouse Introduction

1. Are you currently involved with someone?
1. YES cT1
0. NO
. ...... ..... ...... . . ... ..
A. Are you married to, engaged to, or dating this person? C-tIRO
1. married
2. engaged
3. dating
B. Are you currently living with this person?

1. Yes
0. No
C. How long have you been in the relationship?
I BEGIN INTERVIEW I
(If more than one person, select most nsignificantmrelatiomhip) c7-2
1. YES
0. NO
A. Were you married to, engaged to, or dating this person? ~7230
1. married
2. engaged
3. dating

1. Yes
2. No
BEGIN INTERVIEW
3. Have you dated anyone at all in the past year? c-7-3
1. YES W.
0. NO
1
Interviewer ID:
c7-sPr;ZJ%l
p
FIELD COPY 2 SOURCE
No matter how well a couple gets dong, there are times when they disagree, get annoyed with
...
Refer to first month op the time line I

these responses.
I Hand respondent the response card, and read choices 1 to 6 I
ed. init. ed. date

2
- .
1A.
eT!@
How many times have you discussed an issue calmly?
0 1 2 3 4 5 6
1B. How many times has he/she discussed an issue calmly? erm
0 1 2 3 4 5 6
. .
1C. Has this ever happened? (1IC

,7 1 = Yes 0 = No
. ..
2A. How many times have you gotten information to back up your side of things?' Cl7 ...
0 1 2 3 4 5 6
never Ollce twice 3-5 6- 10 11-20 more than
2B. How many times has he/she gotten information to back up hisher side of things.9 L - r m 3
0 1 2 3 4 5 6
....
2C. Has this ever happened? 1 =Yes , O=No C T C
..
3
3A. How many times have you brought in or tried to bring in someone else to help settle things?
c-=R
0 1 2 3 4 5 6
e73G
0 1 2 3 4 5 6
3 ~ . H ~ this-ever
S happened? c73 e 1 = yes 0 = No
1
4A. How many times have you insulted or swore at him/her? c-f %
0 1 2 3 4 5 6
4B. How many times has he/she insulted or swore at you? C74E
0 1 2 3 4 5 6
4C. Has this ever happened? c q vc 1 = Yes 0 = No

4
5A. How many times have you sulked and/or refused to talk about an issue? C T 513
0 1 2 3 4 5 6
5B. How many times has he/she sulked and/or refused to talk about an issue? C T =
0 1 2 3 4 5 6
6A. How many times have you stomped out of the room, house or yard? C 7 6 Q
.
0 1 2 3 4 5 6
times times times x 20 times 1
6B. How many times has he/she stomped out of the room, house or yard? c.76li3
0 1 2 3 4 5 6
6C. Has this ever happened? c-f 6c 1 = Yes 0 = No

5
7A. How many times have you cried? e-T7/3

0 1 2 3 4 5 6
7B. How many times has he/she cried? C41Q

0 1 2 3 4 5 6
7C. Has this ever happened? c77c 1=yes 0 = No
8A. How many times have you done or said something to spite himher? c-f w
0 1 2 3 . 4 5 6
8B. How many times has he/she done or said something to spite you? c7vn
0 1 2 3 4 5 6
8C. Has this ever happened? c7rc 1=Yes 0 = No

6
9A. How many times have you threatened to hit or throw something at him/her? c79 13 I
0 1 2 3 4 5 6
9B. How many times has he/she threatened to hit or throw something at you? c7q 'r3
0 1 2 3 4 5 6
= No
1OA. How many times have you thrown, smashed, hit, or kicked?- c 7 1elf-
0 1 2 3 4 5 6
1OB. How many times has heishe thrown,smashed, hit, or kicked w ? 10 c7

0 1 2 3 4 5 6
never OILce twice 3-5 6-10 11-20 more than
IOC. HZthis ever happened? ClIOC 1 = yes 0 = No

7
11A. How many times have you thrown something at hwher? 11 f i

0 1 2 3 4 5 6
0 1 2 3 4 5 6
11~. as this ever happened? C 7I I C 1 = Yes 0 = No
12A. How many times have you pushed, grabbed, or shoved himher? c7)263$
0 1 2 3 4 5 6
12B. How many times has hehhe pushed, grabbed, or shoved you? c712g
0 1 2 3 4 5 6
times times times 20 tima
12~.H= this ever happened? ClL2.C 1 = Yes 0 = No

8
13A. How many times h v e you slapped himher? e-rni3

0 1 2 3 4 5 6
13B. How many times has he/she slapped you? C713G

0 1 2 3 4 5 6
13C. Has this ever happened? c7 I x C 1 = Yes 0 = No
14A. How many times have you kicked,bit, or hit himmer w?c;"r?urR
0 1 2 3 4 5 6
14B. How many times has hdshe kicked, bit, or hit you Y&u&? (y4-P
0 1 2 3 4 5 6
14C. Has this ever happened? cT!%C 1 = Yes 0 = No

9
15A. How many times have you hit or tried to hit him/her * ? cr15-n
0 1 2 3 4 5 6
15B. How many times has he/she hit or tried to hit you - ? c71s-Tz
0 1 2 3 4 5 6
ties times times 20 times
.. ... . ..
1 5 ~ . H= this ever happened? -r 1sc 1 = Yes 0 = No
16A. How many times have you beat himmer up? c T\Qn
0 1 2 3 4 5 6
16B. How many times has he/she beat you up? cT1613
0 1 2 3 4 5 6
16C. H= this ever happened? CT16c 1 = Yes 0 = No

10
17A. How many times have you choked h a h e r ?

C-iIln-
0 1 2 3 4 5 6
17B. How many times has he/she choked you? C - l I ~ l 3
0 1 2 3 4 5 6
i '
times times times 20 times - 4
17C. Has this ever happened? C T 17c 1 =Yes 0 = No
18A. How many times have you threatened him/her with a knife or gun? L-i 1 rd3
0 1 2 3 4 5 6
18B. How many times has he/she threatened you with a knife or gun? c 71
0 1 2 3 4 5 6
never once twice 3-5 6-10 11720 more than
18C. Has this ever happened.7 cmvc 1=Yes 0 = No

11
19A. How many times have you used a knife or fired a gun? c--rPm
0 1 2 3 4 5 6
19B. How many times has he/she used a knife or fired a gun.9 C-mE ,
0 1 2 3 4 5 6
19C. Has this ever happened? cT19@1 = Yes 0 = No

1
Subject ID: s uR?3
Interviewer ID:
FIELD COPY 2 SSUrCCE c "?'ssm3-9 P
Parents and children use many different ways of try- to settle differences between
them. I am going to read a list of things that you might have done WHEN YOU HAD A
Hznd respondent response card and read choices 1 to 6
--
ed. init. ed. date
2
1. How many times did you diicuss an issue calmly with *****? CUI
0 1 2 3 4 5 6
. ...... .........
IB. H= this ever happened? CUI 13 1 = Yes 0 = No
2. How many times did you get information to back up your side of thmgs? c uz
0 1 2 3 4 5 6
never O W twice 3-5 6-10 1 1-20 more than
2B. Has this ever happened? cu2B 1 =Yes 0 = No
3. How many times did you bring in or try to bring in someone else to help settle things? cu3
.>
0 1 2 3 4 5 6
3B. Has this ever happened? GV3B 1 =Yes 0 = No

3
4. How many times did you insult or swear at *****? cvct

0 1 2 3 4 5 6
4B. Has this ever happened? c 1 = Yes 0 = No
5. How many times did you sulk and/or refuse to talk about an issue? cu
0 1 2 3 4 5 6
SB. this ever happened?

H~S C V S- 13 1 = Yes 0 = No
6. How many times did you stomp out of the room, or house or yard? cu6
0 1 2 3 4 5 6
6B. Has this ever happened? Cu663 1 =Yes 0 = No

4
7. How many times did you cry? CUT

0 1 2 3 4 5 6
never once twice 3-5 6-10 1 1-20 more ~ d n
.
. ........ ...
7B. Has this ever happened? c 1 = Yes 0 = No
8. How many times did you do or say something to spite *****? cv

0 1 2 3 4 5 6
' 8B. Has thiseverhappened? c u rG? 1 =Yes 0 = No
9. How many times did you threaten to hit or throw somethug at *****? CV 4
0 1 2 3 4 5 6
9B. Has this ever happened? ev cIc3 1 =Yes 0 = No

5
10. How many times did you throw,smash, hit or kick something? CWO
0 1 2 3 4 5 6
10B. Has this ever happened? cu 108 1 = Yes 0 =No
11. How many times did you throw something af *****? C W
0 1 2 3 4 5 6
11B. Has this ever happened? cw1113 1 =Yes 0 = No
12. How many times did you push, grab, or shove *****? cv 1 2
0 1 2 3 4 5 6
never OIlce twice 3-5 6-10 1 1-20 more than
12B. Has this ever happened? CUI2.a 1 = Yes 0 = NO

6
13. How many times did you slap or spank ***** with ? cW3
0 1 2 3 4 5 6
13B. Has this ever happened? v 13g 1 =Yes 0 = No
14. How many times did you kick, bite, or hit ***** w? c v \4
0 1 2 3 4 5 6
14B. Has this ever happened? C V W 1 =Yes 0 = No
15. How many times did you hit or try to hit ***** - evls-
0 1 2 3 4 5 6
15B. Has this ever happened? C W J 7 * 1 = Yes 0 = No

7
16. How many times did you beat ***** up? CWd
0 1 2 3 4 5 6
16B. Has this ever happened? C V W 1 =Yes 0 = No
17. How many times did you burn or scald *****? c 17

0 1 2 3 4 5 6
17B. Has this ever happened? cuw3 1 =Yes 0 = No

1
mm dd yy
Subject ID: sa-3w
Interviewer ID:
Cr2 C~G631iD
FIELD COPY 2
..
For each item that describes ***** now or w&j~ the wt 6 m o w please say "2" if the
item is very true or often true of *****. Say "1" if the item is gome-
of *****. If the item is not true of *****, say "0". Please answer ail items as well as you
0 = Not True
1 = Somewhat True
2 = Very True
C!Zl 0 12 1. Acts too young for his/hw age
cw 0 1 2 4.Asthma
c 6 0 12 5. Behaveslikeoppositesex
cc6 0 1 2 6. Bowelmovements outside toilet
ed. intl. ed. date

2
c'q 0 1 2 7. Bragging, boasting

c-c 0 1 2 8. Can't concentrate, can't pay attention for long
-
cc 9 0 1 2 9. Can't get hismer mind off certain thoughts; obsessions
-0
eel@ 1 2 10 Can't sit still, restless, or hyperactive
-
cc I1 0 1 2 11. Clings to adults or too dependent
CC 1'7 o 1 2 12. Complains of loneliness
@ 13 0 1 2 13. Confused or seems to be in a fog
cc14 0 1 2 14. Criesalot
-o
CC 1
s 1 2 is. Cruel to animals
CC 16 o 1 2 16. Cruelty, bullying, or meanness to others
cc
- I7 0 1 2 17.Day-dreams or gets lost in hidher thoughts
cc-1g 0 1 2 18. Deliberately harms self or attempts suicide
cc I 4 0 1 2 19. Demands a lot of attention
a-zo o 1 2 20. ~atroyshismerownthings
az
- 1 01 2 21. Destroys thmgs belonging to hisher family or others
cc72 0 1 2 22. Disobedient at home
-0
cc23 1 2 23. Disobedient at school
-0 1 2 24. Doesn't eat well
cczy
- 1
cczs'O 2 25. Doesn't get along with other kids
-0 1 2 26. Doesn't seem to feel guilty after misbehaving
-0 1
L'L/ 2 27. Easilyjealous
-0 1 2 28. Eats or drinks things that are not food- don't include sweets
cczq 0 1 2 29. Fears certain animals, situations, or places, other than school
cczo
-0 1 2 30. Fears going to school
*
cc3 0 1 2 31. Fears he/she might think or do something bad

0 1 2 32. Feels he/she has to be perfect
-
cc33 0 1 2 33. Feels or complains that no one loves himmer
ccz? 0 1 2 34. Feels others are out to get himlher
3
ccx01 2 35. Feels worthless or inferior

-0 1 2 36. Gets hurt a lot, accident-prone
cc37 0 1 2

37. Gets in many fights
3-0 1 2 38. Gets teased a lot
cc37 0 1 2 39. Hangs around with others who get in trouble
CcvO 0 1 2 40. Hears sounds or voices that arent there
-
$1 0 1 2 41. Impulsive or acts without thinking
cc-42 0 1 2 42. Would rather be alone than with others
ccq3 0 12 43. Lying or cheating
-0 1 2 44. Bites fingernails
CCqLf.
uqs-0 1 2 45. Nervous, highstrung, or tense
cc% 0 1 2 46. Nervous movements or twitching
9
7 0
- 1 2 47. Nightmares
ccyr 0 1 2 48. Not liked by other kids
-0 1 2 49. Constipated, doesnt move bowels
-0
ccso 12 50. Too fearfulor anxious
-0
[csg 1 2 55. Overweight
am+
-0 1 2 a. Aches or pains (not headaches)
C c-
s - 6 ~0 1 2 b. Headaches
cm
- x 0 12 c. Nausea, feels sick
c- ~ ~ p o 1 2 d. Problems with eyes
-0 1 2
cCg6E e. Rashes or other skin problems
4
6 a )$O 1 2 h. Other physical problems without known medical cause
c-fl 0 12 57. Physically attacks people

mr
-0 12 58. Picks nose, skin, or other parts of body
ccfl 0 1 2 59. Plays with own sex parts in public
-0 12 60.Plays with own sex parts too much
-0
@61 1 2 61. Poor school work
-0
ccgT 1 2 62. Poorly coordinated or clumsy
Ccc? 0 1 2 63. Prefers being with older kids
a 69 0 1 2 64. Prefers being with younger kids
CC-
6s o 1 2 65. Refuses to talk
cc6 0 1 2 66. Repeats certain acts over and over; compulsions
ccF
-0 1 2 67. Runs away from home
ccCr 0 1 2 68. Screams alot
CcGq
-0 1 2 69. Secretive, keeps things to self
0 1 2 70. Sees things thatarent there
cc71
-0 1 2 71. Self-conscious or easily embarrassed
-0
CC-Jz 1 2 72. Sets fires
Cc-7 9 0 1 2 74. Showing offor clowning

cc7g 0 1 2 75. Shy or timid
ccT
0 12 76. Sleeps less thanmost kids
-0 1 2
77 77. Sleeps more than most kids during day and/or night
-0 1 2 78. Smears or plays with bowel movements
-
cc7 9 012 79. Speech problem
-0 1 2 80.StaresblanMy
cc!?j 0 1 2 81. Stealsathome
-0 1 2 82. Steals outside the home
c-
c s0 1 2 83. Stores up thugs he/she doesnt need
5
84. Strange behavior

85. Strange ideas
86. Stubborn, sullen, or irritable
0 1 2 87. Sudden changes in mood or feelings
0 1 2 88. Sulks a lot
0 1 2 89. Suspicious
0 1 2 90.Swearing or obscene language
0 1 2 91.Talks about killing self
0 1 2 92.Talks or walks in sleep
0 1 2 93.Talks too much
0 1 2 94. Teases a lot
0 1 2 95.Temper tantrums or hot temper
0 1 2 96.Thinks about sex too much
0 1 2 97. Threatens people
0 1 2 98. ThUb-SUCking
0 1 2 99. Too concerned with neatness or cleanliness
100. Trouble sleeping
101.Truancy, skips school
102. Underactive, slow moving, or lacks energy
'030 1 2 103. Unhappy, sad, or depressed
cc 9 04 0 1 2 104. Unusually loud
-1 0A-O 1 2 105. Uses alcohol or drugs for nonmedical purposes
-o 1
CCI06 2 106.va.nc~isrn
cc/o7 0 1 2 107.Wets self during the day
- 1
cc!ocdO/ 2 108. Wets the bed
ccroq
-0 1 2 109.Whining
cc-0 1 2 110. Wishes to be of opposite sex
-11I 0 1 2 1 1 1. Withdrawn, doesn't get involved with others
cC~~Q. o 1 2 112. worries
6
- *\
-. I
2 113A.
2 113C.
1
mm dd yy
Interviewer ID:
FIELD COPY 2 S~Ui7CE E7Y rn61D I
1. Are you afraid ***** might be hurt by violence in your neighborhood? Ep q

1. YES 2. NO
2. Are you afraid ***** might be hurt your apartment building or house? E e2
1. YES 2. NO
3. Are you afraid ***** might be hurt in your apartment buildmg or house? e3
1. YES 2. ,NO'
4. Are you afraid ***** might be hurt by violence at school or day care? E fly
1. YES 2. NO
ed. init. ed. date

2
4A. Does this affect where you take *****? E134RO

1. YES 2. NO
5. Have any of your family members been hurt by a violent act? E Rg

1. YES 2. NO
6. Have any of your family members been killed by a violent act? E R6

1. YES 2 : NO E#
7. Have any of your close friends been hurt by a violent act? E837
1. YES 2. NO
8. Have any of your close friends been killed by a violent act? E %?
1. YES 2. NO
E &9
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
The questions I'll be asking you now have to do with acts of violence that ***** may have
witnessed or experienced. Please think carefully about whether she/he was actually
present during violent acts.
10. Has ***** ever seen or been present when somebody was shoved, kicked or punched?
.. .. ... ..... ..... .

1. YES
2. NO
1. Within last week

3. Withinlast year
1. In ****Is home
3. In front of ****Is house/building
7.
25.
In or outside bar
Other (spec@) d ow e d
13. Did heishe know the person or people who this happened to? ER B
1. YES
2. NO
I
13A. Who was it? (MARK AI& THAT APPLY) EQ 1
3Q D
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
25. Other (Specify)
14. How badly was the person or people injured? (MARK THAT APPLY)
1. No injury
er14
2. Knocked down
3. Bruised
4. Cuthleeding
5. Unconscious
6. Broken bonedfiacture
8. Other
15. Did ***** know the person or people who did this? 1=" A- s-
. . .
1. YES
2. NO
1. Parent
2. *****
3. Friend
4. Neighbor
5. Sibling
25. Other (Specify)
5
16. Has ***** seen this more than once? ewg
1. YES
2. NO
16A. How many times has ***** seen this in the past year? ER \6RO
16B. How many times has ***** ever seen this? &I
17. Has ***** ever seen or been present when someone was attacked with a knife? E 13 17
1. YES
2. NO
18. When was the last time he/she saw that? EWg
1. Within last week
2. Withinlastmonth
3. Withinlastyear

I
1. In *****s home
2. In hallway of *****s building
4. In *****s neighborhood
6. At *****s schoollday care
25. Other (specify) &Q ppd
6
20. Did he/she know the person or people who this happened to? /% 2 0
1.Y
2. N
20A. Who was it? (MARK &THAT APPLY) E mf)Bo

1. Parent
2 .- *****
3. Friend
4. Neighbor
5. Sibling
25. Other (Specify) pped
21. How badly was the person or people injured? (MARK AI& THAT APPLY)
ER Z l
1. No injury I
2 . , K n o c k e ddown
3. , B r u i s e d
4. Cuthleeding
5. Unconscious
6 . - B r o k e n bones/fracture
7.,-Medical care obtained
8-. Other
22. Did they die? Em=

1. YES 2 . . N O 8. Don't Know
ER 7 3
1. YES
2. NO
7
23A. Who was it? (MARK THAT APPLY) %?ezxQ

1. Parent
2.- *****
3. Friend
4.- Neighbor
5. Sibling
25. Other (Specify)
24. Has ***** seen this more than once? ER-29

1. YES
2. NO
24A. How many times has ***** seen this in the past year? qgW+F\o
25. Has ***** ever heard a gun shot? e

1. YES
2. NO
26. When was the last time he/she heard that? GW6
1. Within last week
2. Withinlastmonth
3. Withinlastyear
8
27. Where did that happen? EW-7

1. In ****'s home
3. In front of ****'s house/building
25. Other (specify)
28. Has ***** heard a gun shot more than once? E p2

1. YES
2. NO
28A. How many times has ***** heard this in the past year? ER2rRso
28B. How many times has ***** ever heard this? GRZ';,f30
29. Has ***** ever seen or been present when someone was shot?
1. YES
2. NO
ENDOFINTERVIEW
RECORD TIME:
30. When was the last timk he/she saw that?

1. Withinlastweek
3. Withinlastyear
9
31. Where did that happen? GRZ)

1. In ****Is home
25. Other (specify)
32. Did he/she know the person or people who got shot? E &z2.
1. YES
2. NO
32A. Who was it? (MARK&THAT APPLY) 't"= R3-2f30

1. P a r e n t
2. *****
3. F r i e n d
4.Aeighbor
5. Sibhg
6. Other Relative (Specify) c b d
33. .Did they die?

ER 3 3
1. YES 2. NO 8. Don't Know
34. Did he/she know the person or people who did this? E@zv
1. YES
2. NO
10
34A. Who was it? (MARK BLL THAT APPLY) E 34wo

1. Parent
3 *****
3 .,-Friend
4. N e i g h b o r
5.
. .
Sibhg
25. Other (Specify) 1 -

1. YES
2. NO
35A. How many times has ***** seen this in the past year? E R3-Bo
35B. How many times has ***** ever seen this? E r%%s-GO
I ENDOFINTERVIEW I
Subject ID: SV41V

Interviewer ID:
EAS?t?)?\P
1. ***** feels happiest in familiar surroundings. E y t

2. ***** often acts on the spur of the moment. EY2

ed. init. ed. date

3. ***** is something of a loner. EY3
4. ***** sometimes does "crazy" things just to be different. I"YLf

5. ***** likes to be with people. Gus

6. ***** has trouble resisting temptation. EY 6

7. ***** finds people more stimulating than anythi else. E"y4

8. Unfinished tasks really bother *****. EW
9. ***** cries easily. EY4

10. ***** makes friends easily.

11. ***** tends to be somewhat emotional. Eyl

12. ***** is off and running as soon as (s)he wakes up in the morning. Fyl?
13. ***** generally seeks new and exciting experiences and sensations. ey 13
14. ***** finds self-control easy to learn.

15. ***** can tolerate frustration better than most. EY i.5-

16. ***** often fusses and cries. EV 6

17. ***** gets upset easily.

. .-
18. ***** tends to hop from one interest to another quickly. EY 19
19. ***** takes a long time to warm up to strangers. EY101

20. ***** prefers quiet, inactive games to more active ones. ms

21. ***** often says the first thing that comes into hisher head. E 21
22. ***** tends to be shy. EY 22-

23. ***** tends to get bored easily. EY23
24. Usually ***** can not stand waiting. w24

25. ***** has trouble controlling hisher impulses.


27. ***** is very friendly with strangers.

EYTJ
4= Somewhat Characteristic (sort of likeyour child)
28. ***** always likes to make detailed plans before (s)he does something. Ey2
29. ***** generally likes to see things through to the end.

>
30. ***** often has trouble making up hisher mind. Ey30

31. ***** prefers playing with others rather than playing alone.
***** is very sociable.

E v32
32.

33. When alone, ***** feels isolated.
EY33
34. ***** reacts intensely when upset. E Y 3 If

35. ***** is very energetic. Y3S

36. ***** tends to give up easily. EYS6

37. When ***** moves about, (s)he usually moves slowly. E n 7

38. ***** likes to plan things way ahead of time. l33Y
39. Once ***** gets going on something, @)hehates to stop. E Y3

1= Uncharacteristic (NOT at aIl like your child)
40. ***** will try anything once. FY4-0

Interviewer ID:
FESW141P
false for most membem. If the members are evenly divided, decide what is the stronger
try to figure out how other membem see your family. -
1. T 2. F
2. Family members attend church, synagogue, or fairly often
1. T 2. F
3. Family members are rarely ordered around tFE 3
1. T 2. F
ed. init. ed. date
2
4. Family members rarely become openly angry FEct

1. T 2. F
5. We don't say prayers in our family FES

1. T 2. F
6. mere are very few rules to follow in ow family 'I" 1=, 6

1. T 2. F
1. T 2. F
8. We often talk about the religious meaning of Christmas,Passover, or other holidays

fiEg
1. T 2. F
9. There is one family member who makes most of the decisions E
1. T 2. F
10. Family members hardly ever lose their tempers FIE 10

1. T 2. F
1. T 2. F
1. T 2. F
13. Family members often criticize each other FE1

3
1. T 2. F
3
14. Family members have strict ideas about what is right or wrong E 14
1. T 2. F
15. There is a strong emphasis on following rules in our family E1

1. T 2. F

Fa6
1. T 2. F
17. We believe there are some things you just have to take on faith E1
7
1. T 2. F
1. T 2. F
P- FE1q
1. T 2. F
FE20
1. T 2. F
1. T 2. F
22. Family members often try to one-up or out-do each other
1. T 2. F
23. The Bible is a very important book in our home FE23

1. T 2. F
4
24. Rules are pretty inflexible in our household ! E 2cf

=
1. T 2. F
25. In our family, we believe you don't ever get anywhere by raising your voice
FE-25-
1. T 2. F
2. F TE26
1. T
27. You can't get away with much in our family E27
1. T 2. F
HAND SUBJECT RESPONSE CARD
28.- When you answered these questions, who did you have in mind?
FEZ%
1. Siblings
2. Parent
3. Roommate
6. Spouse/Partner
7. Child/Chjldren
END OFINTERVEW
I
Subject ID: s
1= verytrue
2= somewhat true
3- nottrue
1. When I'm with my friends I feel completely able to relax and be myseK
1 -verytrue
FS$l
-
2 somewhat true
-
3 not true
2. I share the same approach to life that many of my fiends do.
1 -verytrue
-
2 somewhat true
PW
-
3 not true
ed. init. ed. date

3. People who know me trust me and respect me. ('Qs$3
1 - very true
2 - somewhat true
3 - not true
4. No matter what happens, I know that my family wiU always be there for me should I need
them.
1 -verytme
-
2 somewhat true
3 - not true
5. When I want to go out to do things, I know that many of my friends would @QY (like)
doing these things with me. psJ%-
1 - very true
-
2 somewhat true
3 - not true
6. I have at least one friend that I could tell anythmg to. .&.sa6
1 -verytrue
-
2 somewhat true
-
3 not true
7. Sometimes I'm not sure if1 can completely (count) on my family.

PS97
-
1 very true
-
2 somewhat true
-
3 not true
8. My family lets me know they think I'm a wo- (valuab1e)person.
-
1 very true
-
2 somewhat true
-
3 not true
9. I feel very close to some of my friends.
-
1 very true
2 - somewhat true
3 - not true
1 - verytrue
-
2 somewhat true
-
3 not true
11. People in my family help me find solutions to my problems. Psql I

1 - very true
-
2 somewhat true
-
3 not true
-
1 very true
-
2 somewhat true
-
3 not true
13. My fiends would take the time to talk about my problems, should I ever want to.
1 -verytrue
PQ13
-
2 somewhat true
-
3 not true
.
14. I know my family will always stand by me.
1 -verytrue
-
2 somewhat true
-
3 not true
15. Even when I am with my fiends, I feel alone.
-
1 very true
-
2 somewhat true
-
3 not true
20
16. I have a teacher or coach who I can g& (count) on and talk to. Ps 8 6
1 - very true
2 - somewhat true
3 - not true
17. I have a grandparent, uncle, or aunt that I feel close to and who helps me out.
PQ17
-
1 very true
2 - somewhat true
3 - not true
-
1 very true
'Ip549l r
2 - somewhat true
3 - not true
19. There is an adult outside my family, for example, a neighbor or religious or

community member, who I can go to for help if1 need it. b"SP )of
1 -verytrue
-
2 somewhat true
-
3 not true
1. Yes 0. No
VSP2 0
E Yes: What is this person's name and what is hidher relationship to you? (Circle all that
apply)
20al. VOpd
First name
20a2. 1 - Immediate Family (sibling, c u d , parent, partner)
-
2 Extended Family
eq Q o n 2
-
6 - Other k p p 4
20b 1. &flf& 20b2. 1 - Immediate Family (sib@, child, parent, partner) "rSc/9:!0@2
-
MemberLeader
6 - Other
20~1. c b d -
20c2. 1 Immediate Family (sibling, child, parent, partner)
-
2 Extended Family
p q 2 oc
First name
-
-
-
5 School or Community Memberkader
-
6 Other &@ IQped
g3 END OF INTERVIEW Q
Date:
m m dd yy
Subject ID:
Interviewer ID:

1. Are you planning on movingAeaving home in the next year? Y N

if "Yes,"
1a. when?
1b. where?
r
If employed, ask Question #2, if unemployed, go to Question #3

if "Yes,":
2a. when? honthlvear) 2b. new employer?
if "Yes,":
3a. when? (rnonthlvear) 3b. employer?
3c. new employment address: (street)
(state) (ziu)
If currently in school, ask Question #4
C:\JMCINTOS\WPDOCS\ROANEW.FRM
if "Yes,"
(citv) (state) (ZID)
5. Do you know of any reason why you might not be able to participate in this Project in the
future? Y N
If, "Yes,"
6. Can you give me the names, addresses, and phone numbers of four close friends or relatives
' who will always know where to find you to help us locate you in the future?
a. b.
Name:
Relationship:
Address:
City/StfZip:
Phone:
C. d. -
Name:
Relationship:
Address:
CityfStfZip:
Phone:
C:\JMCI NTOS\WPDOCS\ROANEW.FRM ROA 2

Try to make the foilawing observations at the close of the session

a. annoyed b. nervous c. bored d. afrz
e.- relaxed f.- interested g. neutral h. curious

i. cooperative j .- confused?
Circle one:
I 2 3 4 5

Circle one:
1 2 3 4 5
1Oa. Please explain the reason for your assessment:
C:\JMCINTOS\WPDOCS\ROANEW.FRM ROA 3
Date:
m m dd yy
Subject ID:
Interviewer ID:

5 . all
6. How much difficulty did the S/PC have in understanding the language of the measures? Did
he/she find it ...
1. Very difficult
2. Fairly difficult
3. Fairly easy
4. Veryeasy
Comm n
Q8
If NO, enter code@)for the party(ies) present during the assessment.
Code
7. Young Adult Self Report YES NO a. b. c.
Coding List
1 = Parent/Guardian 5 = Other Child Family Member
2 = Spouse/Partner 6 = Friend
Comments Section:
PLEASE RECORD ANY ADDITIONAL, COMMENTS:

NOTES
Date:
m m dd yy
Subject ID:
Interviewer ID:
NOTES
NOTES

ASSESSMENT
PRIMARY CAREGIVER
COHORT: 12
FIELD COPY #2
TABLE OF CONTENTS
Age: 12(PC)
~~ ~ I

2. Home
8. Conflict Tactics Scale: ParentKhild
I
Intendewer ID:
Fka, I will ask you about where you and ***** have lived during the past five years;
were born;
Third, I &ask
ll about dif'fennt languages you might speak;
Fourth, I will ask or some general descriptive information about yourself;
FinaIly, I will ask about your ethnic and religions background.
Let's start with Chedring that I have your current address recorded correctly.
ed. G t . ed. date

~
2
Your current address is (redfrom contact she&): Is that right?
I. Yes-
r&R.e/vT
0. No-
apt. #
city State zip code

i;r

9/34
1. rent your home
2. own your home
5. live with someone (your parents, guardha or partner) who owns this home
1A. How long in years and months have you lived here? - -
3% f.0 Years months
2. Please tell me all the other addresses you have had in the past five years, starting with
Y
i
RA,J
@4 2A1. Why did you move from this address [2A]? [circle up to three]

2 =evicted 9 = could no longer afford rent
3 = moved off-campus 10 = found a berter apartment/howe
4 = fre/other hazardous condition 11 = wanted to live away from parents
5 = c u e in maritaVromantic status 12 = roommates left (had to move)
6,#= moved in w/ someone due to finances 13 = on vacatiodgraduated from school
7 = living q u m r s too small/found bigger apartmentlhome
&A &
?$& 2A2. How long did you live at this address [2AJ?
rn*&&.d&.c585eavd
(street address) (city> (state) (zip code)
B&&5f 2B1. Why did you move from this address [ZB]? [circle up to three]

6 = moved in w/ someone due to f m m 13 = on vacatiodgraduated from school
25 = other YL^j'-&& dAL@!P d ,
J'
2B2. How long did you live at this address [ZB]?

wm3b YWS months
Y- months
4
L/h*d&&b&&
(street address) (city) tsta=> (zip code)
%fiAC/ 2C 1, Why did you move from this address [2C]? [circle up to three]

7. 3 = moved off-campus 10 = found a bemr apartmentmouse
5 = + w e in maritavromantic status 12 = roommates left (had to move)
6 = moved in wl someone due to'finances 13 = on vacation/graduated from school
~
25 =other /a'&&
/*
*we& 2C2. How long did you live at this address [2q?
Y- months
Y- months
R8/3&~-/ 2D 1. Why did you move from this address [2D]?[circle up to three]
4 = fre/other hazardous wndition 11 = wanted to live away from parents
5 = change in maritallromantic status 12 = roomma-tes left (had to move)
6 = moved in w/someone due to f m m 13 = on vaeatiodgracluated from school
7 = living quarters too s W f o u n d bigger apartmenthome
25=0&= ~ a ' d ~k / r ,

3& &BL Y- months
Y- months
6
5
22. And where did you live before living here? .
%@&&+ 2E 1. Why did you move from this address f2E]? [circle up to three]

5# = change in marital/romantic status 12 = roommates left (had to move)
25 =other fl&da &

E%&
;43 R2& 2E2. How long did you live at this address [2E]?
months
Y&&&&&
(street address) . (city) (state) (zip code)
M&H 2F1. Why did you move from this address [2FJ? [circle up to three]

5 = change in maritauromantic status 12 = rmmmates left (had to move)
7 = living quarters too smaIl/found bigger apartmenthome
25 =
B/~AFL 2F2. How long did you live at this address [2q?
Y- months
Y- months
6
2G1. Why did you move from this address [2G]? [circle up to three]
$?l&~ e/
5 G'change in marital/romantic status . - 12 = roommates left (had to move)
6 = moved k-w/ someone due to finances 13 = on vacation/graduted from school
923 AG.& 2G2. How long did you live at this address [2G]?
Y- months
hw+ 2H1. Why did you move from this address [2HJ? [circle up to three]
1 = charge of job 8 = went to school

4 = fire/other hazardous mndition 11 = wanted to live away from parents
7 = living quarters too smalllfound bigger apartmentmome
25 = other v-*db ~~
J /
pfi 2H2. How long did you live at thjs address [2HJ?
YWS months
Y- months
,-
7
21. And wheredid you live before living here?
%&,n
211. Why did you move from this address [2g? [circle up to three]

3 = moved off-campus 10 = found a better apanment/house
6 = moved in w/ someone due-to finances 13 = on vacatiodgraduated from school
z=oher ~ ~ d
&
& k
SQ/3&Zd, 212. How long did you live at this address [2:21]?
Years months
2J1. Why did you move fromthis address [q?

mw{ [circle up to three]
1 = cfiange of job 8 = went to school

6 = moved in w/ someone due to f m m 13 = on vacatiodgraduated from school
25=
a3b 232. How long did you live at this address [q?
YWS months
Y- months
8
HZ ***** had any different addresses t b n you in the past five years?
0. NO
1. YES
M4- 9 4.1. How long in years and months has ***** lived at your current address?
4. Please tell me all the addresses ***** has had in the past fwe years, starring with the most
recent one before the current address:.
4A.
4A1. W h y did ***** move fromthis address [4A]? [circle all that apply]
445 94/
1 = change in custody/shared custody 7 = child hospitalid (medical)
2 = h e d with another M y member 8 = parent was hospitalized (medical)
5 = chiid hospitalized (emotionalhehaviord) or in residential treatment
6 = parent was hospitalized (emotionavbehaviorai) or in drug treatment
25 = other @a*czL-cLd%3
JY
%&94a 4A2. How long did ***** live at this address [4A]? Y= months
Y- months
9
48. And where did ***** live
-
. before living here?
!v..*tzcifk
&# - -
f f
(street address) (CirV) (state) (zip c d e )
4B1. Why did ***** move from this address [4B])? [circle all that apply]

2 = lived with another family member 8 = pzrent was hospitalized (medical)
3 = parent was in prison 9 = foster placementfadopted
#.' 9 5 = child hospiralized (emotionalhehavioral) or in residential treatment
6 = parent was hospitaliied (emotiomlhehavioral) or in drug treatment
25 = other 1 / d d G h -& Y
4B2. How long did ***** live at this address [4B]?
Y- months
4C1. Why did ***** move from this address [4q? [circle all that apply]

3 = parent was in prison 9 = foster placernenthdopted
5 = child hospitalized (emotionalhehavioral) or in residential matment
2 5 = other
4C2. How long did ***** live at this address [4C]?

Y- months
.. ..... ..... . . .. . . ...

Y- months
10
4D. And where did ***** live before living here?-
- - IL
(Ciry) (sate) (zip code)
&ai4D 1. Why did ***** move from this address [4D]? [circle all that appiy]
)&q
2 =_lived with another famiiy member 8 = parent was hospitaiized (medid)
* 3 = parent was in prison 9 = foster placement/adopted
f$ 5 = child hospitalized (emotional/behavioral) or in residential treatment
6 = parent was hospitalized (emotiodhehaviord1.)or in drug treatment
25 = other
&3 ya,&. 4D2. How long did ***** live at this address [4D]?
Y- months

- - -
&45/ 4E1. Why did ***** move fromthis address [4EJ? [circle all that apply]
1 = change in custody/shared custody 7 = c u d hospitalized (medical)

3 = parent was in prison 9 = foster placementladopted
5 = child hospitalized (ernotionalhehaviord) or in residential treatment
25 =other v#&
4E2. How long did ***** live at this address [4E]?y ' Y=s months
Y- months
11
NOW 1haye some questions about where differmt people in your f d y were born.
e
A. city B. Stare +& c. country
% ;-A/ 5A. When did ***** come to live in the USA? year: 19
'a 8. Don't Know
5B. How old was ***** when he/she came to live in the USA? age :
8. Don't Know
C. Country
-
8. Don't Know
8. Don't Know
7. Is your mother still living? 1. Yes 0. No 8. Don't Know
A. city +& B. State

- C. Country
c-
I2
A. City B. State c
e. country -
A. City B. State
- C. Country
-
940 9A. When did she come to live in the USA? year: 19
8. Don't Know
A% QhU 9B. How old was she when she came to live in the USA? age:
8. Don't Know
yo 10. Is your father still living? 1. Yes 0. No 8. Don't Know
-
A. City B. State
- c. country
A. City B. State
7
c. country -
& 12A. When did he come to live in the USA? year: 19.- I
8. Don't Know
Bi% A&%o 12B. How old was he when he came to live in the USA? age:
8. Don't Know
-13
Now 1 have some ather quessions about you.
873 r3 13. Are you a U.S.citizen?
0. NO
1. YES
13A. Are you (read choices) 1. currently applying, Go Tn

2. planning to apply, or Q. 14
13B. Are you registeredto vote in the U.S.? 0. NO 1. YES
14.
g& ~6 15. What is your marital status? Are you (Read all choices):
1. Single
2. Separated
3. Divorced
4. Married
5. Widowed
6. Living with Someone as a Partner
15A. Are you currently living with a partner?

... . .
1. Yes
0. No
15AA. Are you currently living with your spouse?
1. Yes
0. No
15AA.l Are you living- apart

- because you are not getting alone or for some other
reason? &t is the reason?
1. Not getting dong

14
15B1. Is your partnedspouse the biological parent of *I**+?
1. Yes
0.
1932. How long have you lived with your partner/spouse?
years months

mm dd yy.
17. What was the first language you learned?
4. Spanish
5. German
6. Lithuanian
11. English AND another language (spem:)
12. Two other languages @ern.-)

A.
B.
4. Spanish 10. Other language (spem:)
5. German
V I
6. Lithuanian
9
12. Two other languages (specjsI:)
19:
7
~
Please note: Insert the name of the hnguage(s) provided in responre to Q. I7 and 18
whenever the tenn JIanpuage(s)JaDpears in the r ~ in7 Q. I 9 I
a. Mostiy [language(s)] b. Mostly English c. Both about the same
I'd like to know what language you use in your M y activities. M e r each question please
tell me whether you use English only, mostly English, both English and panguage(s)]
equally, mostly Panguage(s)l, or Panglla~efsHonly.
m {Q&O 19A. What language do you speak with your children?
1. English only 4. Mostly Panguage(s)l

3. Equally
mfQA0 19B. What language (do/did) you speak with your mother?
1. English only 4. Mostly Panguage(s)]

2. Mostly English 5. P ~ g u a g d s ) only
l
3. Equally

2. Mostly English 5. Ifanguage(s)l only
3. Equally
D:

2. Mostly English' 5 . Elanguage(s)l o d y
3. Equally
16

2. Mostly English 5 - liangwe(s>Ionly
3. Equally

2. Mostly English 5. [Ianguage(s)] only
z
. 19G. In what language are television programs you watch?

i

2. Mostly English 5. ElaW=ge(s)l only
3. Equally
1. English only 4. Mostly flanguage(s)]

2. Mostly English 5. Ilanguage(s)l o w
3. Equally
191. Do you consider your [language(s)] to be ... (read &ices).

1. VeryGood
2. PrenyGood
3. Fair, or
4. Not good at all
19J. Do you consider your English to be.... ( r e d choices)
1. very Good
2. Pretty Good
3. Fair, or
4. Not good at all
speak English well? Would you say.. . (read &ices)
1. Never
2. Sometimes
3. Often,or
4. Always
17
19L. How often has it been hard to get good grades or bo well at a job because of
A?3 /Q'L63 problems understanding English? Would you say.. .(real choices)
I. Never
2. Sometimes
3. Often,or
4. Always
>
#.' "
&GJ
20. Have you attended schml in another Country, this counuy (the US),or both?
. . . .

2. usonly
M f i O 20A. How m y years of school did you have? years (1 - 20)
rn A0/30 20B. At what age did you stop attending school? years old
mmco 20C. Did you receive any type of degree?
0. NO
1. YES
20C1. What degree did you receive?

:e&
.......................
..................
..................
34:jZz
5.: w:......
2 1. Did you finish high school?
0. NO
1. YES
21A. And have you done any studying ,eyond high school?
0. NO
1. YES
-Years months
18
2 / A 0 21M.What is the highest degree you have reached?

1. No degree
2. Associates degree or technical degree
3. Bachelors degree
4. Mastersdegree
5. Doctoraldegree (J.D., M.D., Ph.D., DDS., DO,Ed.D.)
6. Other dhAA0
> rnR9-3 21A3. Are you currently in school?
0. NO .e;$*
.......... ..:.:.:~.:.:.:::::
...............
1. YES

hAw30
21B 1. Are you still in high school?
% &Pa-/ I
0. NO
1. YES
B h d e / e-0 21C. Have you gotten a GED or had any other schooling or training since then?
0. NO
1. YES

kiizrs&K./ 2. other &gree/certificate:

%554rca
0. NO
1. YES
2.
~3 23. Do you identify with an e t h c group?
0. NO
1. YES
24. Which group(s) do you identify with?
4.
mm c
Y+UCB -6
25. How American or [ethnic group] are your customs? Would you .say...(read choices)
1. Very American
2.-Mostly American
1. never
2. sometimes, or
3. often
6 26. Are you Latino or Hispanic?

................... ..
0. NO
.
1. YES
20
&,&J 26A. Which of the following represents your origins? Circle aii that.apply.
1. Cuba
2. Mexico
3. Puerto Ria
4. Spain
5. South America
7. Other & % 2 4 & ?5'
d &
If you were asked to put yourself into only one of these groups, in which one would you place
yourself?
1. Asian
2. Pacific Islander
5. Native American
6. Other -&tL
How often do people dislike you because of your ethnic group or race? Would you say...(read
choices) --
1. never
2. sometimes, or
3. often
How often are you treated unfairly at school or work because of your ethnic group or race?
Would you say...(readchoiCes)
1. never
2. sometimes, or
3. often
4A 30 you say.. .(read choices)
1. never
2. sometimes, or
3. often
21
I
Hand "CARD 4: RELIGION" to the resuondent I
33 33. Do you follow or are you a member of any of the churches or religions listed here?
- 0. NO
1. YES 4
Buddhist
Catholic
Church of Christ
'.g 7
4. Evangelical -
5. HIndu
6. Islamic
8. Jewish
3 a. orthodox
b. Conservative
c. Reformed
d. Other
9. Mormon
10. Pentecostal
H~ 3 ; j c+ 3 11. Protestant
a. Anglican
b. Baptist
3; National Baptist Convention
5 . Other Baptist -d+Z.y~d
c. Episcopalian
d. Lutheran
e. Methodist
1. Episcopalian
2 Afr-icanMethodist Episcopal Church
6&3 33Gcf.5 f. Presbyterian
2. United Presbyterian
g. Seventh Day Adventisj
--
73
34 34. Would you say your religion provides you with...(Read choices)

2. quite a bit sf guidance
35. How often do you attend religious seririce? Do you attend.. . (Read choices)

3. a few times -a year
4. almost never, or
5. never
Reminder for the hitexviewer:
I X i s iruemiew NOT end here.

Aruwer thefobv-ing q m o m yourse&and f o b v the insmrctionprovided:
A. Is the PC manied or living with u pamer?
Yes -->
NO ->
B. Have you obtained i@ormution about the biological father?
Yes ->
NO ->
A
Now some quctstions about your partner:
36. What is hisher first name?

2. 20 to 29 years 5 . 5 0 to 59 years
8. Don't Know

mm
A. city +# d B. State
- c. country
c
SF3 38hj 38A. When did shefhe come to live in the USA? year: 19
8. Don't Know
AM5 Sc963-3 385. How old was shehe when shehe came to live in the USA? age:
8. Don't Know
%639 39. Is Ipartner's] mother still living? 1. Yes 0. No 8. Don't Know
Where was she born?

-
40.
C. Country
IrC
Where does she live now?

41.1
- -
-
4 1.2
A. City
B. State
- C. Country
-
24
&&/& 41A. When did she come to live in the USA?
4/60 41B. How old was she when she came to live in the USA?
"';.1
%3 4a
42. Is [partner's] father stili living? 1. Yes' 0. No 8. Don't Know

- c. counay -
A. City B. State
-.
c. country -
44.2 Where did he-live when he died?
- c. country
-
A. City B. State
MA. When did he come to live in the USA? year: 19-

8% +4+D 8. Don't Know
4'1/&0 8. Don't Know
25
Has [partner] attended school in another counry, this country (the US), or both?
1. another country only A

2. US only
3. another country and US G
45A. How many years of school did [partner] have? ,-. years (1 - 20)
45B. At what age did [partrier] stop attending school? years old
45C. Did [partner] receive any type of degree?
0. NO
1. YES
45C1. What degree did [partner] receive? 60 to
Q. 47
NO
...................... .
0.
1. YES
46A. Has ipartner] done any studying beyond high school?
0. NO
1. YES
1. No degree
4. Master's degree
5. Doctoral (J.D.,M.D., Ph.D., D.D.S.,D.O., Ed.D.)
6. Other
46A3. is [partner] currently in school? 0. NO Go to

1. YES Q.47
26
46B. What is the last grade [partner] completed? (1 - 12)
46B 1. Is fpartner] still in- high school?
46C. Has [partner] gotten a GED or any other schooIing or uaining since then?
0. NO
1. YES

"" ........<...........,
46C2. Is [partner] currently in school or training? 0.
1.
NO
YES
QT4*
.......
.
,
_i_ .......
w:..V...?.,.
47. What country(s) best represents Ipartner's] ~ti011a.I

origin or ancestry?
1.
I'
2.
96 48. Does [partner] identify with an ethnic group?

0. NO
1. YES

1. lYi%&&df&
a49 49. Is fpamer] Larino or Hispanic?
0. NO
1. YES
4Qfii7 49A. Which of the following represents hisfher origins?
1. Cuba
7'4 ' 2. Mexico
3. Puerto Rico
4. Spain
5. South America
7. Other
Hand "CARD 3: RACE/E"ICI?"Y" to the respondent il

50. If you were asked to put Ipartner] into only one of these groups, in which one would you
b3 50 place himiher?
1. Asian
2. Pacific Islander
3. African American I Black
4. Caucasian /white
5 . Native American
6. Other
28
l3is imerview NO1 endhere.

Answer the foUoWing queStiom yourseif and follow the instwrionr provided:
-
A. Have you obtained infonnution about BO7Z the biological mother and
biological fmher?
B. Have you obtained ijonnmion about the biological faher?

......... . .............
Yes ->
NO --> "
I
I
Time stopped:
3u
Now some questions about +****Is father:
51. What is his fust name? Don't Know
5% ai& 52. Is he still living? 1. Yes

0. No
r 8. Don't
4 63- 7' 5z4p What is [*****Is fatherl's age?

8. Don't know
fi a-3 -& 53.2 What was [*****'s fatherl's age when he died?

2. 20 to 29 years 5 . 5 0 to 59 years
8. Don't know
53A. When was- [.*****'s father] born?

mm
A. City d
UD B. State
- c. country -
A. city B. State
-
* A.-city .
*
B. State
- C. Country
-
S.NOT::
.. . .... '::;US,
M 55AO 55A. When did he come to live in the USA? year: 19

8. Don't.Know
5%. How old was he when he came to live in the USA? age:
Pa-R 5 6 A O 8. Don' t Know
% 56 56$$ Is [*****'s fatherl's mother still living? 1. Yes 0. No 8. Don't Know

- -
C.Country
A. City B. State
.- c. country
-
A. City B. State
- c. country
-
83% a 58A. When did she come to live in the USA? year: 19--
8. Don't Know
58B. How old was she when she came to live in the USA?
6% 9-zfio age:
8. Don't Know
f7s 59 59. Is [*****'s htherl's father still living? 1. Yes 0. No 8. Don't Know
Where was he born?
*
60.
A. city &a?! B. State

- C. Country
-
3R
3i
A. City B. State
I
-
C. Country
-
A. city e-&-id B. State

c
C. Counny
-
1
_I
.
8. Dont Know
61B1 How old was he when he came to live in the USA? age:
8. Dont Know
k13 6.G 62* Has [*****sfather] attended school in another country, this country (the US), or both?

2. usonly

..... ..
0. NO
1. YES
62C1. What degree did he receive? &..to

CTI 64
32
Did [*****'s father] f&h high school?
NO
..................................
0.
1. YES
0. NO
1. YES
63A1. How many years of studying beyond high school
63A2. What is the highest degree he has reached?
1. No degree
4. Master's degree
5. Doctoral degree (J.D., M.D., Ph.D., D.D.S., D.O., Ed.D.)
6. Other -f& e
63A3. Is he currently in school? 0. NO
wr
.......... r..b
:....... ..........
Qga
>.>;.
1. YES
633. What is the last grade he completed? (1 - 12)
6331 Is he still in high school?
0. NO
1. YES
63 eo 63C. Has he gotten a GED or any other schooling or training since then?
0. NO
1. YES

m65CIO # 2. other degree/cert3icate: 2
I
e-
3. other schooling:
Lz&r%wwd
63C2. Is he currently in school or training? 0. NO Gat0

1. YES Q- 64
3?
64. What counq(s) best represents [*****I s fatherl's ~ t i o n a origh
l or ancesq?
1. &Ct-rR-d'd&
~ d . 65.
5 Does [*****Is father] identify with an ethnic group?
........... ........... .
0. NO
1. YES
0. NO
1. - YES
;6-a3 &';EM 66A. Which of the following represents his origins?
1. Cuba
2. Mexico
3. Puerto Rico
4. Spain
5. South America
7. Other
34
M 6F 67. If you were asked to put him kt0 o d y one of these groups, in which one would you place
him?
-
1. Asian
2. Pacific Islander
+ 3. African American 1 Black

4. Caucasian / mite
5 . Native American
-
6. Other Y=;L&ce
Titis intemhv M Y or M Y NOT end here.

Answer the following questi~omyourself and f o h the innnrctiOnr provided:
A. Have you obtained informmion about rhe biological mother?

... .. .
Yes ->
NO -->
36
Now some questions about ***+*'s mother
68. What is her first name?
................
0. No
8. Don't Know
~@:1 What is [*****Is motherl's age?

3 . 30 to 39 years 6. 60 or above
8. Don't know
70.2 What was [*****Is mother]'^ age when she died?

8. Don't know
70A. When Was [*****Is mother] born?

--
C. Country
A. City B. State - C. Country -

A. City +
&#wdB. State -rcc-
c. country
-
36
mq~
,+d 72A. When did she come to live in the USA? year: 19
8. Don't Know
8. Don't Know
73. Is [*****Is motherl's mother still living? 1. Yes 0.No 8. Don't Know
c. country
c _
A. City B. State - c. country

-
A. city -7~4 B. State _I
C. Country
-

8. Don't Know
8. Don't Know
76. Is [*****'s motherl's father still living? 1. Yes 0. No 8. Don't Know

v3 ?6
77. Where was he born? .
37
78.1 Where dues she live now?
A. City B. State
- c. counny -
A. City B. State
- C. Country -
1"
'.t B.
293 28M
8. Don't Know '
A@?&&O
8. Don't Know
%% FQ 79. Has [*****Is mother] attended school in another country, this country (the US), or bo&?

2. usonly
79A. How many years of school did [*****Is mother] have? years (1 - 2u)
4% *#O
79/30 79B. At what age did she stop attending school? years old
w3 a C o 79C. Did she receive any type of degree?
0. NO.
1. YES
79C1. What degree did she receive? 6 4 e 4 w d
39
38
& 80 80. Did [+****Is mother] finish high school?
0. NO
1. YES
8OA. And has she done any studying beyond hgh school?
0. NO
1. YES
80A2. What is the highest degree she.has reached?
1. No degree
4. Master's degree
5. Doctoral degree (J. Ph.D., D.D.S., D.O., Ed.D.)
6. Other
0. NO'
a*
................->.:>.:
;.$.@
n.....4.
Li ....:
. -
1. YES. ' .% r..,. ......
80B. What is the last grade she completed? -

(1 12)
80B1 Is she still in high school?

.........
0. NO
1. YES
0. NO
.I. YES
8OC1. What has she received? 1. GED

2. other degredcertificate:
3. other schooling:
40
81. What country(s) best represents *****'s mother's national origin or ancestry?
a 82. Does *****Is mother idenufy with an ethnic group?
0. NO
1. YES
1. Y U ' d & L35&?#-eL7e
& 83 83. Is [*****'s mother] Latino or Hispanic?
0. NO
1. YES
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
7, Other ad,
40
$4 84. If you were asked to put her into only one of these groups, in which one would you place
her?
1. Asian
2. Pacific Islander
bt$ 5 . Native American
6 . Other uaRcd& La%ee&
Y f

HOME
-Y 3
Jntroducrion: Now I'd like to get an idea of what *****'s days are like and what some of
n the things arc that you and ***** do together. A good way to start is for
you to describe a typical day, like yesterday and then I'll ask a few more
% questions. .
-
OBS SCALE I. 1 INTHEHOME?
EMOTIONAL and VERBAL RESPONSIVITY [CIRCLE OM1
1 PC talks with subject during visit a. YES

(beyond introduction and correction). b. NO
** 2. PC answers of the subject's questions or a. YES
- requests verbally. b. NO
** 3. PC encourages subject to contribute to the a. YES
I
conversation during visit by g d n g hidher to b. NO
relate an experience OR by taking time to
- listen to h i d e r relate an experience.
OR sets up the situation that allows the subject
- to show off during visit.
*+ 5. PC spontaneouslyp&ses subject's qualities or a. YES
- behavior twice during the visit. b. NO
** 6. PC uses some term of endearmcntbr some a. YES
diminutive for subject's name when taking b. NO
- about or to the subject durinp;visit.
** 7. When speaking of or to subject,Pc's voice a. YES
- conveys positive felings. b.NO
s u u durinE the visit. b. NO
** 9. PC shows some positive emotional response to a. YES
praise of subject offered by interviewer. b. NO
** 10. Pc's speech is distinct, clear, and audible to the a. YES
- interviewer. b.NO
** 11. PC initiates verbal interchanges with the a. YES
- spontaneous comments.
** 12. PC expresses ideas freely and easily and uses ,- a. YES
- conversation. I
** 13, PC appears to readily understand the a. YES
interviewer's questions. b. NO
I
OBS SCALE I. IN THE HOME?
EMOTIONAL and VERBAL RESPONSIVITY
* 14. Subject has been praised by PC ~ c d ue k a. YES
past week for doing something.
Has ***** done anything you're especially happy b. NO
with this past week? Did you tell **how
I* you
*
Y7
Introduction. Now I'd like to ask you about some of the different cxpe~enccs***** may
SCALE II. I INTHEHOME? I School/

VARIETY OF STIMULATION I (CIRCLE O M ] I DavCare
1. Home has a pet. a. YES
Do you have a pet?
b.NO
2. Family Visits or receives Visits from a. YES
relatives or fiends about ~ c a e
month. b.NO
How often do you visit with friends
or relatives?
3. Subject eats meal per day, on a. YES
most days, with PC and father (or
7VER-3 father figure). b. NO
Does ***** cat at the table with the
family or does *Inn* cat separatdy?
(who docs hdsbe cat with?)
4. Subject sees and spends some time a YES
with &her or father figure
a. b.NO
7YdEx-4 Does *****'s father (or M e r figure)
spend time with hidher? (About
bow often?)
recreation with subject D e every b. NO
#A-5 two.
Does **I** do any outdoor activities
with any family mcmber(s)? (About
bow often?)
6. Subject has gone with a famiiy a. YES
member on one outing gvev &
d- b.NO
Does I****
go on outings with any
family mcmber(s)? (What kinds of
things do they do; about.how often?)
SCALE II. IN THE HOME? SchooV
VARJETY OF STIMULATION [CIRCLE Om] Day Care
7. Family member has taken subject, a. YES a. YES

or arranged for subject to go to a
scientific, historical,
. . a ~ or, cultural b. NO b. NO
museum w a s t vw. UNO.
Has ***** been to any kind of Has ***** done this at
museum or exhibit this year? (Who ili&cr rchoolfdoycnrc?
did hdshe go with?)
8 Family member has taken subject, a. YES a. YES
or arranged for subject to go on a
trip more than 50 miles fiom home b. NO b. NO
st v a . UNO,
Has ***** been on any trips this Eas It**** done &is at
year? hisher sEfiOaU&ycnn?
or arranged for subject to take a
trip on a plane. train (NOT b. NO
. .
subway), or bus
x=.
Has ***I* been on a plane, train or
bus this year?
10. Family member has taken subject, .a.YES a. YES
or arranged for subject to attend
some type of live musical or b. NO
theater pcrformance
bast-
..... ....: . .... :. ..... ..
lBE+s'~,*~~~:~dom&
......... ..i/:
. . ..
'a&
. . . . ...
....
. .. .,
hi
Has ***** seen a i i e musical or any
type of theater performance this past
year?
11. Family has manged for subject to a. YES
receive lessons or organizational
membership to support subject's b. NO
talents. -
. .
flmembership, lessom,
art, rtance. or music lessons)
Does *L*** bdong to any clubs or
lessons? Ask: Where?
SCALE II. IN THE HOME SchooU
VARZETY QF STIMULATION (CIRCLE ONE] Dav Care

(bikng, walking, plqtng in park, b. NO I
plpyrng ball, swimming, checkers,
puzzles)
Does your family have any hobbies?
Does I**** join in on them?

n

commercial famiiy venture 3-4 b. NO
. .
times
(mechamagarage, tailor/clothmng
shop, appliance repair shop, bank)
Does **I** ever go with you on
errands you have to do? 1
Invmrv: 3
odu- These questions are about what sorts of activities ***** might be involved
in.
OBS SCALE III. II INTHEHOME? I SchooY

-
*
DEVELOPMENTAL ADVANCE [CIRCLE ONE] I DavCare
1. Subject has access to a. YES
record/CD/tape player or @io
and & recorddCDdtapes. b. NO
Is there a ncord/CD/tape piayer
that ***** can use on hisher own?
Does hdshe have any of hisher
own tapes or records? (About how
instrument.
(picmo, h m ,ukeieie, guitar,
-
*
sIE3- 34
36
-
4. Subject has access t o m age a. YES a. YES
appropriate books.
Does I**** like to read? A n there b.NO b. NO
m y books in the house hdshe can
rad? (Howmany?)
5. Subject has access to a desk or a YES

other suitable place for reading or
7LE3- 5 studying. b.NO
Does ***** have any homework?
Where does hdshe do it?
5. Subject has access to two types a. YES
of reference materiais in the
HE 3-6 home. b. NO
k there an encyclopedia, dictionary
)r anything like that which *****
:an use?
-
OBS SCALE III. IN THE HOME? SchooY
DEVELOPMENTAL ADVANCE /CIRCLE ONE 1 Dav Care
7 Subject has a library card a. YES

Dots ***** have a public library
card?
8 Subject is encouraged by PC to a. YES
read on hidher own.
D~~ ****a r a d on hisher own or b.NO
do you encourage himher to read?
9. Subject has books a. YES
of hidher own.
Does ***** have any of hisher-own . b.NO
books? (About how many?)
encourages subject to develop or
sustain hobbies. b. NO
Does ***** have any hobbies? If
yes, Did you encourage this? If no,
Are there any you have encouraged
himher to have?
1 1. Subject has access to pieces
of appropriate equipment for
physical development or
organized sportsactivities.
oduction: Now, I'd like to ask you some questions about scheduling, ruies you may have
and how you handle discipline.
OBS SCALE IV. IN THE HOME"

SUPERVISION [CIRCLE OM/
I

school nights.
#E 4- Does ***** have a certain time hdshe has to be b. NO
2. Subject routinely obeys curfew on school nights. a. YES
'1,
Does ***** usually'obcy that rule?
# E 4-fz I 1 b. NO
3 Subject has a set time [curfew] to be home on a. YES
weekend nights.
HE 4- 3 How about on weekends? Does ***** have a cert?in b. NO
time to be home?
flE4-4 D~~ ***ne usually obey that rule?
b. NO
5. PC has established rules about homework and a. YES
checks to see if homework is done.
Do you have any specific rules about doing b.NO
homework? Do you check to see if it is done?
6. PC assisted subject with homework and school a. YES
assignmentsw r w& during current or
most recent school year. b.NO
(About how often?)
7. PC requiressubject to sleep at home on school a. YES
nights.
sleep at home on school nights or can
Docs ****I b.NO
hdshe stay with friends?
8. When PC is not available to subject at home, a. YES
M e r to check in with PC, or their designee, on b. NO
When you aren't at home, does ***** check in with
you or anyone &e?
s3
-
OBS SCALE IV. I INTHEHOME?
SUPERVISION I (CIRCLE ONE]
9. M e r school subject goes somewhere that adult
1 a. YES
h 4- 9 W h e n does ***** go after school? Are there any b. NO

adults there?
10. PC establishes rules for subject's behavior with a. YES

are being followed. b. NO
M k - 40 Do you have any rules about what ***** docs with
hisher friends? Do you talk to ***** about what
hdshe is doing?
without adult supemision for. -
How much time can ***** spend in public places b. NO
without an adult?
12. PC has had contact with two ofthe subject's a. YES
friends we&.
Do you ever get to talk with ******s friends? b.NO
(About how often?)
13. PC talks daily with subject about hidher day. a. YES
Do you get to talk with **every I* day
*about
hisher day? b. NO
14. PC has visited the
. .school or talked to the teacher a. YES
or counselor
,-
Do you ever go to ****a1 s school or talk with the

f / E4- vq teacher or counselor there? (When was the last
b.NO
time?)
15. Family has TV,and it is used judiciously, not left a. YES
on continuously.
(No TV requires an automatic NO) b.NO
16. PC has discussed television programs with subject a. YES
two week.
HE4- ir& Do you talk with ***** about different programs? b.NO
y h e n was the last time?)
17. PC has discussed current events with subject a. YES
ast two weeks,
(arrent events) b. NO
749-I?- Do you ever get to talk with ***** about what
hdshe sees on the news, or in newspapers or
-
*
3
SCALE Tv. M THE HOME''
SUPERVISION [CIRCLE Oh?]
18. PC has discussed the hazards of alcohol and drug a. YES
abuse with subject
During the past year have you spoken with ***I* b. NO
19. PC denies subject access to alcohol (including beer a. YES
or wine) in the home.
Is ***** allowed to drink beer, wine, or other b. NO
alcohol at home?
4
20. PC knows signs of drug usage and remains alert to a. YES
possible experimentation. -
UE4- Do you feel familiar with the signs of drug use and b. NO
2 1. Subject is taken regularly to a doctor's office or a. YES
QXuYaL b.NO
Has *I*** been to a doctor or clinic for a check-up
22. Family has a M y regular and predictable daily a. YES
(meals, Mer school activities, becfnme, how much
7YE 4- #tL
b.NO
W, homework)
Are things like bedtimes, mealtimes, homework
done about the same time each day?
them.
(arjiw, homework before W,clecmng up, other b.NO
kE4- n3 regu&ttions)
Other than the rules we've already talked about, are
there any other d e s you have for *****'s
behavior? Do you usually try to get h i h e r to
foliow them? ~~
24. PC is generaIly consistent in establishing or a. YES

applying f d y rules.
Are there similar rula for the other members of the
hF4-24 family? Do you usually try to get them to follow
b. NO
them?
1. PC does not shout at subject during the visit. a. YES
b. NO -
2. PC does not express overt annoyance with or a. YES

b. NO
3. PC neither slaps nor spanks subject or any other a. YES
M y member during the visit.
b. NO
4. PC does not scold or criticize or put down the a YES
subject during the Visit.
b. NO
5. PC has not lost temper with subject a. YES
D f C V l O m .
I'm sure ***** does things that are annoying. Do b.NO
you ever lose your temper with him/hu?(How
about in the past week?)
6. Subject is allowed to express negative f&gs a. YES
toward PC or can disagree with PC without harsh
\ reprisal. b.NO
When **gets *I * with you or says something
angry
mean, or disagrees with you, how do you handle it?
7. PC reports that instance of a. YES
physical punishment o c c u r ~ d
month. b.NO
Have you had to p h y s i d y punish or spank *****
OBS SCALE VI.
MODELING
I INTHEHOME
K I R C I I ONE 7
** 1. At least rn books are present and visible in the a. YES
home.(Ifnot visible ask:)
Do you get a chance to read? Do you have a place b NO
- you keep books?
-
** 3. PC introduces interviewer to subject. I a. YES
I b. NO
4. PC or other family member buys a newspaper daily a. YES
and reads it.
#6- Does anyone in the house get a chance to read a b. NO
5. PC or other family member subscribes tohuys one a. YES
magazine monthly.
6-5
I% Does anyone in the house buy or subscribe to any b. NO
magazines?
Arc you involved in any religious or community b.NO
activities?
7. PC participates in child oriented organization. a. YES
How about any groups or organizations that do
things for children? b.NO
8. PC has not cried or been visibly upset in subjects a. YES
presence w .
When you feel unhappy or sad, do you let ***** see b. NO
your feelings or do you try to hide them? Have you
cried or been very upset in front of ***** recently?
(When?)
57
Introduction: Now 18 like to ask you about different responsibilities ***** might have.
SCALE VII. IN THE HOME? School/

FOSTERING MDEPENDENCE /CIRCLE ONEJ Dav Care
subject . a. YES
concaning sexuality and personal b. NO
#E 7-5/ hygiene.
x In the past year have you discussed
with ***** the responsibilities and
consequences of sexuality and .
personal hygiene?
2. PC has taught subject how to deal a. YES
with health and safety
emergencies in an age appropriate b.NO
H?-2. manner.
Does ***** know what to do in an
emergency?
3. PC teaches subject to help with a. YES
+/#E?- 3 Do you show ***** how to cook and b.NO
denn?
4. Subjecthaswc&yage a YES
respOIlSibilities. b.NO
HE ?- 4 @ickingup #er hinherse&
putting clothes in h p e r - j
Does I**** have any weekly &om
Dr responsibilities?
5. PC expects subject to put outdoor a. YES
clothing, dirty clothes, and night
clothes in sptcific places. b.NO
&?- 5 [s expected to pick up after
him/berself?
5. PC allows subject to visit with a. YES
fkiends outside schooYday care
+/E?- 6 b.NO
Docs ***** visit with friends outside
,f school?
59
a- -
OBS SCALE VII. IN THE HOME^ SchooU
FOSTERING INDEPENDENCE [CIRCLE ONE] Day Care
9

hidher toydtreasures or
belongings. b NO
#/E 7-3- Does ***** have a place to keep
belongings? .
.r
TIME STOPPED
FIELD COPY # 2
SUBID TIME STARTED
INTID
n
SCALEMII. PHYSICALEkVIRONMENT
[INTERIOR OF HOME]
II INTHEHOME?
(CIRCLE ONE]
I
1. House or apartment is fiee of potentially
dangerous structural or health hazards.
(eqosed outlets, broken windaws, windaws
3. House or apartment is clean; all visible rooms
noise in the house.
8. -
House or apmtmcnt is not overly noisy fiom
9. Household members do not use tobacco. a. YES

b.NO
IO. There are no obvious signs of recent alcohol a. YES
home.
TIME ENDED
-NOR OF HOME]
Day ofweek: M Tu W Th F Sa Su
(CIRCLE ONE)
T h e . of day: Entered home: -*- Ah4 PM
t.r hr .min
Left home: -*- AM PM

hrmin
#/LE 9- i/ 1. Street Layout:
1. -
Through straight
2. -
Through c u r ~ e d
3. H-layout
4. T-layout
5. L-layout
6. cul-de-sac
7. Boulevard
8. Divided Highway
9. Othcr
How would you characterize the land use on this face-block, based on
?+E$x/ 2. -t -level
frontage?
1. Primariiy residential
9. Other
2. Fair condition
4. Do any of the fronts of rcsidcntiaI or commercial units have metal security blinds, gates,
#E9-4 t.4 or ironbars or grills? .
1. None
2. Some
3. Atleasthalf
4. Most
HE 9-5 5. How would you rate the volume of traffic on LC face lock?
2. verylight
3. Light
4. Moderate
5. Heavy
6. Vcryhcavy
6. How w a d you rate the condition of the strcet in the face-block?

#9-6
1. -
very good recent resurfacing, smooth
2. -
Modcratc evidcncc kept in good rrpair
3. -
Fair minor repairs d e d , but not rough surface
4. -
Poor potholes and othcr evidence of ncglcct
flE9-F 7. Is thm garbage, liner, or broken glass (except bedliquor bottles) in the street or on the
sidewak?

3. Yes, quite a bit
4. Yes, just about everywb re
fi%? 8. Are there drug-related paraphernalia, condoms, beer or liquor containers or packaging,
cigareste butts or discarded cigarette packages in the meet or on the sidewalk?
1. None,or almost none

3. Yes, quite a bit
#E 9-9 9. Are there children playing on the sidewalks or in the Street of the face-block?
('4 1. No children visible, or all in yards

2. Yes. one or two children
10. Are there any adults or teenagers in the s t m t or on the sidewalk arguing, fight&,
f j E 9-10 drinking, or behaving in any kind of hostile or threatening way?
1. No persons observed in the strect or sidewalk

4. Yes, three or more behaving in a hostile manncr
11. How did you feel parking, walking, or waiting at thc door in thc face-block?
+/.E 9- //
1. Very comfortable: can imagine living/working/shoppinghere
4. I would be uncomfortable living/working/shoppinghere
63
SCHOOL SCREEN
1
SCHOOL SCREEN: PC [Plq

Date:
mm dd yy
I. Does ***** currently attend school?

(Code YES if cunently on vacation, suspensiOn, etc. and will return to school.)
....c..:.:.:.:..
YES
......:...:.....:.:.~:.!.~.:.~.~.:...~.:
1. m ;mi&g
.................. ..........
l
"-?;"-?;&&T
2. NO .........., A
.,.,, .................
2. why is ***** not in school?
what was the last grade ***** was in?

c/r35 3.
Btade
ed.init. &.date
2
8. What is the name aud address of the school ***** currently attends?
2.
.d
Address
.-
3. 4. 5.
City State m
9.
11. whattyptofschoolisit?
13. What grade is ***** currudy in?

$43 i 3 (Ifdunhgsummcrbreakalnd
willbeenteringinthet)
1. 90. ungradeedsch001
grade
14. In the past ycar, was ***** ever truant (skipped school without an excuse)?
1. YES
2. NO
3
$43 /.T 15. On the average, how often was ***** truant? (Circle one)
a more than once a week

b. once a week
d. onceamonth .
e. a fcw times a year
s43 j6.q 16. In the past year, did ***** cver skip classes without an excuse?
1. YES
17. On the average, how o h did ***** skip classes without an excuse?
8. evayclsy
b. afiwtirnesawcek
. c. onceawak
d. afcwtimesamonth
e. onceamon&
E afiwtimesaytar.
i
4
S45 98 18. Thmk.mg back to the last year ***** was in h@ school/ grade school, was
***** ever truant - skipped school for the whole day without an excuse?
..... .......... ...................................
...........................................
39
1. YES
C;O:m:Q
~
..............:.......... . . :.;.
Gom<.~
%
.
..
..
.
.I
..
..... .....
.................................... 2
2.NO ........:? .:.......x.. d ....
$43 /@ *I
19. How often did ***** skip school for the whole day Without an excuse?
a. more thau once a week
b. oncead
d onceamonth
e. afewtimesayear.
s .A 0 20. ThinLing back to the last year ***** was in high school/ grade !shoOL did *****
evaskipclrrsseswithoutanexnwe?
1. YES
2.NO
2% A f 21. How often did ***** skip classes without au excuse?
a.
b. ahtimesaweek
c. onccaweck
6 ahtimesamonth
e. Cmceamonth
E ahtimesayear.
22. Has ***** ever skipped a grade? 1. YES 2. NO
sr4 6423 23. Has ***** ever repeated a grade? 1. YES 2. NO

24. Many studeats receive special teaching or help in school. At any point since
***** started W e r education has she received any help or special teaching in
-
(Read aloud Circle dl tbat apply.)
a Giftedclass 1. YES 2. NO
b. Special remdation clasdtutoring program 1. YES 2. NO

(icludes summa school)
c. Ltarningprobluns 1. YES 2. NO
d. Class/ program for developmeataty 1. YES 2. NO

e. EngfishasaSecondLanguageor 1. YES 2. NO
LimitedEnghhspeaLing
f SpeeChthcrapyClaSSes 1. YES 2. NO
g. Class/ program fbr physically 1. YES 2. NO
- w M m m b u
sighs problems
h Emotional or behavior problems 1. YES 2. NO
i Special music or art school 1. YES 2. NO
j. Specialscienceprogram 1. YES 2. NO
6
25. Was/Is ***** routinely involved in extracurricularactivities directly connected

with M er school, such as school sports teams, school clubs, music groups, etc.
1. YES mmQ?&;M
..................................................
.......................
.................
......
...
2. NO
SA656
.r
27. What kind of program wash this? (Cmle all that apply)
~ & A ?
1. Recreational (sports, games,crafts)
3. Academic enrichment(tutoriug cia!=)
4. otha(p1easesPecifjl) vrZ/eckl4& 8
G3a8 28. WaslIs ***** involved in my other kind of after school program?
maybe at *****s sdmol, but is more of m &a school program rather than
exaaauriculafactivity.)
1. YES
2. NO
GPPS &Q 29. How many hours didldoes this take place? hours per week
30
72
7
a. DaycardPreschool or Headstart-type program

I
73
8
For U s only: for Elementary and High School type, use the following codes:
1 -Public
-
2 Catholic
-
3 home school
-
-
5 other (please sp*)
b. Elementary School (inchrding Kindergarten)

School Name 1 I
Address (imdude dy,state) School type
3. I - - 1-
+
4.
5. I
-
--
//-
it ~
74
9
1 -Public
-
2 catholic
-
3 home school
-
-
5 Other (please specifl)
a 75
10
3~ 32. How often do you attend scheduled parent/ teacher conferences? (Read choices.)
1. almostalways
2. often
3. seldom
4. mer ..--
56 3 3 33. How often do you attend PTA meetings, local school council meetipgS or any school
related mtx?hgs?(Read choices.)
*at
1. almostalwayi
2. often.
3. seldom
4. never
How would you describe the education ***** is receiVing in hisl her current school?
5-2339 34.
(Read choices.)
I ENDOFINTERVIEW RECORD TIME: I
-7b
FAMILY STRUCTURE &
HEALTH HISTORY
Family Structure and Health History: PC
Date: FS7yHZA T
PART I: F d y Structure
3$
.-
Now I would like to ask some questions about *****Is family. This year I will only be
, getting a general outline of who is in the family. Next year we will come back to this
1.A You told me earlier that you are *****Is:

ffi 640 (READ AND CIRCLE APPROPRLATE CHOICE)

c. f e d e m u s i n f. sister i. other v w a b /"e
l.B You told me d e r that you are *****Is:
Fb 1/50 (READ AND CIRCLE APPROPRIATE CHOICE)
*-d
c. malemusin f. brother i. other &4?&?&&& I t
Isthatright? Y N
ed. init. ed. date

SECTION 1: BIOLOGICAL hl0-

frrst name

(years old)
*.r 3.2 How old w a he when he died? DON'T KNOW

(years old)
4.1 What is your marital status with *****'s biological father?
l a married-still involved
l b divorced
4.2 E b t war your madd status with *****Is f&r when he died?
lb divorced
2a newer married-still involved

A% 5-l / 2.Yes
5.2 Were you living wifh*****'s

F A 5-A biological f&r when he died?
3

(YW
6.1A How much time has *****'s biological father spent with himmer in the past year?
Fb &.id0
a. none
d. once a month
e. twice a month
f. once a week
g- daily
h. other
6.1B Wow much time has *****'s biological father spent with hidher prior to the past
%g-/A8 year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
4
F&6-AAO 6.24 &$ore he died, how much time did +***+'s faher spend with hidher in the past
year?
a. none .
c. intermittent at set times (less than once a month) .
d. onceayear
e. twiceamonth -
f. once a week
g- M Y
h. other
F b 6- 60 6.2B Before he died, how rmrcfi time did *****'s biologicul fmher spend with himlher prior
to the part year?
a. none
b. intermittent a d unpredictable (less than once a-month)
d. o m a year
e. twice a month
f. once a week
g. M Y
h. other
7. ~ o e *****
s have any children of hisher own?
7.2 Name: *'& D.0.B
%%
5
&?3 8 Does he/she have any siblings? 2. Yes 1.No
For each one, I need to h o w their name, age, whether they are a boy of a
whether they are a biological, step, foster, or adoptive sibling of *****, md
whether they are still living. If ****+ has sibllngsl who have a partner or child, I
Bvill n e d to ask you some additional questions about them. Why don't you starf
$4 with the oldest sibling?
BROTHERS
cause of death:
Cdm*3&&
d
IrRd%S/SJ
bio'l mom's name: &UP,D&
bio'I dad's name: &,&e&
MAP
cause of death:
. &cw.4q/J
/56 &e A5
bio'l mom's name:
bio'l dad's name: d&~%&
' &&
- NAP
a3
6
BROTHERS SISTERS
- NAP
mBRIqA3"
7
BROTHERS SISTERS
8
BROTHERS SISTERS '
# % name: &D& # 7s name:

1iving:Y N age//agedied:&&%72j living: Y
cause of death: m#9& cause of death:
BBRGFS 6'
bio'l mom's name:
. ........
Children? Y N ?%8kB&
# girls: b # boys :
RF8s name
living: Y
=use of death:

bio'l mom's name:
partner? Y N age: ,-gender: ME partner? Y N age: -

gender: M/F'
b # girls: # boys ; # girls; # boys :
h
- 9
F14 9 9. You told me about (READ NAMES OF SIBLINGS). Are there any
other siblings of %+***,
either yours or s biological fathers children, that you
****+I
may not have mentioned? 2.ms 1.NO
ing of living quarters for most of the time, without
10. Have you been married to anyone other than *****Is biological father or lived with
FA J
i0 someone else as a partner other than the relationships you have just told me about?
(CIRCLE ONE)
1. -NO:
2. -YES:

# of refationships
1OB. For each of the people you had a relationship with, I need to know their fnst
I. Gender: M E

. . .. . . ...
F&?'OA6& 2. Gender: M/F .I *-%L

first name
m f ~MA/
q la married-still involvd 2a never married-still involved
n lb divorced 2b never married-no longer
-
involved
'q
Id widowed . 2c never married, partner died
F.&foB43 3. Gender: M/F .1 *

first name
~3 la married-still involved 2a never married-still involved

la
~&-;/oh#q married-stiLl involved 2a never married-still involved
lb divorced 2b newer married-no longer
IC married, but sepamted involved
.1 I -
first name
\ F Z M ~ A N
la ~
marrieci-still involved 2a never manied-still invoked
IC married, but separated illV~1Ved
1d widowed 2c never rxxmied, partner died
11
f i l 3 gyb la married-still involved 2a never married-still involved

lb divorced 2b never marriedlno longer
n . .-
f / 3 37' 11. Has *****Is biological father been married to anyone or lived with someone else as a
partner oher than the relatiomhips you've just told me about? (CIRCLEONE)
1 - DON
2 - NO:
3 - YES:
11A. how many other relationships has he had?

# of rehtionships-
11B. For each of the people *****IS biological fathers had a relationship with, I
first name. I also-needto know whether he was married or
need to know their.................................
living &em @ .....
T & - d... 3 and whether he is sm in the rehtio~hip]. If the
reiationshq has ended, I d to know if it was due to divorce, separation or
..,..I........
being widowed.
1. Gender: M/F .1 *-=4?!5

first name

Id widowed 2c never married, eiker
partner died
2k don't know
. -
12
2. Gender: M/F .1

Id widowed 2c never married, either.
partner died
2k dontknow
-
3. Gender: M/F .1

partner died
2k dontknow
4. Gender: MLF .1 L?%#w&L

first name-

partner died
2k dontknow
5. Gender:. M/F .1
first name
la married-still involved 2a never married-still invplved

lb divorced 2b never married-no longe3
p-r died
2k dontknow
13
6. Gender: M/F .1
~6 la married-stili involved 2a never married-still invoIved

Id widowed 20 never married, either
partner died
2k don't know
- -
$4
/53 +/fi g+ 7 . Gender: M/F
~6//& /y,p la married-still involved 2a never married-still invoived

partner died
2k don'tknow
..
-. ... . - .
-.-. . .. . ... ..- . , .. . ..
14
SECTION 2: BIOLOGICAL FATTER
d+u?.
12. - is ****+'s
fmt name
f3 - y' -
13: 1 . How old is she? DON'T KNOW
- ( y . w s old)
b
13.2 How old was she when she died? DON'T.KNOW
(years old)

F6 f4- 4
la marrid-still involved
l b divorced
14.2 What was your m&aLs t a With **+**'s mother when she died?
lb divorced

2.Yes
15.2 Were you living with ***** 's

biologicd-motherwhen she did?
15
1%. Was there a time bar you lived together? 1.
2. yes ,&j*&:Q 9.-::;;:f-sM

................................
.......................
;.
15A1. When did you stop living together? (Year>
16.1A How much time has *****s biological mother spent with himmer in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g.
h. other
16.1B How much time has *****s biological mother spent with him/her prior to the past
year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
i6
16.2 &%re she died, haw m c h t h e did *++*+

's biological mother spend with hm/her in
the past year?
a. none
c. intermitrent at set times (less than once a month)
d. once a year
e. twice a month
f. once a week
g. M Y
9 h. other
16.2B Beore she died, how much time did ***** 'S biological mother spend with himiher
prior to the past year?
a. none
d. once a year
e. twice a month
f. once a week
g.
h. other
17. Does ***** have any children of hismer own?
Children? 2.Yes 1,No

A C
17.1 Name: ~&&$$+%& D.0.B Gender: M/F F . f ? , YCO
17.2 Name: D.0.B Gender: M/F F&f-?- & C O
3c0
17
,-lc/3 i 9 18. Now I h a w some qu&ons about s st*'^ brothem and sisters, &dm%v
biological, step, foster, o r adoptive siblings.
For each one, I need to know their name, age, whether they a r e a boy or a @I,
whether they are a biological, step, foster, or adopthe sib- of *****? =d
whether they are living. If ***** has !jiMngs who have a paftner or child, I
-
- a.$;. the oldest a bg?
BROTHERS SISTERS
# l b name:
living: Y N
e ? !age/age d i d . FfiS'&f9
# 1s name:
living: Y N
/F/37tBL
c%ki%%wd
age/age d i d ~ % & & G
cause of death: FA S8&B/&
F;3 YBR .s As
hio'l mom's name: dfz.qp& bio'l mom's name:
bio'l dad's name: ."%
A
-! bio'l dad's name:
.
- NAP - NAP
...... .....
*#M/6 F&/&&723 F3MPO'fi W/BA,{S rnBYY/&F H / S

parmer? Y N age:
. gender: M E partner. Y Pi age: gender: M/F
Children? Y N i%f8&.z/43 Children? Y N FZ37/&k21/5
b# giriS:rnA/!* # boys : m-ys
#2b name:
living: Y pi agefage died: B/8-
F'R#Aa.&3 cause of death:
6% 7 a e s r .'
- NAP
%f&&'AJ3 BzE&#&
/3 f l
partner? Y N age: ,-gender: MA?
Children? Y N 6EijB&-RA
q5
-
BROTHERS SISTERS
#3b m e : lzl?%wwd # 3s name: *
living: Y N age&edied: 1%1'8&.3$ living: Y N age/lage died:/i3/8&34
/
cause of death: Y8B3A cause of death: rnHAW3

//
FA 7'8RE 343 fA-/&es35'
bio'I dad's name: bio'I dad's name:
- Nfw - NAP
-.
46
19
BROTHERS SISTERS
# S name: d +
living: Y N agefage died: FA/&M5d
cause of deatix B;/eB5j3
:
FEW&& 5/3
bio'I mom's name:
bio'l dad's name:
- NAP
&/8Pq%A Wd??Ys-& &A' Pds-A
partner. age: vender: WF
Children? Y N BA'k/54
b # girls: p # boys : E&~'&QLX
living: Y M age/age diexkF~~J~68,

cause of deab: rn/&&B6/3
IY
,%/8RS 65 A / B R I 6s
w,
- NAP - NAP
20
BROTHERS SISTERS
x 7s name:
living: Y N age/age died: ,%kfiM%
cause of death: cause. of dath: A??&md
r*
EJ/&Rl-7A FA-/BE239 '
- NAP - NAP
BHPV 1sR.c9Cy;5423 F;s&!!5G%3 F&MM9J E&&w7s ,&3kwfi?J
partner. Y age: -, gender: M E partner? Y N age: gender: M/F
Children? Y N ~ A + ' L ~ G % Children? Y N F A / ~ , c z ~ S
'# girls: -
t # boys .-,Fr3/ipA03&
# 8 b name: Was name:

living: Y N age/agedied: living: Y N age/age died:

- NAP - NAP
partner? Y N age: -gender: ME partner? Y N age: vender: M E
*#girls: 4bOys:.- .#girls: .#boys: .
i.,
\'
21
A4 @ other siblings of *****, either yours or *****' s biological mother's children, t h t you
may not have mentioned? 2.Yes 130
same or opposite sex that-includes sharing of living quarters for most of the time, without
being married to him/her at that time.
F&&O 20. Have you been married to anyone other than *****'s biological mother or lived with
someone else as a partner other than the relationships you've just told me about?
(CIRCLEONE)
1. - NO:
2 . - YES:
F&mm 20A. How many other relationships have you had?

X of relationships
20B. For each of the people you had a relationship with, I need to know their fust
whether you are still in the relationship. If the relationshq has ended, I need
*
1. Gender: M/F .I
first name

-22

Id widowed 2c never maxried, parmer died
3. Gender: M/F .1 +-5

fmt name

-
4. Gender: M/F .I *d
fmt name
la married-still involved 2a never married-stiU involved

-
5. Gender: MIF -1
first &e
'la married-still involved 2a never married-still invoived

6. Gender: M E .1
first name

23
mns+ 7. Gender: M/F .1
,J=&jCL3&M
- & la married-still involved 2a never married--still involved
l b divorced 2 b never married-no longer
-
Fh&/ 21. Has *****ISbiological mother been married to anyone or Iived with someone else as a
1 - DON'T KNOW
2 - NO:
3-YES:

# of relationships
21B. For each of the people *****IS biological mother had a reiationship with, I
need to know their first name. I also need to know whether she was married
m., $ whetfier &e is sm in the relationship].
................. ., ..., .......
or riving with them @ *........xi. w
........<.........................
...................
1. Gender: MfF -1
. first name

partner died
2k don't know
24
2. Gender: WF .1
first name
la married-stiIl involved 2a never married-still involved

ld widowed 2~ never married, either
partner died
2k don'tknow
-
3. Gender: M/F . . l W
first name

partner died
2k don'tknow
4. Gender: ME .1
first name
- la married-still involved 2a never married-still involved

partner died
2k don'tknow
5. Gender: M E .I
la married-still involved 2a never married-still inv?ived

lb divorced 2b never married-no longe;'
partner died
2k don'tknow
25
pfi aG 6 6.Gender: M/F .I A d

J first&e
(z=,,;z 7WM6
partner died
2k dont.know
- -
ga
f&&y&~+ 7. Gender: M/F .1
F&A//3/p? la married-still involved 2a never married-still iwoived

IC married, but separated hVdVed
partner died
2k dont know
SECnON 3: Other Caregiver
[MalelFemaieJ
22. JXhat is =*+**'sbiological mother's name? DON'T #NOW

'&/fed. first name
3&3- f 23.1 How old ,isshe? DON'T W O W

(years old)
23.2 How old was she when sfre died? DON'T KNOW
(years old)
324- / A 0 24.1A How much t h e has *****Is biological mother spent with m e r in the past year?
a. none
-
c, intermittent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
24.18 Row much time has *****I s biological mother spent with himmer prior to the past
5z4- year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27
%3 %4.#;z,?40 242% Bejfore she died, how much time did ***+*'s mother spend wirh h a h e r in the
prut year?
a. none
c. intennittent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
.-.
24.28 Bt$ore she died, how much time did *****'s bioiogicai mother spend with
=eA4- A930 hidher prior to the past year?
a. none
b. intennitrent and unpredictable (less than once a month)
d. once a month
e. twice a month
f. once a we&
g- M Y
h. other

first name

(years old)

fAZ6 I a (years old)
28
27.114 How much time has *****'s bioiogicd father spent with him in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g. W Y
h. other
27.1B How much time has *****Is biological father spent with himmer prior to the past
year?
a. none
F/3 x ?- ;/Ac b. intermittent and unpredictable (less than once a month)
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
27.U Btfore he died, hmv much time did *****Is biologicalfarher spend with
himher in the part year? !
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
4
27.23 Bejt3r~he died, how much rime did *****'s biological faher spend m2h
himher prior to rite p a r year?
f=zjA?- &?A0 -
a. none
b. intermittent and unpredictable (less than once a mon&)
d. once a month
e. twice a month
f. once a week
+ g. M Y
h. other
-
3 2 8 - i 28.1 Are +***+'sbiological parents living together now? 2.Yes 1. No 3.DON.T

KNOW
28.2 Were *+**+'s biobgicd parem living togerher when ****+Is mrher@kther
died?
29.1 What iS the marital status of *****'s biological father and mother?
la married-stillinvoIved ,
lb divorced
27 29- a/ 29.2 what was the mnrd stmus of *****'s biological f&r and mather when
*****'s mother@&r died?
lb divorced
IC married; but separated
2b never married-no longer kvoived
!
30
Does he/she have any sibiings? 2.Yes 1.No 2. DON'T KNOW

For ea& one, H need t o h o w their name, age, vhetha they are a boy or a m,
whether they are a biological, step, foster, o r adoptbe sibling of *****Y
whether they are stiff.E m. E*****has siblings who have a partner or child, I
will need t o ask you some additional Qllestions about them. Why don't you start
BROTHERS SISTERS
# I b name: L5Ge4eOd # &e:
IS 6&e@79-&L
living: Y N age/age died: k33ox1A-q living: Y N aie/age died:F&35WA
F&2?!24Bi/A cause of death: B*AB+s'
K
FA a&2
/?
S
FAaBe52v3
bio? step? foster? adopt? bio? step'?foster? adopt?
bio'l mom's name: bio'1 mom's name:
="Oqf& ~w
p a r . Y N age.-j ~ g c ~ e r :
M/F
3 a ~ ~ f 4
Children? Y N F%%?QLT/~~
b # gkis: # boys : &&$2m723
+
#2b name: &&Z#zw d #2s name:

living: Y N living: Y N
v
agefage died.FA304wq agefke d i d . F A 5 W f i

cause of death: F;s 50H53jfi came of death:
Y
F/3 3SoAEA6 /=/3gORS~Sy

bio'l mom's name: bio'l morn's name: &-e,&-
bio'l dad's name: bio'I dad's name:
- NAP - NAP
- 31
BROTHERS
living: Y N age/age died. 633944Gj Ihing: Y N age/age died: -3-
# V
Cause of death: /=&*&B3: cause of death:

&-
I' V'
F&&?B.s 343 F X 3B&S as
- NAP
#am=3s
3330Py3f
partner. age: -
NF6cigP/3B m-GzA
gender: M/F
G330PA3S A23ZwY3S
Children? Y N Fi830k/38
b #' girls: # boys : BJaSC3k-3 + # boys :m*Z3G3S
B4b name:
iiving: Y N age/age died:/%3~X4449
cause of death: E43.30&4&
F/a a 8 e 2.96 f%33Oa54S

~
bio? step? foster? ad bio? step? foster? adopt?

bio'l mom's name: bio'l mom's name: -
143OPXY&3 M30#+& F~*0~423

Children? Y N FA.MR/&&
# girfs: -b # boys :
,.. .. . .. , .. ____._.. .. . -. . .- -. ,. .. .. .
32
BROTHERS SISTERS
# 5 b name: # 5s name: P A
living: Y N
t #
living: Y . N age/age died:B*4&5< age7Ge died.FAXXWS
cause of death: mam5g cause of death:
:
.i?oez
FA 543
-
F& a4.S.TS
/ "

bio'l morn's name: bio'I mom's name:
~
- NAP
i'AaaF3-s
-gender: M/F
*4;4opAq's -3DAM5s
partner. Y N age:
Children? Y N F&,~cw/&~
# girls: # boys :J--w?&5-&
# & name
living: Y
cause of death:
:R330RE 6 s
bio? step? -foster?adop
F ~ s o M ~ -%%+?6S
753eA9p
partner .. Y N %e. - rn30S6Pi
*;/6A
gender: M/F
& 3QPt3c;s
partner? Y N age:
S
gender: M/F
Children? Y N -0kZ6.4
33
BROTHERS SISTERS
#%name: # 7s name:
Fr3 343 living: Y N agejage d i e d F B m ! q ; 5 living: Y pd =;$age died: i73.3~44
cause of death: FA s m 3 e cause of death:
Jg
nS?&ZS FAoleE3S y J
bio? step? foster? a bio? step? foster? adopt?
bio'l dad's name: bio'l- dad's name:
- NAP ...
%30P?
partner? Y N age:
rnS/?&uender:
m*AA%
M/F
C& JOp& -&p& F&CPd: 9s
p m e r ? Y N age: -gender: M/F
living: Y N ageJage died: liviug: Y N agelagedied:
cause of death: cause of death: -

NAP - NAP
partner? Y N age: -gender: MA? pamer? Y N age: -gender: M/F
+ # girls: + # boys : + # girls: * # boys :
\
34
F& ,3f 3 1. You told me about (READ NAMES OF SIBLINGS). Are there any
2.Yes 1.No 3. D O N ' T m O W
~ 6 3
32. Do you know if either of
~ *****Is biological parents were married to anyone else or
lived with someone else as a partner? (CIRCLE ONE)
1 - DON'T KNOW
2 - NO:
3 - YES:
FEY 3R 84/Y a Bio mother: # of relationships
FA& AFf Bio father: # of relationships
32B. For each of the people [the biological mother/father] had a relationship with, I nezd to
know thek first name. ..,... need to know whether [shehe they] [were/was] married
..*......I...also
or living with them w
2- _..%. whether [she/he/they] [k/are) still in the
...._+..
.?.*n_____.
Biological mother.
F/3 3 A B ~ 6 f 1. Gender: M E .1 .K2$z&-dk

\ fmt name h
F A SA, AMMI l a married-still involved 2a never married-stiu invoived
partner died
- 2k don'tknow
35
2. Gender: M/F .1 * .
fmt name
la manid-still involved 2a never married-still involved

partner died
2k don'tkaow
3. Gender: 'MIF .1

partner died
2k don'tknow
4. Gender: M/F .1
first name
la married-stiu invoived 2a never married-still involved

partner died
2k don'tknow
5. Gender: MIF .1
first m e
la married-still involved 2a never married-stiil hvoived

partner died
2k don't know
- ., . .. . . ... .. _,. . , -L... ._>.. .. I
36
6 . Chder: MlF

Id widowed 2 never married, either
parmer died
2k don't know
7. Gender: M/F -1-.

frrst name

partner died
2k don'tknow
Biological fatheE
1. Gender: ME
fmt name
la married-stiu involved 2a never married-still involved

partner died
2k don'tknow
2. Gender: MA? .1
fmt name
l a married-still involved 2-a never married-still i n v o h d

Id widowed 2c . never married, either
partner died
2k don'tknow
- 37
3. Gender: M/F - .I
frrst name

partner died
2k don't know
4. Gender: M/F .1
first name

partner died
2k don'tknow
5 . Gender: ME .l
la married-still involved^ 2a never married-still involved

parmer died
2k don'tknow
38
.1

m3A*B/"566 l b divorced 2b never married-no longer
Id widowed 2c never married,.either
partner died
2k don'tknow
jG53LBPM.71 l a married-still involved 2a never married-still involved

1d widowed 2c never married, either
partner died
2k don't know
Fa33 33. How old was ***** when he/she fust came to live with you?
Age
-.
39
34. e s to ***** living with you?
What c ~ c ~ t a n c Ied
vc-*db Y J

3. biological mom in prkion 1 1. biological mom hospitalized: medical reason
/7
7. biological mom in another country i15,) biological mom lost custody(specify reason)
8, bioiogical dad in another country -' i/c*'dh a$&ype&
q6\ biological dad lost custody (specify reason)
L/d;RC'dh m.
I '
@ other reason (specify reason)

u-idh &p-p&&
/'
40
/"A 3 5 35. Has ***** aiways lived with you since the frst time shehe came or have there been
periods during which shehe did not live with you? (CRCLE ONE)

b. Has not aiways lived
35A. Describe other living arrangements since ***** first &e to live with YOU:
41
Now r haw some quezdiom about the h e since ***+* Yipst came to live wifi you.
~ f 36-
i 36. I n e 4 to know whether you have lived with anyone as a partner while ***** has b c n
1 -NO:
2 - YES:
F/3 367sU 36A. How many relationships have you had during this time?
- # relationships
#.;I
36B. For each of the people-you bad a relationship with, I need to know their first
whether you are still the relationship. If the relationshy has ended, I need
1. Gender: M/F .1 -d
fmt name

2. Gender: W .1 +
fist name
la married-stiU involved 2a never married-still involved

3. Gender: M/F .1
first name
la married-still involved 2a never manied-still involved

lb divorced 25 never manied-no longer
Id widowed 2c never married,partner died
. . . . ..... . . . . . .. . . . ..A_ _....
42
4. Gender: ME .1 G k i y p e L
fmt name

IC marrkd, but separated involved
-
5. Gender: M/F -1 -4d-
- fmname

l b divorced ' 2b never married-no longer
m3645 6. Gender: M E --1

first name
la marrid-still involved 2a never married-still involved

- IC married, but separated involved
7.Gender: M/F
Ps36& -7- first name
K& 36'R/Y$ la married-still involved 2a never married-still involved

\
43
37. Does +****regularly spend any nights of ihe week in another household or anywhere
else? [This does not include day care]
2.Ys I .No
M = materna.- grandparent, child,

P = paternal -Other]
1 '
-41
A B C D
.1 Name BorN MorP
E Other relation
-
G Nights each monk F/3 379s

H Other arrangement: F=& 37- 7%'
.2 Name BorN MorP
E Other relation
F Nightseachweek F/33Z-kF
G Nights each month: r=/4 3Z-
H Other arrangement: 3-3-
/q337-3.& F43J-3C F&9-

A B c D
.3 Name BorN MorP
E Other relation .-
-I I
F Nights each week /'=/3 27- 3 F
G Nights each month: F43-2- 36
H Other arrangement: F/337, 3 4
I
. , - , .. .... .. . .. . .
... ... ~.. . . .. .. .1 , ,. .
%. . . . . .. , ..
44
38 . In *****'sentire family ..... including anyone: parents, siblings, yourself, ams,
who is **+**particularly dose to? YOUcan Iist as many people as you want - anyone
in &e family who you think ***** feels close to.
B = biological *
Iparent, sibling,
> N = nonbioiogical
-
P =paternal .
A B c D
.1
.2
.3
.4
.5
-6
.7
.a
.9
45
39. Now I need to list dl the people who live in this household except for **++*. For
each person who Eyes here, I would like you to tell me how he o r she is mhted to *+*++.
For example, I want you to teU me if the person you list is *****Is brother o r aunt or
cousin. Even if a person who l i v s here is not related to *****, I need you to zist them
&O.
. I3 = biological [parent, sibling,

N = nonbioiogical amdude,
A B c D
ii439-p;Cs FR39- I'c
.1 Name &e& BorN MorP I *
Fk539-LA E+539-LC
.2 Name 6ZkWW-f-45 BsrN MorP G & Qv + -q e d
M339-3A FA39-3C
.3 Name BorN MorP
.6 Name BorN MorP

/=&39-?/3 F/3 39-?C
.7 Name BorN MorP
F/339-& x339-dG
.8 Name BorN MorP
,%&- PA H 5 %9c
.9 Name BorN MorP
.IO Name BorN MorP

B339-m 3339-//C
.lI Name BorN MorP
F&3P-/AA 59J.C e
.12 Name BorN MorP
R339-/.5k3 f%39-/3
_. .13 Name @%I /%
Y mmk&
BorN MorP
46
Part E: Family Health History

40. Now, I have some questions about *****Is family's health histoq. I need to know
A&4 0 if anyone in *****ls f d y inchding everyone that was just mentioned in tiris interview,
has any of the following health problems. For each person you list, please tell me how be
or she is related to ***** and whether he o r she is a biological or non-biologid relation.

- [Sugar Diaberes,Sugar in Biood/Urine]

M=maternal grandparent, child,
P = paternai self, other]
.1
.2
rn .yD,3c
Y "
/5:/3.%9-3/3
.3 Name-, BorN MorP
.4
-5
.6
.7
.8
\ .9
.10
-11
,* 12
- -13
47
41. E@& Blood %pressure: (circle one) 2. Y s 1.No

flypefiemion.
B = biological [parent, sib&,

N = nonbiologicai auntluncle,
I
%!
.1
.2
.3
-4
.5
.6
.7
.a
.9
-10
.ll
.12
\
.13
.14
. . - . ... >..,.. .. . .
. . .... . . .. . , . , -. -.
48
F& 42. Beart Problems: (circle one) 2. Yes I .No
liyeart Am.&, Coronary, A h y r h a ]
R m to ****+
B = biological @arent, sibiing,
N = nonbiological auntlunck,
M=maternal . grandparent, child,
9
49
43. Stroke: (circle one) 2. Yes 1.No
tr-
I3 = biological [parent, sibling,
-1
.2
.3
.4
.5
-6
.7
.8
.9
.10
*3
m43- 4!/3 -H C
.ll Name BorN MorP
.12
r3 43- f 3 A F;rJ 93../3c
3
-13 Name W/p* # I
or^ or^
\
.14
......... .................... . . . . . . . . . . . . . . . . . . ... 1 ........ . . . . .
50
B = biological Cparent, sibiing,

N = nonbioiogical aunthcle,
.1 .
.2
.3
.4
.5
.6
.7
.a
.9
.10
-11
f 12
\ .13
-14
51
52
46. M e r chronic problem (slpeciEy): (circle one) 2. Yes 1.Bo
M =m a k d grandparent, child,
$
.' A B C D
F43%6-JA /=a.%-/c
-1 Name BorN MorP
A B C D
FW6-LLA F&-Y6-RC
.2 Name BorN MorP
A B C D
FA&.3A FR9i-JC
-3 N
,m
a-,e BorN MorP

Y f
A B C D
LE3 @-4& F&&, 4-c
.4 Name BorN MorP
E IUNESS (please specify):

Yp'
A B C D
F43M-5 A /c/34g-5e
.5 Name BorN MorP
\ h
E ILLNESS @lease specify): de&%e&
LEGAL HISTORY
131
F d y Mental Health and Legal EEstorgt
Subject ID:
+4 Now Im going to ask you some more questions about all the people in * * * * * i ~ / ~ ~ ~
CMd 1. Has drinking ever caused my of the people mentioned to have problems with health,
2 . m 1.NO

M = matema! grandparent, child,
P = paternal other]
A B c D
edinit, &.date
I33
2
,z~& 2. Has drug use ever caused any of the people mentioned to have problems with h d t h ,
2.YES 1.NO
to **it*
B = biologid @.rent, sib@,

P = paternal other]
P
A B C D
3
FM3 3. Has anyone mentioned ever suffered frcm depression, that is, they have felt so low for a
period of at least two w e b that they hardly ate or slept, or couldn't work or do whatever
- usually do?
they
2.YEs 1"

N = nonbiologid
M = maternal - grandparent, child,
P = paternal other]
4
Fiy4 4. Has anyone mentioned ever had frequent trouble with the law, often become involved in
fights, had trouble holding a job, or was a frequent discipline problem in schcwl?
2.YES 1.NO

$ - P = paternal other]
I36
5
F H 3- 5. Has anyone mentioned ever had problems with their nerves or had a nervous breakdown?
2.YES 1.NO
to *****
B = biological Iparem, sibling,
N = nonbiological . aunt/uncle,
P = paternal other]
A B
/G$%Lir*A
.1 Name BorN
FNE-RA3
.2 N
-m
a-.e BorN
FM5- 4
45
-3 Name & B or N
-4 Name
.5 Name
.6 Name
.7 Name
5- 8
i=/Y 23
- - % - e.8
ma N BorN
Y '
/=N3= 9 /43
.9 Name B or N
FH5" mk3
.10 Name B or N
6
,.qjib 6. Has anyone mentioned ever Ealked to a doctor or a counselor about any emotional
2 . w 1"

I M = maternal grandparent, child,
P = paternal other]
A B C D
.1 Name ,a!!/ BorN MorP

F/y6-&3 , e ~ 6kC
- Fmg- & %
A B C D
.2Name -eiTe BorN MorP
E Reason for treatment: &
+
FW6- 3& FW6."5c F&f,&-3%
A B C D
.3Name - L BorN MorP

FNJ- $4 FMK- +e .'/*lg-@+
A B C D
AName c BorN MorP

/=/v&-m5/?=iZ/d"_ 3-c F&c4-.-3-5P
A B C D
S N a m e &4 BorN MorP

F/yo-d& md-6C FM6-.6*
.6Name BorN MorP
I38
7
FJlst -7 7. Has anyone mentioned ever been hospitalized because of emotional problems, or because
2.YES 1.NO

N = wnbiological aunduncle,
$*4
P = paternal other]
A B C D
.1 Nm
,a-,e B or N Mor P
.2 Name BorN MorP

/p-?-3& FMJ- 3c F / Y 7-3s-
B C D
-3Name BorN MorP

F/C/z-4/ if F/t/?-4C PAY??- w
B C D
.4 Name BorN MorP
E Reason for treatment: &kz&&Q&&
F#?-& FMZ5C Pmg-5&
.5 Name BorN MorP
-6 Name BorN MorP

8
8. Have any of the people you've mentioned ever attempted suicide?
2.YEs 1.NO
to *****
B = biological . Iparent, siblmg,
N = nonbiulogical aunt/uncle,
P = paternal other]
9
9
F 9. Have any of the people youve mentioned ever commitred suicide?
N = nonbiological auntluncle, .
FW9- 3/3 FMQ-3e

.3 Name BorN MorP Fly 9-3%
10
3
getfing into trouble, or emotional problems?
(CIRCLE ONE)
1 - no one eke
c

Hospitmlized for alcohol, emotional problems, or drugs - page 7
Talked to a counselor about drugs, alcohol or emotionai problems - page 6
Nervous breakdown page 5-
Eights, frequent trouble with law, trouble holding a job - page 4
Sufered from depression - page 3
Drinking caused problems with health, family, job, or police - page 1
- 11
Now I have some q u d o n s about whether there is anyone mentioned who has had
trouble with the poLicg or who has k n arrested. Please do not indude routine M : c
F& fc7 10. Has anyone that youve mentioned had trouble with the police or been arrested? (CIRCLE
om
1. NO:

FMIOAL FMYDA3 ~~9i3.44
1 2 3 4
B or N M or P
Name Relation
10B. Do you how what heishe did? (CIRCLEONE) 2.m 1.NO
10Bl. E m fit
......,:1,. ...........
.... .,.*., ..... ................
..... .%
..
did he/she do?
1OC. And were there any other reasons heishe was in trouble with the police?
(CIRCLEONE)
2. YES 1.NO
lOCl . ................
............................................
:. .... What other offenses led to himmer having trouble with the police?
IOD. Is he/she jail or prison now? (CIRCLEONE) 2.YEs 1.NO

12
~eyy 11. Has anyone else had trouble with the po1ic-z or been arrested? (CIRCLE ONE)
1. NO:
2. YES
+4
F&HJ& FMib?A3 HfW9
1 2 3 4
B or N M or P
Reiation
FHff&O 11B. Do you know what helshe did? (CIRCLE ONE) 2.YEs 1.NO
Fz+Yc 0 11C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
.__Vi_ ..............
11Cl. ..... ~ .~ ...........;. . What other offenses led to himmer having aouble with the police?
11D.. Is hefshe in jail or prison now? (CIRCLE ONE) 2 . m 1.NO

13
FM/A 12. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2 . YES
I,
44 12A. What is hisher name and how is he/she related to *****9
/ i # FM/;ZA3
/ & F M& MAP .&
1 2 3 4
Ae&y7-&&
/
B or N M or P
Relation
m., m_. What did helshe do?
...... ...............
.... ..........................
12B1.
//
(CIRCLE ONE)
2 . m 1.NO
.......A..................
120. Is he/she in jail or prison now? (CIRCLE ONE) 2.YEs 1 .NO

14
Fp;5
~ 3 13. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
8 END OF l[NTERvIEW 8 RECORD TIME 1

2. YES ASK13A.: 13D
+. 13A. What is hisher name and how is he/she related to *****?

&Y/3#4A F-/Y/3.43 FW329
2 3 4
B or N M or P
Relation
,5993 &I 13B. Do you h o w what he/she did? (CIRCLE ONE) 2.YEs 1.NO
FN/5 CD 13C. And were there any other reasons heishe was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
... ......... ... i.
13C1. @?fZ@$ What other offenses led to m e r having trouble with the police?
e.A ~
F/Yf3Bo 13D. Is he/she in jail or prison now? (CIRCLE ONE) 2.YEs I .NO
15
F M /4 14. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
1
i
o END OF INTERVIEW e RECORD TIME
2. YES

E/vif?wA# F#Y443 E.wl54549
1 2 3 4
B or N M or P
Relation
FW/4/3d 14B. Do you know what he/she did? (CIRCLEONE) 2 . m 1.NO

................... ....
.................
1 41.~ : #'JT
......................
What
$m $he/& do?
did
......................
FH i&c 0 14C. And were there any other reaSons he/she was in trouble with the police?
(CIRCLEONE)
2 . m 1.NO
.......................
14C1. ;@im
What other offenses led to himmer having trouble with the police?
Fflf4a-0 14D. Is he/she in Jailor prison now? (CIRCLE ONE)

16
~ f i f y 5 1j. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES
$4
15A. What is hisher name and how% he/she related to *****?
HY5&=+4 F&/5#3 F9Yj5-794;
1 2 3 4
B or N M or P
Relation
~p+y5bo 15B. Do you know what he/she did? (CIRCLE ONE) 2 . w 1.NO
im-...............
..................................
1 5 ~ 1 .-. .>...4*; pr
fit did he/& do?
. *
, c p
~ ~ 3g 15C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . m 1.NO
K m
...........................
......................
15C1. What other offenses led to himmer having trouble with the police?
& z
fly
,%M /T 15D. Is he/she in jail or prison noy? (CIRCLE ONE) 2.m LNO
! c18
17
16. Has anyone else had troubie with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES
................... . . .

fwfgAA FN764-3 F/Liffd&4
1 2 3 4
B or N M or P
Relation
~ ~ ~ 6 / 416B.
5 oDo you know what helshe did? (CIRCLEONE) 2.YEs 1.NO
16Bl
- ........ ..x3:....:..............<:*
what .did he/she do?
&
F
d Y
/=By d p ~ 16C. And were there any other reasons he/she was in trouble with the police?
(CrRCLE ONE)
2 . m 1 .NO
mf~w
16D. Is he/she in jaii or prison now? (CIRCLE ONE) 2.YEs 1,NO
- 18
17. Has anyone else had trouble with the poiice or been arrested? (CIRCLE ONE)
1. NO:
-I U
2. YES ASIC 1?A 17D -

3,)
- F W M L FHfl.93 FHA?&+
1 2 3 4
B or N M or P
Relation
FH/4&0 17B. Do you know what he/she did? (CIRCLEONE) 2.YEs 1.NO
:
17B1 ...,.,.,......
.... m $ !what
...................
$ did he/&
:.:
do?
,+v/xw 17C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . m 1.NO
..................
17c1. .... %
.*,. X
..% what other offenses led to W e r having trouble with the police?
FMf3Bi3 170. Is he/& in jail or prison now? (CIRCLE ONE) 2.m 1.NO
e END OF INTERVIEW e RECORD TIME FM;Ic/+-7/#y

EMPLOYMENT & INCOlME
Date: .=W'??
mm dd yy
PART I; Primary Caregiver/Adult Subject Employment

4=#
hours each week.
--
&.init. &.date
Page 2
1. Working full-time in one job -- ...

working Wpart-time in additional job(s)

1,4 4. Permanent leave (disability)



9. Temporary jobs, d o m i l work
-

(NOT a homemaker)

Page 3
Ez 2. Have you been employed in a paying position in the past 5 years? (CIRCLEONE)
NO: $ Have you done volunteer work in the past 5 years?
YES:
Working full-time h one job ------

Working f'ull-time in one job AND --
3. On leave (temporary illness) -


6. Workiug part-time in two or more jobs -


11. Retired, working part-time jobs ------
12. Retired, w o r m temporary jobs ---

F / J /vi
/
Page 4
PART: I
SECTION: 1
3. How many jobs do you currently hold? (CIRCLEONE)

1. One Job
2. Two Jobs
3. Three Jobs
1.4
I
5. What are your main responsibilities? fla44h m5-

Yry

1. ltssthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
7. more than50,OOO
8. dontknow
7. How long have you been in thisjob?

2.27 Y- months
How many hours each week do you usually work?

hours/wetk
If 1Job ONLY,GO TO Page 15, (part r) Question 45A.

Page 5
lob 2: And your other job?
10. What are your main responsibilities? VUb&&

/ /
a#
a 2fY 11. Which of these numbers best fits your salary in this job? (CIRCLEONE)
1. less than5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. dont know

Y- months
13. How many hours each wtek do you usually work?

hours/week
Page 6
And your other job?
2Z/6 16. Which of these numbers best fits your salary in this job? (CIRCLEONE)
1. less than5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. morethan50,OOO
8. don'tknow
g-7 0 17. How long have you been in this job?

Y- months
@ 1&' 18. How many hours each week do you usually work?
I GO TO Page 15, (part I) Question 45A. I

Page 7
PART: I
SECTION: 2
Section 2. On leave/disabiIity
67 79 19. How many jobs did you hold before you went on leave/disability? (CIRCLEONE)
1. One Job
2. Two Jobs D*
3. Three Jobs I),
d 19A. Of these jobs, I want you to.frrst tell me about the one you considered to be your
20. What was your job title? v a , d h
21. What were your main responsibilities? P+*d& &

/ #
E/ &CIS/ 22. Do you continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO

2) 22B. Which of thae numbers best fit(s) your full salary in this job? (CIRCLEONE)
1. lessthan5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,000
8. dont know
Page 8
22A. Do you receive your f'ull salary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
pension plan, SSI or any benefits? (CIRCLEONE)
1. less than 5,000

2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more thanSO,000
8. don't know

Y- months
hours/week
Y- months

If More than 1Job, GO TO Next Page, (part 0 Question 26. L
Page 9
26. What was your job title? VLLRc/db M,

/ J
27. What were your main responsibilities? flQ-+-"dk w, //
'*?
&a8 20. Do you continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO
I
1. lesSthan5'000
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don't know
6Lt%9O 28A. Do you receive yoyr full salary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
I 61.
Page 10
28C. Which of these numbers best fit@ your partial salary, including
1. lessthan5,Ooo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know

Y- months
a30 30. How many hours each week were you usually worlung
hours/weck
Ez-3/ Y- months
If 2 Jobs ONLY,GO TO Page 15, (part I) Question 45A.

Page 11
iob 3; And your other job?
32. What was your job title? /a&&&&& P Y
33. What were your main responsibilities? 1 / W &

Yfl
1. YES
2. NO

1. lessthan5,OOO
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don't know
1. Full
2. Partial
Page 12
&/ 3-L/CQ 34C. Which of these numbers best fit(s) your partial salary, including pension
1. less than5,Ooo
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5 . between 30,000and 39,999
7. more than50,OOO
8. don't h o w
gz35 35. How long had you been in this job

before you went on leave/disabiIity?
Y= months
&36 36. How many hours each week were you usually working
hours/week
a 3.72 37. How long have you been on leave from this job?
Y-
-
months
.
Page 13
PART: I
SECTION: 3
38. What types of jobs have you done recently? vmSd&

/ Y
iy
39 39. About how many hours each week do you usually work? hours/week

40. How much money have you earned from these jobs h the past year? (CIRCLE ONE)
1. less than5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. more than50,OOO
8. don't know
I GO TO Page 15, (part I) Question 45A. J

Page 14
PART: I
SECTION: 4
43. How many hours each wee do you usually volunteer? (CIRCLE ONE)
1. 1-2
2. 3-5
3. 6 - 12
4.- -
13 20
5. > 20

EZ44 months

Page 15
PART: I
SECTION: 5
1 Section 5 . Job Distance I
IF respondent has more than 1 job listed during the interview, s t a ~with the primary job,
Iprimary/Only Job]
45A. Where is your job located? (Iftravefs to various b c a t h s , record d r e s s of main once.)
9
/&*&A &
address
city zip code
d?/&&30 45B. How far is your work from where you live? (CIRCLE ONE)
-
. . .
0 works at home _. 4-6tolOmile~
2-1to2miles -
E/ I/sL'La 45C. How do you usuaUy get to work? (CIRCLEall that apply)
1-walk 6 - ~arp001
4 - bicycle
-
5 other
(using the mode of tramportation listed in Question 4 5 0
minutes
Page 16
[Seconay job 21
46A. Where is your job located? (If travels to various bca.rions record address of main office.)
Pd4A:dA
address
city State zip code
~!?,/&6'&o
4b. How far is your work from where you live? (CIRCLEONE)
0 - works at home 4-6to 10miles

5/46co 46C. How do you usually get to work? (CIRCLEall that apply)
1-walk 6-carp00l
2 - drive myself -
7 driven by relative/fiiend
4 - bicycle
5 - other
&/46BO 461). On the average, how long does it take you to get to work?
(using the mode of trausportation listed in Question 46C)
minutes
If 2 Jobs ONLY, If there is a partner, go to Page 18, (part n)Question 1.

If there is partner, go to Page 35, (part m), Question 1.
Page 17
[Secondary job 31
47A. Where is your job located? (If truveh to various locations, record address of main office.)
b4%&=4k u&
address
city State zip code
% 0 - works at home 4-6tolOmiles

3-3t05deS work site
1-walk 6 - carp001
4 - bicycle
-
5 other
470. On the average, how long does it take you to get to work?
minutes
If there is a partner, go to Page 18, (part Ill Question 1.

If there is M partner, go to Page 35, (part m)Question 1.
Page 18
PART: II
PART II: Partner Employment
work situation:

- 1. Working full-time in one job
2. Working full-time in one job AND -

Page 19

-1
4. Permanent leave (disability) - -- G ion ?
!l


9. Temporary jobs, OcCBsionaI work
-
11. Retired,working part-time jobs

. (NOTa homemaker)
17. Volunteer work only, full/part-time - Q2

Page 20
&Le&
2. Has your partner been employed in a paying position in the past 5 years? (CIRCLE ONE)
2. NO: AS& Has your partner done volunteer work in the past 5 years?
1 -Yes
2 - NO
sKz%
........... '..,+ ................
r-
1. .,.;.
. . . .
......................
2. W0rJdn.g full-time in one job AND

working fflpart-time in additional job(s)


6. W o r m part-time in two or more jobs -



Page 21
PART:II
SECTION: 1
a P3 3. How many iobs does he/she currentlv hold (CIRCLEONE)?

1. 0;;Job
2. Two Jobs .
3. Three Jobs Read
$,a 3A. Of these jobs, I want you to first tell me about the one heishe considers to be hidher
4. What is his/her job title? Y&'d& *, //
5. What are his/her main responsibilities? fl-&f&%

zip6 6. Which of these numbers best fits hisher salary in this job? (CIRCLE ONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
a++- 7. How long has he/she been in this job?

Y- months
sip 8 , 8. How many hours each week does he/she usually work? hourdweek
If 1 Job ONLY,GO TO Page 32, (part II) Question 45A
;
:- And hisher other job?
9. What is hisher job title? Y/*'dk
IO! What are hisher main responsibilities?.

f f l

&"p {+ ,
11. Which of these numbers best fits his/her salary in this job? (CIRCLEONE)
1. lessthan5,000
4. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don't know

5P)
72Y Y- months
13. How many hours each week does he/she usually work? hourdweek
&/P /&3
~~
If2 Jobs ONLY, GO TO Page 32, (part II) Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part rr) Question 14.
14. What is his5er job title?
~~
15. What are hisher main responsibilities? v-*dh
&Tp~6 16. Which of these numbers best fits hisher salary in this job? (CIRCLEONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,OOO
8. don't know
ap{& 17. How long has he/she been in this job?

Years months
GO TO Page 32, (part II)Question 45A. 1

Page 24
PART: II
SECTION: 2
1 Section 2. On leave/disability I
S/P/Q 19. How many jobs did he/she hold before he/she went on leave/disability? (CIRCLEONE)
1. One Job
2. Two Jobs
.4
3. Three Jobs
20. What was hisher job title? &f%kd&

c&e#.w&
2 1. What were hisher main responsibilities? P&.aid& A p/ /&
&PA& 22. Does hdshe continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO
I
Y I
1 Hand respondent response card #2
Page 25
22B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
1. less than5,OOO
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know
22A. Does heishe receive hisher full salary or part of hismer salary?
~~p~~~~ (CIRCLE ONE)
1. Full
2. Partial
22C. Which of these numbers best fit(s) hisher partial salary, including pension plan,
KG%a c 0 SSI or any benefits? (CXRCLE ONE)
1. lessthan5,OOO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,OO
8. don't know

C5ZP 23 before he/she went on Icave/disability?
Y- months
gzP& 24. How many hours each week was he/she usually working
E.PL5 Yf=S months
Page 26
26. What was hisher job title? &@p&

//
27. What were hidher main responsibilities? YaA6kdf& &B&

9
Does he/she continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO
/ p j g & ~ 28B. Which of these numbers best fit@) hisher full salary in this job? (CIRCLE ONE)
1. lessthan5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. morethan50,OOO
8. don't know
2%%B 4 0 28A. Does he/she hisher salary? (CIRCLE ONE)

1. Full
2. Partial
Page 27
28C. Which of these numbers best fit(s) hidher partial salary, including pension pian, SSI or any
1
benefits? (CIRCLEONE)
-
1. less than5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
8. don't know

before he/she went on leave/disabiiity?
30. How many hours each week was helshe usually working
Y
m months
~
If2 Jobs ONLY, GO TO Page 32, (part Il) Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part Il) Question 32.
7; And hisher other job?
32. What Was hisher job title? b&%.-ie--

Y '
33. What were hisher main responsibilities? Jt2-.?zL*d& - 4

/ /
'*I - - -
E/P 34 34. Does he/she continue to receive money from this position? (CIRCLE ONE)
1. YES
2. NO
Which of these numbers best fit(s) hisher full salary in thisjob? (CIRCLE ONE)
1. less than 5,000

2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49.999
7. more than 50,000
8. don't know
MA. Does he/she receive hisher full salary or part of hisher salary? (CIRCLE ONE)
a p 34590
1. Full
2. Partial
Page 29
zip J ~ C O 34C. Which of these numbers best fit(s) hisher panial salary, including pension pian,
1. less than5,OOO
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. more than 50,000
8. don't know

&2@35 before he/she went on ieave/disability?
&)a
, 36 36. How many hours each week was he/she usually working
&..,,037 37. How long bas heishe been on leave from this job?
YWS months
A GO TO Page 32, (part Ill Question 45A. I

Page 30
PART: II
SECTION: 3
Section 3. Temporary work 1
38. What types of jobs has he/she done recently? p-d& M,
PY
&'/p39 39. About how many hours each week does he/she usually work?
hours/week
How much money has heishe earned from these jobs in the past year? (CIRCLEONE)
s/p40 40.
1. less than 5,000

4. between 20,000and 29,999
5. between 30,000and 39,999
7. more than 50,000
8. don't know
I GO TO Page 32, (part nr) Question 45A. 1

Page 31
PART: II
SECTION: 4
L&.-&*ag&
"4
How many hours each week does hdshe usually volunteer? (CIRCLEONE)
&/P93 43.
1. 1-2
2. 3-5
3. 6 - 12
4. -
13 20
5. > 20

a$44 months
Page 32
PART: II
SECTION: 5
Section 5. Job Distance
IF partner has more than 1 job listed during the interview, start with the primary job, THEN
Iprimary/Only Job]
&A. M e r e is your partner's job located? flf travels to various locations, record address of main
oflce.)
Le&&
' &
address
city State zip code
z/p+j-m 45B. How far is hisher work from where you live? (CIRCLEONE)
0 - works at home 4-6tolOmila

2 - 1 to2miles 6 - Varix according to
S/P&5CO 45C. How does he/she usually get to work? (CIRCLEall that apply)
l-walk -
6 carp001
2 - drive myself -
-
4 bicycle
-
5 other
a P 4 W 45D. On the average, how long does it take m e r to get to work?

minUttS
Page 33
[Secondary job 21
46A. Where is hisher job located? (If travels to various locations, record address of m a i nofice.)
city State zip code
I(/P96hO 46B. How far is hisher work from where youjive? (CIRCLEONE)
I,?
0 - works at home .. ,,, 4-6tolOmiles

2-1to2mileS 6 - Varies according to
3-3to5des work site
&/@46cD 46C. How does he/she usually get to work? (CIRCLEall that apply)
1-walk 6-yrpo0l
2 - drive myself -
7 driven by relative/friend
4 - bicycle
-
5 other
If2 jobs ONLY, GO TO Page 35, (part III) Question 1.

If More than 2 Jobs, GO TO Next Page, (part II) Question 47A.
I as
Page 34
[Secondary job 31
47A. Where is hisher job located? (If travels to various bcmions, record d r e s s of main m c e . )
i%%&&?4-&&
address
city State zip code
2/P4?& 4"B . HOWfar is hisher work from where you b e ? (CmCLEom)

5 - greater than 10 miles
. .
1-iessthanamile
2-1to2des 6 - Varies according to
3-3to5des work site
1-Walk 6-l.~upool
3 - budsubway -
8 commuter train
4 - bicycle
5 - other
F/@ -99AO 470. On the average, how long does it tak himher to get to work?
minutes
1 GO TO NEXT PAGE, (part III) Question 1. 1.

Page 35
PART III.
Other than from your job, please tell me whether you received income from any of these
sources m the past tax year. Have you received....(read each choice and circle all that apply)

(NOTchild support or alimony),combined

or workers compensation

g* federal grant, financial aid, scholarships 1. YES 2. NO

@leasespecify)
Now I am going to ask you some questions about your total income. First,I will ask about your
.&/A,&$? 0 2A. From these sources of income AND the income from any jobs you had in the last tax year,
1. less than $5,000

2. between $5,000 and $9,999
3. between $10,000and $19,999
4. between $20,000and $29,999
5. between $30,000and $39,999
6. between $40,000 and $49,999
8. don't know
s/~&&o2B. From these choices, what was your total household income in the last tax year before taxes?
household.
1. lessthan$5,OoO
2. between $5,000and $9,999
3. between $10,000and $19,999
4. between $20,000and $29,999
5. between $30,000and $39,999
6. between $40,000and $49,999
8. don't know
RECORD TIME
SCHOOL SCREEN: S 118 year olds only]
Date:
mm dd yy
Subject ID:
Interviewer ID:
mm COPY 2
Time Started:- I
5. Are you currtlltiy in school?
'1,
(Code YES i f m d y on vacation, suspension, etc. and will return to school.)
1. YES
2. NO
2. Droppedout
3. lZx.pdlled
4. LongtamiUnessorinjury
5. other@leasespecjfy)
~ ~
3. what was the last grade you were in when you wcre in school?
%-e?. ,
............... .>q
w
gj-f..g q
..,...... ........
I I
ed. init. ed. date
- // -
8. What is the name and address of the school you currently attend?
1.
Name of school
2.
Address
3. 4. 5.
City state Zip
9. When did you enroll in this school?
1. 2.
month Y W
10, what is your school ID number?
11. whattyptofschoolisit?
1. public
2. catholic
3. home school
4. Private,non-Catholic
5. other(p1~spCcifjr)
12. Is it a..?(Read choices)

01. High school
02. Trainingprogntm
03. Tradeschool
04. Tccbnicalschool
05. 2-year college(city college)
06. eyearcollege
07. University
08. Other (please spec@)
3
13. What grade are you currently in?

(Ifduring summer break and ***** is between grades - code what grade *****
will be entering in the fall.) Enter grade er Eircie99ifin rrngtndcd schod

grade
14. the past year, were you ever truant -skipped school for the whole day without
an excuse?
1. YES W,:;m;Q&J
...................................................
. . .
..... ........... ............
:. .:..
...........................................
.............?..'.... ............
2.NO # ;mq....;lg
.......................................
15. On the average, in the past year, how often did you skip school for the whole day
WithoLltanexCwe?
a more than once a week

b. onceaweek
d. onceamonth
e. afewtimesayear.
16. In the past year, did you eva skip classeswithout an excuse?
1.m a:m;&gg
w x y + ? ~ % w , % . ................ .::
......
c.......................
17. 011 the average, how often did you skip classes without an excuse?
a. everyday
b. afewtimesaweek
c. onceawtek
e. onceamonth
f afewtimesayear.
4
18. Thmkmg back to the last year you were in high school/ grade school,were you
ever truant-skipped school for the whole day without an excuse?
1. YES
2.NO
9
19. How often did you skip school for the whole day without an excuse?

b. onceawttk
c. a fcw times a month
d. onceamonth
e. afewtimcsayear.
20. Thinking back to the last year you were in high schooVgrade school, did you evez
skip classes without an cxcuse?
21. How offendid you skip classeswithout an excuse?
a- everyday
b. a few times a week
c.onceaweck
d.afiwtimesamonth
e.onceamnth
f ahtimesayear.
22. Have you eyer skipped a grade? 1. YES 2. NO
23. Have you ever repeated a grade? 1. YES 2. NO

5
24. Many students receive special teaclung or help in school. At any point in your
education, did have you received any help or special teachmg in any of the
following areas?
-
(Read choices circle all that apply.)
a. Gifted class 1. YES 2. NO

b. Special remediation class/ tutoring program 1. YES 2. NO
c. Learningproblems 1. YES 2. NO

Limited English Speaking
f speechtherapyclasses 1. YES 2. NO

sight problems
A Emotional or behavior problems 1. YES 2. NO

i. Special music or art school 1. YES 2. NO
j. Specialscimceprogram 1. YES 2. NO
6
25. W e d are you routinely involved in extracmidar activities directly comected

with your school, such as school sports teams, school clubs, music groups, etc.
1. YES GO TO Q. 26
2. NO GDToQ.28
26. How many hours does/ did this take place? hours per week
'-1
27. What kind of pro& was/ is ihis? (Circle all that apply)
1. Recreational (sports, games, &)

2. Anistic (music,dance, art)
3. Academic enrichment (tutoring, classes)
4. Other (please specifl)
28. Weref are you involved in any other kind of after school program?
("his may be at *****'sschool., but is more of an af&crschool program rather than
actracurrjcular activity.)
29. How maay hours did/ does this tske place? hours per week
30, What kind of program was/ is this? (Circle all that apply)
1. R#xeatioaal (sports, gamts, crafts)

2. k w c (music, dance, art)
3. Academic enrichmmt (tutorin& classes)
4. other (please specify)
7
3 1. What schools have you attended in the past?
~-
For RAs only: for Elementary and High School type, use the following codes:
1 -Public
-
2 Catholic
-
3 home school
-
-
5 Other (please specify)
b. Elementary School (including Kindergarten)

School Name Address (include city, state) School type Dates enrolled Grades
1. hm:
to:
2. &om:
to:
3. &om:
to:
4. &om:
to:
5. fiorn:
to:
8
1
School Name Address (include city, state) School type DatcsenroUed Grades
1. fiom:
to: I I
3.
4.
9
For U s only: for College, University, and Trade School type, use the following codes:
-
2 Training program
-
3 Trade school
-
4 Technical school
-
5 2-year college (city college)
-
6 4-year college
"4
Colle e/ Univcrsi / Trade School
School Name Address (include city, state) School type Datesenrolled I Grades
fiom:
to: I 1
I
c 1 I
hm:
hm: I I
2. to: I
3. &om:
to:
hm:
to:
15-
34. Thinkipg back to YOU last Sch001- that is, YOU last high School/ grade School how -
would you descriie the education you nceivtd? (Read choices.)
a excellent
b. good
c. hrir
d. poor
I END OF INTERVIEW RECORD TIME:


1. Are you currently involved with someone? c7- 1
1. YES EYES, Am and w.
0. NO f[fNO,ASz(;Z
A. Are you married to, engaged to, or dating this person?

1. married
2. engaged
3. dating
B. Are you currently. living with this person?

1. Yes
0. No
I
t
I
I
BEGIN INTERVIEW

CT#&
(If more than one person, select most "significant"relationship)
1. YES
0. NO
A. Were you married to, engaged to, or d

aw this person?
1. married
2. engaged
3. dating

1. Yes
2. No
c. How long were you in this relations-$?
BEGIN INTERVIEW I
1. YES W*
0. NO .
mD COPY 2
L a%x4ece
the other person, or just have fights because theyre in a bad mood or tired or for some other
reason. They also &e many different ways of txying to settle their differences. Im going to
read some Mugs that you and your partner might have done when you had an argument in
...
Refer to first month on the time line I

I want you to think about how many times EACEl of you have done the following, using one of
these responses.
Hand respondent the response card, and read choices 1 to 6 I
ed. init. ed. date

2
0 1 2 3 4 5 6
%
t
1
0 1 2 3 4 5 6
1=Yes 0 = No
2A. How many times have you gotten information to back up your side of thmgs? C7AU
0 1 2 3 4 5 6
2B. How many times has he/she gotten information to back up h i s k r side of things?
0 1 2 3 4 5 6
never OnCe twice 3-5 6-10 1 1-20 more than
2C. Has this ever happened? 1 =Yes O=No a-&c/

3
0 1 2 3 4 5 6
never
Y, I*#
once twice 3-5 6-10 11-20 more than
1 - - times times times 20 times
0 1 2 3 4 5 6

0 1 2 3 4 5 6
4B. How many times has heishe insulted or swore at you?
0 1 2 3 4 5 6

4
5A. How many times have you sulked and/or refused to talk about an issue?
0 1 2 3 4 5 6
never once twice 3-5 . 6-10 11-20 more than
5B. How many times has he/she sulked andor refused to talk about an issue?
0 1 2 3 4 5 6
6A. How many -times have you stomped out of the room, house or yard?
0 1 2 3 4 5 6
0 1 2 3 4 5 6

5
0 1 2 3 4 5 6
never once twice 3-5 6-10 11-20 more thm
0 1 2 3 4 5 6
8A. How many times have you done or said something to spite m e r ?
0 1 2 3 . 4 5 6
0 1 2 3 4 5 6

0
9A. How many times have you threatened to hit or throw something at W e r ?
0 1 2 3 4 5 6
never O W twice 3-5 6-10 1 1-20 more than
9B. How many times has heishe threatened to hit or throw something at you?
0 1 2 3 4 5 6
1OA. How many times have you thrown, smashed, hit, or kicked?-
0 1-- 2 3 4 5 6
never O W twice 3-5 6-10 11-20 more than
10B. How many times has heishe thrown, smashed, hit, or kicked w?
0 1 2 3 4 5 6
IOC. Has this ever happened? . 1=Ya 0 = No

7
0 1 2 3 4 5 6
:,
C~9Yk3 11B. How many times has he/she thrown something at you?
0 1 2 3 4 5 6
12A. How many times have you pushed, grabbed, or shoved m e r ?
0 1 2 3 4 5 6
0 1 2 3 4 5 6

a
C 7 f3u 13A. How many times have you slapped himher?
0 1 2 3 4 5 6
lb'd
4'
13B. How many times has heishe slapped you?
0 1 2 3 4 5 6
. . . . .
13C. Has this ever happned? 1 =Yes 0 = No
14A. How many.times have you kicktd,bit, or hit himmer w?
0 1 2 3 4 5 6
never OILce twice 3-5 6-10 11-20 more than
14B. How many times has he/she kicked, bit, or hit you u?
0 1 2 3 4 5 6
never Ollct twice 3-5 6-10 11-20 more than
14C. Has this ever happened? . 1 =Yes 0 = No

9
15A. How many times have you hit or tried to hit h M e r ?
0 1 2 3 4 5 6
$4
0 1 2 3 4 5 6
0 1 2 3 4 5 6
16B. How many times has he/she beat you up?
0 1 2 3 4 5 6
16C. Has this ever happened? 1-= Yes 0 = No

10
c71/7& 17A. How many times have you choked him/her?
0 1 2 3 4 5 6
:;I
c7 /?A
0 1 2 3 4 5 6

C777C
18A. How many times have you threatened himmer with a knife or gun?
0 1- 2 3 4 5 6
18B. How many times has he/she threatened you with a knife.or gun?
0 1 2 3 4 5 6
never OaCe twice 3-5 6-10 11-20 more than

11
CT/.~A 19A. How many times have you used a knife or fired a gun?
0 1 2 3 4 5 6
q4
cmx?45 19B. How many times has he/she used a knife or fired a gun?
0 1 2 3 4 5 6
CT {QC 19C. Has this ever happened? 1 = Yes 0 = No

1
Parents and children use many different ways of trying to seffle differences between
II U
Hand respondent response card and read choices 1 to 6 1
- -
&.init. &.date
2
c& 1 1. H o w - m y times did you discuss an issue calmly with *****?
0 1 2 3 4 5 6
........... . .....
24
a - . -
CLL jf6 1B. Has this ever happened? 1 =Yes 0 = No
0 1 2 3 4 5 6
never OllCe twice 3-5 610 11-20 more than
times times times 20times .

LLe u + L 5
a53
t 3. How many times did you bring in or try to bring in someone else to help settle ttungs?
0 1 2 3 4 5 6
-343 3B. Has this ever happened? 1 =Yes 0 = No

3
ea.lsi 4. How many times did you insult or swear at *****?
0 1 2 3 4 5 6
$4
5. How many'timesdid you sulk and/or refuse to talk about an issue?
0 1 2 3 4 5 6
6. How many times did you stomp out of the room,or house or yard?
0 1 2 3 4 5 6
never Ollce twice 3-5 610 11-20 more than

CbL 2 7. How many times did you cry?
0 1 2 3 4 5 6
e&&345 7B. Has this ever happened? 1 =Yes 0 = No
%t!- 8 8. How many times did you do or say something to spite *****?
0 1 2 3 4 5 6
e&&& 8B. Has this ever happened? 1 =Yes 0 = No
?& 9 9. How many times did you threaten to hit or throw something at *****?
0 1 2 3 4 5 6

5
How many times did you throw, smash, hit or iuck somethlnp?
0 1 2 3 4 5 6
11. How many times did you throw something af *****?
0 1 2 3 t 4 5 6
never OIUX twice 3-5 6-10 11-20 more than
12. How many times did you push, grab, or shove *****?
0 1 2 3 4 5 6
time times times 20 times

6
&a/3 13. How many times did you slap or spank ***** with ?
0 1 2 3 4 5 6
times times times 20'times
'L
! ,y '
2.4- Y.4, 14. How many times did you kick, bite, or hit ***** w?
0 1 2 3 4 5 6

f4k3
y3- 15. How many times did you hit or try to hit ***** * ?
0 1 2 3 4 5 6
never OIlct twice 3-5 6-10 11-20 more than

f3-e)
7
When you had a problem with ***** in the past year.. .
-
/6 16. How many times did you beat ***** up?
0 1 2 3 4 5 6
16B. Has this ever happened? 1 = Yes 0 =.No

4 fan
c a /? 17. How many times did you burn or scald *****?
0 1 2 3 4 5 6

-1

rib
I
Chiid Behavior Checklist: Ages 4-18
Interviewer ID:
@CLR&/R-
I am going to read a Ibt of items that describe children and youth.
I Hand PC Response Card 1
For each item that describes ***** pow or

.. please say "2" if the
item is verp true or often true of *****. Say "I" ifthe item is somewhator
can, even if some do not seem to apply to ***I*.

0 = Not Tme
1 = Somewhat True
2 = Verg True
@Cj 0 1 2 1. Acts too young for hismer age

-
C C A 0 1 2 2. Auergy
c c 3 0 1 2 3. Argues a lot
7
f T . 4 0 1 2 4. Asthma
-0
cc5- 1 2 5. Behaves like opposite sex
C C b 0 1 2 6. BoweI movements outside toilet
ed.intl. ed.date
2
-0 1 2 7. Bragging,boasting
-0 1 2 8. Can'tconcen~~,can'tpayantntionforlong
-0
&' 9 1 2 9. Can't get hisha mind off certain thoughts; obsessions
CC 1'0 0 1 2 10 Can't sit still, restless, or hyperactive
Ceh' o 1 2 11. Clingstoadultsortoodependent
ec'l4.t: o 1 2 12. complains OfioNiinCss
CCr3 0 1 2
7 13. Confusedor seems tobe h a fog
CC-0 1 2 14. Cries alot
&&if50 1 2 15.Crueltoanimals
- /60 1 2 16. Cruelty, bullying, or meanncss to others
ce-
'y 0 1 2 17. hy-dnamsorgets lost inhismerth~ughts
CL3 @' 0 1 2 18. Deliberately harms self or attempts suicide
cc 79 0 1 2 19. Demands alotof attention
ceao o 1 2 ~ O . D C S W O J B ~ ~ S ~ ~ ~ ~ ~ I ~ S
-
CCRJO 1 2 21.~thingsbe1ongingtohismerfamilyorothers
CCAA 0 1 2 22.Disobedicntatbome
CCL3 0 1 2 23. Disobedientatschool
-
C C A O~ 1 2 XDoesn'teatd
- 12
CeL5-0 25.Docsn'tgetalongwithotherkids
L-
'LA60 1 2 26.Doesn'tseemtof#lguiltyaftermisbehaving
C-CkfO 1 2 27. Easilyjcalous
-
CC 1158 0 1 2 28. Em OT drhk~t h h p that are not food- don't incluck sweets
CC-A9 0 1 2 29. Fears certain animals, situations, or places, other tban school
cif 3 0 0 1 2 30.Fears going to school
CC- 0 1 2 31. Fears hc/she might think or do something bad
CC 3 h 0 1 2 32. Feels he/she bas to be perfa
-
Ce33 0 1 2 33.F~lsorwmplaipsthatnoo~lwtshim/hcr
-
CC 34 0 1 2 34. Feels others are out to get him/htr
3
35. Feels worthless or inferior

36. Gets hun a lot, accident-prone
37. Gets in many fights
38. Gets teased a lot
39. Hangs around with others who get in trouble
40. Hears sounds or voices that aren't there
41. Impulsive or acts without thinking
42. Would rather be alone than with others
43. Lying or cheating
44. Bitcs frngeraails
45. Nervous, highstrung, or tense
46. Nentous movement0 or twitching
47. Nightmans
48. Not liLtd by other kids
49. Constipated, docsn't move bowels
50. Too fearful or anxious
51. Ftels dizzy
52. Fetls too guilty
53. ovueatiag
54. overtired
55. overweight
56. Physicalproblems without known medical cause:
a Aches or pains (not headaches)
b. Headaches
c. Nausea, feels sick
d. Problems with eyes
e. Rashes or other skin problems
gC5d-Y-0 1 2 f. Stomach aches or cramps
c"5.590 1 2 g.Vomiting, throwing up
a
4
-
CC 56% 0 1 2 h. Other physical problems without known medical cause
Le 3-2 0 1 2 57. Physically attacks people

Cc 540 1 2 58. Picks nose, skin, or other parts of body
-
CC 9-9 0 1 2 59. Plays with own sex parts in public
[C 60 o 1 2 60. plays witb own sex parts too m u d
CC 6-1 0 1 2 61. Poor school work
- 0 12
CC?~& 62. Poorly CoOrdiDated or dumsy
-
cc 6 3 0 1 2 63. Prefcrsbeing witholderkids
-
cc 64 o 1 2 64. Prefers king with younger kids
cC63-0 1 2 65.Rcfusestotalk
-
CC 6.6 0 1 2 66. Rcpeats certainacts over andover; compulsions
cc 67 0 1 2 67. Runs away from home
cC6if o 1 2 68.Screamsalot
CC 63)0 1 2 69. Secretivt, keeps things to self
cc* 0 1 2 70.Sasthi~gsthatarentthere
-
CC 7y 0 1 2 71. Selfnscious or easily embanassed
-0 1 2
CT?x/ 72.Setsfir#.
cc ?3 0 1 2 73. Scxualproblems
CC-
79 0 1 2 74. Showing off orclownbg
-
CC?TO 1 2 75.Shyortimid
-
~ 2 9 60- 1 2 76. Sleeps less thanmost kids
-
CC ?? 0 1 2 77.Sleeps more than most kids during day and/or night
cC?d 0 1 2 78.Smearsorplayswithbowelmavements
7
-
CC 79 0 1 2 79. Speech problem
cca 0 12 80.StarsbWy
-
CC dY 0 1 2 81. Stealsathome
CC 0 1 2 82. Steals outside the home
CC-
83 0 1 2 83. Stores up things he/she doesnt need
85. Strange ideas
86. Stubborn, sullen, or irritable
87. Sudden changes in mood or feelings
88. S u b a lot
-
ccb9 0 1 2 89. Suspicious
C C 9 0 0 1 2 90.Swearing or obscene language
cc9/ o 1 2 91. Talks about killing self
-i-
C C Q A 0 1 2 92. Talks or walks in sleep

-0
cc93 1 2 93. Talks too much
CCW 0 12 94. Teases a lot
cc95-o 1 2 95. Temper tantrums or hot temper
-0 1 2 96. Thinks about sex too much
C C Y T 0 1 2 97. Thtcateps people
ccstp 0 1 2 98. Thumbsucking
ccm 0 1 2 99. Too c~ncernedwith neatness or clcaaliaess
G C j W 0 1 2 100. Trouble sleeping
101. Truancy, skips school
102. Underactive, slow moving,or lacks energy
103. Unhappy, sad, or d q r d
104. Unusually loud
105. Uses alcohol or drugs for nonmedical purposes
106. Vandalism
107. Wets self during the day
108. Wets the bed
109. whiaing
110. Wishes to be of opposite sex
11 1. Withdrawn, doesnt get involved with others
112. Wonits
6
-0 1 2 113A. ~.~W*dbd
-0 1 2 113B. c
-0 1 2 113C. -
ENDOFINTERmW
RECORD TIME: C 5 c L E?/W
. ...
0N-T sELA-7
I
2
24 Y.40 4A. Does this affect where you take *****?
1.- YES 2-. NO
24 5 5. Have any of your family members been hurt by a violent act?
1
4
2 A6 6. Have any of your family members been Wed by a violent act?
1.- YES 2 .,-NO
1.- YES 2. NO
8. Have any of your close friends been Wed by a violent act?
1- YES 2 . , N O
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
me questions I'll be as- you now have to do with acts of violence that ****+may have
present during Violent acts.
(54 i o 10. Has ***** ever seen or been present when somebody was shoved, kicked or punched?
1. YES
2. NO
1. Withinlastweek
3. Withinlastyear
1. In ****'s home
6. At ****'s scho0Yday care
25. Other(specify) Y-'da &
+
1. YES
2. NO
4
13A. Who was it? (MARK &I, APPLY)

THAT
1. Parent
2.- *****
3. Friend
4. N e i g h b o r
5. Sibling
6.- Other Relative (Specify)
25. -
Other (Spec@) LCu..LC&f23 &
&,*
24 Y v
1 . 3 0 injury
2. Knockeddown
3. Bruised
4-. Cut/bleeding
5. Unconscious
6 . B r o k e n bones/fracture
8-. Other
1. YES
2. NO
~ '

1. Parent
2-. *****
3.,-Friend
4.,-Neighbor
5.- Sibling
6.,-,Other Relative (Specify) YZZ,SZG
25. Other (Specify) VL&VQ.&&& &
5
. 2 / Y /& - 16. Has ***** seen this more than once?
1. YES
2. NO
&*Lj/5&0 16A. How many times has ***** seen this in the past year?
S A A&30 16B. How many times has ***** ever seen this?
s d /-+- 17. Has ****+ever seen or been present when someone was attacked with a knife?
... ..
1. YES
. .....
2. NO
When was the last time he/she saw that?
1. Within last week

2. Withinlastmonth
3. Withinlastyear
1. In ****'s home
3. In front of ****'shousehuiiding
6. At ****'s schwl/day care
25. Other (spec@)@
6
1. YES
.....

1. Parent
2.- *****
3.- Friend
4-. Neighbor
. .
5. Sibllng
6.- Other Relative (Specify) v d L e s d & J%yjcwd--
25 Other (Specrfy) L-J&~AA - 0~
6
2 1. How badly was the person or people injured? (MARK THAT APPLY)
1.
..
N O KiJUry
2. Knockexidown
3. Bruised
4-. Cut/bIeeding
5. Unconscious
6 . L r o k e a bones/fracture
7-. Medical care obtained
-8. Other
22. Did they die?
1 .- YES 2..-NO 8. Don't Know
1. YES
2. NO
7
,+
2 4 3~ 23A. Who was it? (MARK THAT APPLY)
1.- Parent
2:-, *****
7 Friend
4-. Neighbor
. .
5. Srblmg
6. Other Relative (Specify) Y-'dLk &am&
25. Other (Specify) Y ~ L ' d &f&Z&
F
'?#'4
24k4 24. Hai ***** seen this more than once?

1. YES
2. NO
22 @w#$~24A. How many times has ***** seen this in the past year?

2 3 Z&&O
S A A 9- 25. Has ***** ever heard a gun shot?
1. YES
2. NO
24 6* 26. When was the last time he/she heard that?
1. Withinlastweek
3. Withinlastyear
8
1. In ****Is home
4. In ****IS neighborhood
6. At ****'s schoollday care
25. Other (spec@) fk
Has ***** heard a gun shot more than once?
1. YES
2. NO
28A. How many times has ***** heard this in the past year?
28B. How many times has ***** ever hard this?
s;4 29. Has ***** ever seen or been present when someone was shot?
1. YES
2. NO
1 END OFINTERMEW 11
I RECORD TIME:
S&38 30. When was the last time he/she saw that?
1. Withinlastweek
3. Withinlastyear
9
1. In ****Is home
2. In hallway of ****'s builLing
'3. In front of ****Is househuilding
,4. In ****'s neighborhood
1 25. Other (specify) fi'&&~'Llid& &
32. Did he/she know the person or people who got shot?
.............
1. YES
2. NO
32A. Who was it? (MARKALL THAT APPLY)
1. Parent
2.- *****
3. Friend
4. Neighbor
5. Sibling
6.- Other Relative (specify) v - d 4 ~ ctJx?.ppJo~
25. Other(Spec3y) J-%& & G &Ia y & &
33. Did they die?
1.- YES 2.- NO 8. Don't Know
34. Did he/she know the person or people who did this?
1. YES
2. NO
10

1. Parent
2.- *****
3. Friend
4. Neighbor
. .
5. Siblmg
6.- Other Relative (Specify) /Gad&. & ~ j ~ - e &
25. Other (Specify) bG%e.&d&
/F
.G&&Tq
2% 33- 35. Has ***** seen this more than once?
1. YES
2. NO
SA 3 5 x 0 35A. How many times has ***** seen this in the past year?
35/30 358. How many times has ***** ever seen thir?
EASI TEIMPERAllMENT SURVEY
Interviewer ID:
FIELD COPYc-2 e 11
iJ4
For each one, try to rate ***** on a d e from 1 to 5, w i t h 1 being uncharacteristic or

not at all like ***** and 5 being charaderistic or very much like *****.
1. ***** feels happiest in familiar surroundings. 2Y f
1= uncharacteristic (NOTat all like your child)
3= Neither Uncbaracteristic nor Characteristic
2. ***** often acts on the spur of the moment. 2YA5

ed. init. ed. date
2 37-
3. ***** is somethug of a loner. 5.y .s?
c-
1= Uncharacteristic (NOTat il like your child)

4. ***** sometimes does crazythings just to be different. 294

2= Somewbt Uncharacteristic (NOT very much like your child)
5. ***** likes to be with people. 2-Y 5-

3= Neither Uncharacteristic nor characteristic
6. ***** has trouble resisting temptation. 2Y 6
1= Unc6aracteristic (NOT at all like your child)

7. ***** finds people more stimulating than anything else. SY-7

8. Unfinished tasks really bother *****. SJ!?8
9. ***** cries easily. S$9

?>>
10. ***** makes friends easily. s9 YO

4 = Somewhat Characteristic (sort of like your chiid)
11. ***** tends to be somewhat emotional. 2.977

2= Somewhat uncharacteristic (NOT very much like your child)
12. ***** is off and running as soon as (s)he wakes up in the morning. 69/%
13. ***** generally seeks new and exciting experiences and sensations. CY13

14. ***** fmds self-control easy to learn. 2-<y

1'4
1= Uncharacteristic (NOTat all like your chiid)

?:j! 2= Somewhat Uncharacteristic (NOTvery much like your child)
15. ***** can tolerate frustration better than most. 2 3 /9-

1= Uncharacteristic (NOTat all like your a d )
5= Characteristic (very much like your a d )
16. ***** often fusses and cries. SY 16

.1= Uncharacteristic (NOTat aU like your child)
4 = Somewhat Characteristic (sort of likc your child)
17. ***** gets upset easily. i5.Y 1.2

5= Characteristic (very much like your chiid)
18. *f*** tends to hop from one interest to another quickly.

19. ***** takes a long time to warm up to strangers. 2.Y /9
1= Uncharacteristic (NOT-at all like your child)

20. ***** prefers quiet, inactive games to more active ones. e59 LO
21. ***** often says the frrst thing that comes i.nto hisher head. 29Rj
1= Uncharacteristic (NOTat ail like your child)
22. ***** tends to be shy.

2= Somewhat Uncharacteristic (NOT very much like your chid)
***** tends to get bored easily.
24. Usually ***** can not stand waiting. 2YA4

,I$
- 2= Somew.ht Unchara#eristic (NOT very much like your child)
25. ***** has trouble controlling hisher impulses. 29-25

26. ***** is always on the go. 2YAG
. 1= Uncharacteristic (NOTat all like your child)

2= Somewhat Unchamcteristic (NOTvery much like your child)
4= Somewhat characteristic (sort of like your chiid)
27. ***** is very friendly with strangers. =2-YAT

5= characteristic (very much like your child)
28. ***** zilways likes to make detailed plans before @)hedoes somedung. EYi8

29. ***** generally likes to see things through to the end. 29 R 9

't$ 1= Uncharacteristic (NOTat all Iike your child)
30. ***** often has trouble making up hisher mind. 2-9

3s
4 = Somewhat Characteristic (sort of lie your child)
3 1. ***** prefers playing with others rather than playing alone. 2931
32. ***** is very sociable. s9&9

1= Uncbaracteristic (NOTat ail like your child)
33. When alone, ***** feels isolated. t Y 33
34. ***** reacts intensely when upset. 2 Y 34

q 2 =
3=
Somewhat Uncharvteristic (NOTvery much like your child)
Neither Uncharacteristic nor Characteristic
35. ***** is very energetic. czj.35-

3= Neither Uncharacttristic nor Characteristic
36. ***** tends to give up easily.

3= Neither Uncharacrristic nor characteristic
5= Characteristic (very much like your chiid)
37. When ***** moves about, (s)he usually moves slowly. 2-Y 3.3
1= Uncharacteristic (NOTat d like your child)
38. ***** likes to plan things way ahead of time. 2 3 38
1= Uncharacteristic (NOT at ail like your child)
39. Once ***** gets going on something, (@hehates to stop. 2-Y 39

2,
4 3= Neither Uncharackristic nor Characteristic
40. ***** will try mything once. s-9 40

8 EM) OF INTERVIEW e
Family Environment d e : Short Version
mm dd yy
Inteniewer ID:
You may feel that some of the statements are true for some family members and fake for
fake for mast members. If the members are evenly divided, decide what is the stronger
Remember, we would iike to know what your current family seems like to you. So do not
t r y to figure out how other members see your family.
1. T 2. F
1. T 2. F
fc5 3 3. Family members are rarely ordered around
1. T 2. F
&.init. &.date
2
?=ti? 4 4. F d y members rarely become openly angry

1. T 2. F
f%5 5- 5. We dont say prayers in our family

1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
9. There is one family member who makes most of the decisions
1. T 2. F
1. T 2. F
11. We dont believe in heaven or hell
1. T 2. F
1. T 2. F
13. Family members oftcn criticize each other
1. T 2. F
&' 14. Family members have strict ideas about what is right or wrong
1. T 2. F
There is a strong emphasis on following rules in our family
1. T 2. F
Family members sometimes hit each other
1. T 2. F
We believe there are some u s you just have to take on faith
1. T 2. F
Everyone has an equal say in family decisions
1. T 2. F
If there's a disagreement in our family, we try hard to smooth thmgs over and keep the
P-
1. T 2. F
FIAU 20. In our family each person has different ideas about what is right and wrong
1. T 2. F
21. We can do whatever we want to in OUT family
1. T 2. F
FI 22. Family members often try to one-up or outdo each other
1. T 2. F
FCX 3 23. The Bible is a very important book in our home
1.' T ' 2. F
4
/=& A 9 24. Rules are pretty inflexible in our household
1. T 2. F
25. In OUT family, we believe you don't ever get anywhere by raising your voice
1. T 2. F
Fa25 ??. Family members believe that if you sin you wiU be punished
1. T 2. F
/Fx 2 7 27. You Can't get away with much in our family
1. T 2. F
1 I
I HAND SUBJECT RESPONSE CARD I
28.- When you answered these questions, who did you have in mind?
1. Siblings
2. Parent
3. Roommate
6. SpousePartner
7. ChildChildren
END OFINTERVEW
RECORD TIME: E s s S7/M

I .
Interviewer ID:
PS&P&A/B--
1= verytrut
2- somewhattrue
3= nottrue
PS@ 9 1. When Im with my fiends I feel completely able to relax and be myself
-
1 very true
2 - somewhat true
3 - not true

PSPb
1 -verytrue
-
2 somewhat true
-
3 not true
ed. init. ed. date

/"3sp3 3. People who h o w me trust me and respect me.
1-vexytrue
-
2 somewhat true
-
3 not true
PSP -9 4. No matter what happens, I know that my family will always be there for me should I need
them.
-
1 very true
2 - somewhat true
3 -nottrue ~
5. When I want to go out to do things, I know that many of my fiends would g&y (lzh)
P S P 3- doing these things With me.
1 -verytrue
-
2 somewhat true
-
3 not true
PSP 6 6. I have at least one fiend that I could tell anything to.
1 -vexytrue
2 - somewbat true
-
3 not true
7. Somethes rm not sure if1 can completely (count) on my M y .
1 -verytrue
-
2 somewhat true
-
3 not true
8. My M y lets me h o w they thinlr I'm a (vahable)person.
1 -verytrue
-
2 somewhat true
-
3 not true
9. I feel very close to some of my fkends.
-
1 very true
-
2 somewhat true
-
3 not true
10. People in my family have coddence in me.
1 - very true
2 - somewhat true
3 - not true
1
Q''
11. People in my family help me .find solutions to my problems.
1 - very true
2 - somewhat true
3 - not true
-
1 very true
-
2 somewhat true
-
3 not true
13 My fiends would take the time to talk about my problems, should I ever want to.
-
1 very true
2-somewhattrue
-
.
3 not true
14. I know my f d y will always stand by me.
-
1 very true
2 - somewhat true
-
3 not true
15. Even when I am with my fiends, I f

d alone.
-
1 very true
-
2 somewhat true
-
3 not true
Psp rG 16. I have a teacher or coach who I can & (count) on and talk to.
-
1 very true
-
2 somewhat true
-
3 not true
Ps/f=,
/.i& 17. I have a grandparent., uncle, or aunt that I feel close to and who helps me out.
1 -verytrue
-
2 somiwhat true
-
3 not true
ASP /a 18. I have a brother, a sister or a cousin who listens to me and understands my problems.
-
1 very true
-
2 somewhat true
-
3 not true
PSP / g 19. There is an adult outside my f d y , for example, a neighbor or religious or

community member,who I can go to for help if1 need it.
1 -verytrue
-
- 2 somewhat true
3 - not true
PSP L.0 20. Is there anyone in particular that you think helps you out when you need it?
1. Yes 0.No
@'Yes: What is this person's name and what is hisher re!ationship to you? (Circie d that
d 20a2. 1 - Immediate F d y (sibling, child, parent, partner)

20al.
'firstM
name 2 - Extended F d y
-
6 Other
PSsoOk5L
20bl. 9 - d -
20b2. 1 Immediate F d y (sibling, child, parent, partner)
<;a First name - 2 --ExtendedF d y
-
-
-
5 School or Co
6 - Other
PSPrnCfi
20cl. -
20c2. 1 Immediate Family (sibfing, child, parent, partner)
'First name 2 - Extaded F d y
-
-
-
5 School or Community MemberLeader
6-0th-
IBEND OF INTERVIEW 8
RECORD TIME: BBP27JN
z54
Date:
m m dd yy
PROJECT OW HUMMY DEVELOPMENT CHICAGO NEIGBBQRBOODS

I
Y N
Ifemployed, ask Q u e # & ifmemphyed, go to Question#3~
2. Do you plan on changing jobs in the near futurt? Y N

if"Yes,":
2a when? 2b. new employer?
2c. new employment address:
mJ) -)
3. Do you think it is likeiy you will obtain work in the near future? Y N
if "Yes,":
3a when? LmOnthlvcar) 3b. employer?
3c. new employment address:
[Cltvl (state)
If currently in schooi, ask Question #4
C:UMCINTOS\WDOCS\ROANEW.FRM
2 61
4. Do you plan on changing schools, or going away to school? Y W
if "Yes,"
4a what will the new school be?
4b. new school address:: buret)
fciw) (state)
5. Do you know of any reason why you might not be able to participate in this Project in &e
future? Y N
If, "Yes,"
$ 5a Please explainwhy:
6. Can you give me the names, addresses, and phone numbers of four close fiends or relatives
who y d l always know where to find you to help us locate you in the future?
b.
Name:
Relationship:
Address:
City/St/zip:
Phone:
c d. -
Name:
Relationship:
Address:
CityfStlZip:
Phone:
2d2
Tryto make the foilowing observations at the close of the session
7. Did the respondent seem (check all that appiy):

a- annoyed b. nemous c. bored d. afiad
e.- relaxed f. interested g. neutral h-. curious
-1. cooperative -
1 confused?
+ 8. Please note any other observations about the respondent's demeanor:
9. Using the scale below, make your best assessment of the participant'slikelihood of
Circle me:
1 2 3 4 5
Little l i k e l i d G n a t likelihood
9a . Please explain the reason for your assessment:
10. Using the scale below, make your best assessment of the difsculq we will have in locating
Circle one:
1 2 3 4 5
1Oa. Please explain the reason for your assessment
C:U MCINTOS\WPDOCS\ROANN. FRM ROA 3

Date:
mm dd yy
Subject m:
Interviewer ID:
To bc completed by the R c s d Assisant at the conclusion of the as~essnent.

,,>I
1. Was the entire assessment administered in Enghsh?
1.
2.
2. Parent/Guardian
3. Spousflarber
6. Other
many measures were administered in a language other than English?
5. HOW
1. less than o n e - f o d
3. between one-halfand three-fourths
4. more than be-fourths
5. all
6. How much difficulty did the S/PC have in Understanding the language of the measures? Did
+ he/& find it ...
1. very difficult
2. Faidydifficult
3. Fairly easy
4. veryeasy
7. Was all of the assessment administeredin private- that is, no one was actively listening to any
8. Were the following masures administered in private?
If NO,enter cows) for the party(ies) present during the assessmenL
Code
1. Child Behavior Checklist YES NO a b. c. -
2. ConfIictTactics YES NO a. b. c.
3. Deviance of Peers YES NO a-b. c.
4. SeifReportofOffending YES NO a.-b--c-
5. SubstanctUse YES NO a b. c.
6. YouthScifReprt YES NO a. b. c.
7. Yo:. sAdultSeifReport YES NO * a b. c.-
1 = ParendGuardian 5 = Other Child F a y Member

2 = Spouse/Parmer 6 = Friend
Comments Seaion:
PLLUE RECORD ANY ADDITIONAL COMMENTS:
\
Date:
mm dd yy
Interviewer II):
ES
4
..
...

ASSESSMENT
SUBJECT
COHORT: 12/15
FIELD COPY #2
TABLE OF CONTENTS
Age: 12/15 (Subject)
1. Vocabulary: WISC-R
2 Deviance of Peers
3 Substance Use: 12-15
4 WRAT: Reading
5 Health Screen
6 Pubertal Development
7 Exposure to Violence
8 Self Report of Offending
9 . Youth Self Report
10 Provision of Social Relations
WISC-R
1
WISC-R
Only ask the following questions of subjects who speak either English or Spanish. Do not
A
$ou should answer the nest set of questions in the language you know the best, that is, the
language you know the most words in.
3
2
Vocabulary (WISC-R)
Subject ID: sw/w
a correct answer, ask M e r Explain what you mean. or Tell me some more about it. and
write a (Q), indicating that you have queried this answer, on the answer sheet a f h his5er
clearly correct answer, write a (Q) on the answer shect, query the response again, and record
hidher answer. In general, ifan answer is not clearly correct, qucry it, but do not make more
than 2 queries to any item. If an answer is clearly incorrect or ifthe child does not know the
word,go on to the next item.
* .
b W m
I am going to say some words. Listen carefully and tell me what each word means. What
does mean?
1. KNIFE
Correct Query Incorrect

somahing you cut with To hunt with Play with it
Tostabwith sharp Put it in your pocket
Aweapan It can kill people I have one
Can peel an apple with it Caneatwithit
Its sharp and can hUri someone
Taken from the We-r I n t e m c e S d e for w r e n - Revised, New York

Psychological Corporation, 1979.
&
ed. init.. ed. date
DEVIANCE OF PEERS
c
Deviance of Peers
Date: r n P B A 7
mm dd yy
Subject ID: J&/Z
@ow I am going to ask you some questions about your friends and people you spend time
with. All of these questions are about thin@these people have done in the past year,
that is since...
2
During the past year, how many of the people you spend time with have done eacb of the
following fhings. Choosing torn,
3. Allofthem
2. Someofthem
1. Noneofthem
1A. Are any of your friends d o r people you spend time with in school?
1. YES
2. NO
1. Have been invohd in school activities, not including sports? Would you say...
Pi1
3 2 1
ed. init. ed. date
7
2
Deviance of Peers
During the past y w , how many of the people who you spend time with...
xp& 2. Have been involved in school athleticslspons?

3 2 1
3 All of them Some of them None of them
w3 3. How many have gomn along well with teachers and adults at school?
3 2 1
P 4 4. How many have been thought of as a good student?
3 2 1
&p5 5. How many have obeyed school rules?
3 2 1
p;p 6 6. How many have slupped school without an excuse?
3 2 1

W;L
3 2 1
3
Deviance of Peers
% 3 2 - 1
Allofthem . Some of them None of them
9. How many have been involved in religious activities or church groups?
3 2' 1
3 2 1
3 2 1
3 2 1
13. How many have been generally honest and told the truth?
3 2 1
4
Deviance of Peers
p i 4 14.b Have lied, disobeyed, or &ed back td adults, such as parents, teachers or others?
3 2 1
15. How many have purposely damaged or destroyed property that did not belong to them?
my5
3 2 1
16. How many have stolen something worth $5 or less?

wig
3 2 1
P/? 17. How many have stolen something worth more than $5 but less than $5001
3 2 1
18. How many have stolen something worth more than $5003
Wf8
3 2 1
19. How many have gone into or tried to go into a building to steal something?
WfY
3 2 1
5
Deviance of Peers
Have taken a motor vehicle, such as a car or motorcycle, for a ride or drive without the
W# 20.
owner's permission?
3 2 1
W 2 d 21. How many have gotten into physical (fst) fightswith schoolmatedco-workers or
friends?
3 2 1
22. How many have hit someone with the idea of hutting them?
WA;z/
3 2 1
23. How many have attacktd someone with a weapon with the idea of seriously hurting
WL3 them?
3 2 1
24. How many have used a weapon or force to get money or t h u g s from people?
P A 4
3 2 1
25. How many have sold drugs, such as heroin, Cocaine, crack, or LSD (other than
5 marijuana).
3 2 1
6
Deviance of Peers
'4
%Q?6 26. How many have used marijuana or pot?

3 2 1
27. How many have used any form of alcohol, including wine, liquor, or beer?
ML+
3 2 1
How many have used drugs, such as heroin, Cocaine, crack,or LSD (other than
w&? 28. marijuana)?
3 2 1
~ j 29.
g How many have used tobacco?
3 2 1
All of them Some of them Nom of them
;bps0 30. How many have had sexual intercourse?

(Remrd " don't understand" if applicable)
3 2' 1
I
I
Hand Subject response card #2 I
I2
7
Deviance of Peers
During the past year, how often have people you spend time with done the following?
Choosing tom (1) Never, (2) Once/Twice, (3) Several Times or (4) Often.
How often have they asked you to go drinking with them? Would you say.. ..
W3i 31-
"8 1 2 -3 4
Never OncelTwice Several Times Often
How often have they put pressure on you to drink?
1 2 3 4
Never OncelTwice Several Times Often
33. How often have they said that you have to get drunk to have a good time?
w33
1 2 3 4
Never OnceITwice SeveralTimes Often
How often have they offered (gave or sold) marijuana or pot to you?
1 2 3 4
Never Once/Twice ScveralTmes Often
How often have they said that you have to get high on drugs to have a good time?
1 2 3 4
Never OncerrWice ScveralTimes Often
P36
1 2 3 4
8 END OF INTERVIEW 8
SUBSTANCE USE
IS
Substance Use Intemiew
[12 & 15 Year Old Subjects]
Date:
m m dd yy
Subject ID:
Interviewer ID:
FIELD COPY 2
Time started
This questionnaire is about your use of cigarettes, alcohol, marijuana and other drugs.
As with all of the other questionnaires, every answer you give me will be private. No one .
outside this research project is allowed to find out what your answers are. Remember, at
the beginning of the study, I told you about the special protection to ensure your
privacy? The Federal Certificate of Confidentiality makes it illegal for anyone, even your
parents or people at school, to see or find out what your answers are in this study.
If you don't know the meaning of a word, just ask me.
used them in your entire life choosing from one of these choices...
Hand subject response card #1,refer to these choices for Wetime use. I
These are the choices for telling me how m a n y times you have used alcohol or a drug in
your whole life. The choices are: 0. Never, 1. 1-2 Days, 2.3-5 Days, 3. 6-11Days,
4. 12-24Days, 5. 25-50Days, 6. 51-99Days, 7. 100-199 Days, or 8. 200 or more Days.
ed. init. ed. date

Page 2
have used them in the past year, that is since....

Hand subject response card #2, refer to these choices for past year use.
In thhkhg about the past year, the choices are the same, however, there is some extra
infohtion to help you f w out your answer:

1. 1-2days
2. 3-5days
3. 6 .11 days.. ...........means every other month
4. 12 .24 days ...........means 1 or 2 times each month
5. 25 .50 days ...........means several times each month
6. 51 .99 days ...........means 1 or 2 days each week
7. 100 .199 days........means 3 .4 days each week
8. 200+ days.............means almost every day
For each of the drugs I ask you about, I also want you to tellme how many times you
have used them in fhe past month,that is since....
Hand subject response card #3, refer to these choices for past month use.
In thhkhg about the past month, the choices are a little different and here is some extra

1. 1-2days
2. 3 .5 days ..............
means once each week
3. 6 .9 days ..............
means twice each week
4. 10 .14 days... : .......
means three times each week
5. 15 .20 days ...........
means four times each week
6. +
21 days.. ............means almost every day
i
Page 3
Section I: Substance Use

The first questions are about cigarette smoking.
1A. Have you EVER smoked cigarettes? (CIRCLE ONE ANSWER)
NO....0 - Go& Q. 2A
I
sv /A0 Yes...l
L
1B. About how old were you when you frrst smoked a cigarette?
SvYA0 Years Old
How many days have you smoked cigarettes.. .

Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

GVfC 0 Days
1C. Ever in 1 2 3 4 5 6 7 8
your whole life?
1D. Duringthe 0 1 2 3 4 5 6 7 8
~ last12months?
Never 1-2 3-5 6-9 10-14 15-20 21+

CYYED Days Days Days Days Days Days
1E. Duringthe 0 1 2 3 4 5 6
last 30 davs?
Page 4
1F. During the past 30 days, how many cigarettes did you smoke on an average day?
(CIRCLEONE ANSWER)
SWFO
2 - 1-Scigarettesaday
, 4 - About 1 pack a day (16 - 25 cigarettes)
s v f &{ 1-Did you use what was in the house? ..................................... 1. Yes 0. No
S v f 6 R 2-Did you buy it from friends, family, or other people you know?... 1. Yes 0. No
svy,s 3 3-Did you buy it from a store?............................................... 1. Yes 0. No
Jvf64 &Did others share it with you?............................................... 1. Yes 0. No
w+5 ..................................................
5 -Did others give it to you? 1. Yes 0. No
6 -Did you trade goods for it? (trade somethmg for it?)................. 1. Yes 0. No
SW66
7 -Did you trade services for it? (do something for it?).................. 1. Yes 0. No
S W Gz
sv 6 8 8 -Did you steal it?............................................................. 1. Yes 0. No
f & 9 9 .Did you get it by scam, fraud, or con?................................. 1. Yes 0. No
SVjS70
10-Did someone else buy it for you?......................................... 1. Yes 0. No
2Q
Page 5
1H. During the past 12 months,when you smoked cigarettes, what have been your most
for m?
1 - Was it for fun,kicks, or excitement?..................................... 1. Yes 0. No
2 - Was it to relax or relieve tension?........................................ 1. Yes 0. No
4 - Was it to have.a good time with your friends?.......................... 1. Yes 0. No
5 - Was it to fit in with a group you l i i ?................................... 1. Yes 0. No
6 - Was it to get away from your problems or troubles? .................. 1. Yes 0. No
-
8 Was it because of anger or frustration?.................................. 1. Yes 0. No
9 - Was it to help yourself fall asleep?...................... ;................ 1. Yes 0. No
10 - Was it to help yourself stay awake?..................................... 1. Ycs 0. No
13 - Was it to end a pregnancy?.............................................. 1. Yes 0. No
14 - Was it to make sex better?............................................... - 1. Yes 0. No
15 - Was it for any other reason? (specify:)................................ 1. Yes 0. No
A.
B.
21
Page 6
I I
2A. Have you EVER taken or used smokeless tobacco? Other names for smokeless
tobacco are: snuff, plug, dipping tobacco, chewing tobacco.
(CIRCLEONE ANSWER)
NO....0 - Goto Q. 3A
SVdAO Yes ...1
2B. About how old were you when you first used smokeless tobacco?
Years Old
SVA/30
How many days have you used smokeless tobacco...

Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

SPRCO Days
2C. Ever in 1 2 3 4 5 - 6 7 8
, your whole Me?
2D. Dwingthe 0 1 2 3 4 5 6 7 8
last12months?
SVA ;bo
Never 1-2 3-5 6-9 10-14 15-20 21+

sva 0 Days Days Days Days Days Days
2E. Duringthe 0 1 2 3 4 5 6
last 30 davs?
2 1
Page 7
2F. How did you get any smokeless tobacco you used during the last 30 days?
sv&~y 1-Did you use what was in the house?..................................... 1. Yes 0. No

.1 4-Did others share it with you? ...............................................
5 -Did others give it to you?..................................................
1. Yes
1. Yes
0. No
0. No
$ -Did you trade goods for it? (trade something for it?) ................. 1. Yes 0. No
7 -Did you trade services for it? (do something for it?) .................. 1. Yes 0. No
9 .Did you get it by scam, fraud, or con?................................. 1. Yes 0. No
10-Did someone else buy it for you?......................................... 1. Yes 0. No
sVdF ~ O
2G. During the past l.2 months, when you used smokeless tobacco, what have been your
U?
s y 46 f 1 .was it for fun, kicks, or excitement? ..................................... 1. Yes 0. No

\1 4 .Was it to have a good time with your friends? .......................... 1. Yes 0. No

6 .Was it to get away from your problems or troubles? .................. 1. Yes 0. No
8 .Was it because of anger or frustration?.................................. 1. Yes 0. No
10 .Was it to help yourself stay awake? ..................................... 1. Yes 0.No
-
11 Was it to help manage your weight? .................................... 1. Yes 0. No
13 .Was it to end a pregnancy?.............................................. 1. Yes 0. No
14 .Was it to make sex better?............................................... 1. Yes 0. No
S V & ffJ-
~ 15 . Was it for any other reason? (specify:) ................................ 1. Yes 0. No
A. -
B.
23
Page 8
The following questions are about drinking alcohol, including BEER, WINE, WINE
COOLERS, and LIQUOR. A drink means a 12 02. can or bottle of beer, a 4 02. glass of
wine, a 12 02. wine cooler, or a shot glass of hard liquor (like scotch, gin, vodka).
Liquor also includes a mixed drink.
I I
3A. Have you EVER had a drink of beer or wine cooler, or hard liquor - not just a sip
or taste? (CIRCLE ONE ANSWER)
NO....0 -
'* SI340 Yes...l
3B. About how old were you when you first drank alcohol?
SV360 Years Old
-
How many days have you had alcohol to drink not just a sip or taste.. .
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

sv3co Days
3C. Everin 1 2 3 4 5 6 7 8
your whole life?
3D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-S 6-9 10-14 15-20 21+

CV3EO Days Days Days Days Days Days
3E. Dllringthe 0 . 1 2 3 4 S 6
last 30 davs?
Page 9
3F. During the last 30 days how many days have you had 5 or more drinks in a row?
(CIRCLE ONE ANSWER)
SV3FO
0 - None
1-once
2 - Twice
3 - 3-5 times
4 - 6-9 times
-
5 10 or more times
3G. During the past 12 months, about how many days have you gotten drunk or very higb
on alcoholic beverages?
Number of days drunk or very high in the past 12 montbs:

Page 10
The next few questions are about beer only.
I (CIRCLE ONE ANSWER)

-
4A. Have you EVER had a drink of beer not just a sip or taste?
NO....0 - Ga to Q* SA
Yes...l
4B. About how old were you when you fust drank beer - not just a sip or a taste?
sv 4 B O Years Old
-
How many days bave you drank beer not just a sip or taste.. .
r
-
SWCO -
Never 1-2
Days
3-5
Days
-
611
hYS
12-24
Days
25-50
Days
51-99
Days
-11;
100-
I 200+
Days
4C. Ever in 1 2 3
your whole We? -
4D. Duringthe 0 1 2 3
last 12 montbs? -
Never 1-2 3-5 6-9 10-14 15-20

SV4k-0 Days Days Days Days Days
I
4E. Duringthe
last 30 days?
0 1 2 3
4 1 5
7b
Page 11
5 . ~60
4 4G. On those days when you drank beer, about how many drinks did you have?
Usual number of bottles or cans per day on the days you drank in the past 30 days:
.4H. How did you get any beer you drank during the last 30 days?
$I/ r/,~ h
JV 4f71 1 .Did you use what was in the house? ..................................... 1. Yes 0. No
2 - Did you buy it from friends, family, or other people you know?... 1. Ycs 0. No
L -
3 Did you buy it from a store?............................................... 1. Ycs 0. No
4 .Did others share it with you? ............................................... 1. Yes 0. No
5 - Did others give it to you?.................................................. 1. Ycs 0. No
6 .Did you trade goods for it? (trade something for it?)................. 1. Yes 0. No
7 .Did you trade services for it? (do something for it?).................. 1. Yes 0. No
8 - Did you steal it?............................................................. 1. Yes 0. No
-
9 Did you get it by scam, fraud, or con? ................................. 1. Yes 0. No
sv L / f / i o -
10 Did someone else buy it for you? ......................................... 1. Yes 0. No
Page 12
41. During the past l2 months, when you drank beer, what have been your
?-
1 - Was it for fun,kicks, or excitement?..................................... 1. Yes 0. No

2 - Was it to relax or relieve tension?................... .................... 1. Yes 0. No
3 - Was it to feel good or get high?............................................
L 4 - Was it to have a good time with your friends?..........................
1. Yes
1. Yes
0. No
0. No
3- WF it to fit in witb a gmyp you like?................................... 1. yes 0. No
6 - Was it to get away fromyour problems or troubles?.................. 1. Yes 0. No
7 - Was it because of boredom, nothing else to do?....................... 1. Yes 0.No
8 .Was it became of anger or frustration?.................................. 1. Yes 0. No
9 .Was it to help yourself fall asleep? ....................................... 1. Yes 0.No
10 .Was it to help yourself stay awake? ..................................... 1. Yes 0.No
11 .Was it to help manage your weight? .................................... 1. Yes 0. No
13 .Was it to end a pregnancy? .............................................. 1. Yes 0. No
14 .Was it to make sex better? ............................................... 1. Yes 0. No
15 .Was it for any other reason? (specify:) ................................ 1. Yes 0. No
A.
B.
Page 13
The next few questions are about wine and wine coolers only.
5A. Have you EVER had a drink of wine or wine coolers - not just a sip or taste?
(CIRCLE ONE ANSWER)
gv540 NO....0 -
Yes...l
?'d
sv5/30
5B. About how old were you when you first drank Wine or wine coolers - not just a sip or a
taste?
Years Old
-
How many days have you drank wine or wine cooIcrs not just a sip or taste.. .
NWW 1-2 35 6-11 12-24 25-50 51-99 100- 200+

h SP55-0 Days
5C. Ever in 1 2 3 4 5 6 7 8
your whole life?
5D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SY5-0 Days Days Days Days Days Days
I I
5E. Duringthe 0 1 2 3 4 5 6
last 30 days?
. .... .. ..... ..
-2'i
Page 14
~ ' 5 6 0 5G. On those days when you drank wine or wine coolers, about how many drinks did you
have?
Usual number of drinks per day on the days you drank in the past 30 days:
5& How did you get any wine.or wine coolers you drank during the last 30 days?
g - f i 5f ~ 1-Did you use what was in the house?..................................... 1. Yes 0. No

2-Did you buy it from friends, family, or other p p l e you know?. .. 1. Yes 0. No
.I 3-Did you buy it from a store? ............................................... 1. Yes 0. No
&Did others share it with you? ............................................... 1. Yes 0. No
5 -Did others give it to you?.................................................. 1. Yes 0. No
6 -Did you trade goods for it? (trade something for it?) ................. 1. Yes 0. No
gya-j/fo 10-Did someone else buy it for you?......................................... 1. Yes 0. No
I
Page 15
51. During the past 12 months,when you drank wine or wine coolers, what have been your
for so?-
1 .Was it for fun,kicks, or excitement? ..................................... 1. yes 0. No

2 .was it to relax or relieve tension?........................................ 1. Yes 0. No
k i.4
4 - Was it to have a good time with your friends?..........................
5 - Was it to fit in with a group you like?...................................
6 - Was it to get away from your problems or troubles?..................
1. Yes
1. Yes
1. Yes
0. No
0. No
0. No
9 .Was it to help yourself fail asleep?....................................... 1. Yes 0. No
12 - Was it to help get rid of a hangover? ................................... 1. Yes 0. No
-
13 Was it to end a pregnancy? .............................................. 1. Yes 0. No
-
14 Was it to make sex better? ............................................... 1. Yes 0. No
sv5.7/5 -
15 Was it for any other rcason? (spec*:) ................................ 1. Yes 0. No
A.
B.
31
Page 16
The next few questions are about hard liquor. Hard liquor includes scotch, gin, vodka and
mixed drinks like rum and cokes, gin and tonics and screwdrivers.
I6A.
(CIRCLEONE ANSWER)
-
Have you EVER had a drink of hard liquor not just a sip or taste?
No...-0 - e$&Q27A
Yes...l
. ...................i_..i,...,...n./
. . ...... .;......;.....
.
.
i
L.. .. .... .. .. .
5//6/30
6B. About how old were you when you first drank a mixed drink or shot of hard liquor - not
just a sip or a taste?
Years Old
-
How many days have you drank a mixed drink or hard liquor not just a sip or taste.. .
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

SV6CO Days
6C. Ever in 1 2 3 4 5 6 7 8
your whole life?
6D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SVGEO Days Days Days Days Days Days
6E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 17
6G. On those days when you drank mixed drinks or hard liquor, about how many drinks did
SY660 you have?
Usual number of drinks per day on the days you drank in the past 30 days:
dH. How did you get any mixed drinks or hard liquor you drank during the last 30 days?
SpSfl1 1-Did you use what was in the house?..................................... 1. Yes 0. No

3
..................................................
5 -Did others give it to you? 1. Yes 0. No
6 -Did you trade goods for it? (trade something for it?) ................. 1. Yes 0. No
7 -Did you trade services for it? (do something for it?) .................. 1. Yes 0. No
9 - Did you get it by scam, fraud, or con?................................. 1. Yes 0. No
10-Did someone ebe buy it for you?......................................... 1. Yes 0. No
33
Page 18
61. During the past 12 months, when you
. . drank mixed drinks or hard liquor, what have been
YOU r?
Sp6z { 1 .Was it for fun, kicks, or excitement?..................................... 1. Yes 0. No

3 - Was it to feel good or get high?............................................ 1. Yes 0. No
-
tBb Was it to fit in with a group you like?................................... 1. Yes 0. No
-
7 Was it because of boredom, nothing else to do?....................... 1. Yes 0. No
-
8 Was it because of anger or frustration?.................................. 1. Yes 0. No
-
9 Was it to help yourself fall asleep? ....................................... 1. Yes 0. No
10 - Was it to help yourself stay awake? ..................................... 1. Yes 0. No
11 - Was it to help manage your weight? .................................... 1. Yes 0. No
13 - Was it to end a pregnancy? .............................................. 1. Yes 0. No
14 - Was it to makc sex better? ............................................... 1. Yes 0. No'
-
s v 6 ~ f s - 15 Was it for any other reason? (specify:) ................................ 1. Yes 0. No
A.
B.
7u
Page 19
The following questions are about other drugs.
I I
7A. Have you EVER used marijuana or hashish? Other names are grass, pot, hash, or
hash oil. (CIRCLE ONE ANSWER)
NO....0 - &tbQ,
SYjzAO Yes... 1
sv%3o
7B. About how old were you when you first used marijuana or hash, even once?
Years Old
How many days have you used marijuana or hash...

I Never I 1-2 I 3-5 I 6-11 I 12-24 loo- I200+
7C. Ever in
-I
I
our whole life?
1
7D. Duringthe
last 12 months?
5' 6
' I 8
SV.7AO
Never 1-2 3-5 6-9 10-14 15-20 21+

sI/3K) Days Days Days Days Days Days
7E. Duringthe 0 1 2 3 4
last 30 days?
3 5
Page 20
7F. How did you get any marijuana tbat you used during the last 30 days?
sd/?rFJ1-Did you use what was in the house?..................................... 1. Yes 0. No
L 3-Did you buy it from a dealer?.............................................. 1. Yes 0. No
-4
6 -Did you trade goods for it? (trade somettung for it?)................. 1. Yes 0. No
7 -Did you trade services for it? (do something for it?) .................. 1. Yes 0.No
.............................................................
8 -Did you steal it? 1. Yes 0. No
sy?~yo10-Did someone else buy it for you?......................................... 1. Yes 0. No
7G. During the past 12 months, when you used marijuana, what have been your m ~ s t
&
?
Sv f 6 1 1 -Was it for fun,kicks, or excitement? .....................................
1. Yes 0. No
-1 3 .was it to fie1 good or get high?............................................

4 .Was it to have a good time with your friends?..........................
1. Yes
1. Yes
0. No
0. No
5 .Was it to fit in with a group you li?................................... 1. Yes 0. No
9 .Was it to help yourself fatl asleep?....................................... 1. Yes 0. No
s v 36 7 5 15 .Was it for any other reason? (specify:) ................................ 1. Yes 0. No

A.
B.
?lo
Page 21
I I
8A. Have you EVER used Cocaine or Coke in any form, such as powder (or Snow),
NO....0 - h a O Q* M A
sr/8/0 Yes...l
q
SVB&O
8B. About how old were you the frrst time you used cocaine, in any form?
Years Old
-
How many days have you used any form of Cocaine powder wcaine, crack, fieebase or cocoa
paste.. .
Never 1-2 3-5 6-11 12-24 25-50 51-99 lOe. 200+

199
i!?w?co Days Days Days Days Days Days
Days
Days
8C. 1 2 3 4 5 6 7 8
Ever in YOU
whole Me?
8D. 0 1 2 3 4 5 6 7 8
Duringthe last
12 months?
Never 1-2 3-5 69 10-14 15-20 21+

. sv8EO Days Days Days Days Days Days
8E. 0 1 2 3 . 4 5 6
During the
30 days?
, last
37
Page 22
8F. How did you get any Cocaine that you used during the last 30 &p?
svgF{ 1-Did you use what was in the house? ..................................... 1. Yes 0. No
5 -Did others give it to you?..................................................
I
1. Yes 0. No
6 b i d you trade goods for it? (trade something for it?) ................. 1. Yes 0. No
g t / g p ~ ~10-Did someone else buy it for you?......................................... 1. Yes 0.No
8G. During the past 12 months, when you used Cocaine, what have been your
W?
s v.86 1 .Was it for fun, kicks, or excitement?..................................... 1. Yes 0. No
........................................
'f
2 .Was it to relax or relieve tension? 1. Yes 0. No

L 4 .Was it to have a good time with your friends?.......................... 1. Yes 0. No
5 .Was it to fit in with a group you l i i ? ................................... 1. Yes 0. No
7 .Was it because of boredom,nothing else to do? ....................... 1. Yes 0. No
8 .Was it bezause of anger or frustration?.................................. 1. Yes 0. No
.....................................
10 .Was it to help yourself stay awake? 1. Yes 0. No
s P 8 G A 5 15 .Was it for any other reason? (specify:) ................................ 1. Yes 0.No

A.
I
B.
Page 23
These questions are just about crack. Crack is cocaine in rock or chunk form.
I sV9Ao
Yes...l
NO....0 - Go $0 Qr 1DA
SYQk30
9B. About how old were you when you first used crack,even once?
Years Old
How many days have you used crack...

Never 1-2 3-5 6-11 12-24 25-50 51-99 1W 200+

SV9CO Days
9C. Ever in 1 2 3 4 5 6 7 a
your whole life?
9D. Duringthe 0 1 2 3 4 5 6 7 8
, last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SV9EO Days Days Days Days Days Days
9E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 24
9F. How did you get any crack that you used during the last 30 days?
s b g ~ 1-Did
i you use what was in the house? .................................... 1. Yes 0. No
3-Did you buy it from a dealer? ............................................. 1. Yes 0. No
5 -mpothers give it to you?.................................................. 1. Yes 0. No
6 -Did you trade goods for it? (trade something for it?)................. 1. Yes 0. No
7 -Did you trade services for it? (do somethg for it?).................. 1. Yes 0. No
9 - Did you get it by s w n , fraud, or con?................................. 1. Yes 0. No
SpgFyu 10-Didsomeone else buy it for you?......................................... 1. Yes 0. No
96. During the past l2 months, when you used crack, what have been your
W?
s~/,q6i1 .Was it for fun, kicks, or excitement?..................................... 1. Yes 0. No
. 2 .Was it to relax or relieve tension?........................................ 1. Yes 0. No
7 .Was it because of bredom, nothing else to do?....................... 1. Yes 0. No
10 .Was it to help yourself stay a&? ..................................... 1. Yes 0. No
.

sv36l5 15 .Was it for any other reason? (spec@:) ................................ 1. Yes 0. No
A.
B.
Page 25
I I
1OA. Have you EVER inhaled or sniffed any substance like glue, gasoline, paint or
markers to get high? (CIRCLEONE ANSWER)
NO....0 - Go to Q. 1IA
CL/ Y o A U Yts...l
jvroao
?a4
1OB. About how old were you when you first inhaled or sniffed a spray or liquid to get high,
even once?
Years Old
How many days have you inhaled or sniffed anything to get high...
3-5 6-11 12-24 25-50 51-99 loo- 200+
I Days Days Days Days Days Days 199

Days
Days
1OC. Ever in 1 2 3 4 5 6 7 8
your whole life?
1OD. Durrng the 0 1 2 3 4 5 6 7 8
last 12 months?
su 10EO
r.-.I
~ ~~
1-2
Davs ~~
1 I 1 I I I
3-5
Davs
6-9
Davs
10-14 15-20
Davs Davs
21+
Davs
10E. Duringthe 0 1 2 3 4 5 6
last 30 daw?
Page 26
I I
11A. Have you EVER used any psychedelic drugs or hallucinogens, like LSD, PCP,
angel dust, Ecstasy, or psychedelic mushrooms? (CIRCLE ONE ANSWER)
NO......................... 0-
Doesn't understand.. ...5 -
Yes........................ 1
'.a
sv w n o
11B. About how old were you when you frst used psychedelic drugs or hallucbogens, even .
once?
Years Old
How many days have you used psychedelic drugs or hallucinogens...

-~
NCV- 1-2 3-5 6-11 51-99

Days Days Days Days
SVHC0
11C. Ever in
your whole He?
1 2 3
~
4 6
7 1 8
11D. During the 0 1 2 3 4 6
iast 12 months? 7 1 g
su Ym-0
Never 1-2 3-5 6-9 10-14 15-20 21+

s v //c3 Days Days Days
4151"
Days Days Days
11E. During the 0 1 2 3
last 30 daw?
I
Page 27
12A. Have you EVER used Heroin? Other names for heroin are smack or dope.
(CIRCLE ONE ANSWER)
NO.........................0 -
Doesn't understand.....5 -
Sv72WO Yes........................ 1
+q
sv4,zII3 0
12B. About how old were you when you fmt used heroin, even once?
Years Old
How many days have you used heroin.. .

Never 1-2 3-5 6-11 12-24 25-50 51-99 100. 200+

Wfazco Days
12C. Ever in 1 2 3 4 5 6 7 8
your whole lite?
12D. During the 0 1 2 3 4 5 6 7 8
last 12 months? #
Never 1-2 3-5 69 10-14 15-20 21+

SVfAEO Days Days Days Days Days Days
12E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 28
Now we would like to ask you abut other drugs that doctors can prescribe but that you
may have used on your own to get high.
The next questions are about Barbiturates.
Barbmtes are sometimes prescribed by doctors to help people relax or get to sleep. They
I
are sometimes called downers, goofballs, yellows, red, blues, and rainbows.
132. Have you EVER used barbiturates without a doctor's prescription, or in a manner not
prescribed by a doctor? (CIRCLE ONE ANSWER)
NO .........................
0.
Doesn't understand..... 5 .
SV7'3AO Yes........................ 1
13B. About how old were you when you fust used barbiturates, even once?
Years Old
How many days have you used barbiturates...

#
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- ux)+

S W 3 GO Days
13C. Ever in . 1 2 3 4 5 6 7 8
your whole life? ~-
13D. During the 0 1 2 3 4 5 6 7 8

last 12 montbs?
Never 1-2 3-5 6-9 10-14 15-20 21+

SU1'3EO Days Days Days Days Days Days
13E.During the 0 1 2 3 4 5 6
last 30 daw?
Page 29
The next questions are about Tranquilizers.
Tranquilhemi are sometimes prescribed by doctors to calm people down, quiet their nerves, or
relax their muscles. Librium, Valium, Xanax, Halcion and Dalmane are all tranquilizers.
14A. Have you EVER used any kind of tranquilizers without a doctor's prescription or
in a manner not prescribed by a doctor? (CIRCLE ONE ANSWER)
NO......................... 0-
Doesn't understand.. ...5 .
Yes........................ 1
Sv%M43
14B. About how old were you when you first used tranquilizers, even once?
Years Old
How many days have you used tranquilizers...

Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

SVMCO Days
14C Ever in 1 2 3 4 5 6 7 8
your whole We?
14D.During the 0 1 2 3 4 5 6 7 8
iast 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SVf40
. Days Days Days Days Days Days
14E.During the 0 1 2 3 4 5 6
last 30 davs?
Page 30
The next questions are about Amphetamines.
Amphetamines have been prescribed by doctors to help people lose weight or to give people
more energy. They are sometimes called uppers, UPS, speed, bennies, dexies, pep pills, and diet
pius. Amphetamines do NOT include any non-prescription drugs, such as over-the-counter diet
I
pills (like Dexatrim) or stay-awake pills (libNo-Doz), or any mail-order drugs.
154 Have you EVER used any kind of amphetamines without a doctor's prescription
or in a manner not prescribed by a doctor? (CIRCLE ONE ANSWER)
NO......................... 0-
Doesn't understand.. . .5 - .
S P /5&0 Yes........................ 1
svy5 B O
15B. About how old were you when you first used amphetamines, even once?
Years Old
How many days have you used amphetamincs...

Never 1-2 3-5 6-11 12-24

SPITGO Dars Days Days Days
15C. Ever in
our whole life?
1 2
314
15D. During the
last l2 m o d s ?
0 1 2
314
sv 95-m
Never. 1-2 3-5 6-9 10-14 15-20 21+

1E. Duringthe 0 1 2 3 4 5 6
Page 31
The next questions are about Steroids.
16A. Have you EVER used any kind of steroids without a doctor's prescription or in a
manner not prescribed by a doctor? (CIRCLEONE ANSWER)
NO......................... 0.
Doesn't understand.. ...5 .
SvY6 4 0 Yes........................ 1
SvV6 5 0
16B. About how old were you when you used steroids, even once?
Years Old
How many days have you used steroids...

NCVW 1-2 35 6-11 12-24 25-50 51-99 100- 200+

m-/sco Days
16C. Ever in 1 2 3 4 5 6 7 8
your whole life?
16D. During the 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SVf6.EO Days Days Days Days Days Days
16E. Duringthe 0 1 2 3 4 5 6
1 s t 30 dam?
43
Page 32
-
17A. Have you ever injected my drug through your skin or into a vein without a doctors
pracription or in a manner not prescribed by a doctor?
(CIRCLEONE ANSWER)
NO......................... 0-
Doesnt understand... .5 - .
SPGh6 Yes ........................ 1
17A. 1 About how old were you when you first injected a drug, even once?
.SV-GAd Years Old
17A.2 Please tell me the namts of the drug(s) that you have injected.
1.
2.
3.
178. How many times have you EVER injected a drug through your skin M into a vein?
1-2 tima ...................... 1

3-5 times ...................... 2
6-9 times. .................... 3
10-19 times ................... 4
20-39times ................... 5
40-99 times ................... 6
IO0 or more tims ........... 7
sv W C D
17C. In the past 12 months, how m y times have you injected a drug through your skin or
into a vein?
otimcs ...............:........ 0
1-2 times ...................... 1
,3-5 times...................... 2
6-9 times...................... 3
10-19 times.... ............... 4
20-39times................... 5
40-99 times................... 6
100 or more times........... 7
Page 33
Annver the foUowing question yourself and fol& the imttuctions provided:
Has the respondent reponed ANYsubstance use?

NO ->
Yes ->
i>@
the questions on the next few pages refer to the past 12 months. That is, since...
I Refer to first month on the time line. I

18. During the past 12 months, have you had a period of a month or more when you
any of the following drugs or alcohol, -
, or g&g
mer their?
(CIRCLEYES or NO FOR 18aa - 180
sv , q0
~ aa. cigarettes........................ 1. Yes 0.No
SVAfflO
............................
a. alcohol 1. Yes 0. No
;r8 bo b. marijuana (or hashish) ......... 1. Yes 0. No
su18 c.cQcaine........................... 1.Yes 0. No -
sv BO d. "naCk"........................... 1. Yes 0. No
S v / & 0 e. inhalants (such as glue) ........ 1. Yes 0. No
sv/8 f 0 f. other drugs ...................... 1. Yes 0.No
19. During the past 12 months, have you used any of the following drugs or alcohol
l?
(CIRCLEYES or NO FOR 19aa - 1%)
SV.irQt9AO aa. cigarettes........................ 1. Yes 0. No

Sv5f9AO a. alcohol............................ 1. Yes 0. No
SV?%%?JO b. marijuana (or hashish)......... 1. Yes 0.No .
sv.5/!?co c. cocaint........................... 1. Yes 0. No
&V-SrYJJO d. "crack" ........................... 1. Yes 0. No
SV+/sO e. inhalants (such as glue)........ 1. Yes 0. No
sv&u=o f. other drugs...................... 1. Yes 0. No
I
Page 34
20. During the past 12 months,have you experienced tolerance for alcohol or any of the
foliowing drugs, so that using t h e h?
(CRCLE YES or NO FOR 2Oaa 2Of) -

I
s p ~ ~ ~ ~........................
aa. cigarettes o 1. Yes 0. No
svaB0 a. alcohol ............................ 1. Yes 0. No
S
?
- V -A 7-A-D
b. marijuana (or hashish) ......... 1. Yes 0. No
SViWCO
c. uxaine .......................... i. 1. Yes 0. No
suA&o;ao d. "crack............................ 1. Yes 0. No
e. inhalants (such as glue)........
- -
SV*z/c,ZO 1. Yes 0. No
s v m ~ of. other drugs...................... 1. Yes 0. No
21. Wi
n g the past 12. months,
. . have you often or
f (such as riding a
bike or drivii a car, using heavy machincry, or swimming)?
(CIRCLE YES or NO FOR 21aa 210 -

aa. cigarettes........................ 1. Yes 0. Ng
SVA/BAO
a. alcohol............................ 1. Ye 0, No
-
SYdZA40
JU&%O
b. marijuana (or hashish)......... 1. Yes 0.No *
Sv&/CO c. cocaine........................... 1. Yes 0. No

SVdzl/BO d. "crack"............................ 1. Yes . 0. No
g u& e. inhalants (such as glue)........ 1. Yes 0. No
gp&ff=o f. other drugs...................... 1. Yes 0. No
22. During the psst 12 months, did your use of alcohol or a drug Cause you to have
?-
spAg&.o ........................
aa. cigarettes 1. Yes 0. No
s v ~ g . ~ ~ ............................
a. alcohol 1. Yes 0. No
S A h 0 b. marijuana (or hashish)......... 1. Ycs 0. No
S v R R C O c. cocaine........................... 1. yes 0. No
sunLBO d. "crack"........................... 1. Yes 0. No
SU;eAEO e. inhalants (such as glue)........ 1. Yes 0. No
- -
S A A F O f. other drugs....... .............. I. yes 0. No
C n
Page 35
23. 24.
During the past 12 months,have you During the past 12 months,were you
!amxi to cut down or stop using any able to stop your use of this every time
of the following drugs or alcohol? you wanted to?
(CIRCLEYES or NO FOR 23aa - 230 (CIRCLEYES or NO FOR 24aa - 240
S P A 3 AAO S V ~ 4 t r f0
f
aa. cigarettes.................. 1. Yes: aa. cigarettes................ 1. Yes
0. No 0. No
SVA3AO SPA3A0
a. afcohol...................... Y&: a. alcohol....................
.i
1. 1. Yes
0. No 0. No
svx 3/3 0 JL(Pe4/30
b. marijuana (or hashish).... 1. Yes: b. marijuana (or hashish). 1. Yes
0. No 0. No
SVR3CO wiz4cL3
c. cocaine. ..................... 1. Yes: c. cocaine................... 1. Yes
0. No 0. No
. $&&a
svR 3 BQ SVA430
d. "crack" ...................... yts.
:..'
,.:.......;.....;.;.....5......:::...:.......5 d. "crack".................. 1. Yes
0. No 0. No
svd-3 0 sv~4EO
e. (a& glue). .. 1 Ye. iw*q .7,..w<,..,,!/,..,A:*
..............
...........1.......Y .......... e. inhalam 1. Yes
0. No
,,A,*
SPA! 3 F O
f. other drugs ..................ycs.g&*
. ...~ .... ..... %.&& g f. other drugs.............. 1. Yes
No
"
0. 0. No
-
Page 36
-
Section 11: Perceptions of Drug Risk
These questions am about how much YOU think people might hurt themselves when they smoke
cigarettes, drink alcohol, or use drugs.
On each one, I want you to think about how much a pemon might hurt themselves if they do Merent
things -Doyouthink thak they ' hurtthemselves,
' hurtthemselves,
they lammbum
$
,' they -
hurt themselves, or
they hurt themselves?
1. How much do you think a person would hurt themselves if they smoke one or more packs of cigarettes
each day? Do you think that they definitely won't hurt themselves, they probably won't hurt themselves,
they probably wiU hurt themselves, or they definitely will hurt themselves?
1 2 3 4
S V A i kfi*lY probably probably d e f ~ t cyl
won't won't Will Will
2. How much do you think a person would hurt themselves if they try marijuana once or twice? Do you
think that they definitely won't hurt themscives, they probably won't hurt themselves, they probably will hurt
themselves, or &cy defrnitcly will hurt thermrehtes?
1 2 3 4
definitely PdablY Probably def~tely
won't won't will Will
3. How about if they smoke marijuana every now and then? Would you say they...(mad choices)
2 3 4
probably probably definitely
won't Will Will
4. How about if they smoke marijuana regularly (pretty @en)? Would you say they ...(read choices)
1 2 3 4
deftnitely probably probably definitely
SPA4 won't won't Will Will
52
Page 37
5 . How much do you think a person would hurt themselves if they try Wants once or twice? Do you think
1 2 3 4
s
y A5 definitely probably probably definitely
won't won't Will WiU
6. Hoq about if they use inhalants regularly @rm@en)? Would you say they ...(read &ices)
1 2 3 4
definitely probably probably definiitely
W A6 won't won't will Will
7. How much do you think a person would hurt themselves if they try heroin once or twice? Do you think
themselves, or they defditely will hurt themselves?
1 2 3 4
sI/A3 defrnitely
won't
probably
won't
probably
Will
defeitely
Will
8. How about if they use heroin regularly @my @en)? Would you say they.. .(red choices)
1 2 3 4
definitely
svr9 e? won't
Probably
won't
probably
will
def~tcly
will
9. How much do you think a person would hurt themselves if they try Cocaine once or twice? Do you think
that they def~itelywon't hurt themselves, they probably won't hurt themselves, they probably will hurt
1 2 3 4
SW 7 definitely
won't
probably
won't .
probably
will
definitely
Will
10. How about if they use powder cocaine every now and then? Would you say they ...(read
choices)
1 2 3 4
$vAtO won't won't Will Will
53
Page 38
1 1. How about if they use powder Cocaiae regularly @ r q often)? Would you say they.. .(read choices)
1 2 3 4
def~tely probably probably def~tely
SV&;r# won't won't Will Will
12. How much do you think a person would hurt themselves if they try crack once or twice? Do you think
that theyhefiniteiy won't hurt themselves, they probably won't hurt themselves, they probably will hurt
themselves, or they definitely will hurt themselves? .
1 2 3 4
V A m dtftnitely probably probably defdtely
13. How about if they use "crack" cocaine every now and then? Would you say they...(red choices)
1 2 3 4
defrntely probably probably def~tely
14. Use "crack"wcaine regularly (pretty @en)? Would you say they...(rcad choices)
1 2 3 4
ShWq definitely Probably probably defdtely
won't won't will
1.
Will
15. How much do you think a person would hurt themselves if they use steroids every now and then? Do
, probably won't hurt themselves, they probably will
you think that they definitely won't hurt t h c ~ l v c sthey
hurt themselves, or they d e f ~ t e l ywill hurt themselves?
1 2 3 4
t A9?5 definitely Probably probably definitely
. 16. How about if they use steroids regularly @rerfy@a)?Would you say they.. .(re& chokes)
1 2 3 4
Page 39
- eer. -w
17. How much do you think a person would hurt themselves if they have one or two drinks of alcohol nearly
every day? Do you think that they definitely won't hurt themselves, they probably won't hurt themselves,
2 3 4
probably probably definitely
won't Will Will
18. Hok about if they have four or fwe drinks of alcohol n~arlyeveryday? Would you say they...(read
choices)
1 2 3 4 .
SF/ id' won't won't Will Will
.
19. How about if they have fne or more drinks of alcohol twice a week? Would you say they.. ( r e d
choices)
I 2 3 4
defhiitely probably probably definitely
S I / A ~won't~ won't WiU Will
Now I am going to ask you some questions about how easy or hard it would be for you to get alcohol or
drugs if you wanted to. For each one, I want you to decide if it would be very easy to get, pretty easy
to get, very hard to get, or probably impossible to get.
SVh &OAO
20A. How easy or hard would it bc for you to get c i g a r e ~ ?Would it be probably impossible to get, very
hard to get, pretty easy to get, or very easy to get?
1 2
Probably very
Impossible Hard
20. How about beer, wine, or liquor? Would it be...( r e d dzoices)
1 2
SVAU Probably very
Impossible Hard
2 1. How about Marijuana? Would.it be.. .(red choices)
1 2 3 4
Probably very pretty very
Impossible Hard b Y b Y
3
Page 40
,
22. How about LSD? Would it be...(read choices) 5-VHRL
1 2
Probably very
Impossible Hard
23. How about PCP? Would it be...(reud chiccs) SYAL3

1 .t 2
Probably very .
Impossible . Hard
24. How about Cocaine or crack? Would it be...( read choiccs) S PA a 4

1 2
Probably very
Impossible Hd
25. How about Heroin? Would it be...(rcod choices) S V A - 2 5-
1 2 3 4
Probably very pretty very
Impossible Hard Easy Fssv
26. in the past month,bas someone tried to sell you drugs? Yes 1
No 0
9v4z 6
WRAT: READING
CAUTl(31Ci:'EXAMINER USE ONLY!
t
OABOSE R T H U P - I V Z J Q r z
see red - milk was

see
-1 - - -
then ti! jar -. letter .; city

rtien jahr Iet-'Cr sit-ee
-_.__- -. . -. ~ -. ____
i .between i cliff 1 stalk .: grunt
: bi-tween k l i-
f - __ stawk grunt
, . . . ___ .. . . ... . __ . __ __ -
. --__ ____
j ': huge plot : sour humidity
-
hyoclj
.- - - -- .--
plot
- -. __ -
. . -. ... -
sowr
__ .- . -. - .-
hyoo-mid-i-tee
. -____
I1
,
,- clarify residence urge 1,: rancid

kl LIr -:-
E rez-i-dCns
-. .
.. - -. -. .. .. _-
urj
-_ __
__
ran-sid
!. -_. conspiracy -. -- deny 2:. quarantine 22. deteriorate

i
4
k6n -spir-1-
see
-
di-nT - - .-. - -kwor-Hn-teen ~ di-teer-i-z-rayt
rudlmentary mosaic 7-
-. rescinded
f --
-.
roo-di-men-[e-ree moh-z3 Y-i k ri-sind-ed
1 :;mitosis
1
3 :protuberance 21 longevity 21 predilection
mTtoh-sis roh-too-b&rhs Ion-jev- I-tcc prcd-l-lek-sh&
-i
- -. - _- __-_-_--
\;-. regime :.. b?atify z j internecine 25 regicidal

rS-:h eem bi - t -:
ti-- in-Gr-nee-seen, -nes-een - 1- sT& I
rej
i--.-----
I '
- . __ - - -_____ -_
/I-puerile ;,factitious 32 lucubration Letter Reading
pyoo-;-r;i fa k -iish-us loo-kyuu-bray-shGn
-- -- -- . -__ _.
._- __
I
II;epithalamion ' inefji caci ou s 22 synecdoche Word Reading +

in - e I-i- kn y- s h;s si-nek-dz-kre
I ep-i-thZ-lay-mi-&
Total
1
1
5/10RULES Reading
OBSERVATlONSlREMARKS:
-
b
c - ,
Photocopying of fhis test IS a violation of copyrighf law.
50 \N$ WIDE RANGE

1 5 Asnley Place. Subre 1 A Wilrnington. DE 19804.13 14
HEALTH SCREEN
HEALTH SCREEN: S
Subject ID: sm/w

Interviewer ID:
HL?7c/R#/;b
Now I have some questions about your h d t h .
1. Would you say that in general your health is excellent, very good, good, f&, or poor?
1. excellent
2. verygood
3. good
4. fhir
5. poor
2. Now thinkhg about your physical health, including being sick or injured, for how many
.
days during the past 30 days was your physical health not good?
number of days
3. Now &inking about your mental health, which includes stress, depression, and problems
with emotions,for how m y days during the past 30 days was your mental health not
good?
number of days
ed. init. ed. date

you from doing your usual activities, such as self-care, work, or recreation (play)?
number of days
END OFINTERVIEW
RECORD TIME:
Y
PUBERTAL DEVELOPMENT
63
Pubertal Development Scale
Intemiew ID:
Pas te# /r
L
FIELD COPY 2
Now, Im going to ask you some questions about physical development.
1 Would you say that your growth in height has not yet begun to spurt, has barely
started, is definitely underway, or does growth seem completed? (if asked, spurt =
more growth than usual)
1 2 3 4
No yes (Barely) Yes (Defitdy) Development Completed
2. And how about the growth of body hair? Would you say that your body hair has not
Pa ;z yet started growing,bas barely started growing,or d m growth seem completed? (if
asked, body hair = underarm or pubic hair)
1 2 3 4
No yes (Barely) Yes (Definitely) Development Completed
Adapted from Pubertal Development Scale: Petersen, Crockett, Richards, & Boxer (1988).
A self-report measure of pubertal status: Reliability, validity and initial norms.
m,
m, 117-133.
65
3. Have you noticed any skin changes, especially pimples?
1 2 3
No Yes (Barely) Yes (Definitely)
POYS OdYJ
4. Have you noticed a deepening of your voice?
1 2 3 4
No Yes (Barely) Yes (Defintely) Development Completed
%
[BOYS only1
5. Have you begun to grow hair on your face?
1 2 3 4
[Girls only]
6. Have your breasts begun to grow?
1 2 3 4
[Girls only]
7. Havc you begun to menstruate (get your period)?
1 2 3
No yes (Barely) Yes (Definitely)
jm?&D/y PBt-;40Y
7a. What was the date of your first period: - , -
month year
7al. If you don't know the date, how old were you? AGE, &NR
age
8. How tall are you?

feet inches
9. How much do you weigh? pounds
10. Do you think your development is earlier or later than most other boydgirls your age?
1. much earlier
2. somewhat earlier
3. aboutthesame
4. somewhat later
5. much later
END OFINTERVIEW
RECORD TIME
i

Date:
mm dd yy
Subject ID:
Interviewer ID:
FIELD COPY 2
I'm going to ask you some questions about Violence and how it m a y have affected you or
1. Are you afraid you might be hurt by violence in your neighborhood?
1.- YES 2-. NO
2. Are you afraid you might be hurt your apartment build- or house?
1
-. YES 2. NO
3. Are you afraid you might be hurt in your apartment building or house? I
1
-. YES 2. wo
4. Are you afraid you might be hurt by violence at school or work?
dinit. &.date
31
1.- YES 2. NO
1 .- YES 2 . , M O
1 .- YES 2.,-NO
1-* YES 2. WO
1 .- YES 2. NO
9. At what age do you think a child is affecttd by observing violence? (circle one)
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
3
The quesiions I'll be asking you now have to do with acts of violence that you may have
Have you ever seen or been present when somebody was shoved, kicked or punched?
E & -/o 10.
1. YES
2. NO
1. Withinlastweek
3. Withinlastyear
1. In your home
3. In front of your housebuilding
4. Inyourneighborhood
6. At your schwYday care
7. Inoroutsidcbar
25. other(specify)
13. Did you know the person or people who this happened to?
E A 5/3
1. YES
2. NO
3.3
4
E fi ~3~ 0 13A. Who was it? (MARKAIL THAT APPLY)
1. Parent
2.- 88888
3. Friend
4.Neighbor
5. Sibling
25. Other (Specify)
'.a
14. How badly was 'the person or people injured?
E43 f 4 (MARK THAT APPLY)
l . , N o injury
2. Knockcddown
3. Bruised
4. Cut/blteding
5. Unconscious
6. Bmkcnboncs/fracane
7 . , M e d i c a l carc obtained
-8. other
E45 f5
1. YES
2. NO
15A. Who was it? (MARK ALL "HAT APPLY)

1. Parent
88888
2
-.
3.-Fricnd
4. Neighbor
5. Sibling
6. Other Relative (Specm)
25. Other(Spec@)
1. YES
2. NO
f640 16A. How many times have you seen this in the past year?
EA5 f 6 /30 16B. How many times have you ever seen this?
at
Have you ever seen or been present when someone was attacked with a knife?
I
E fi ~7 17.
. 1. YES
2. NO
18. When was the last t h e you saw that?
1. Withinlastweek
2. Withinlastmonth
3. Withinlastyear
1. Inyourhome
3. In front of your house/building
In your neighborhood
,
4.
6. At your schooYday a r e
25. Other(spec8y)
35
6
EL3 At9 20. Did you know the person or people who this happened to?
1.YES
2. NO
20A. W h o was it? (MARK ALL THAT APPLY)
1. Parent
2-. *****
3. Friend
4. Neighbor
5.- Sibling
= . - r (Specify)

(MARK ALLTHAT APPLY)
l . , N oi n .
2 . . , I down
3. Bruised
4. cut/bleeding
5. Uncopscious
6 . , B r o k e n boneS/fracture
7. Medicareobtained
-8. other
E n ;zL 22. Didthey die?
1.- YES 2 . , N O 8. Don't Know
E13 n3
1. YES
2. NO
7
E 3 40 . 23A. Who was it? (MARK THAT APPLY)

1. Parent
2.- *****
3. Friend
4. Neighbor
5. Sibling
25. Other (Specify)
6 w 24. Have you seen this more than once?
1. YES
2. NO
E/$Z&AO 24A. How many h e s have you seen this in the past year?
24B. How many times have you ever seen this?

JEnz5-
1. YES
2. NO-
E & ~6 26: When was the last time you h a d that?
1. Withinlastweek
2. Withinlastmonth
3. Withinlastyear
8
F A 2? 27. Where did that happen?
1. In your home
3. In front of your busehuilding
25. Other(specify)
28. Have you heard a gun shot more than once?
1. YES
2. NO
2% R8.4-0 28A. How m y times have you heard this in the past ycar?
28B. How many times have you ever heard this?
29. Haveyou ever sea or been present when somcone was shot?
E&29
1. YES
-2. NO
I ENDOFINTERVIEW I
I RECORD TIME. I
9
,E a 3 D 30. m e n was the last t i e you saw that?

1. Withialastwtek
3. Witblastyear
3 1. Where did that happen?
1. In your home
2. . In your hallway or building
3. In front of your houschuilding
6. At your schoollday care
25. Other (specify)
32. Did you know the person or people who got shot?
1. YES
2. NO
F/332#5 32A. Who was it? (MARK THAT APPLY)

1.- Parcnt
2-. *****
3. Friend
4.,Neighbor
5. Sibling
25.- Other (Specify)
74
10
E/3 3 3 33. Did they die?
1.- YES 2 . . N O 8.,-Don't Know
33 39 34. Did you know the person or people who did this?
1. YES
2. NO
34A. -Whowas it? (MARK BLL .THAT APPLY)
1. Parent
2-. *****
3. F r i e n d
4. Neighbor
5..Siblii
25. Other(Specify)

E / 4 35-
1. YES
2. NO
35A. How m y times have you seen this in the past year?
35B. How many times bave you ever seen this?
ENDOFINTERVIEW
RECORD TIME
Date: S R O W 7 -
mm dd yy
Subject ID: $&&/E
of the study, I told you about the special protedion to ensure your privacy? The Federal
school, to see or f h d out what your answers are in this study. No one except our
your parents, or anyone else.
I am going to describe some things that people do. Flrst, tell me if you have fper done
any of these things. Them I will ask how many times you have done the thing during the
~ ~~
ed. init. ed. date
533
1
SRO
SECTION I.
SR d G 0
1A. Run away from home and stayed away 1C. How old were you
-
overnight? you did this?
1. Yes- Age
0. NO-
SR /.BO
s;e fa o 1D. W h c n w a* s youdid
~
V?
month year
x of tima

YE* 1. alone
2. with others
SR ;/FO
this?
1. Yes
0. No
2
SRO
2 Are you still in grade schoolhigh

school?
1. Yes-AskltA
0. N O -
SR &A3
you did this?

..... .....
2A4. When was last & YOU
were absent from school without
an excuse?
2A2. How many times have you done this JR r ~ 4m --
a sa~4y
month year
?-
# of times
J0e ozh3
Jy=uw=: 2B3. How old were you
2B1. Absent from gradernigh school without you did this?
an excuse?
Age
1. Yes-
0. N O - SKOzA4
2B4. Whenwas- you
were absent from grade/high
2B2. HOWmany times in your W school without an excuse?
did you do this? S R ~ 4 3 W f sflz&qY
month year
# of times
3
SRO
sde 3CD
3A. Carried a hidden weapon? 3C. How old were you
a you did this?
1. Yes-
0. NO-
. . . . .. ...
-
Age
S& 3 A 0 CPR 3m
3B. How many times have you done this 3D. Whenwas- YOU
V? canid a hidden weapon?
# of times
4
SRO
4A. Caused trouble in a public place so that

people complained about it, such as J z +GO
being loud or disorderly? 4C. How old were you
you did this?
1. Yes - fhntQ-4B
0. NO - GO to Q . 3 4

?-
# of tima
4E. ' Did the police talk to you about

this?
1. Yes
0. No
4%450
I
5
SRO
5A. Purposely damaged or destroyed J.2560

to you? (for example; bredung, dutting you did this?
1. Yes-
0. NO-

?- month year
# Of times
5E. Wcre you done or with others?
1. alone
2. with others
SR 5 E O
this?
1. Yes
0. No
5f 0
6
SRO
e vou
SR6Co
car, or vacant lot?. you did this?
1. Yes-
0. NO-

V?
# of tima

1. alone
2. with others
6&-6EO
this?
1. Yes
0. No
7
SRO
past;
SR3CO
7A. Enteral or broke into a building to steal 7C. How old were you
something? you did this?
1. Yes-
0. NO-
7D.
78. HOWmany times have you done.this
V?
# Of times
E. Were you alone or with others?

1. done
2. with others
6-zF'EQ
this?
1. Yes
0. No
JR FFO
SR8CO
8A. Stolen something from a store? you did this?
1. Yes-
0. NO-

SR 8/30 V?
# of tima

items you stole?
$-,---*--
S&$ED
1. alone
2. with others
&&8F0
guards talk to you about this?
1. Yes
s&c!?SO 0. No
41
9
SRO
SR 940 SR QCO
you from any member of your
.
you did this?
household?
Age
1. Ye-
0. NO- S.Z9)3D
9D. Whenwas- . you did
SK9Ao this?
?-
-
Sk9;b/4r -
se9ay
month year
# of times
Sfi 9 E O
9E. Were you alok or with others?
1. done
2. with others
2 % 9FO
this?
1. Yes
0. No
10
SRO
SA YO
10. Have you ever had a job? easf;
P
ie /oca
1OC. How old were you
you did this?
Age
HaYumw=: SR / O B 0
SR 3foIQo 10D. Whenwas- you dik
1OA. Taken something that did not belong to this?
you from your place of work or your SRjOlSM sRfloa9
employer? month year
1. Yes-
0. NO- JS
R +OO
S& ;/OB0
10B. How many h e s have you done this 1. alone
V? 2. with others
SA?mf.0
1OF. Did your supcrvlsor frnd out
# of times about this?
Sk joso
1OG. Did he/she call the
police?
1. Yes
0. No
i
s3
11
SRO
past;
e vou ever;
SA M&D SA?+ K O
91 1A. Snatched someone's purse or wallet or 1IC. How old were you
picked someone's podktt? you did this?
1. Yes-
0. NO-
S& +%30
?-
# Oftimes
SR //EO
1. alone
2. with others
sle 7Ym
this?
. 1. Yes
0. No
12
SRO
&-
b e 7%40 S& /AGO
you from a cat? . you did this?
1. Yes-
-
Age
0. NO-
&57%230
?-
SR /&O
1. alone
2. with others
SR i4FD
this?
1. Yes
0. No
13
SRO
&R Y3RO SR /3m

you did this?
1. Yes-
0. NO-
JA?Y 3 f i O SR f3Bi
13B. How many times have you done this 13D. WhenwasfkhUmc
- ywdii
m? this?
si13mSRi3W
month year
# of times
SR /34=L3
1. alone
2. with others
SR 1 3 F D
this?
1. Yes
0. No
14
SRO
vou
S' M f l O .W W C O
sell? you did this?
1. Yes-
0. NO-
SE W A O
?-
# of times
S& 4 9 F O
1. alone
2. with others
J& 7vm
14F. Did the police t a k to you about
this?
1. Yes
0. No
15
SRO
JR Y 5 A O $4 Y5CO
something? you did this?
-
1. Yes- Age
0. NO-
SE-Y 5 A O
?-
#of times
4-w /5FO
1%. Did the police talk to you about
this?
1. Yes
0. No
16
SRO
S'R 9 6 A O SR 46CO
16A. Used credit or bank cards without the 16C. How old were you
owner's permission? did this?
1. Yes -
0. N O -
SR /6&0
?-
month year
# of times
g ,16EO
16E. Did the police mlk you about
this?
1. Ycs
0. No
44
i
17
SRO
You
..
Sie ;rMO SR /7CO

17A. Sold marijuana or pot? 17C. How old were you
you did this?
1. Yes-
. 0. NO-
S%? /?A0
178. How many tima have you do= this
?-
# of times
sg f 3 E O
17E. Wen you alone or with others?
1. alone '
2. with others
J6e /?fO
Did the police talk to you about
this?
1. Yes
0. No
18
SRO
SR Y4AO %2 /&CO
18A. Sold cocaine or crack? 18C. How old were you
you did this?
1. Yes -
0. NO-
$& r;4/30
18B. How many time have you done this
# of times
SR A P E 0
1. alone
2. withothers
SR f & F O
this?
1. Yes
0. No
19
SRO
pasf;
ever;
SR Y 9 4 0
19k Sold heroin? G Z mco
1. Yes- you did this?
0. NO-
J.23/Y&O
19B. How many times have you done this in
# of times
&d? /90
19E. Were you done or with others?
1. alone
2. with others
S R f9FO
this?
1. Yes
0. No
20
SRO
SR U C D
S&
20A. Hit someone
go 40
with
you did this?
1. Yes-
0. NO-
JemAD
V?
SR PZDEO
# of times 20E. Who did you hit?
3. father 4. child
5. parmer 6. roommate
7. other (specify):
a. Jk? &OED&
b. s/e R O O A
C. S& K-0 r z

doctor?
1. yes J&;eOFU
0. No
2OG. Did the police talk to you about

this?
S R A49 60
1. Yes
0. No
21
SRO
SR d M 0 21C. How old were you the fmt time

21A. Hit someone you did this?
with the idea of hwting them?
S R oe K O
1. Yes-
0. NO- 21D. Whenwas- * youhit
S&d460 them?
V? $&tdAQ --
sR#tlrb&
month year
AY
f did you hit? SROe/O

# of times 21E. who
-O
(CIRCLEALL THAT APPLY)
3. father 4. child
5. partner 6. roommate
7. friead 8. neighbor
9. acquaintanct
10. gang member 11.stranger
12. other (spec* :
a B
SA.? 44508
b. S R a f EDA
C. SR Lf EOC

doctor? gKoeff0
1. Yes
0. No
this? SRdZ5/&0
1. Yes
0. No
22
SRO
that vou

you did this?
22A. Attacked someone with a weapon?
1. Yes-
0. NO-

V? . .
# of times
%Eeg%%c? Skarf
3. father 4. child
9. acquaintance
12. other (spec@):
a. 6202 E Y O H
b. LIZ ozz E Y D R
c. SRdR#OG

1. alone
2. with others
sk?doe 0
1. Yes
0. No
SR RIZFO
this?
1. Yes
23
SRO
S&43CO
23A. Used a weapon or force to get money or 23C. How old were you
things from people? you did this?
1. Yes-
-
Age
0. NO- SA A 3 B O
62380
*
SR this?
?-
--
S&R3AW
month year
SR0C3Aw
# of times SR&3&0
1. school
2. playground
3. street
4. buSncss
5. bar
6. car
7. other
1. alone
2. with others
S R &3 777
this?
1. Yes
0. No
SR 23 GO
24
SRO
SR&WO s& 44CO

24A. Thrown objects, such as rocks or bottles, 24C. How old were you
at people (other than events you have you did this?
already mentioned)?
1. Yes-
0. NO- SR A4BO
SR AW30 this?
24B. How many times have you done this a&Gik& w4m
?- month year
# of times
S.240
1. alone
2. with others
SR PZ4FO
this?
1. Yes
0. No
a
25
SRO
~~ ~
~Zd54L) S R .ZFco
someone was hurt or threatened with you did this?
harm?
1. Yes-
0. NO-
SR 25/30
V?
# of times
1. Yes
0. No
SRR5r-O
25F. Was anyonc hurt seriously
1. Yes
0. No
26
SRO
You have had or

have
SR26CO
e vou ever; 26C. How old were you
&RdZ-6&0 you did this?
with someone agiimt their will? Age
SRR6Rd
1. Yes - 26D. Whenwas- you did
0. NO- this?
--
sU62w
S&62J~
SR a6no month year
?- 26E. Were you alone or with others?
SR26EO 1.
2. with others
# of times
this?

1. Yes
%!2660 0. No
or same sex?
1. same sex
AGJ 0. opposite sex

@ Z6ZO 1. Yes
0. No
-
27
SRO
SR 2 x 0
SR 2 7 # 0 27C. How old were you
27A. Been paid by someone for having sexual you did this?
relations with them?
1. Yes-
0. NO-
S&0'?2
V?
# of times
SR 230
this?
1. Yes
0. No
28
SRO
Sk?ZS#O
28A. Used a false name or alias to try to SRIzd%O
obtain something you were not entitled 28C. How old were you
to, such as a job or bank loan? you did this?
1. Yes-
0. N O -
$6 a8A-a
SRR8AO this?
12 months?
--
SUoG82lW SRIc&*p
month year
# of times
SR&BEO
1. Yes
0. No
29
SRO
S4eoeQAO SR R9CO
29A. Given false information (other than a 29C. How old were you
false name) on an application for a job, you did this?
a tax form, or an application for a loan -
or bank account? Age
1. Yes- se029m
0. NO- 29D. Whenwas- you did
this?
S& oz9A 0 SRA9BW-a&=
-
29B. How many times have you done this month year
?-
# of times L9EO
29E. Did the police or a govenunent
1. Yes
0. No
30
SRO
,$Z 3080
30A. Obtained welfare benefits or SR 30co
unemployment checks that you were not 3OC. How old were you
entitled to? you did this?
-
1. Yes- Age
0. NO-
S R 3 0 h
S'30AO 30D. Whenwas- you did
7 7
month year
# of times
JE 30EO
agent talk to you about this'?
1. Yes
0. NO
a
31
SRO
31A. Been given a ticket for a driving SR 3 f C D

offense? 31C. How old were you
you did this?
1. Yes-
0. NO-
-
Age
SR37%0
3 1B. How many times has this happened in
?-
# of times:
CY4
31E. Have you had your driver's
2?" 35//330
31B1. Did any of these driving offenses involve 1. Yes
alcohol? 0. No
1. Yes
0. No
32
SRO
ste3sm SR32 co
32A. Driven a motor vehicle when you did not 32C. How old were you
have a driver's license or after your you did this?
driver's license had been suspended?
SR 32 2.0
SR3LAO 32D. Whenwas- . you did
?- --
% 9 3 U &S;eSbsI
month year
# of times
SR 32 0
this?
1. Yes
0. No
1 1

column.
If all initial questions = no. Go TO Q. 33 I
I IS
I
33 !
SRO I
!
I
SECTION II
$g 33 33. How old were you the first time b your whole life that you were in trouble with the
police: (Circle Never or record age)
to.Q?S
:j .........
.........:.>: .,~,~.~. .......,... ......:
.i
..............;<: ....... v>:..........

-Age
34. As a result of any police contact in your life, have any of the following things ever
happened to you?
SR 34- f 34.1. were you ever warmi and released? 0. No 1. Yes
34.2. Were you held in jail for some time? 0. No 1. Yes
34.3. Were your parents ever told? 0. No 1. Yes
34.5. Were you ever referred for couaselii? 0. No 1. Yes
39- 6 34.6. Were you ever sent to a treatment program?

0. No
1. Yes
34.6A. What tteatment programs have you been sent to?
1.
3.
Gc 3 y , .3- 34.7. Did you ever go to juvenile or adult court after b e i i in trouble with the police?
0. No
.....
1. Yes
34
SRO
sg 34- 3 4 ~34.7A. Were you ever on probation? 0. No 1. Yes
L 34.7C. Did you ever have to make restimtion?

34.71). Have you had to do community service? 0. No 1. Yes
~ 2 3 47
-E c) 34.7E. Have' you lived in a juvenile or correctional center?
34.7F. How many times have you lived in a juvenile or C O K ~ C ~ ~ O M ~

center?
1. only once
2. More thanonce
34.76. What juvenile or correctional centers have you lived in?
3.
4.
5.
Of the contacts you have had with the police over the past 12 months, on how many
S R 35- 35- occasions were you arrested or charged with an offense?
36. For each time you were arrested or charged in the w, please tell me what you
SR 36 did, when and where it happened and whether you went to court.
ll't
SR 3 6 - f b O 36.1B. month (circle one): 1. Jan 4. Apr 7. Jul 10. oct

d 2. Feb 5. May 8. Aug 11. Nov
. 3.Mar . 6.Jun 9. Sep 12. Dec
fco 36.1C. year (circle one): 2. 1995 3. 1996
- 7m
2. Other:
-9 ~ 036.1E. state: 1. Illinois

2. Other:
- 36.1F. Did you go to court because of this?
O.NO -
-
1. Yes $
3iz
E Ewm

2. Adult
3. Family
4.Traffic
5. Other
- fH(J 36.1H. Have you been arrested or charged for anything else?
O.NO - m 3
-
1. Yes - - ? - -
36
SRO

SR 36-&/30 2. Feb 5. May 8. Aug 11. Nov
'4 3. -Mar 6. Jun 9. Sep . 12. Dec
J"&
36- dco 36.2C. year (circle one): 2.1995 3. 1996

c Rrn 36.2D. city: 1. Chicago
2. Other:
- 36.2E. state: 1. Illinois

2. Other:
- xp&) 36.2F.Did you go to court because of this?

O.No- C'
z as0 36.26. What type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffic
5. Other
O.NO - G 5 i . j
1. Yes - GkJtEJ3tE3!i!i
SRO I

36- 3/30 36.3B. month (circle one): 1. Jan 4. Apr 7. Jul 10. Oct
"4
. 3.Mar . 6.Jun 9. sep 12. Dec
36.3C. year.(circle one): 2.1995 3. 1996
1 In what city and state did this happen?

36.31). city: 1. chicago
---
2. other:
\If
2. Othcr:
36.3F. Did you go to court' because of this?
0. NO . 6 j
1 . Y e s - m
sk 3 6 -3 G O 36.36. what type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffic
5. Other

38
SRO

6 2 36- L/AO 2. Feb 5. M a y 8. Aug 11. Nov
,#' 3. Mar 6. Jun 9. Sep 12. Dec
36.4C. year (circle one): 2. 1995 3. 1996

2. Other:

2. Other:
O.NO - H
1. Yes - q4-
2. Adult
3. Family
4. Traffic
5. Other
0. NO - E$---
1. Yes - to:R36S4
J I
SRO

36.5B. month (circle one): 1. Jan 4.A p r 7. Jul 10. oct
SR 3 6 - 5r 4 .1 2. Feb 5. May 8. Aug 11. Nov
36.5C. year (circle one): 2.1995 3. 1996
36.5D.city: 1. Chicago
2. Other:

2. Other:

O.NO - * L
1. Yes -ggp-fs@

2. Adult
3. Family
4. Traffic
5. other
36.58. Have you been atrested or charged for anything else?
3
40
SRO
36.6A.Whik did you do?

SPe 36- 6 A 0 2. Feb 5. May 8. Aug 11. Nov
'-4 3.-Mar 6. Jun 9. Sep 12. Dec
36.6C. year (circle one): 2. 1995 3.1996

2. Other:

2. Other:

O.NO - - .
1.yeS--

2. Adult
3. Family
4. Traffic
5. Other

t l
SRO
31 4.What did you do?

36.7B. month (circle one): 1. Jan 10. oct
SR %-?A0 2. Feb
4. Apr
5. May
7. Jul
8. Aug 11. Nov
54
. 3.Mar . 6.Jun 9. s q 12. Dee
36.7C.year (circle one): 2. 199s 3.1996
In what city and state did this bappen?

36.7D.city: 1. Chicago
2. Other:

2. otber.
36.7F.Did you go to court because of this?
O.NO -
1. Yes--

2. Adult
3. Family
4. Traffic
5. Other
sde 36- f7m

42
SRO

stc 36*&AD 2. Feb 5. May 8. Aug 11. Nov
y 3. Mar 6. Jun 9. sep 12. Dec
36.8C. year (circle one): 2.1995 3. 1996

2. Other:

2. Other:
O.NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5. Other

.-
SRO

36.9B. month (circle one): 1. Jan 4. Apr 7. Jul 10. oct
JR 36-3430'"I 2. Feb 5 . May 8. Aug 11. Nov
36.9C. year (circle.one): 2. 1995 3. 1996
--
2. Other:
36.9E. state: 1. Illinoh

2. other:
O.NO
1.yCs-- . I
36.96. Wbat type of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffic
5. m er
O.NO -
SR 3 6 - 9f/o 1. Yes - K W 6 Z l O i i
44
SRO
36.10B. month (circle one) 1. Jan 4. Apr 7. Jul 10. oct

SR 36- / O B 0 2. Feb 5. May 8. Aug 11. Nov
2q 3. Mar 6. Jun 9. Sep 12. Dec
36.1OC. yeai (circle one): 2.1995 3. 1996
--
' 2. Other:

2. Other:
O.NO
1. Yes - fipJ$)$)

2. Adult
3. Family
4. Traffic
5. Other
*3
SRO
SR 3F
3 7 ~For~ each time you went to court please tell me the reason for your appearance and what
type of court you went to. .
37.1A.Why were you in COW?

2. Adult
3. Family
SR 3 J - JbO 4. Traffic
5. Other
about?
l.YeS-pwfEQ5: * .
0. NO -EnQm-l
37.2B.What type of court did you go to? 1. Juvenile

2. Adult
3. Family
S t 33-2430 4. Traffic
5. Other
J28
46
SRO
about?
1. Yes - GOto Q33.3A
0.NO - E n d b t h w
RECORD TIME:

2. Adult
SR 3?-3A0 3. Family
4. T d i c
5. Other
about?
1. Yes -
O.NO -
I RECORD TIME: I
37.4A.Why were you in wurt?

2. Adult
3. Family
4. Traffic
SR 37- W O 5. Other
I24
47
SRO I
i
about?
1. Y ~ s- #to Q.37.5A
0. NO - E n d h t m
1 RECORD TIME:

2. Adult
3. Family
SR 3?- 5-EJo 4. Traffic
5. other
about?
1. Yes -
O.NO -
RECORD TIME: I
37.6A.Why were you in anut?
37.a.What type of court did you go to? 1. Juvenile

2. Adult
3. Family
S R 37- 6 h O 4. Traffxc
5. Other
n4vc you o c a u GUUL u UIC p a r year lor anyrnrng omer tnan WMI you ve aueaay toia me
about?
1. Yes - Go m 4.37.7A .
0. NO - Ihdht-w
1 RECORD TIME: I
37.7B. What type of court did you go @? 1. Juvenile

'.I
2. Adult
3. Family
4. Traffic
SR 37- + B O 5. Other
about?
I RECORD TIME: I

2. Adult
3. Family
4. T M i c
SK 37-8/30 5. Other
ENDINTERVIEW. RECORD TIME:

YOU-THSELF REPORT
6
I 3-3
Youth Self Report
Subjet
I am going to read a list of items that describe people.
Hand Subject Response Card 1 I

For each item that describesyou 5 ._ - please say Z if the item
is very true or often true of you, 1 if the item is somewhat or sometimes true of you, or
if the item is not true of YOU.
O=NotTrue
1 = Saanewhat or Sometimes True
2=VeryTrneorOftenTrae
YSj 0 1 2 1. I act too young for my age
9 S L 0 1 2 2. Ihaveanallergy
YS3 0 1 2 3. Iarguealot
YSY 0 1 2 4. Ihaveastbma
9s5- 0 1 2 5. I act like the opposite sex
Y S-
6- 0 1 2 6. Ilkeanimals
s/s? 0 1 2 7. Ibrag
- eddate
-
dint
135
2
YSR
8. I have trouble concentrating or paying attention

9. I cant get my mind off certain thoughts
10. I have trouble sitting still
1 1. Im too dependent on adults
12. I feel lonely
13. I feel confused or in a fog
14. I cry a lot
15. I am pretty honest
16. I am mcan to others
17. I daydream a lot
18. I deliberatty try to hurt or kill myself
19. I try to get a lot of attention
20. Idcstmymyowntbgs
21. I destroy things belonging to others
22. I disobey my parents
23. I disobey at school
24. I dont eat as well as I should
25. I dont get along with other kids
26. I dont feel guilty after doing something I shouldnt
27. I am jealous of others
28. I am w X i to help others when they ntcd help
29. I am afraid of certain animals, situations, or places, other than
SChOOl
30. I am afraid of going to school
31. I am afraid I might think or do something bad
32. I feel that I have to be perfect
33. I feel that no one loves me
3
YSR
34. I feel that others are out to get me

35. I feel worthiess or inferior
36. I accidentally get hurt a lot
37. I get in many fights .
38. I get teased a lot

39. I hang around with kids who get in trouble
40. I'hear sounds or voices that other people think aren't there
41. I act without stopping to think
42. I would rather be alone than with others
43. I lie or cheat
44. I bite my fingernails
45. I am nervous or tense
46. Parts of my body twitch or make nervous movements
47. I have nightmares
48. I am not liked by other kids
49. I can do certain things better than most kids
50. I am too fcarful or anxious
51. I feel dizzy
52. I feel too guilty
53. I eat too much
54. I fecl overtired
55. I am overweight
a. Aches or pains (not headaches)
b. Headaches
c. Nausea,feel sick
d. Problems with eyes .

f. Stomach aches or cramps
4
YSR
g. Vomiting, throwing up
h. Other physical problems without known medical cause
57. I physically attack people
58. I pick my skin or other parts of my body
59. I can be pretty friendly
60.I like to try new thrngs
61. My school work is poor
62: I am poorly coordinated or clumsy
63. I wouid rather be with older kids than with kids my own age
64. I wouid rather be with younger kids than with kids my own age
6S.IrefusetOtalk
66. I repeat certain actions mer and over
67. I run away fiom home
68. I scream a lot
69. I am secntiyc or keep things to myself
70. I see things that other peapie think aren't there
71. I am self-conscious or easily embanassed
72.ISCtfircs
73. I can work well with my hands
74. I show offor clown
75. I am shy
76. I sleep lcss thau most kids
77.I sleep more than most kids during the day andlor night
78. I have a good imagination
79. I have a speech problem
80. I stand up for my rights
81. I steal at home
82. I steal from places other than home
83. I store up things I don't need
5
YSR
84. I do things other people thlnk are strange

85. I have thoughts that other people would think are strange
86. I am stubborn
87. My moods or feelings change suddenly
88. I enjoy being with other people
89. I am suspicious
90. Iswear or use dirty language
91. I think about killing myself
92. I like to make others laugh
93. I talk too much
94. I tease others a lot
95. I have a hot temper
96. I think about sex too much
97. I threaten to hurt people
98. I like to help others
99. I am too concerned about being neat or clean
100. I have trouble sleeping
101. I cut classes or skip schml
102. I dont have much energy
103. I am unhappy, sad, or depressed
104. I am louder than other kids
105. I use alcohol or drugs for nonmedical purposes
106.Itrytobefiirtoothers
107. I enjoy a good joke
108. I like to take life easy
109. I try to help other people when I can
110. I wish I were of the opposite sex
6
YSR
111. I k p from getting involved with others

112. I worry a lot
L d
I RECORD TIME:
Subject ID: S&fi/B-
FIELD COPY 2 soace

Time Started: PSf57/M
,I
Now I would like to h a w something about your relationships with other people.
I Hand Respondent the Response Card and Read Choices
For each of the statements I read, please use this s d e and tell me the answer that best
1= verytme
2= somewhattrue
3= nottrue
1. When rm with my fiends I feel completely able to relax and be myseK

BP4
1 -veTytrue
-
2 somewhat true
-
3 not true
2. I share the same approach to Me that many of my fiends do.

PSPA
1 -verytrue
-
2 somewhat true
-
3 not true
ed. init. ai.date

3. People who know me trust me and respect me. i
1 - very true
-
2 somewhat true
-
3 not true
4. NOmatter what happens, I know that my f . Y will always be there for me should I need
them.
-
1 very true
-
2 somewhat true
y -
3 not true
5. When I want to go out to do things, I know that many of my fiiends would &y (like)
1 -verytlue
-
2 somewhat true
-
3 not true
6. I have at least one fiimd that I could tell auything to.

1-verytlue
-
2 somewbat true
-
3 not true
7. Sometimes rm not sure if1 can completely rt)y (cow@ on my fsnlily.
1 -veIytrue
-
2 somewhat true
-
3 not true
8. My farrriy lets me know they think Im a worthwhile (vcJuabk)person.
1 -verytnre
-
2 somewhat me
-
3 not true
I44
9. I feel very close to some of my fhends.
-
1 very true
-
2 somewhat true
-
3 not true
-
1 very true
-
2 somewhat true
-
3 not true
11. People in my f d y help me find-solutionsto my problems.
1 -verytrue
-
2 somewhat true
-
3 not true
12. People who h o w me think I am good at what I do.
-
1 very true
-
2 somewhat true
3-nottrue
13. My fiends would take the time to talk about my problems, should I ever want to.
1 -verytrue
-
2 somewbat true
-
3 not true
14. I know my M y will always stand by me.
1 -verytrue
-
2 somewhat true
-
3 not true
15. Even when I am with my fiends, I fcel alone.
1 -verytrue
-
2 somewhat true
-
3 not true
16. I have a teacher or coach who I can & (counr) on and taIk to.
-
I very true
-
2 somewhat true
-
3 not true
la. I have a grandparent, uncle, or aunt that I fcel close to and who helps me out.
1 -wrytrue
-
2 somewhat true
-
3 not true
1 -verytrue
-
2 somewbt me
-
3 not true
19. There is an adult outside my W y , for aample, a neighbor or religious or

1 -verytrue
-
2 somewhat true
-
3 not true
20. Is there anyone in particularthat you thinl.helps you out when you need it?
1. Yes 0, No
+
EF Ye: What is this person's name and what is hidher relationship to you? (Circle all that
PSPUAU
20a2. 1 - Immediate Family (sibling, child, parent, partner)
20a** First name 2 - Extended Family
6 - Other
PSPAQAR
-
20b2. 1 Immediate Family (sibling, child, parent, partner)
-
2 Extended Family
-
-
-
5 School or Community Member/Leader
6-other
PSPBZOCA
20cl. -
2 0 ~ 2 . 1 Immediate Family (sibling, child, parent, partner)
14irst name -
2 Extended F d y
-
-
4 Church MembdLder
-
5 School or Community MemberLeader
6-0ther
I@ENDOFINTERMEW@
RECORD TIME:
A S S E S S m DEBRIEFING
Date:
m m dd yy
Subject ID:
Interviewer XD:
?*#
1 . Was the entire assessment administered in English?
YES G o t 0 4 6
NO G o t o Q 2
YES Go to Q 2.1 Specify language .

NO G o t 0 4 3
YES Go to Q'5
NO GotoQ4
2. Parent/Guardian
3 . SpousePartner
6. Other
5. How many measures were administered in a language other than English? 1

5. all
6. How much difficulty did the SfPC have in understanding the language of the measures? Did
hdshe find it ...
'*@
1. Very difficult
2. Fairly difficult
. 3. Fairly easy .
4. Veryeasy

NO GotoQ8
Code
1. Child Behavior Checklist YES NO a. __ b . c.
2. Conflict Tactics YES NO a.-b. c.
4. Self Report of Offending YES NO a. b. c. __
5. Substance Use YES NO a. b. c.-
6. Youth SelfReport YES NO a b. c.
7. YoungAdultSelfReport YES NO * a b. c.
Coding List
1 = Parent/Guardian 5 = Other Child Family Member
Comments Section:

Date:
mm dd 9
Subject ID:
Interviewer ID:
I53
NOTES
..
NOTES
.. .
C G
ORT: 15
I. Demographic dk CuHtplral Information
2. Home
4- Schooll Screen: 9-15
4. Family Structure & ealth History
5. Family Mental Health dk Legal History
7. Conact Tactics Scale: PartnerBpouse
8. Conflict Tactics Scale: Parent/Child
IO. EX~QS t~ U ~~
Violence
Subject ID:
FIELDCOPY2 Jwee
Time Started - 3CTMBS//&
First, I will ask you about where you and ***** have lived during the past five years;
Second, I am going to ask about where you, *****, and other members of your f d y
were born;
Third, I whl ask about Herent languages you might speak;
Fourth, I will ask for some g m d descriptive information about yourself;
Finally, I will ask about your ethnic and religions background.
Lets start w i t h checkine that I have vour current address recorded coTrtfctly.
ed. init. ed. date

2
Your cunent address is (razdfrom contm sheet): Is that right?
apt. #
city Stafe zip code
1. rent your home

2. own your home
4. live with someone (yourparents, guardians or partner) who rents this home
5. live with someone (yourparents, guardians or partner) who owns this home
243 A40
1A. How long in years and months have you lived here? -
Y-
-
months
2. Please tell me alI the other addresses you have had in the past fwe years, starting with
2A.
v=aL!t?".d G
&
+
-
&
,
/ /
@& AAI' 2A1. Why did you move from this address [2A]? [circle up to three]

2 =evicted 9 = could no longer afford rent
3 = moved off-campus 10 = found a bener apartmendhouse
6 , p moved in w/ someone due to f a c e s 13 = on vacatiodgraduated from school
7 = living quarters too small/found bigger aparunendhome
a,&, ,&A & 2A2. How long did you live at this address [2A]?
%4a%!5# 2B1. Why did you move from this address [2B]? [circle up to three]
1 = change of job 8 = went to sc13001

6 = moved in w/someone due to finances 13 = on vacatioxdgraduated from school
25 =o&er 4 ,
/'

Q&U3dr
Yf=S months
Y- months
4
(state) (zip d e )
%&F8c/ 2C 1. Why did you move from this address [2C]? [circle up to three]
1 = change of job 8 = went to schoa

2 = evicred 9 = could no longer afford rent
3 = moved off-campus 10 = found a better apaxtment/house
5 =$b,nge in marital/romantic status 12 = rmmmates left (had to move)
6 = moved in w/ someone due to 'fmw 13 = on vamiodgraduated fromschwl
7 = Iiving quarters too smaIl/found bigger apartmenthome
25 =
@&&e&2C2. How long did you live at this address [ 2 q ?

Y- months
Y- months
7 3 6 d ~ y2D1. Why did you move from this address [2D]? [circle up to three]
5 = change in maritavromautic status 12 = roommates left (had to move)
6 = moved in wl someone due to f m m 13 = on vacation/graduated from school
25 = other ~~*~~ P d
3/25 &BL 202. How long did you live at this address [2D]?
Y- months
. . ... ....... . .
Y- months
6
5
2E. h d where did you live before living here? .
vr&.(;&& de&
(street address) /' ( C W (srate) (ZIPc d e )
h3A&f 2E1. Why did you move from this address f2E]? [circle up to three]

3 = movedoff-campus 10 = found a better aparunentlhouse
4 change in marital/romantic status 12 = roommates left (had to move)
6 = moved in w/ someone duelo finances 13 = on vacatiodgraduated from school
25 =other a ?
x3 &E& 2E2. How long did you live at this address [2E]?
Y- months
v&e.,-d& /'
%a/=/ 2F1. Why did you move from this address [2a?[circle up to three]

4 = fxe/other hazardous condition 11 = wanted to live away from parents
6 = moved in wl someone due to finances 13 = on vacatiodgraduatesl from schooi
7 = living quarters too smalllfound bigger apartmenthome
25 =other v ~ L b
J ~
G&ktr~, 2F2. How long did you live at this address [2n?
Y W months
Y- months
6
2G. And where did you live before Iiving here?
sed g/ 2G1. Why did you move from this address [2G]? [circle up to three]

3 = moved off-campus 10 = found a better apamnentfhouse
5 $'change in marital/romantic status ' - 12 = roommates left (had to move)
6 = moved in-w/ someone due to finances 13 = on vacatiodgraduated from school
25 = other
&Gh 2G2. How long did you live at this address [2G]?
Y- months
Y- months

c _ _c
-
2H1. Why did you move from this address [ZH]? [circle up to three]
f4?&%/-;l
1 = cfianee of job 8 = went to school
4 = firdother hazardous condition 11 = wanted to live away from parents
25 = othe
Qfi 2H2. How long did you live at this address [2H]?
Y*S months
Y== month
r
7
21. And wheredid you live before living here?
w&lfzz4211. Why did you move from this address [24? [circle up to three]

3 = moved off-campus 10 = found a better apartmendhouse
$& change in maritaUromantic status 12 = roommates left (had to move)
6 = moved in w/ someone due'to finances 13 = on vacatiodgraduated from school
@&&I#& 212. How long did you live at this address [2Q?
YWS months
Y- months .

7 --.c- *_
2J 1. Why did you move from this address [q?

"4,i:3]
1 = c h g e of job 8 = went to school
g3fi 272. How long did you live at this address [q?
YWS months
Y- months
8
HS ***** had any different addresses titan you in the past five years?
0. NO
1. YES
How long in years and months has ***** lived at your current address?
currents
4. Please tell me all the addresses ***** has had in the past fme years, starting with the most
recent one before the current address;.
4A.
/4&& - p_
(street address) (city) (stab) (zip d e )
343 9744 4A1. W h y did ***** move from this address [4A]? [circle all that apply]
1 = change in custody/shared custody 7 = child hospitalized (medid)

2 = lived with another famiiy member 8 = parent was hospitalized (medical)
5 = child hospitalized (emotionalhehaviord) or in residential treatment
6 = parent was hospitalized (emotiodhehaviord) or in drug treatment
25 = other

Be44A9 Y- months
Y- months
9
43. And where did ***** live before living here?
8 6 943 9 4B 1. Why did ***** move from this address [4B])? [circle ail that apply]

3 = parent was in prison 9 '= foster placement/adopted
Q * 5 = child hospitalized (emotionalhehavioral) or in residential treatment
6 = parent was hospitalized (emotioWebaviora1) or in drug treatment
25 = other /-k&& +& Y
&QA& 4B2. How long did ***** live at this address [4B]?
b?)
&C/ 4C1. W h y did ***** move from this address [ 4 q ? [circle all that apply]

5 = child hospitalized (emotionalhehaviod) or in residential treatment
6 = parent was hospitalized (emotional/behavioral)or in drug treatment
25 = O t h e r
w.i/e&4C2. How long did ***** live at this address [4C]?

Y- months
.....
Y- months
4D. And where did ***** live before living here?.
I _ - IC
(CirY) (state) (zip code)
weas/4D1. my did ***** move from this address [4D]? [circle all that apply]
1 = change in custody/sllared custody 7 = child hospitalized (medid)

2 =.lived with another family member 8 = parent was hospitaiized (medid)
r 3 = parent was in prison 9 = foster placernenthdopted
'
,
17 5 = child hospitalized (ernotionalhehavioral) or in residential treatment -

6 = parent was hospitalized (emotionahehavioral) or in drug treatment
ya,xl 4D2. How long did ***** live at this address [4D]?
Y- months
Y- months
&3 & 4E1. Why did ***** move from this address [4E]? [circle all that apply]

2 = iived with another family member 8 = parent was hospitalized (medical)
3 = parent was in prison 9 = foster piacement/adopted
5 = child hospitalized (emotionalhehaviod) or in residential treatment
6 = parent was hospitalized (emotiondlbehavioral) or in drug treatment
25 = other v d h
L 6 &&A/ 4E2. How long did ***** live at this address [4E]?v '
Y- months
Veafs months
11
NOW H have some qutstiom about where different p q i e in your f a y were born.
B. State V L - C. Country
. . . . .. . ........ ...................... .
i-4-j . 5A. When did ***** come to live in the USA? year: 19
".#- 'I 8. Don't Know
w5 3-633/ 5B. How old was ***** when he/she came to live in the USA? age:
8. Don't Know
C. Country
-
64-4 6A. When did you come to live in the USA? year: 19
8. Don't Know
pa-sa 64/ 6B. How old were you when you came to live in the USA? age:
8. Don't Know
943 F 7. Is your mother still living? 1. Yes 0. No 8. Don't Know
8.
A. city
Where was she born?
+& B. State C. Country

-
A. City B. Stak -
s
c. Country -
A. City B. State
- C. Country
.4
gt$o fy' 9A. When did she come to live in the USA? year: 19
8. Don't Know
m QAcb 9B. How old was she when she came to live in the USA? age:
8. Don't Know
yo 10. Is your father still living? 1. Yes 0. No 8. Don't Know
-
B. State c. country
-
.
A. City
A. City B. State
- c. country
A. City B. State
__c
c. country
% /dm 12A. When did he come to live in the USA? year: 19,- I
8. Don't Know
3?% /A450 12B. How oid was he when he came to live in the'USA? age:
8. Don't Know
-13
/3 13. Are you a U.S.citizen?

................... .. .......
0. NO
1. YES
13A. Are you (read choices) 1. currently applying, GQTII

2. planning to apply, or Q. I4
3. not planning to become citizen
13B. Are you registered-to vote in the U.S.? 0. NO 1. YE
14. What is your social security number?

m&*d-&
--- -
(NAP)
~5 15. What is your marital status? Are you (Read dlchoices):
15A. Are you currently living with a parmer?

BE5 f5-m.7
1. Yes
0. No
+c&,#o15AA. Are you currently living with your spouse?

1. Yes
0. No
% /mV."rp 15AA.1 Are you living apart because you are not getting along or for some other
reason? What js the reason?

14
1531. Is your pamedspouse the biological parent of *-*+*?

gF;"7R 72234
1. Yes
15B2. How long have you lived with your parmerlspouse?

/5h&
WJt, jd5&&M
years months

L$ mm dd yy
%/& 17. What was the first language you learned?
4. Spanish 10. Other language (specify:)
5. German &
,-
YY
6. Lithuanian

A.
B.
9% "/$ 18. What is your primary language now?
1. English 7.Russian
4. Spanish 10. Other language (spem:)
5 . German
W Y
6. Lithuanian
12. Two other languages (spem:)

15
fg 19:
Please note: Insert the name of the language(s) provided in response to Q. 17 and 18
whenever the term !lungua$e(s)J appears in the text in Q. 19
-
1
a. Mostly [language(s)] b. Mostly English C. Both about the same
"CARD 1: LANGUAGES" to the respondent 1

I'd Like to h o w what language you use in your M y activities. After each question please
tell me whether you use English only, mostly English,both English and ~angnage(s)]
equally, mostly P=guage(s)l, or Panmla9ets)l O ~ Y .
m SS&O 19A. What language do you speak with your children?
1. English only 4.Mostly [language(s)]

2. Mostly English 5. [language(s)l O d Y
3. Equally
19B. What language (do/did) you speak with your mother?
1. English only 4. Mostly @mguage(s)]

2. Mostly English 5 . Panguage(s)l O d Y
3. Equally
1. English only 4. Mostly [lauguage(s)]

2. Mostly English 5 . r~anguagewiO ~ Y
3. Equally

2. Mostly English' 5. rlaoguage(s>lonly
3. Equally
16
1. English only 4. Mostiy [Ianguage(s)J

2. Mostiy Engiish 5. [language(s)] o d y
3. Equally

2. Mostly English 5. rl~guage(s>l only

2. Mostly English 5 - rl~guage(s)lonly
3. Equally

2. Mostly English 5. P-e(s)l Odgr
3. Equally
191. Do you consider your panguage(s)] to be ... (read choices).

1. VeryGood
2. PrettyGood
3. Fair, or
4. Not good at all
19J. Do you consider your English to be.. .. (read choices)
1. Very Good
2. Pretty Good
3. Fair, or
4. Not good at all
19K. How often has it been hard for you to get along with others because you dont
speak Engiish well? Would you say.. . (read cfroices)
1. Never
2. Sometimes
3. Often,or
4. Always
17
19L. How often bas it been hard to get good grzdes or do well at a job because of
h?5 / Q i O problems understanding English? Would you say. -.(read choicas)
1. Never
2. Sometimes
3. Often,or
4. Always

%a ?
20. Have you attended school in another country, this country (the US), or both?

2. usoniy
0. NO
1. YES
20C 1. What degree did you receive?

:*
................
...................
.>0: , ,
................
Q$ ;+&
........
.... ?! .......
Did you finish high school?
0. NO
1. YES
21A. And have you done any studying-beyondhigh school?
0. NO
1. YES
-years months
18
w32 fa& 0 21M. whar is the highest degree you have reached?
1. No degree
2. Associate's degree or tedmical degree
4. Master's degree
5 . Doctoral degree (J.D., M.D.,Ph.D., DDS., DO,Ed.D.)
6. Other 5% &/&&3
2 1A3. Are you currently in school?

eiy:;
......................
0. NO
1. YES .QE.. $=
.................

& A m 0
% af%J-/ G
0. NO
1. YES
21C. Have you gotten a GED or had any other schooling or mining since then?
0. NO
-1. YES

0. NO
1. YES
22. What country(s) best represents your ~ t i o n aorigin

l or ancestry?
2.
Do you identify with an e h c group?
0. NO
1. YES
24. Which group(s) do you identify with?
1. V.ah&h
2.
3.
4.
+&
ZFm c
Y a a L k
In Q. 24, circk the d e r ofthe 'primury' ethnic group.
25. How American or [ethnic group] are your customs? Would you .say...(read cfraices)
1. Very American
2.-Mostly American
25A. How often have you had probiems with your family because you prefer American
customs? Would you say ...( rendchaices)
1. never
2. sometimes, or
3. often
a6 26. Are you Latino or Hispanic?
0. NO
1. YES
I 7 II
Hand "CARD 2: LATINO/HISPAMC" to the remondent
20
&Jh-,&J 26A. Which of the following represents your origins?
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
7. Other
yourself?
1. Asian
2. PacXic Islander
3. African American I Black
4. Caucasian I White
5. Native American
6. Other --&id
28. How often do people dislike you because of your ethnic group or race? Would you say.. .(read
&ices)
1. never
2. sometimes, or
3. often
29. How often are you treated uufairly at school or work because of your ethnic group or race?
Would you say...(rerrd choices)
1. never
2. sometimes, or
3. often
you say.. .(read choices)
1. never
2. sometimes, or
3. often
21
Hand "CARD 4: RELIGION" to the resuondent

Jl
& 33 33. Do you follow or are you a member of any of the churches or religions listed here?
- 0. NO
1. YES 4
Bj5 3 3 C#-/ 1. Buddhist

2. Catholic
*
3. Church of Christ
4. EvangeIical
?q a! -
5. Hindu
6. Islamic
b . Conservative
c. Reformed
d. Other
9. Mormon
10. Pentecostal
&,3 3 3 , & # / 3 11. Protestant
a. Anglican
*/333wy b. Baptist
5. Other Baptist
P1'
c. Episcopalian
~4133 3 G C / ~ d. Lutheran
&% 3 3 & / 6 e. Methodist
1. Episcopalian
3 3 GC/+ f. Presbyterian
1. Presbprian Church in the U.S.A.
2. United Presbyterian
g. Seventh Day Adventis
12. Oaer Au??! d
%A 3 4 34. Would you say your religion provides you with...(Read choices)

2. quire a bit .of guidance
3 35, How often do you attend religious seririce? Do you attend.. . (Read choices)

,d 2. once or twice a month
4. almost never, or
5. never
This interview aQlES NOT end here.

Annver the folkwing questbns yourseratadf o b v rhe instnrctiOnr provided:
A. Is the PC married or living With a punner?
Yes ->
NO -->
B. Have you obtained ig%mna'ionabout the bioiogicaifather?
Yes ->
NO -->
36. What is hisher first name? &5e-o&p&

/ v
/613 37 37. What is Ipartnerl's age?

8. Don't Know

mm
38. Where was Ipartner] born?
d- B. State c. country
-. c
A. City +#
*
....
364f 38A. When did shehe come to live in the USA? year: 19
8. Don't Know
rn 3 8 6 3 - i 383. How old was shehe when shehe came to live in the USA? age:
8. Don't Know
Q93 39 39. Is [partner's] mother still living? 1. Yes 0. No 8. Don't Know
-
Where was she born?
-
40.
e. country
Where does she live now?

41.1
- -
-
41.2
A. City
B. State
- C. Country
-
24
Tb ,4Lh and 4138:
&&/IQc, 41A. When did she come to live in the USA? year: 19
8. Don't h o w
m4Y/3(J 41B. How old was she when she came to live in the USA? age:
8. Don't Know
j4n +a 42. Is [partner's] father still living? 1. Yes 0. No 8. Don't Know

-
c. Country -
A. City B. State
.__.
e. country
A. City B. State
- c. country
-
44A. When did he come to live in the USA? yeat: 19-

Sk5 +V?%D 8. Don't Know
B73 44450 8. Don't Know
25
Has Ipartner] attended school in another country, this country (the US), or both?
1. another counuy only A

2. US only
45A. How many years of school did Ipartner] have? years (1 - 20)
45B. At what age did [pamier] stop attending school? years old
45C. Did Ipartner] receive any type of degree?

.................. .....
0. NO
1. YES
Q* 4-7
46. Did [Partner] finish high school?
0. NO
1. YES
46A. Has [partner] done any studying beyond high school? -
0. NO
1. YES
1. No degrex
4. Master's degree
5. Doctoral (J.D.,M.D., Ph.D., D.D.S., D.O.,Ed.D.1
6. Other
46A3. Is [partner] currently in school? 0. NO Go io

1. YES Q. 47
29
463. What is the last grade banner] completed? (1 - 12)
463 1. Is @ m e r ] stdl in high school?
46C. Has [partner] gotten a GED or any other schcoiing or uahing since then?
0. NO
1. YES

46C2. Is [partner] currently in school or training? 0. NO :e;.

...........................
...............
1. YES :Qg42
47. What country(s) best represents [partner's] ~ t i o n aorigin

l or ancestry?
1.
I'
2.
3.
&3 98 48. Does [parmer] identify with an ethnic group?

0. NO
1. YES
48A. Which group($ d w he/& idenufy with?
28
49 49. Is I$artner] Latino or Hispanic?
0. NO
1. YES
% YQfio 49A. Which of the following represents hidher origins?
1. Cuba
?.# 2. Mexico
3. Puerto Rim
4. Spain
5. South America
6. Other Cenud American
7. Other
50. If you were asked to put Cpartner] into only one of these groups, in which one would you
% 5-0 place himher?
.... .. ....
1. Asian
2. Pacific Islander
3. African American J Black
4. Caucasian J White
5 . Native Ameri
6. Other
28
7X.r interview MBY or NUT end here.

Answer the following qupStiom yourself and foLLoW the instnrcrom provided:
-
A. Have you obtained information about BOiX the bioiogical mother and
bioiogicaifaher?
8. Have you obtained informmion about the biological farher?
Yes ->
NO -->
Time stopped:
Now some questions about *+***'s father:
51. What is his frst name? Don't Know
6'3 52. Is he still living?

8. Don't know
73 3-3 -& 53.2 What was [*****'s fatherl's age when he died?

8. Don't know
53A. When was-E*****'s

father] born?
mm YY
A. City+ , -@&? B. State

- C. Country
A. City B. State
- C. Country
-

-
+ -A. -city . B. State
-c-
c. counuy
30
w5 9-5.40 55A. When did he come to live in the USA? year: 19

8. Don't Know
@735 6A8 8. Don't Know
% 56 56?$' Is [*****Is fatherl's mother still living? 1. Yes 0. No 8. Don't Know

-
d?&! B. State C .Country
7
A. City
A. city &N d B. State

- c. country
58.2 Where'did she live when she died?
A. City B. State c. country

c_
%% a di3 58A. When did she come to live in the USA? year: 19
8. Don't Know
35 9-23r3C.3 8. Don't Know
323 5'9 59. Is [*****'s hther]'s father still living? 1; Yes 0. No 8. Don't Know
60. where was he born?
A. City B. State
- C. Country
4_
31
I
Hf

-
A. city -YP& B. State
"C
c. Counary
A. city e4 B. Stak
I
C. Country
-
"8 f
.
8. Don't b o w
61B: How old was he when he came to live in the USA? age:
8. Don't Know
Has [*****'s father] attended school in another country, this country (the US), or both?

2. usonly
62A. How many years of school did [*****'s father] have'? years (1 - 20)
62C. Did he rmive any type of degree?
0. NO
1. YES
62C1. What degree did he receive? Goto

Q- 64
32
Did [**$**'sfather] f ~ high

h school?
0. NO
1. YES
0. NO
1. YES
63Al. How many years of studying beyond high school
63A2.What is the highest degree he has reached?
1. No degree
4. Master's degree
5. Doctoraldegree (Y.D., M.D., Ph.D., D.D.S., D.O., M.D.)
6. Other &m~,e.td
e
/ f l
&
...............
8
436 3 4 3 63A3. Is he currently in school? 0. NO ..................
1. YES Q&g
63B. What is the last grade he completed? (1 - 12)-
63B1 Is he still in high school?
0. NO
1. YES
63C. Has he gotten a GED or any other schooling or training since then?
0. NO
1. YES
63C1. what has he received? 1. GED

%6 5 C f Q f 2. other degree/ceAficak:
--
2
7-
3. other schooling:
c&ed#w&
63C2. Is he currently in school or training? 0. NO Go t o

6-3c,
1. YES CL. 6 4
33
64. What country(s) best represents [*****'s fatherl's ~ti011a.iorigh or ancesv?
mr&-s
65. Does [*****'s father] identify with an ethnic group?
.'?,# .a 0. NO
1. YES
3.
0. NO
1. - 'IES
I
&k1po 66A. Which of the following represents his origins?
1. Cuba
2. Mexico
3. Puerto Rim
4. Spain
5. South America
34
%3 S p 67. If you were asked to put him kt0 only one of these groups, in which one would you place
him?
1. Asian
2. Pacific Islander
, 3. African American I Black
$" 4. Caucasian / white . -
5. Native American
6. Other rz&&'dc&
7% intew'ao MAY or M Y NOT end here.

Answer the fouoWing questionS yourself and f o h the inrtnrcsiOnr provided:
A. Have you obtained ir#onnmion about the biological mother?

. ........ .. ..... ..
Yes ->
NO ->
Time stopped:
35
68. What is her fxst name? Don't Know

0. No
8. Don't Know
~p.1what is [*****'s motherl's age?

8. Don't know
70.2 What was [**+**'s motherl's age when she died?

2.20 to 29 years 5 . 50 to 59 years
8. Don't know
70A. When Was [*****Is mother] born?

c. country
7 c
'
A. City B. state
- C. Country -
72.2
A. city
B. state
.Y
c. counay
-
36
,+o 72A. When did she come to live in the USA? year: 19
8. Don't Know
?A,&? 72B. How old was she when she came to live in the USA? age:
8. Don't Know
0. No
b
e23 9 3 73. , Is [*****Is motherl's mother still living? 1. Yes 8. Don't Know
4,j'
C. Country
-
A. City E. State .- c. country -
A. city m ~ ~E. State

d c _
C. Country
_I_
+c#o
.%h?) 75A. When did she come to live in the USA? year: 19
8. Don't Know
;z5/3c> 8. Don't Know
76. Is [*****Is motherl's father still living? 1. Yes 0. No 8. Don't Know

v3 ?6
37
A. City B. State
- c. country
-
A. City B. State
- C. Counh-y -
B.
8. Don't Know
8. Don't Know
79. Has [*****Is mother] attended school in another country, this country (the US), or both?

2. usonly

. ... .
0.
.
NO
1. YES
79C 1. What degree did she receive? L A e 4 W Y - D d
39
38
Did [****+Is mother] finish high school?
0. NO
1. YES
80A. And has she done any studying beyond high school?
NO
.............
0.
1. YES
d?a# 80A1. How many years of studying beyond high school?

'if
-years months
80s.What is the highest degree she has reached?

m CeSOAU
1. No degree
4. Master's degree
Ph.D., D.D.S., D.O., Ed.D.)
8OA3. Is she currently in school?

.66
............g&
0. NO' .............:+:........
......... ....
yEs
%.
:
1. - ' :@.$@
&%30 SOB. What is the last grade she completed? -

(1 12)
$OB 1 Is she still in high school?
0. NO
1. YES
pt93 c?uc3
0. NO
.l. YES
8OC1. What has she received? 1. GED
x
2. other degree/certifcate:
3. other schooling:
39
80C2. Is she currently in school or training?
0. NO Go to
1. YES Q. 81
81. What country(s>best represents *****Is mother's ~ t i o n aorigin

l or ancestry?
1. k--d&
2.
- f"
3.
Does *****'s mother identlfy with an ethnic group?
0. NO
1. YES
1. Y a ' d & L34e.aW-eoe
Is [*****Is mother] Latino or Hispanic?
0. <NO
1. YES
B
....... ..... ..... .. .... .. .........
83A. Which of the following represenk her origins?
8340
1. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
6. Other Centrd American
7. Other -d,
40
Hand CARD 3: RACEEIC1TY to the res
$4 84. If you were asked to put her kt0 only one of these groups, in which one would you pface
her?
1. Asian
2. Pacific Islander
3. African American / Biack
5. Native American
6. Other Y - & k d
PYY

HOME
H O W . Inventory: AGF 15
h r o d u c tion- Now I'd like to get an idea of what *****' days are like and what some of
the things arc that you and ***** do together. A good way to start is for
'.I you to describe a typical day, like yesterday and then I'll ask a few more
questions. .
OB SCALE I. IN THE HOME?
I EMOTIONAL and VERBAL WSPONSNITY I [CIRCLE ONEJ
s
+* I
I I
1. PC talks with subject &during visit a. YES

lbevond introduction and correction). b. NO
** 1 2. PC answers m of the subject's questions or I a. YES
I requests verbdy. I b. NO
PC encourages subject to contribute to the a. YES
conversation during visit by getting M e r to b. NO
relate an experience OR by taking time to
listen to M e r relate an ex wience.
accomprishment of subject during interview
splamewhentalking
** 10. PC's speech is distinct, clear, and audible to the a. YES

interviewer. b. NO
I
1
11. PC initiates verbal interchanges with the a. YES
** interviewer, asks questions, d e s b. NO
spontaneous comments. I
** 12. PC expresses ideas fieeiy and easily and uses a. YES
conversation.
** 13. PC appears to readily understand the a. YES
intervieweis questions. b. NO
I I
EMOTIONAL and VEARBALRESPONSMTY I /-CIRCLE ONE]
I
e 14. Subject has been praised by PC pxice dun% a. K S
past week for doing something.
Has ***** done anything you're especially happy b. NO
with this past week? Did you tell ***** how you
47
muctim Now I'd like PO ask you about some of the different erperiemcrs ***** may
have had OP is having.
OBS SCALE II. IN THE HOME? schoov

I VARIETY OF STIMULATION I [CIRCLE OAEJ 1 DavCare
Do you have a pet?
relatives or fiends about k c e a
3. Subject eats QE
I meal per day, on
most days, with PC and father (or

eat at the table with the
4. Subject sees and spends some time

with m e r or fhther figure
a YES I
a. b. NO
Does a*aaa's fmther (or Ezther figure)
spend time with hirn/her? (About
Bow often?)
5. PC or other famiy member a. YES
d o n with subject mct eVery b. NO
two.
Does ***** do any outdoor activities
with m y family member(s)? (About
how often?)
member on one outing
E!xk- b. NO
Does ***** go on outings with any
family member(s)? (What kinds of
things do they do; about how often?)
rn THE HOME? SchooY
(CIRCLE OhrEJ Dav Care
7 . Family member has taken subject, a. E 5 a. YES
or arranged for subject to go to a
scientific, historical, art, or cultural
. . b. NO
museum D ~ Sv a .
Has **I** been to any kind of
museum QP exhibit this year? (Who
did hehhe go with?)
or arranged for subject to go on a
trip more than30 miles ffom home b. NO b. NO
Ehs ***** been OQ any trips this
9. Family member has taken subject, a. YS a. YES

or arranged for subject to take a
uip on a plane, train (NOT b. NO b. NO
. .
subway), or bus
Yfar.
Bas ***** been on a plane, train or
bus this yem?
10. F d y member has paken subject, a YES a. YES

or arranged for subject to attend -
some type oflive musical or b. NO
................
............. b. NO
theater performance
Dast.
mas seen a live anusid or any
wype sftheater performance this past
VWW?
1. Family has m g e d for subject to a. YES a. YES

receive lessons or organizational
membership to support subject's b. NO b. NO
talents. -
(Y membership, &Mnnartic lessons,
mt, h c e , or music lessons)
3oes ***** belong to any dubs or
wganizations or take any kind of
essons? Ask: Where?
12. Subject is regularly kciuded in a. YS
famiry's recreational hobby.
(bihng, walhng, playing in park, b. NO
playing bad, swimming, checkers,
pzies)
Does your famay have any hobbies?
Does ***** join in on them? -

commerciai family venture 3 2 b. NO
. .
times
(inechanidgarage,tailor/ciothing
shop. appliance r e p ? shop, bank)
Docs ***** ever go with you on
errands you have to do?
5"
a. YES a. YES
b. NO
other suitable place for reading
Is there an encyclopedia,
dictionary or anything like that
which ***** can use?
I b. NO
8. Subject is encouraged by PC to a. YES
read on hidher own.
Does ***** rend on hisher o m or b. NO
do you encoumge himher to read?
9. Subject has e or mpfe books a. YES

of hisher own.
&F3- 9 ***** have aw QflhiS/heFOWXI
h e S b. NO
books? (About how maw?)
10. PC or other family m m k r a. YES
encmrages subject to develop or
sustaia hobbies. b. NO
Does ***** bave any hobbies? If
yes, Did you encourage ahis? If no,
Are there any you have
a. YES
b. NO
OBS SCALE IV. IN THE HOME7
I SUPERVISION [CIRCLE ONE]
school nights.
have a cemin time hdshe has to be b. NO
2. Subject routinely o b e s curfew on school nights. a. YS

b. NO
3. Subject has a set time [curfew] to be Rome on a. YES
weekend nights.
How about on wetkends? Does ***** have a certrrin b. NO
time to be home?
Docs ***** usually obey that rule?
b. NQ
5. PC has established rules about homework and a. YES
checks to see ifhomework is done.
Do you have any specific wries about doing b. NO
homework? D o you cheek to see if it is done?
6. PC assisted subject with homework and school a. YES
assignments me? dk- during current or
most recent school year. b. NO
(About how often?)
7. PC requires subject to sleep at home on school a. E S
nights.
Does ***** slctp it home on school nights can b. NO
hclshe stay with friends?
When PC is not available to subject at home,
8. a. YES
HF4- 8 him/her to check in with PC, or their designee, on b. NO
When you arent a t home, does ***** check in with
you or anyone else?
53
9. M e r school subject goes somewhere that adult
superrision is provided.
Where does ***** go after school? Are there any
10. PC establishes rules for subject's behavior with

are being followed.
Do you have amy rules about what I**** does with
hishes friends? Do you talk to ***** about what
Do you ever get to talk with *****'s friends?
or counselor. -
. .
Do you ever get to talk with ***** about what

on the news, or in newspapers or
57
II\J JXE HOME?
SUPERVISION [CIRCLE ONEJ
IS. PC has discussed the hazards of aicohoi and drug a. E S
abuse with subject ~ a svt a
During the past year bave you spoken with ***** b. NO
19 PC denies subject access to alcohol (including beer a. YES
or wine) in the home.
b ***** allowed to drink beer, wine, or other b. NO
alcohol at home?
20. PC knows signs of drug usage and remains alert to a. YES
possible experimentation:
Do you feel faamiiiar with the signs of drug use and b. NO
21. Subject is taken regularly to a doctor's office or a. YES
ciinic for check-ups and preventive health care
sLrmzu=* b. NO
Has ***** been to a doctor or ciinic for a check-up
22. Family has a W y regular and predictable daily a. E S
(mea&, after schmi actlvtties, bedime, haw much b. NO
W,homework)
Are things like bedtimes, mealtimes, homework
done about the same time each day?
tilm.
&FG- a3 (mrjkw, homework before n/: cleaning up, other b. NO
reguiatiom)
Other than the mles we've already tdked about, are
there a~grother d e s you have for *****'s
behavior? Do you usudy try to get himmer to
follow thew?
Are there simiiar rules for the other members of the b. NO
family? Do you usually try to get them to follow
them?
s c m v. IN THE HOME?
1. PC does not shout at subject during the visit. a. YES
b. NO
2. fC does not express overt annoyance with or a. YES
b. NO
3. PC neither slaps nor spanks-subject or any other a. YES
fmdy member during the Visit.
b. NO
4. PC does not scold or Criticize or put down the a. YES
subject during the visit.
b. NO
5. PC has not lost temper with subject more than a. YES
us w&.
I'm sure ***** docs things that are annoying. Do b. NO
you ever lose your temper with himher? @ow
about in the past week?)
6. Subject is dowed to express negative f e h g s a. YES
toward PC or can disagree with PC Without harsh
reprisal. b. NO
W b c ~***** gets angry with you or says something
mean, or dkaqms with you, how do you handle it?
7. PC reports that ILQ instance of physical punishment a m
occurred 7.
Have you had to physicaIly punish or spank ***** b.NO
** 1. At least &Q books are present and visible in the a. YES
home. (ffnot visible ask:)
Do you get a chance PO rend? Do you have a place b. NO
you keep books?
1 ** I 3. PC introduces interviewer to subject. I a. YES

+/F6- 3
4. PC or other family member buys a newspaper daily
j4F8-4
5. PC or other family member subscribes tohuys one
voked in amy rdigi~usor community
8. PC has not cried or been visibly upset in subjects a. YES

presence more
tsa-t week.
When YOU feel unhappy or sad, do you let ***** see b. NO
your feelings or do you try t~ hide them? Have you
cried or been very upset in front of ***** recently?
(when?)
Introduction: Mow I'd like to ask ~ about d i i k e n t ressponsibi8ities ***I* wight have.
Q U
om SCALE 'diI. IN THE HOME? SchooV

FOSTERING INDEPENDENCE [CIRCLE ONE] Dav Care
I
subject -ast v a
concerning sexuality and personal
hygiene.
In the past year have you discussed
with ***** the responsibilities and
with health and safety

emergencies in an age appropriate
manner.
Dots I****b o w what to do in an
D o you show *I*** Bow to cook and
4. Subjecthas-
Does ***** have any weddy chom

or responsibilities? i
5. PG expects subject to put outdoor a YES
dothing, dirty clothes, and night
clothes in specific piams. b. NO
Is ***** expected to pick up after
hiderself?
6. PC allows subject to visit with a YES
fiends outside schooVday care
Ce each. b. NO
Does *****. visit with fiends outside
af school?
5%
i
OBS SCALE W. IN TfE HOME SchooY
FOSTERING IMDEPENDENCE [CIRCLE ONE] Day Care
L
1

hidher toydtreasures or
belongings. b.NO
li I belongings?
TIME STOPPED
n OBS
dangerous structural or heaith hazards.

h . 8 - ../ (eqosed outlets, broken windows, windows
** 2. House or apartment has 8s least 100 square
+*
**
**
*I
9. Household members do not use tobacco.

1 b. NO
10. There are no obvious sips of recent alcohol a. YES
home.
( h g puraphemlia, beer cans, liquor

[ E X m O R OF HOME]
Date: -, - -
,
mm dd w
(CIRCLE ONE)
iqTimeof day: ~nteredhome:
Lefc home: -e- AM PM

hrmin
1. Though - straight
2. Through - curved
3. H-layout
4. T-layout
5. L-layout
6. Cul-de-sac
7. Boulevard
8. Divided Highway
~
9. Other
Mow would you characterize the land use on this face-block, based on m t - l e v d
f/F9-z 2.
frontage?
2. primariiy commercial
4. Primady industrid
a. primarily park, playground
9. Other
How wcdd you rate the gene& condition of .DLPS~of h e housing Units or other buiidings
hF9-3 3*
in the faceblock?
1. Well kept, g d repair

2. Fair condition
1. NOIE
2. Some
3. At least W
4. Most
1. PJlOlraffiCpcrIni~
2. VeryIight
3. Eight
4.. Modcratt
5. Heavy
6. Verykvy
7YF9-6' 6. How would you rate the condition of the street in thc fact-block?

7. Is there garbage, litter, or broken glass (except becrfiquor bottles) in the street or on the
H ? R7 sidewalk?
>

3. Yes, quite a bit
4. Yes,just about everywhere
8. h e there drug-related paraphernalia, condoms, beer or liquor containers or packaging,
cigarene butts or discarded cigarem packages in the street or on the sidewalk?

3. Yes, quite a bit
4. Yes,just about everywhere
HE?-9
No children visible, or ail in yards
17>$
1.
drinking, or behaving in any-kindof hostile or threatening way?
1. No persons observed in the strext or sidewalk

4. Yes, three or more behaving in a hostile k r
11 How did you fed parking, walking, or waiting at the door in the face-block?
#F9- /i
1. Very comfortablc: can imagine living/working/shopping here
4. I would De uncomfortable living/worbg/shopping here
5. I felt afhid for my personal safety
f
SCHOOL SCREEN
1
SCHOOL SCREEN:PC [9-15]

Date: %9TE
mm dd yy
1. Does ***** currently attend school?

Why is ***** not in school?
3. what was the last grade ***** was in?

grade
~~ ~~
ed. init. ed. date

2
2.
Address
3.
- 4.
-
5.
4
'I City State
10. what is *****Is school ID number?
11. What type of school is it?
14. In the past year, was ***** ever truant (skipped school without au excuse)?
1. YES
2.NO
3
34/5- 15. On the average, how often was ***** truant? (Circle one)

b. once a week
d. once a month .
* j f 3 figf 16. In the past year, did ***** ever skip classes without an excuse?
1. YES
2. NO
17. On the average, how often did ***** skip ciasses without an excuse?
a.
b. afiwtimesawak
. c. onceaweek
e. onceamonth
f. ahtimesayear.
4
18. Thdang back to the iast year ***** was in high schooY grade school, W ~ S
***** ever truant - skipped school for the whole day without an excuse?
1. YES
2.NO
Sz3 /gi f
19. How often did ** * * skip school for the whole day without au excuse?

b. onccaweek
d. onccamonth
e. afewtimesayear.
*r&
dzc 20. Thinkiag back to the last year ***** was in high school/ grade school, did *****
eva skip ctasseswithout an cxcusc?
&-& R / 21. How often did ***** skip classeswithout an excuse?

a everyday
b. ahtimesaweek
c. onceaweek
d. ahtimesamonth
e. onceamonth
f afewtimesayear.
&fa A X 2. Has ***** ever skipped a grade? 1. YES 2. NO
.s43 6-5 3 23. Has ***** ever repeated a grade? 1. YES 2. NO

5
24. Many students receive special teaching or help in school. At any point since
***** started M e r education has dhe received any help or special teaching in
-
(Read aloud circle all that apply.)
a. Giftedciass 1. YES 2. NO
b. Special remediation clasdtutoriag program 1. YES 2. NO

c. Learning problems 1. YES 2. NO


Limited~Speahcing
E sptechthcrapyciasses 1. YES 2. NO

sight problems
h Emotionalor behavior problems 1. YES 2. NO

i. Speual d c or art school 1. YES 2. NO
j. Spccial science program 1. YES 2. NO
71
6
S,3 A rj- 25. Wadis ***** routinely involved in extmamicular activities directly connected
with M er school, such as school sports teams, school clubs, music groups, etc.
1. YES GU'TOQ. 26
2. NO
t
27. What kind of program wash this? (Circle all that apply)
1. Rtcreational (sports, games, crafts)

3. Academic mrichmmt (tutorin& classes)
4. other@leasespccify) L8~Z&dd4L -6 @kt5
28. Was& ***** involved in any other kind of after school program?
(This may be at *****'s school, but is more of BII after school program rather than
~clllaractivity.)
30. What kind of program d i s this? (Circle all that apply)
1. R#xeatioaal (sport& games, crafts)

2. Artistic (music, dance, aft)
3. Academic earichment (tutorins, classes)-
4. other (please specify) YLL&i&'k &*%5.z&&)&?&
J I
72
7
73
8
For U s only: for Elementary and High School type, use the following codes:
1 -Public
-
2 Catholic
-
3 home school
-
4 p r i m , non-Catholic
-
5 Other (please specify)
b. Elementary School (hdudinp:Kindergarten)

1 School Name I I
Address (include city, state) School type Datesenrolled I Grades I
74
9
For RAs only: for Elementary and High School type, use the following codes:
1 -Public
-
2 Catholic
3 - home school
-
-
5 Other (please speci@)
c. Highschool
I School Name I
Address ( i d e city, state) School type
3.
+
10
How often do you attend scheduled pared teacher conferences? (Read choices.)
1. almost always
2. often
3. seldom
4. never
S B 3 3 33. How often do you attend PTA meetings, local school council meetings or any school
?
1. almost always
2. ofim .
3. seldom
4. never
34. How would you describe the education ***** is receiving in his/ her CUfTent school?
5 3 39 (Read choices.)
a. d e n t
b. good
c. fair
d. poor
I ENDOFINTERVIEW RECORD TIME: I

F M L Y STRUCTURE &
ALTH HISTORY
36
'q f
Now 1 would like to ask some questions about *****IS family. This year I will only be
getting a general outline of who is in the family. Next year we will come back to this
M,
let me review a few details.
1.A You told me earlier that you are *****!s:

F-73 f A 0 (READ AFdD CIRCLE APPRQPlRzATE CHOICE)

c. f e d e m u s i n f. sister i. other ~~~~~ * pdd
1.B You told me miier that you am *****k
FA 1/50 (READ AND CIRCLE APPROPRIATE CHOICE)
b. foster father e. grandfather h. uncie
c. malecousin f. brother i. other $ 4 f z . 5 2 L & Gi+U
T +r %p -d
b that right? Y N -
ed. init. ed, date

ri3 - d 3.1 How old is he? DON'T #NOW
(years old)

P!7
j 3-@L (years old)
__
cj5 9.-
4 4.1 What is your marital status with *****IS biological father?
lb divorced
2a never married-stiil involved
2b never maulid-no longer involved
4.2 Wm was your marital stc~nrswith *+*+*Is f'her when he died?
1b divorced

2. Yes
5.2 Were you living With*****Is

biohgicalfather when he died?
3

@ear>
6.1A How much time has *****s biological father spent with hidher in the past year?
F6 6-i d 0
a. none
b. intermitrent and unpredictable (less than once a month)
d. o m a month
e. twice a month
f. once a week
g- M Y
h. other
6.1B How much time has *****s biological father spent with himmer prior to the past
6-/ A 3 0 year?
-
a. none
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
3
a. none
d. once a year
e. twiceamonth .
f. once a week
g- M Y
.-
h. other
z$j 6- &o 6.2B Before he died, how m h time did *****Is biologicalfaher spend with himfherprior
to the past year?
a. none
d. once a year
e. twice a month
f. once a week
g- M Y
h. other
.e
A B - c
7.1 Name: D.Q.3 Gender: M/FF;9ZfC(
7.2 Name: D.0.B Gender: M/F F&?-dc:

- 8
$--,I3 Does he/she have any siblings? 2. Yes 1.No
or each one, I need to h o w their name, age, whether they are a boy o r a &l,
whether they are a biological, step, foster, or adoptive sibling of *****
whether they are sttill E m . E *+*** has s i b h g s who have a partner o r a$,
7
1
WU need to ask you some additional questions about them. Why don't you start
I f wtth the oldest sibling?
7
BROTHERS SISTERS
cause of death:
L~U&JC&L~
FA86eS?'s/ *.

bio'l mom's name: ~&@et@~ed
bio'l dad's name: &;,~e& / *
- NAP
cause of death: J
/Acw?mz-&tA'
Fdg &be A5 il

bio'l mom's name:
bio'l dad's m e : ,&,e&&&&&
- NAP
6
BROTHERS SISTERS
. ......
........... ... ..
- NAP
BROTHERS
-NM
.. .
BROTHERS SISTERS .
~rnname: A?,O~&
living: Y N agdage d i a i : a w g
Cause of dea,th: m m 9 . came of death:
FA8RZ9S / '
bio'l mom's name: * f P - d bio'l mom's name:
bio'l dad's name: .d/JZfl&
f b
bio'l dad's name:
- NAP
W6'Y N
F&@/575 F.&PiX-;zS
age: gender: M/F
Children? Y N F&B~~?S
cause of death:

bio'l mom's name:
bio'l dad's name:
partner? Y N age: .-gender: ME partner? Y N age: -gender: M E '

# giris: b # boys : b # girls: # boys :
+
- 9
F6 9. YOUmid me about ( R E D N M E S OF SIBLINGS). Are there a y

other sibiings of =++**,either yours or T*****' s bioiogical father's children, that you
10. Have you been married to anyone other than biological father or lived with
El3 40
*****IS
(CIRCLE ONE)
1. - NO:
2. -YES:
1QA. How many other relationships have you had?

# of relationships
10B. For each of the people you had a relationship with, I need to h o w their fust
name. I also nesi to know whether you were married or living with them and
whether you are stiU in the relationship. If the relationship has ended, I need to
h o w if it was due to divorce, separation or being widowed.
1. Gender: M E
la married-still involved - 2a never married-stilf involved

1b divorced 2b never married-no longer
-
2. Gender: M E .I *
first name
-
4 kL
la married-still involved- 2a never married-still involved

IC married, but separated invorved
Id widowed . 2c never married, partner died
3. Gender: M/F .1
fmt name
la manied-still involved 2a never married-sal involved

IC married,but separated involved
Id widowed Zc never married, partner died
4. Gender: RI/F -1
la married-still involved 2a never manied-still involved

1d widowed 2 s never married, parmer died
5,. Gender: M/F .1

firstname -
la married-still involved 2a never manied-still invoived

Id widowed 2c. never married, partner died
00
11
f& fD& k@fb la married-still involved 2a never married--still involved

l b divorced 2b never mmiedao longer
Has ***+*Is biological father been married to anyone or lived with someone else as a
1 -DON
2 - NO:
3 - YES:

# of relationships
113. For each of the people *****Is biological fithers had a relationship with, I
need to know their...first ..... .,. . I also-needto know whether he was married or
............name.
m;w$
.
f i v e with &em ....-..-.-......
,,,,
...-
a in the r&tionship]. If &e
a d whether he is s
reiationshq has ended, I need to know if it was due to divorce, separation or
being widowed.
1. Gender: M E .1 ---%?5
frst name
l a married-still involved - 2a never married-still involved

parmer died
2k don't know
la manied-su21 involved 2a never married-stiU invoived
partner died
2k dont know
3. Gender: M E .1

partaer died
2k dontknow
4. Gender: WF 1
first name-

partner died
2k dontknow
5. Gender:. M/F .1
first m e
la married-still invoived 2a never married-stiU involved

l b divorced 2b never mrried-no longer
parmer died
2k dontknow
13
6.Gender: M/F .1
~6 ~ / d la married-still invoived 2a never married-stiIl invoived

l b divorced 2b never manid-no longer
IC married, but separated irrvolved
partner died
2k dont know
.1
,CB f
f ~7 la married-still involved 2a never married-still hvolved
partner died
2k dontknow
&=?e. 12. - is *++++'s
fmt name
.
f.3 - j'- 13: 1 How oid is she? DON'T KNOW

5 (years old)
'4
13.2 How old war she when she died? DON'T. KNOW
(years old)
lb divorced
14.2 @ut was your marital s c m u ~With *****'s mother when sfre died?
l b divorced

2.Ys
-
15.2 Wen?you living With *****'s

biologicd-motherwhen she d i d ?
15
!5A. Ws there a time that you lived together? 1.
Q
if
a y e or Q.
2. Yes t B Q . EM
15A1. When did you stop living together? (Year>
16.1A How much time has *****s bioiogical mother spent with fummer in the past year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
16.1B How much time has *****s biological mother spent with him/her prior to the past
:z5f6- mo
a. none
c. intermittent at set times (less than
- once a month)
d. once a month
e. twice a month
f. once a week
g-
h. other
53
a. none
d. once a year
e. twice a month
f. once a week
g- M Y
h. other
-_
16.2B Bgforc she died, how much rime did ***+*s biological mother spend with himher
=45 7.25- A /a0 prim- to the part year?
a. none
b. intermittent and unpredictable (less thao once a month)
d. once a year
e. twice a month
f. o w a week
g. M Y
h. other
17. D m ***** have any children of hisher own?.
children? 2.Yes 1.No -

A c
Gender: M/F
D.0.B- L Gender: M/F

17
Does he/she have any siblings? 2.Yes I .NO
For each one, I need to know their name, age, whether they are a boy or a &I,
whether they are a biological, step, foster, o r adoptive sib- of *****7 and
whether they are stiil living. If ***** has SibEngs who have a partner o r child, I
will need to ask you some additional Q.s about tfran. Why don't you start with
- 3
'# + the oldest sibhg?
BROTEERS SISTERS
# ~ name:
b # Is name: L4?ze&mLI P 7 3 7 a
IC living: Y N agelage died: Ffif8Alfff. livmg: Y N agelage died:A5iS&G
cause of death: A4Y8ABJk cause of death: mj/&4..75
/Y L
FZ3 A9R S, 1"s
bio'l mom's name: d e P ! bio'l mom's name:
bio'l dad's name: a bio'l dad's name:
- NAP - NAP
g 7.3~//3 ,e3/&&% BA'P4
partner? Y N age: Fender: M E
Children? Y pi F & / ~ K Z ; / / ~
' # giris: ' # boys : &&&%227'23
#2b name:
living: Y N agefage died: ,49/&M+
cause of death: FRHAW&5
6 i H N d ' -
/ J

bio'l morn's name:
bio'i dad's name:
- NAP
45
-
BROTHERS SISTERS
# 3 b name: 6&4?+9#& # 3s name:
living: Y N
9
living: Y N agefig= diexi: agtjage d i e d : & k ~ 3 4

cause of death:
:
-/cm3k3 cause of death: F&*ABSS
a224.W9&
fA-/ae& 5'
+
FA &?&Z 323 3
bio? step? foster? adop bio? step? foster? adopt?
- NAP - NAP
# 4 s name: n
living: Y N agefqe d i e d : B B h 4 ' 9

cause of death: F&t?Am4S
k
Fi 18R14S
bio'l mom's name:
bio'l dad's name:
- NAP - NAP
BROTHERS SISTERS
# 5 b name: -0
living: Y N agefage died: Fh='&W5k

cause of death: Fb/@-5&
-d
FAf&#e&5k3
bio? step? foster? adopt? *
bio'l mom's name: bio'l morn's name: &
- NAP
F&/IRS 6-s
-
20
BROTHERS SISTERS
7s name:
living: Y N age/age died: F M M Z
cause, of d a h : A3&4Wd
FA/8RS4ZA - F&-,as 3
: '
bia? step? foster? adopt?
~
bio'l m&'s name: bio'l mom's name:

bio'l dad's name: bio'l dad's m e :
- NAP - NAP
F&/&M9& F;8kP/?S FaAPR&?6
Children? Y N F A / $ L X Z ~ . S
# girls: -
. *#boys: E6/iQ/SD+&
#8b name: #8s name:

1iVing:Y N agehgedied: living: Y N agehgedied:
cause of death: cause of deatk

- NAP - NAP
panner? Y N age: gender: prp/F partner? Y N age: vender: M E
# girls: ,#boys:
,
-
, .#girls: *#boys:,-. .
21
19. You toid me about (READ NAMES OF SIBLINGS). Arc there any
F& f l other siblings of *Or**, either YOUS or *****s bioiogical mothers children, tbar you
20. Have you been married to anyone other than *****sbioiogical mother or lived with
F23hO
someone else as a partner other than the relationships youve just toid me about?
(CIRCLE ONE)
.... ............... ... ......
1. - NO:
..
2. -YES:

F23PaOM
# of relationships
20B. For each of the people you had a relationship with, I need to know their f i t
whether you are still in the relationship. If the relationship has ended, I ne!&
1. Gender: M/F .1
fmt m e
la married-stiU involved 2a never married-still invoivd

49
3. Gender: M/F .1 -d
fmt name
la married-still involved 2a never married-stiil involved

4. Gender: MfF .1 dk++vd

first name

-
5. Gender: M E .I
la manied-still involved 2a never married-stiil involved

Id widowed 2c never married, panner died
6. Gender: M/F .1
first name
la married-stiil involved 2a never married-stiii imolved

23
F& la married-still invo~ved 2a never married-still involved

l b divorced 2 b never married-no longer
-
F&&# 21. Has *****'sbiological mother been married to anyone or lived with someone else as a
1 - DON'T KNOW
2 -NO:
3-YES:

# of relationships
21B. For each of the people *****IS biological mother had a relationship with, I
need to know their fmt name. I also need to know whether she was married
.................... ..:._......,. .
or living with them @E;-$
............ ....................
<
.-.. a d whether she is still in &e relationship].
1. Gender: M/F .l
first name

Id widowed - 2c never married, either
pamxr died
\ 2k don'tknow
24
2. C-ender: WF .1 h -
frst name
la married-still involved 2a never married-stiil invoIved

IC married, but.separated involved
partner died
2k don't h o w
3 . Gender: M/F . .I-

frst name
la married-still involved 2a never married-still invoIved

Id wjdowed 2c never married, either
partner died
2k d o n ' t h w
4.Gender: ME -1
fmt name

partner died
2k don'tknow
5. Gender: M/F .l
fust name
la married-still involved 2a never married-stiil involved

IC marrid, but separated invoived
parmer died
2k don't know
25
4. Gecder: M E .1
' first&e

.lb divorced 2b never married-no Ionger
partner died
2k don'tknow
7. Gender: M/F .1
la bnnied-still involved 2a never married-still involved

partner died
2k don't know
26
b/fed- 22. What is **+**'s biological mother's name? DON'T KNOW

fmt: name
5&3- f 23.1 How old ,isshe? DON'T F3lOW

(years old)
23.2 Mow old wlz~she when she died? DON'T mow

(years old)
32+- / A 0 24.1A How much time has a**f*'s biological mother spent with himmer in the past year?
-
a. none
b. intermittent and Plnpredicbbie (less than once a month)
c. intermitent at set times (less than once a month)
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
24-13 How much time has *****'s biological mother spent

-
with himlher prior to the past
5 2 4 - fE30 year?
a. none
c. intermittent at set times (less -&an Q= a month)
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
27
Ft3 A4- &A@, 24.2A B q h she died, how much time did s mother spend wirh himher in the
*****I
pmt year?
a. none
d. once a month
e. twice a month
f. once a week
g. M Y
h. other
24.2B &$ore she died, how much time did +****Is biological mother spend with
%5 24- L h U hidher pnor to the parr year?
a. none
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
d a p 25. What is *****IS biological father's name? DON'T KNOW

fmt name
rBA.6 - +. 26.1 How old ishe? DON'T KNOW

(years old)
26.2 How old WLZThe when he died? DON'T ISNOW

%5;z6 - 625 (years old)
a. none
b. intermittent and uqredicrabIe (less t b n once a month)
d. once a month
e. twice a month
f. once a week
g. M Y
q h. other
27.1B How much time has *****IS bio1ogica.I father spent with himfher prior to the past
year?
a. none
FA3 R 3 - /Bo b. intermittent and unpredictable (less than once a month)
d. once a month
e. twice a month
f. once a week
g. U Y
h. other
27.2.4 Before he died, how m h time did *****'s biobgicai faher spend with
himher in the past year?
a. none
F b # Z ? - 298 b. intermittent and unpredictable (less than once a month)
d. once a month
e. twice a month
f. once a week
g- M Y
h. other
. 70
-/
27.B Bqbre ,TIS died, how much r i m did s biological faher spend wi;h
hiidher prior to the p a t year?
55 , Z 7 - P Z A O -
a. none
b. intermittent and unpredictable (less than once a mona)
d. once a month
e. twice a month
f. once a week
g. daily -
h. ot6er
_-
I/
28.1 Are ****+'s biological parents living together now? 2.Yes 1. No 3.DON.T
3A!g--/
KNOW
28.2 Were +***+'J biological parents Living together w k n **+**Is mther/father

died?
29.1 What is the marital stam of *****'sbiological father and mother?
la married-stiU involved
lb divorced
-;s 29- a/ 29.2 Gvhm was The m l a l stmus of *****'s biological faher and mother when
****+'s mother/fmher died?
lb divorced
IC manied; but separated
2b neve: married-no longer 3nvolved
30
Does he/she have any sfbhgs? 2.Yes 1.No 3. DON'T KNOW
For each one, P need $0 h o w their name, age, whether they a r e a boy o r a @I,
whether they are a biologid, step, faster, o r adoptive Sib- of I*+*+, a d
whether they EW? stizl E-. If"*** fias siblings who have a partner or child, I
will n e d t o ask you some additional questiom about them. Why don't you starl
- ,
$, 5
with theoldestsibihg.
BROTHERS SISTERS
-'.
#III name: ~%d #~sname: d v d

F5 30Li living: Y N age/age died: F/350&/8/ living: Y N agelage died:/r&3M?
cause of d a h : F&S&B#% cause of d a h : &33Qh?XY;/S
d R e d
# #
FA3BE2-255 F#JO&2/S
I - NAP
- 31
Q. 30 Continued I
BROTHERS SISTERS
# 3 b name:
living: Y N
&e
agefage died:
# 3s name:
living: Y
FA 5.D.4B3.5 cause of death:
cause of death:
&-&%?a%&/
FZJ3SSeG 3s
Y* I/'
m<i@&.g 313
bio? step? foster? adopt? bio? step? foster? adop
bio'l mom's name: . d w bio'l mom's name:
- NAP
!%3Q&?&S W Y 3 s A??*KJs
pattner? Y N age: gender: M E
Children? Y N F A ~ C P L / ~ S
living: Y N %&&e died:

cause of death: F,Samqs
&
?%3O&S&S
bio'l mom's name:
bio'l dad's name:
BROTHERS SISTERS
# 5 b name: &-
& # 5s name: P ?
living: Y N age/age died:rA.%XJA5-- living: Y N age?& died. FB ~OHHS:
cause of death: F&S'OU*5& cause of death:
K
F& .3oaes 5
43 ifi3245 5-s
/ "

- NAP - NAP
Children? Y N F&.3'Oki/5-&
* # girls:- '# boys : +=om523
cause of death:
R330A2 6 5
bio? step? -foster?adopt?
bio'I morn's name:
- NAP
& 3DPH6s F23SOM6.S A53Op& 6s
partner? Y N age: -gender: MIF
33
BROTHERS SISTERS
#7b name: 4-d # 7s IliLme:
living: Y N agehge died;tZW?W living: Y N &&age died: B . ~ M X
cause of death: F& 5 m - 3 / 3 cause of death:
J J
FR3C,7/3EE. FASORE35
bio'l dad's name: bio'l-dad's name:
f=&jOP.4 F&Xw&y& FRdD Fw 3;s

N c&;4c~"/i'S
living: Y N age/age died: Mug: Y N age/age died:

- NAP - NAP
mrmer? Y N age: . . gender: WF p m e r ? Y N age: .-gender: M/F
'# girls: '# boys : # girls: * # boys :
34
Fe 3j 3 1. You told me about NAMES OF SIBLINGS). k e there any

other siblings of ***** that you may not have menrioned?
2.Yes 1.No 3. DON'TKNOW
For definitional purposes "partner" here refers to a s e d relationship with someone of &e
beinp married to m e r at that time, I
~ f i 332.~ Do you know if either of *****Is biological parents were married to anyone else or
lived with someone else as a partner? (CIRCLE ONE)
1 - DON'T KNOW:
2 - NO:
3 - YES:
Ffi sa Ab&/ -r Bio mother: # of relationships
FA332 &A=/ Bio father: # of relationships
32B. For each of the people [the biological mother/hther] had a relationship with, I need to
know their fvst name. I also need to h o w whether [shehe they] [were/was] married
or living with them w$mi
.................................................
<
A
,
.
.-
.
. ...................... a in the
and whetfier [she/he/tfiey] [is/are] s
relatiomhip]. If the relationship has ended, I need to know if it was due to divorce,
FR s a , - s / l ; r ~ l la married-still involved 2a never married-stiU involved

partner died
2k don'tknow
35
2 . Gender: MIF .1 +&-L
frst name
la married-stdl involved 2a never married-still involved

partner died
- 2k dontknow
3. Gender: -M/F .1
la married-still involved 2a never manid-still involved

partner died
2k dont know
4. Gender: M/F .1
frrst name

partner died
2k dont know
5. Gender: MIF .1
first m e

partner died
2k donthow
36
~ & 3 2 3 , , y ~ &la- manied-sri21 involved 2a never married-still involved

-
partner died
2k don'tknow
f
'a#
7 . Gender: MfF .1--

r/33&2dM6 ? frrst name
-
F& 3~ /gjy#$ la married-still involved 2a never married-still involved
partner died
2k don't know
Biological father:
1. Gender: M E .1
+.3 3L A X l F i .
first name
pfi 3~ JL/~ la married-still involved 2a never married-still involved

lb divorced 2b never marrid-no longer
partner died
2k don'tknow
F . 3a &=A 2. Gender: M/F .I

fmtname -
362 &a /Y& la married-still avoive 2a never rua~A-stil1 ,.ava,~ed

Id widowed 2c . never married, either
parmer died
2k don'tknow
3. Gender: M/F .I
- fxst name

partner died
2k don't know
4. Gender: M/F .1
first name

partner died
2k don'tknow
5. Gender: M/F .1
fmt name

lb divorced 2b never married-nolonger
partner died
2k don'tknow
\
6. Gender: M/F .I h w
frsr name
la manied-still involved 2a never married-still invoived

partner died
2k don'tknow
-.1
fmt name

id widowed 2c never married, either
partner died
2k don'tknow
33. How old was ***** when he/she fmt came to live with you?
Age
39
34. What circumstances led to +**+*riving with you?

(WRiTE i N RESPONSE AND CIRCLE CODES)
1. biological mom died 9. biological mom hospitalized. substance use

4. biological dad in prison 12. biological dad hospitaIM. medical reason
5. biological mom abandoned ***** 13. biological mom hospitalize& psychiatric
/7
7. biological mom in another country i
L
15.1 biological mom lost custody(specify reason)
8. biological dad in another country YG*,.di!&
/161 biological dad lost custody (specify reason)
l-,' i/apcdh
$
J other reason (specify reason)
Ua/Rc*Cdh h m !
/'
40
FA 35- 35. ~a **+=*always lived with you since h e first time s k 5 e came or have ere been
pericds during whch she5e did not live with you? (CIRCLE O W )

354. Describe other living arrangements-since***** fmt &e to h e with you:

41
wow I have some questions about the t i m e sin&? **=+*fm m e to Bye ~& you.
Ffi 36- 36. I need to know whether you have lived with anyone zs a partner while **++=has b e n
... ... . .
1 -NO:
2 - YES:
How many relationships have you had during this time?

# relationships
For each of the people-you had a relationship with, I need to know their frst
name. I idso need to know whether you were married or Iiving with them and
whether you are still in the relationship. If the reIationship has ended, I need
1. Gender: M/F .1 -4 m ,
first name

2. Gender: hU3 1
--
first name

3. Gender: M/F .1
frst name
la married-still involved 2a never married-still i n v o I v ~

149
42
4. Gender: M/F .1 +&

first name
la married-stiil involved 2a never married-still involved

5. Gender: M/F .I -&

- fmname
l a married-still involved 2a never married--still involved

l b divorced. 2b never married-no longer
6 . Gender: M/F . l e
first name

IC married, but separated invohed
Id widowed 2c never man-ied, partner died
7.Gender: M/F .1
first name
la married-stiu invoived 2a never married-still involved

l b divorced 2b never manied-no longer
IC d e d , but separated involved
ld widowed 2c never married, partner died
43
37. Ems **=** regularly spend any nights of the week in another household or anywhere
else? does not include day w e ]
2.Ya 1.NO
t *****
B = biological barent, sibling,
N = nonbiological aunthcle,
M = materna.. grandparent, child,
P = paternal other]
.1 Name L BorN MorP
E Other relation
-
E Other relation
IF Nightseachweek N3S-AF
G Nights each month: B 3 57-
H Other arrangement: FB .331- 2 9 I
.3 Name BorN MorP
E Other relation .-
-I I
F Nights each week F/3 3-7..3
G Nights each month: F/33?- 3s
H Other arrangement: s&$7- 3H
44
38 . Ia *++**'sentire family ..... inchding anyone: pzrents, siblhgs, yourself, zunfs,
who is **++*particdariy dose to? You can list as many people as you W a l t - anyone
in &e family who you think ***** feels dose to.
to *e***
B = biological . [parent, sibling,
N = nonbiological - aunt/uncfe,
M = maternal gmdparent, child,
P =paternal . other]
A B c D
FA 3&J.k3 fz33&Jii
-1 Name BorN MorP
.2
.3
.4
.5
.6
-7
.8
-9
.S,./U& ~ j O i 5
.10 Name BorN MorP
45
39. Now I need to list dl the people who Eve in this household except for *++*+.For
ga& pernon who h e s here, I would like you to tell me how he o r she is rekited to a****.
For example, P want you to tell me if t h e person YOU list is *****IS b r a ~ e ror ailILt or
~ o u ~ i nEven
. if a person who Lives here is not related to *****, I need you to List t h m
also.
. B = bioiogical Eparent, sibling,

N = nonbioiogical
M = mted grandparent, child,
P =paternal
.1
.2
.3
.4
.5
.6
.7
.8
.9
\
.IO
.ll
.12
46
Diabetes: ( M e one) 2. Yes 1.No

. [Sugar Diabetes, Sugar in BIodUnne]
'I
A B C D
-1
-2
.3
.4
.5
.6
.7
.8
\ '9
-10
.iI
* 12
47
41. &$Blood fissure: (&de one) 2. Y s 1.No

/Eypertenrion]
B = biological barent, sibling,

A . c D
.3
.4
.5
.6
.7
.8
.9
-10
-11
.12
\
-13
* 14
48
grandparent, child,
.1
.2
.3
.4
.5
.6
.7
.8
.9
-10
.ll
* 12
-13
.14
49
grandparent, child,
-
#,' 'I
.1
.2
.3
.4
.5
-6
.7
.a
-9
.10
R W to *****
E = biological Cparent, sibling,
N = nonbioiogical aunthcle,
P =pated self, other]
. I
52
to *****
B = bioiogical barent, siblmg,
N = nonbiologid aunduncie,
M = matfmal grandparent, child,
P =paternal . self, other]
B
- d
?.$.
A C D
F&4?6-fi3 FZS46-/C
.I Name BorN MorP
A B C D
FNd-AA &346-.Lc
.2 Name BorN MorP
E ILLNESS @lease specify):

Y "
a B C D
.3

A B C D
44i-44 F&&t-
F/(3
.4 Name BorN MorP d u
Y f
A B C D
-5 Name &qd BorN MorP
E ILLNESS @lease specify): dae%wd

LEGAL HISTORY
Now Im going to ask you some more questions about all the people in * * + * * s I y o u ~
%.9
J+Yd 1. Has drinking ever caused any of the people mentioned to have problems with health,

M = materna!
A B C I)
F&/- 7x3
-1 Name d B or N
FH#-&:A
.2 Name 3 or N
FAY/- 5/3
.3 Name B or N
43 FWf-
.4 Name dmPZ%%&B or N
FM/- 5-23
.5 Name -
IC& B or N
-6 Name &&&/-?;---;$
/ /
F&//-923
.7 Name B or N
FHY- @A
.8 Name B or N
2
&
z
, 2. Ea drug use ever caused any of the people mentioned to have problems with h d t h ,
2.YES 1.NO
A B C D
FjYd-fA
.1 Name -dG B or N
3
FH3 3. Has anyone mentioned ever suffered from depression, that is, they have felt so Iow for a
period of at least two Weeks that they hardly ate or slept, or couldnt work or do wh-
dtever
- usually do?
they
2.ES 1x0
to *ti**

. P =paternal - other]
A B C D
1-35
4
F& .$. 4. Has anyone mentioned ever had frequent trouble with the law, often became involved in
fights, had trouble holding a job, or was a frequent discipline problem in schml?
2.YES 1.NO
R W to *****
A B C D
/& F M 4 - ?C
.1 Name BorN MorP /+y&-
5
&jg- 5. Has anyone mentioned ever had problem with their nerves or had a Eervous breakdown?
2.YES 1.NO
R e b to ****+
N = nonbioiogical aunthncle ,
P = paternal other]
A B
Ay5-?#
-1 N
,m
a-.e B or N
FNs:&&
-2 Name &@WPd B or N
F / Y L 366
-3 Name B or N
.4 Name
.5 Name
FM5- 64
.6 Name B or N
CrW 5-
.7 Name B or N
CM 5- &A
.8 Name B or N
/=HK923
B or N
6
problem or probiems they might have had with alcohol or drugs?
2.m 1
B = biological
N = nonbiological
i
M = maternal
A B C D
.lName A+@** ;d/ BorN MorP

/qy6--,&3 ,g/Y6.--dc FM6- A%
A IB C D
.2Name & BorN MorP
E Reason for treatment: d e

54
/=44&-.. F W C 3c F/LfG- 3w
A B C D
.3Name dkG%hW-@L BorN MorP

RYL Q . FMJ-+e /=MC 9%
A B C D
.4Name d e ~ * t ! B~
orN MorP

F/ydE-z-j-& .cF/g- 5c F/2/8.-5-53
.5 Name BorN MorP
.6 Name BorN MorP
138
FM .F 7. Has anyone mentioned ever been hospitalized because of emotional problem, or bemuse
2.YES 1.NO

N = wnbiological auntfuncle,
P =paternal .
BorN MorP
A B C D
.2~ame E& BorN MorP
.3 Name BorN MorP
.4 Name BorN MorP

-5 Name BorN MorP
.6 Name

8
8. Have any of the people you've medoned ever attempted suicide?
2.YEs 1.NO
to *****
B = bioiogical , [parent, sibhug,
N = nonbioiogical . aunduncie,
'I P = paternai other]
?
9
/"fig 9. Hweany o the people you've mentioned ever commined suicide?
2.YEs 1.NO
B = biological- [parent,sibling,
N = nonbiological aunt/uncie, .
M = maternal
A B C D
9A. So, none of the people mentioned have had any problems with aicohol or drugs,
(CIRCLE O W )
1 - no one else

Figfits, frequent trouble with law, trouble holding a job - page 4

Drug use caused problem with health, family, job, or police - page 2
Drinking c a d problems with health, family, job, or police - page 1
- 11
Now I have surne quesi5ons about whether there is anyone mentioned who has had
troubie w i t h the police o r who has been arrested. Please do not indude routiae t r a c
fflfa 10. Has anyone that youve meationed had trouble with the police or been arrested? (CIRCLE
o w
1. NO:
10A. What is &/her name and how is he/she related to *****?

FMa4L. FM@A 3 F/yfD&.4/
1 2 3 4
B or N M or P
Name Relation
ZOB. Do you know what he/she did? (CIRCLEONE) 2 . w 1.NO

....................................
10Bl. .......................
\
what did he/& do?
&d
r * v
1OC. And were there any other reasons hdshe was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
................................... .:
lOC1. .E
........Y
.. E
.: 2 3 What other offenses led to him/her having trouble with thee police?
..........
10D. Is helshe in jail or prison now? (CIRCLE ONE) 2.YEs 1.NO

12
fy 11. Has anyone else had trouble with the policc or been arrested? (CIRCLE ONE)
1. NO:
2 . . YES
11A. What is hisher name and how is heishe reiated to *****?

?,$f
F.fj&A FN64x13 f-fyflw

1 2 3 4
B or N M or P
Relation
FHf3'430 11B. Do you know what he/she did? (CIRCLEONE) 2.YEs 1.NO
11B1. What did he/she do?
/emVCO 1IC. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . w 1.NO
11C1. @?'$m:g
./ .....,............ .:,.
< -,........:
What other offenses led to him/her having trouble with the police?
<
I1D. Is he/she in jail or prison now? (CIRCLE ONE) 2 . m 1.NO

13
F/"rA.& 12. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
.....
2. YES

/LIpJJ&x., FW/ZA3 f&7k+
1 2 3 4
Ae@?p&/
B or N M or P
ame Relation
12B. Do you know what he/she did? (CIRCLE ONE) 2.YEs 1 .NO
...................................
......................................
What did he/&e do?
12B1.
d/
i-.-je//&co 12C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . w 1.NO
..................
...........................
12C1. :@i?@Z@ What other offenses led to hudher having trouble with the police?
Bo 12D. Is heishe in jail or prison now? (CIRCLE ONE) 2 . m , 1 .NO

14
13. Has anyone else had trouble with the police or been arreszd? (CIRCLE ONE)
1. NO:
U il
2. YES -
ASK 138. 13D
1 6
13A. What is hisher name and how is helshe related to *****9

7
F/Y/W& Ffl7'3.43 Fev3274

2 3 4
B or N M or P
Relation
,ZN/~ 13B. Do you know what he/she did? (CIRCLE ONE) 2.m 1.NO
E $-- What did he/she do?

............. ;... ...................
1331.
7
......................................
FH73 C& 13C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
................. ....
13C1. :$F'?EE@What other offenses led to hidher having trouble with the police?
:"
130. Is he/she in jail or prison now? (CIRCLE ONE) 2.m 1.NO

15
F M /4 14. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES
14A. What is his5er name and-how is he/she related to *****?

F#/WL F#Y%573 -YJY;44
1 2 3 4
v
B or N M or P
'Name Relation
14B. Do you know what he/she did? (CIRCLE ONE) 2 . m 1 .NO
(CIRCLEONE)
2 . m 1.NO

fkl 7/td 1j. Has anyone else had trouble with the police or been arrested? (CIRCLE ON)
1. NO:
h il
. . . .
2. YES . .
$ 15A. What is hidher name and h o w b he/she related to *****?

F/e7527A F&/$&.3 F?t?/ij-i99
1 2 3 4
B or N M or P
Relation
M~SJ-~Q 15B. Do you know what he/she did? (CIRCLE ONE) 2 . m 1.NO
...... y?,..~."...... :.:.
15B1. ..............:. ..,. ............ what did he/she do? . I
, c f3-6
~ 0 15C. And were there any other reasons helshe was in trouble with the police?
(CIRCLE ONE)
2 . m 1.NO
...:.: ......... ...........,.........:.:
\
&&
v y
,=-&$f5 15D. Is he/she in jail or prison now? (CIRCLE ONE) 2.m I.NO I
1. NO:
2. YES

FflS/6AL F&/6,93 ffl/d&g
2 3 4
M or P
Relation
16B. Do you know what helshe did? (CIRCLE ONE) 2.YEs 1.NO
........................
16B 1. mi
........................................ What did he/& do?
d?=%W-@d J V
(CIRCLE ONE)
2 . m 1 .NO
16C1. .:
...@ m a other offenses led to himher having trouble with the police?
...... :.-............ -.:
...... ...............
<..What
16D. Is he/she in jail or prison now? (CIRCLE ONE) 2.ES 1.NO

- ia
~w /.F 17. Ha myone eke had trouble with the poiice or been arrested? (CIRCLE ONE)
1. NO:
B
2. YES

- / = V H L Ffifl93 F/Y7z&q
1 2 3 4
& & B or N M or P
Relation
17B. Do you know what &/she did? (CIRCLEONE) 2 . m 1.NO
1m1.i.............@................
im
... ........... *
;<::2
What did he/She do?

n
EMPLOYILMIENT & INCOME

Date: &&PA BHZS
mm dd yy
PART I: R-im,aq Caregiver/Adult Subject Employment

ti
1. Please tell me which of these statements best d d b e s your present work situation.
For this interview, llfull-time'lis 35 or more hours each week and '(part-time"is less than 35
hours each week.
1 Hand respondent response card #1

Page 2
1. Working full-time in one job ---

2. W o r m N1-time in one job AND --
working fiWpart-time in additional job@)

t


-
15. Unemployed, looking for work --

(NOT; homemaker)
17. Volunteer work only, full/part-time - , 2

Page 3
2 2. Have you been employed in a paying position in the past 5 years? (CIRCLE ONE)
NO: ASK Have you done volunteer work in the past 5 years?
(CIRCLERESPONDENT'S CHOICE)
Working full-time in one job ---------
Working full-time in one job AND --





9. Temporary jobs, occasional work --
IO. Retired, working full-time
11. Retired, working part-time jobs -------

12. Retired, workmg temporary jobs ---
IS 5
Page 4
PART: I
SECTION: 1
Section 1. Full / Part-timi!
s2-3 3. How many jobs do you currently hold? (CIRCLEONE)

1. One Job
2. Two Jobs
3. Three Jobs
3A. Of these jobs, I want you to first teu me about the one you consider to be y o u
5. what are your main responsibilities? &i?&-r ;&&/ & & @ k d #'
Y K

CqB
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don'tknow

Y- months

61 8 hours/week

Page 5
lob 2: And your other job?
9. What is your job title? &a&'dL& &-&.

I'
10. What are your main responsibilities? &w2aqdce
Hand remondent remonse w d #2
81 f./ 11. Which of these numbers best fits your salary in this job? (CIRCLE ONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. more than50,000
8. don't know
12. How long have you k n in this job?

&71& Y- months
2/ f 3 13. How many hours each week do you usually work?

hours/week
If2 Jobs ONLY,GO TO Page 15, (part I) Question 45A.

And your other job?

SZ/6 16. Which of these numbers best fits your salary in this job? (CIRCLEONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. more than50,000
8. don't know
5-7 -.J;z 17. How long have you been in this job?
Y- months
1&? 18. How many hours each week do you usually work?
hours/week
GO TO Page 15, (part I) Question 45AI I

Page 7
PART: I
SECTION: 2
19. How many jobs did you hold before you went on leave/disability? (CIRCLE ONE)
1. One Job
2. Two Jobs 2% @art&
3. Three Jobs 20, (paxt a.
d 19A. Of these jobs, I want you to-fusttell me about the one you considered to be your
21. What were your main responsibilities? H=&&.&.- &&&@o$J c5&
22. Do you eontinue to receive money from this position? (CIRCLEONE)
1. YES
2. NO
22B. Which of these numbers best fit(s) your full salary in this job? (CIRCLEONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know
Page 8
22A. Do you receive your full dary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
22c. Which of these numbers best fit@)your partial salary, including

1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. betwen 30,000and 39,999
6. between 40,000 and 49,999
7. more tbanSO,000
8. don't know

hours/week
Y- months
W
If 1Job ONLY, GO TO Page 15, (part 9 Question 45A.
27. What were your main responsibilities? &+zz-&J-dk

&&W@d/
//
1. YES
2. NO
28B. Which of these numbers best fit(@ your full salary in this job? (CIRCLE ONE)
1. less than5,OOO
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. morethau50,OOO
8. don't know
&/A&&O 28A. Do you receive yo? full salary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
I 61.
Page 10
28C. Which of these numbers best fit(s) your partial salary, including
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10.000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49.999
7. more than50,OOO
8. don't know .

Y- months
30. How many hours each week were you usually worlung
hours/week
2z9 31. How long have you been on leave from this job?
Y- months
If2 Jobs ONLY, GO TO Page 15, (part I) Question 45A.

If More than 2 Jobs, GO TO Next Page, (part D Question 32. L
Page 11
And your other job?
33. What were your main responsibilities? L/fa&&& L

Y'
't
1. YES
2. NO

34B. Which of these numbers best fit@) your N1salary in this job? (CIRCLEONE)
1. lessthan5,000
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
1. Full
2. Partial
Page 12
tf-/ J.UC0 34C. Which of these numbers best fit(s) your partial salary, including pension
plan, SSI or any benefits? (CIRCLEONE)
1. less than5,Ooo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
7. more than50,OOO
5
8. don't know
Z35- 35- How long had you been in this job

before you went on leaveidisability?
Y- months
hours/week
How long have you been on leave from this job?
I GO TO Page 15, Question 45A (part I). I
.
Page 13
PART:I
SECTION: 3
tion 3. Tempor
38. What types of jobs have you done recently? LJ&&L.LA& - 4

* J
B
&/ 39 39. About how many hours each week do you usually work? hourdweek
1 Hand respondent response card #2 1

SI 40 40. How much money have you earned from these jobs in the past year? (CIRCLEONE)
1. less than5,000
2. between 5,000 and 9,999
4. betwen 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. more than50,000
8. don't know
GO TO Page IS, (part I) Question 45A. I

Page 14
PART: I
SECTION: 4
k Y
\ Section 4. Volunteer work I
V i A A k dk?k.p@&
4
IsuLdk GL
43. How manyhours you usually volunteer? (CIRCLEONE)
1. 1-2
2. 3-5
3. 6 - 12
4. 13-20
5. > 20

2749 Y- months
I GO TO Page 15, (part 9 Question 45A.

Page 15
PART: I
SECTION: 5
during the interview, start with the primary job,
~rimary/OniyJob]
45A. Where is your job located? (7ftrave& to various locafions, record address of mnin ofice.)
t
~~ ~~
city State zip code
How far is your work from where you live? (CIRCLE ONE)
0 - works at home 4-6tolOmile~

3-3to5des work site
1 &$TCO 45C. How do you usually get to work? (CIRCLE all that apply)
1-walk 6-
2 - drive myself -
3 - bus/Subway -
8 commuter train
4 - bicycle
5 - other
45D. On the average, how long does it usually take you -toget to work?
&/qa-ao (using the mode of transportation listed in Question 45C)
minutes
If 1 Job ONLY, If there is a partner, go to Page 18, (part lf) Question 1.

If there is PQ partner, go to Page 35, (part m)Question 1.
Page 16
[Seconmy job 2)
46A. Where is your job located? (If traveh to various locations record address of main ofice.)
PdN&d& &3@&/ I
address
/ J
city State zip code
E/ &6&Q 46b. How far is your work from where you live? (CIRCLEONE)
0 - works at home 4 - 6 t o 10miles

1 - less than a mile -
-
3 3 to 5 miles work site
6/46co 46C. How do you usually get to work? (CIRCLE all that apply)
1-walk 6-crrpo0l
2 - drive myself -
-
3 bus/subway -
8 wmuter train
4 - bicycle
5 - other
Ei96a0 46D. On the average, how long docs it takc you to get to work?
(using the mode of lransportation listed in Question 46C)
minutes
If 2 Jobs ONLY, If there is a partner, go to Page 18, (part nr) Question 1.

If there is pp partner, go to Page 35, (part m),Question 1.
If More than 2 Job, GO TO the Next Pane, (part 1) Question 47A. A
Page 17
[Secondary job 31
47A. Where is your job located? (If travels to various locations, record address of main office.)
$.4%.,2&
&d&-@&3 &
address
~~ -
city State zip code
&/qyqc) 47B. How far is your work from where you live? (CIRCLE ONE)
0 - works at home GO TO next directic#lbox. 4-6tolOmiles

&&q-Q 47C. How do you usually get to work? (CIRCLEall that a p p , j )

1-walk -
6 carp001
2 - drive myself 7 - driven by relativehend
-
3 budsubway 8 - commuter aain
4 - bicycle
5 - other
/47B0 47D. On the average, how long does it take you to get to work?
minutes
If there is a partner, go to Page 18, (part n)Question 1.

If there is l l partner,
~ go to Page 35, (part III)Question 1.
Page 18
PART: II
PART It: Parfaer Employment
1. Please tell me which of these statements best describes your spouse'slpartner's present
work situation:

Page 19
1. Working full-time in one job - ion 4

2. Working full-time in one job AND --

1
4. Permanent leave (disability) ----- io


8. Permanent leave (disability) io

12. Retired, worlung temporary jobs
13. R M , not working
14. Homemaker full-time --


(NOTa homemaker)
Page 20
2. NO: Has your partner done volunteer work in the past 5 years?
1 -Yes
2 - NO
1. YES:

working fulypart-time in additional job(s)




9. Temponvy jobs, occasional work

.. ...............

Page 21
PART: II
SECTION: 1
3. How many jobs does helshe currently hold (CIRCLEONE)?

1. One Job
2. Two Jobs
3. Three Jobs
f 3A. Of these jobs, I want you to first tell me about the one helshe considers to be his/her
v / P r m
4. What is his/her job title? J a ' d & & &&/
/'
5. What are hisher main responsibilities? f@4%2k Y Y
i;rP6 6. Which of these numbers best fits his/her salary in this job? (CIRCLE ONE)
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
How long has helshe been in this job?

6P;L 7.
Y=S months
SIP 8 . 8. How many hours each week does he/she usually work? hourslweek
I' j 3
Page 22
If 1 Job ONLY, GO TO Page 32, (part II)Question 45A

If More than 1 Job, GO TO the Next Page,(part m Question 9.
q: And hisher other job?
9. What is hisher job title? &&&fi,&f4..
~-
B
10. What are hisher main responsibilities?. Y-&b
Y

s/p/{ 11. Which of these numbers best fits hisher salary in this job? (CIRCLE ONE)
1. lessthan5,Ooo
4. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
7. morcthan50,OOO
8. don't know
12. How long has heishe been in this job?

SZP 7% Y W months
t9-P 43 13. How many hours each week does he/she usually work? hours/week
If 2 Jobs ONLY,GO TO Page 32, (part 11)Question 45A.

Page 23
14. What is hisher job title? kB&hJ&

/ d
15. What are hisher main responsibilities? L&**u*&
~~
&zp/G 16. Which of these numbers best fits hislher salary in this job? (CIRCLE ONE)
1. less than5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 3 9 9 9
7. more than50,OOO
8. dont know
17. How long has heishe been in this job?
18. How many hours each week does heishe usually work? hoursiweek
Page 24
PART: II
SECTION: 2
1 Section 2. On leave/disability 1
2iPiQ 19. How many jobs did he/she hold before he/she went on leave/disability? (CIRCLEONE)
1. One Job
f
2. Two Jobs
3. Three Jobs
20. What was i d h e r job title?
21. What were hisher main responsibilities? b+&Gk'nAk A p . p d /

//
22. Docs he/she continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO

Page 25
~ i w P &22B. ~ ~of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
~ Which
1. less than5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. more than50,000
8. don't know
Does he/she receive hidher full salary or part of hisher salary? (CIRCLE ONE)
1. Full
2. Partial
22C. Which of these numbers best fit@ hisiher partial salary, including pension plan,
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than50,OO
8. don't know

Y W months

before he/she went on leave/disability? hourslweek

Years months
Page 26
26.
27.
#
Does he/she continue to receive money from this position? (CIRCLEONE)

1. YES
2. NO

S p l j g ~ ~28B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
1. ltssthan5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. more than50,OOO
8. dont know
&/PR$ A 0 28A. Does hc/she receive hisher full salary

..........or
. . . . part
. .. of hisher salary? (CIRCLEONE)
1. Full
2. Partial
Page 27
28C. Which of these numbers best fit(s) hidher partial salary, including pension plan, SSI or any
1. less than 5,000

2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
f 7. .more than 50,m
8. don't know
29. How long a d he/she been in this job

months
before he/she went on leave/disability? uiWS/Week
Y= months
If2 Jobs ONLY,GO TO Page 32, (part II) Question 45A.

If More than 2 Jobs, GO TO the Next Page, (part n)Question 32.
32. What Was hisher job title? Pi%& LL &&/ &zj&@c?&

Y '
33. What were hisher main responsibilities? U W & * d L ~ /&;&

/ J
c . -
Z/P 34 34. Does he/she continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO

- w ~34B. Which ofthese numbers best fit@) hisher full salary in thisjob? (CIRCLE ONE)
1. leSsthan5,OOo
2. between 5,OOo and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49.999
7. more thanS0,OOO
8. don't know
&XI0 34A. Does heishe receive hisher full salary or part of hisher salary? (CIRCLEONE)
1. Full
2. Partial
Page 29
E/'@3kCO 34C. Which of these numbers best fit(s) hisher partial salary, including pension plan,
1. less than 5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
3 7. more than 50,000
8. don't know

227-935 before heishe went on leave/disability? -
Y- months
How many hours each week was hehhe usually working

Y*S months
I GO TO Page 32, (part II) Question 45A.

Page 30
PART: II
SECTION: 3
38. What types of jobs has he/she done recently? /W&& 2d,
/I
t ' / p39 39. About how many hours each week does he/she usually work?
hours/week

40. How much money has helshe earned from these jobs in the past year? (CIRCLE ONE)
&/p YO
1. less than 5,000
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. more than 50,000
8. don't know
GO TO Page 32, (part II)Question 45A. I

Page 31
PART:II
SECTION: 4
L4-aLf'd k- a D
43. How many hours each week does he/she usually volunteer? (CIRCLEONE)
&/P 93
1. 1-2
2. 3-5
3. 6 - 12
4. 13 - 20
5. > 20

sr34p months
I83
Page 32
PART: II
SECTION: 5
IF partner has more than 1 job listed during the interview, start with the primary job,TBEN
Iprimary/Only Job]
45k. Where is your partners job located? (If traveh to various locations, record address of main
@e.)
city State zip code
E / p 9 5 ~45B. How far is hisher work from where you live? (CIRCLEONE)
-
0 works at home 4-6tolOmile~
1-lessthanamile -
2-1to2milcs 6 - Varies according to
3 - 3 to5 miles work site
S/P45Z.O 45C. How does he/she usually get to work? (CIRCLEall that apply)
1-walk -
6 carp001
-
2 drive myself 7 - driven by relative/friend
-
4 bicycle
5 - other
.f/y04,=7 450. On the average, how long does it take himmer to get to work?
minutes
Page 33
[Secondary job 23
46A. Where is hisher job located? flf traveh to various locations, record address of main office.)
city State zip code
S/P96/30 $6B. How far is hisher work from where youlive? (CIRCLEONE)

&/@426Co 46C. How does he/she usually get to work? (CIRCLEall that apply)
1-walk 6-yrp001
2 - drive myself 7 - driven by relative/fiiend
3 - bushbway 8 - commuter train
4 - bicycle
5 - other
46D. On the average, how long does it take himher to get to work?
&/PQ6BO (using the mode of transportation listed in Question 46C)
minutes
If 2 jobs ONLY,GO TO Page 35, (part m)Question 1.

If More than 2 Jobs, GO TO Next Page, (part XI)Question 47A.
[Secondary job 31
47A. Where is hisher job located? (rf travels to various locatiom, record d r e s s of main office.)
mad&& &?+?pe6&,
/ Y
address
city State zip code
- is hisher work frpm where you lbe? (CRCLE ONE)

sp&gm 4 q . How far
0 - works at home -
4 6 to 10 miles
-
2 1 to 2 miles 6 - Varies according to
21@4ao47C. How does he/she usually get to work? (CIRCLEall that apply)
1-walk 6-catpool
3 - buslsubway 8 - commuter train
4 - bicycie
5 - other
5/P 47D. On the average, how long does it take himmer to get to work?
minutes
GO TO NEXT PAGE, (part m) Question 1.

Page 35
PART IIt.
sources m the past tax year. Have you received....(read each choice and circle all that apply)

income or supported by parher
c. any public assistance, such as DPA or AFDC 1. YES 2. NO


g. federal grant, financial aid, scholarships 1. YES 2. NO
z. money from any other source 1. YES 2. NO

(please specify) me&& - h & B 4 /
Now I am going to ask you some questions about your total income. First, I will ask about your
1 Hand respondent response card #2 w
&/,t?A 0 2A. From these sources of income AND the income from any jobs you had in the last tax year,
1. less than $5,000

2. between $5,000 and $9,999
3. between $10,000 and $19,999
4. between $20,000 and $29,999
5. between $30,000 and $39,999
6. between $4O,OOO and $49,999
8. don'tknow
2B. From these choices, what was your total household income in the last tax year before taxa?
Household income includes your income and any income Coming in from anyone else in the
household.
1. leSsthanS5,000
2. between $5,000 and $9,999
3. between $10,000 and $19,999
4. between $20,000 and $29,999
5. between $30,000and $39,999
6. between $40,000 and $49,999
7. more than $5O,OOO
8. don't know
8 END OF INTERVIEW 8 RECORD TIME

Now, I have some quedons about your relationships.

1. Are you currently involved with someone? @Ti
0. NO XNO, rn2
A. Are you married to, engaged to, or dating this person?

1. married
2. engaged
3. dating
B. Are you currently. living with this person?

1. Yes
0. No
months
I BEGIN RWERVEW I
(If more than one person, select most "significant" relationship)
c7#&
1. YES
0. NO
. . . ..... .. .
A. Were you married to, engaged to, or dating this person?

1. married
2. engaged
3. dating

1. Yes
2. No
I 1
BEGIN INTERVIEW 1
4
For this interview, I would like you to tfiink of all your dating
0. NO use.
1
Interviewer ID:
&77-~P&Xl/B
...
the past year, that is, Since
--
!I
these responses.
1 Hand respondent the response card, and read choices 1 to 6 1
&,init. ed. date

2
0 1 2 3 4 5 6
74
IB. How many times has he/she discussed an issue calmly?
0 1 2 3 4 5 6
1=Ya 0 = No
2A. How many-timeshave you gotten information to back up your side of thmgs?
0 1 2 3 4 5 6
2B. How many times has he/she gotten information to back up hisher side of things? T&&
0 1 2 3 4 5 6
never OIlCe twice 3-5 6-10 11-20 more than
2C. Has this ever happened? 1 =Yes

3
0 1 2 3 4 5 6
t-4 f . times times times 20 times
0 1 2 3 4 5 6
C73G 3C. Has this ever happened? 1 = Yes 0 = No
0 1 2 3 4 5 6
hes times times 20 times
c7 9 4 4B. How many times has he/she insulted or swore at you?

0 1 2 3 4 5 6
never once twice 3-5 . 6-10 11-20 more than

4
When you had an aqgmat With your partner in the past year,
Cr 54 5A. How many times have you sulked andor refused to E& aoout an issue?
0 1 2 3 4 5 6
cic 5& 5B. How many times has he/she sulked andor refused to talk about an issue?
0 1 2 3 4 5 6
C T 5-c 5C. Has this ever happened? 1 =Yes 0 = No
7
* 64- 6A. How many times have you stomped out of the room, house or yard?
0 1 2 3 4 5 6
C76-45
0 1 2 3 4 5 6
times thes times 20 times
C76 c 6C. Has this ever happened? 1 = Yes 0 = No

5
0 1 2 3 4 5 6
0 1 2 3 4 5 6
8A. How many times have you done or said something to spite M e r ?
0 1 2 3 . 4 5 6
0 1 2 3 4 5 6
never once twice 3-5 - 6-10 11-20 more than

E
9A. How many thes have you threatened to hit or throw something at hidher?
0 1 2 3 4 5 6
q
9B. How many times has heishe threatened to hit or throw something at you?
0 1 2 3 4 5 6
10A. How many times have you thrown, smashed, hit, or kicked w?
0 1 2 3 4 5 6
e-
*/ YO6 10B. How many times has heishe thrown, smashed, hit, or kicked something?
0 1 2 3 4 5 6

7
11A. How many times have you thrown somedung Wher?
0 1 2 3 4 5 6
I
'4
11B. How many times has he/she thrown something af you?
0 1 2 3 4 5 6
12A. How many times have you pushed, grabbed, or shoved him/her?
0 1 2 3 4 5 6
0 1 2 3 4 5 6

c7f.3 +
, 13A. How many times have you slapped himher?
0 1 2 3 4 5 6
43 13B. How many times has he/she slapped you?
0 1 2 3 4 5 6

CTf3c
C7j.A 14A. How many times have you kicked, bit, or hit hindher w?
0 1 2 3 4 5 6
cT j - 6 14B. How many times has he/she kicked, bit, or hit you ?-
0 1 2 3 4 5 6
c'7-2w5 14C. Has this ever happened? 1 =Yes 0 = No
LOO
9
c7 ys# 15A. How many times have you hit or tried to hit h d h e r ?
0 1 2 3 4 5 6
never once twice 3-5 . 6-10 1 1-20 more than
'$
CT/f>-& 15B. How many times has he/she hit or tried to hit you ?
0 1 2 3 4 5 6
C7f6& 16A. How many times have you beat him/her up?
0 1 2 3 4 5 6
c7-/sq 16B. How many times has he/she beat you up?
0 1 2 3 4 5 6
16C. Has this ever happened? 1. = Yes 0 = No

CTK6G
10
(-57y.74 17A. How many times have you choked hWher?
0 1 2 3 4 5 6
c7 /-7A 17B. How many times has he/she choked you?
0 1 2 3 4 5 6
CTj7.7C 17C. Has this ever happened? 1 = Yes 0 = No
Df&23 18A. How many times have you threatened himmer with a knife or gun?
0 1- 2 3 4 5 6
27-/&/.3 18B. How many times has he/she threatened you with a knife or gun?
0 1 2 3 4 5 6
never OLLce twice 3-5 6- 10 11-20 more than
BOTH

0/ & C
c7f.g~ 19A. How many times have you used a knife or fired a gun?
0 1 2 3 4 5 6
!.$$
c7-;/94 19B. How many times has he/she used a knife or fired a gun?
0 1 2 3 4 5 6
CT YQC 1X. Has this ever happened? 1 =Yes 0 = No

1
Conflict Tadics Scale: Parent-Child
Parents and children use m a n y different ways of trying to settle differences between
PROBLEM WITH ***** in the past year, that iS, Since ...
Refer to first month on the b e h e
I Hand respondent response card and read choices 1 to 6 1
I_
ed.init.
-
&.date
2
1. How-my times did you discuss an issue calmly with *****?
0 1 2 3 4 5 6
'9
?Ad . -
-
0 1 2 3 4 5 6
times times limes 20limes '
3. How many times did you bring in or try to bring in someone else to help settle dungs?
0 1 2 3 4 5 6
never OIlct twice 3-5 6-10 11-20 more than
33. Has this ever happened? 1 =Yes 0 = No

3
When you had a problem with *+*** in the past year...
CLZ 4 4. How many times did you insult or swear at *****?
0 1 2 3 4 5 6
5. How many times did you sulk andor refuse to talk about an issue?
0 1 2 3 4 5 6
6. How many times did you stomp out of the room, or house or yard?
0 1 2 3 4 5 6

4
7 7. How many times did you cry?

0 1 2 3 4 5 6
<$
L% 34 78. Has this ever happened? 1 = Yes 0 = No
%iC 8 8. How many times did you do or say something to spite *****?
0 1 2 3 4 5 6
never OllCe twice 3-5 6-10 11-20 more than
times times time3 20 times
C&&/3 8B. Has this ever happened? 1 =Yes 0 = No
9 9. How many times did you threaten to hit or throw something at *****?
0 1 2 3 4 5 6

&-L 96
5
e& ;I%r 10. How many times did you throw, smash, hit or kick?-
0 1 2 3 4 5 6
'ty
10B. Has this ever happened? 0 = No
e& YO 9 1 = Yes
C k 7Y 11. How many times did you throw something *****?
0 1 2 3 t 4 5 6
11B. Has this ever happened? 1 =Yes 0 = NO

cL2 m5
el55 %& 12. How many times did you push, grab, or shove *****?
0 1 2 3 4 5 6
never OIiU twice 3-5 6-10 1 1-20 more than

C& #&p3
6
When you had a problem with ***** in the past year. ..
/3 13. How many times did you slap or spank ***** ?
0 1 2 3 4 5 6
1
times times times 20times
t$
.L%Z 93 & 13B. Has this ever happened? 1 =Yes 0 = No
2 44 14. How many times did you kick, bite, or hit ***** w?
0 1 2 3 4 5 6
LLt 14B. H& this ever happened? 1 =Yes 0 = No
d3- 15. How many times did you hit or try to hit ***** * ?
0 1 2 3 4 5 6

& y3-43
7
When you had a problem with *+**+in the past year...
/6 16. How many times did you beat ***** up?

0 1 2 3 4 5 6

44 7kb3
CLL /? 17. How many times did you burn or scald *****?
0 1 2 3 4 5 6
67!2x&
7-/M
. -
1
Interviewer ID:
c23c L &&
I Hand PC Response Card 1 I

~
For each item that describes ***** m w or -t

. . 6 months. please say "2" if the
item is very true or often true of *****. Say "1" if the item is or-s tNc
of *a***. u the item is of I****, say "0". we answer a~ items as well as you
0 -Not T m e
1= Somewhat True
2 = Very True
@-
c ! o 1 2 1. Actstooyoungforhis/haage
-
C C A 0 1 2 2. Allergy
cc 3 o 1 2 3. Argueialot
cL-4 0 1 2 4.Asthma
-0 1 2
CC 5- 5. Behaveslikeoppositesex
C C 6 0 1 2 6. Bowelmovemcntsoutsidctoilet
ed.intl. &.date
c-
d + 0 1 2 7. Bragging, boasting
d-
c 8 0 1 2 8. Can't concentrate, can't pay attention for long
-0 1 2
CL' 9 9. Can't get hisher mind off certain thoughts; obsessions
-
LYr%, 0 1 2 10 Can't sit still, restless, or hyperactive
CL' {f' 0 1 2 11. Clings to adults or too dependent
-
c c BR 0 1 2 12. complains of loneliness
CC/3 0 1 2 13. Confusedorsetmstobeinafog
C L i.L/ O 1 2 14. Cries a lot
d 0 1 2
~ ' f5- 15. Cruel to animala
-
6L' 60 1 2 16. Cruelty, bullying, or meanness to others
G
-* f& 0 1 2 17. Day-dreams Or gets IOSt h hismcr thoughts
EE 48 O 1 2 18. Dclibcratcly harms self or attempts suicide
CC f9 0 1 2 19. Demands a lot of attention
eeao o 1 2 20.~estroyshi~/hero~n~
-o 1 2
CcRlP 21. Destroys thiugs belongiug to hisher family or others
L"AA 0 1 2 22. Disobedient at home
-
CcJ3 0 1 2 23. Disobedient at school
~-
~ 2O -1 9
2 24. Doesn'teatwcU
CCA-2- 0 1 2 25. Doesn't get along with other kids
-0 1 2
L't A 6 26. Doesn't seem to feel guilty aftcr misbehaving
CCA?O 1 2 27. Easilyjcalous
-0 1 2
CC A% 28. Eats or drinks things that arc not food- don't include sweets
-0 1 2
CC 29. Feats certain animals, situations, or places, other than school
-
LZ' 3 0 0 1 2 30. Fears going to school
CC 0 12 31. Fears helshe might think or do something bad
CC 3A 0 1 2 32. Feels helshe has to be perfect
CC 33 0 1 2 33. Feels or complains that no one loves himher
-
CC 34 0 1 2 34. Feels others are out to get himmer
3
-
LZ 3 5 0 1 2 35. Feels worthltss or inferior
CC36 0 1 2 36. Gets hurt a lot, accident-prone
cc .5? 0 12 37. Gets inmany fights
L'C39 0 1 2 39. Hangs around with others who get in trouble

CC -&Q 0 1 2 40. Hears sounds or voicts that aren't there
CC &/' 0 1 2 41. Impulsive or acts without thinktng
-7
CC %5 0 1 2 42. Would rather be alone than with others
CCY3 0 1 2
7 43. Lying or chaw
c'L'Y~ 0 1 2 44.Bitesfingernails
cc 6'5- 0 1 2 45. Nervous, highsfrung,or tense
CC 46- 0 1 2 46. Nervous movements or twitching
-
CC L/? 0 1 2 47. Nightmans
.LL 4'8 0 1 2 48. Not liked by other kids
C-
CcW- O 1 2 49. Constipated, docsn't move bowels
-0 1 2
CC3-0 50. Too fcarful or anxious
-0 1 2
CC3-f 51.Fetlsdirty
C C 3-A 0 1 2 52. Feels tooguilty
cc 3-3 0 1 2 53. ovucatipg
-
7
c c 5 % 0 1 2 54.ovcrtircd
cC-55-0 1 2 55.overwcight
56. Physical problems without known medical caw:
- 12
Ci t7-6 r , O a Aches or pains (not headaches)
- 12
L'd 5.5B 0 b. Headaches
CL'56-C 0 1 2 c. Nausea, feels sick
L'C -
56dO 1 2 d. Roblemswithcycs
-
Cr 3-6
& 0 12 e. Rashes or other skin problems
cc-
;;6+ 0 1 2 f. Stomach aches or cramps
cc"5:;~ 0 12 g.Vomiting, throw& up
4
-
L*L'%A 0 1 2 h. Other physical problems without known m e d i d
LL?9-7 0 1 2 57. Physically attacks people

LZ 5d 0 1 2 58. Picks nose, skin, orothcrpartsofbody
-
cc 3-9 0 1 2 59. Plays with own sex parts in public
cc -o 1 2 60.~iayswithownsexpartstoomu~h
CC 6
"
' 0 1 2 61. Poor school work
C?dA 0 1 2 62. Poorly coordinated or dumsy
-
63 0 1 2
C-L 63. Prefers being with older kids
cc-
47 o 1 2 64. Prefers being with younger kids
-
CC6:5-0 1 2 6.kfusestotalk
=i,
LX,o 12 66. Repeats ccreainacts over and over; compulsions
CC d? 0 1 2 67. Runs away fiom home
-
CL-63 0 1 2 68. Screams a lot
cxdi9 0 1 2 69. Secretive, keeps things to self
L'C 7%' o 1 2 70.~e#thingsthatarcn'tthtre
C-
c ? i 0 1 2 71. Selfconscious or easily embarrassed
-
CCFA 0 1 2 72.setstiues.
Cc 73 0 1 2 73. Sexual problems
-
Cc' 74 0 1 2 74. Showing off or clowning
-
GC'2 5 0 1 2 75. Shy or timid
-
Ck-3'6 0 1 2 76. Sleeps less than most kids
-
CC 7? 0 1 2 77.Sleeps more than most kids during day and/or night
-
CC ?d' 0 1 2 78. Smtarsorplayswithbowelmovemmts
GC-
29 0 1 2 79. Speech problem
cc Br? 0 1 2 80. Stares blanldy
Cc-
dY 0 1 2 81. Stealsat home
CC 84 0 1 2 82. Steak outside the home
Cc: 8.5 0 1 2 83. Stores up things heishe doesn't ntcd
5

& j-2 0 12 85. Strange ideas
CC $6 0 1 2 86. Stubborn, sullen, or irritable
L-L cf 0 1 2 87. Sudden changes in mood or feelings
CC 88 0 12 88. Sulks alot
CCd% -0 1 2 89. Suspicious
CC
d
-
%y@0 1 2 90.Swearing or obscene language
CC $? 0 12 91. Talks about killing self
-
CCQA 0 1 2 9Z.Talksorwalkshsieep
ccyg 0 1 2 93.Talkstoomuch
LL 94 o 1 2 94.TC~SCS
a lot
CC -
93- 0 1 2 95. Temper tantrums or hot temper
c,c-
96%o 1 2 96.Thinkshut sextoomuCh
cc.w 0 12 97.Threatempeople
Cc@f -0 1 2 98.Thumb-sucking
CC $% 0 1 2 99.Too~~mdwithneatnessorcleanlincss
CC/D 0 1 2 100. Trouble sleeping
dcf0r -0 1 2 101. Truancy, slups school
LC 0 1 2 102. Underactive, slow moving, or lacks energy
LC -
/V.3 0 1 2 103. Unhappy, sad,or depressed
cC fP4 0 1 2 104. Unusually loud
-
CC ,493- 0 1 2 105. Uses alcohol or drugs for n o n m d d purposes
L%-
/DE 0 1 2 106. Vandalism
CC -
/L7 0 1 2 107. Wetsselfduringtheday
L% ,422 0 1 2 108. Wets the bed
tC-
/e9 0 1 2 109. whiaing
c c-
H? 0 1 2 110. Wishes to be of opposite sex
c C-f7/ 0 1 2 111. Withdrawn, doesnt get involved with others
cc- f4& o 1 2 112. Worries
6
1
2
Y4-p' 1. Are you afraid ***** might be hurt by violence in your neighborhood?
1.- YES 2 . 2 0
&4& 2. Are you afraid ***** might be hurt your apartment building or house?
1.- YES 2.- NO
3. Are you afraid ***** might be hurt your apartment building or house?
24.3
1.- YES 2.- NO
1- YES 2-. NO
ed. init. ed. date

2
4A. Does t h affect

~ ~ where you take *****?
1.- YES 2.- NO
294 5 5. Have any of your family members been hurt by a violent act?
1.- YES 2.- NO

?-i
2.46 6. Have any of your family members been killed by a violent act?
1.- YES 2.-NO
1.- YES 2.- NO
8. Have any of your close friends been Wed by a violent act?
1. YES 2. NO
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
The questions 7'?l be asking YOU now have to do with acts of violence that ****+may have
witnessed or experienced. Please think e a r e M y about whether shehe was a c t d y
present during violent ads.
cs.4-90 10. Has ***** ever seen or been present when somebody was shoved, kicked or punched?
1. YES
2. NO
1. Within last week

3. Withinlastyear
1. In ****'s home
7.
25.
In or outside bar
Other (specify) ~+%&'L-L&& &we /
1. YES
2. NO
4
1. Parent
2.- *****
3. Friend
4. Neighbor
5.
. .
Siblrng
6. Other Relative (Specify) P G k - d L C
25. -
Other (Specify) Le2-e L&ak &&W&.
1 . 2 0 injury
2. Knockeddown
3. Bruised
4-. Cut/blding
5. Unconscious
6. Broken bonedfracture
8-. Other
15. Did ***** know the person or people who did tbis?
. . 1. YES
2. NO
1. Parent
2-. *****
3. Friend
4..Neighbor
5.
. .
Sibimg
6.- Other Relative (Specify) L ~ ~ ~ Kd &?+
- Z Gh
25. Other (Spec@) =&92%@& + 2
6f
5
. {E
2
M .16. Has ***** seen this more than once?
1. YES
2. NO
24r'o'f9c7 16A. How many times has ***** seen this in the past year?
2-34Lqno 16B. How many times has ***** ever seen this?
&'" /+ 17. Has ***** ever seen or been present when someone was attacked with a knife?
1. YES
2. NO
1. Withinlastweek
3. Withinlastyear
1. In ****'s home
3. In front of ****'s houselbuilding
25. Other (specify))
6
2 A L-tc 20. Did he/she know the person or people who this happened to?
1. YES
2. NO.

24L O # Q
1. Parent
2.- *****
3. Friend
4. Neighbor
5. Sibling
6. Other Relative (Specify) vdLmkM& d k y p w 5
25. Other (Spec@) b - k % a d ~ L ?b*-L.rl,
2 1. How badly was the person or people injured? (MARK THAT APPLY)
1.
..
No mjury
2. Knockeddown
3. Bruised
4. Cut/bleedii
5. Unconscious
7 . 3 e d i c a l care obtained
-8. Other
22. Did they die?
1.- YES 2. NO 8. Don't Know
..
1. YES
2. NO
7
24.43 23A. Who was it? (MARK BLL THAT APPLY)
1. Parent
2-. *****
3. Friend
4. Neighbor
. .
5. Sibllng
6. Other Relative (Specify) VS4z4'&&& &-py&&
25. Other (Specify) Va.&L'L.d& &a
r--
?.$f
2ku4 24. Has ***** seen this more than once?

1 . YES
2. NO
2 3 &+&3 24A. How many times has ***** seen this in the past year?
How many times has ***** ever seen this?

2.4 a&&o 24B.
S A R 3- 25. Has ***** ever heard a gun shot?
- 1. YES
2. NO
r*&6" 26. When was the last time he/she heard that?
1. Withinlastweek
3. Withinlastyear
8
&i 27. Where did that happen?
1. In ****IShome
25. Other (specify) /-&& & A-oYLf
Has ***** heard a gun shot more than once?

1. YES
2. NO . ...
28A. How many times has ***** heard this in the past year?
28B. How many times has ***** ever heard this?
c
%
? ;cy 29. Has ***** ever seen or been present when someone was shot?
1. YES
2. NO
1 END OFINTERVIEW II
I RECORD TIME:
1. Withinlastweek
2. Withinlastmonth
3. Withinlastyear
9
1. In home
****IS
****IS
.3. In front of ****Is househuilding

,4. In ****s neighborhood
6. At ****Is schml/day care
25. Other (specify) P G A W ~ L ~h ~ d
1? Y /
s..3#& 32. Did he/she know the person or people who got shot?
1. YES
2. NO
I n 32.40 32A. Who was it? (MARK BLL THAT APPLY)
1. Parent
2.- *****
3. Friend
4. Neighbor
. .
5. Siblmg
6.- other Relative (specify) y-a-4k &fpd
25. other (Spec@) /&&-d&&
I
Did they die?
1 .- YES 2.- NO 8. Dont Know
Did he/she know the person or people who did this?
1. YES
2. NO
10
1. Parent
2-. *****
3. Friend
4. Neighbor
5. Sibling
6.
25.
Other Relative (Specify) ~G.K&z&-&
Other (Specify) ,*
&kyp~-&
.Yzbf&H9& & k & + 7
1. YES
2. NO
SA 35AO 35A. How many times has ***** seen this in the past year?
279 35AO 35B. How many times has ***** ever seen this?
I RECORD TIME: 1
236
Interviewer ID:
FIELDCOPY2
1. ***** feels happiest in familiar surroundings. 2Y a"

2. ***** often acts on the spur of the moment. 2y'A

&.init. &.date
3. ***** is something of a loner. c -3
1= Uncharacteristic (NOTat a2 like your child)
4. ***** sometimes does crazy things just to be different. 69.4

t
a 2= Somewbt Uncharacteristic (NOT very much like your child)
5. ***** likes to be with people. SY 4-

6. ***** has trouble resisting temptation. 2 ~ 6

7. ***** finds people more stimuiating than mythug else. ZY?

1= Uncharacteristic (Nmat all like your child)
8. Unfiihed tasks really bother *****, 245 8
2= Somewhat Uncharacterktic (NOTvery much like your child)
9. ***** cries easily. SY 9

i
?? 1= Uncharacteristic (NOT at all like your child)
10. ***** makes friends easiiy. 29 i o

11. ***** tends to be somewhat emotional. S Y 7-Y

12. ***** is off and nrnning as soon as (s)he wakes up in the morning. xr4//%
13. ***** generally seks new and exciting experiences and sensations. sy/3
14. ***** finds self-control easy to learn. 2.Y / 4

Y

15. ***** can tolerate frustration better than most. 2-9d9-

4 = Somewhat Characteristic (sort of likc your child)
16. ***** often fusses and cries. sy /$

17. ***** gets upset easily. 2-9

1.2
18. **+*+tends to hop from one interest to another quickly. C5-y i 8
- 2= Somewhat Uncharacteristic (NOT very much like your child)
19. ***** takes a long time to warm up to strangers. 2.9/ 9

1 = Uncharacteristic (NOT-at all like your child)
20. ***** prefers quiet, inactive games to more active ones. 2Y LO

21. ***** often says the fust thing that comes into hisher head. 29Lf
3 = Neither Uncharackristic nor Characteristic
22. ***** tends to be shy. &%&

23. ***** tends to get bored easily. 2Y.A3

2= Somewhat uncharacteristic (NOTvery much like your child)
24. Usually ***** can not stand waiting. ?SY&.&

Somewbat Uncharwterbtic (NOTvery much like your c u d )
4
2=
25. ***** has trouble controlling hisher impulses. 2YA35
1= uncharacteristic (NOTat all like your child)

26. ***** is always on the go. 2.Y&6

27. ***** is very friendly with strangers. zSYR-7.

2= Somewhat Uncharacteristic (NOTvery much l ike your child)
28. *++**always likes to make detailed plans before (s)he does something. sy&@
29. ***** generally likes to see things through to the end. 29A9
1
30. ***** often has trouble malung up hisher mind. 29 3s

31. ***** prefers playing with others rather than playing alone. 2.93/
32. ***** is very sociable. s9300

33. When alone, ***** feels isolated. t Y 3.3
34. ***** reacts intensely when upset. 2-,4."

34

2= Somewhat Unchar?xeristic (NOTvery much like your child)
35. ***** is very energetic. 2933-

3= Neither Uncharacttristic nor Characteristic
4 = Somewhat Characteristic (soft of like your child)
36. ***** tends to give up easily. %2 36

4= Somewhat characteristic (sort of like your child)
37. When ***** moves about, (s)he usually moves slowly. 2-93.9
3= Neither Uncbaracteristic nor Characteristic
38. ***** likes to plan things way b e a d of time. s;.5'8
1= Uncharacteristic (NOT at all like YOU^ child)
39. Once ***** gets going on something, (s)he hates to stop, 39

2-9
3= Neither Uncharackristic nor Characteristic
40. ***** will try mything once. 25-940

FS S
Date: ---
m u ~dd yy
Subject ID: SA&/..

Interviewer ID:
FSSRA/X
You may feel that some of the statemeits are true for some family members and false or
false for most members. If the members are evenly divided, decide what is the stronger
Remember, we would like to know what your current family seems like t o you. So do not
1. We fight a lot in our fr'amily
1. T 2. F
1. T 2. F
1. T 2. F
ed. init. ed. date
F2 4 4. Family members rarely become openly angry
1. T 2. F
5. We don't say prayers in our family
1. T 2. F
2i6. There are very few rules to follow in our family
1. T 2. F
7. Famiiy members sometimes get so angry they throw things
1. T 2. F
1. T 2. F
9. There is one family member who makes most of the decisions
1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
14. r a m u y memuers nave suict l a w aoous wnat 1s rignt or wrong
1. T 2. F
1. T 2. F
. 16. Family members sometimes hit each other

q
1. T 2. F
1. T 2. F
1. T 2. F
P-
1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
F2X 3 23. The Bible is a very important book in our home
1.' T . 2. F
4
24. Rules are pretry inflexible in our household
1. T 2. F
FCa5 25. In OUT family, we believe you don't ever get anywhere by raising your voice
1. T 2. F
FSL6 36.
#'
Family members believe that if you sin you will be punished
1. T 2. F
Fs 2 7 27. You can't get away with much in our family

1. T 2. F
1 FUND SUBJECT RESPONSE CARD I

Ad 28.- When you answered these questions, who did you have in mind?
A
1. Siblings
2. Parent
5. other
/ 7 7
3. Roommate
4. Otherfamilymember
6. SpousePartner
7. Child/Children
END OF INTERVIEW
I RECORD TIME: &E sE7/N 1

I
Interviewer ID:
FIELDCOPY2
tr
s&fl & &?S&P&#/W
. v
79
I Hand ResDondent the ResDonse Card and Read Choices
1= verytrue
2= somewhat true
3= nottrue
1. Wha I'm with my fiends I feel completely able to relax and be myself.
1 -verytrue
-
2 somewhat true
-
3 not true

PSPb
1 -verytrue
-
2 somewhat true
-
3 not true
ed. init. ed. date

3. People who h o w me trust me and respect me.
1 - very true
-
2 somewhat true
-
3 not true
4. NOmatter what happens, I know that my f d y will always Ue there for me should I need
them.
-
1 very true
2 - somewhat true
8
"8 3 -nottrue .
5. 'whenI want to go out to do things,I know that many of my fiiends would (like)
-
1 very true
-
2 somewhat true
3 - not true
PSP 6
' 6. I have at least one fiiend that I could tell anythtng to.
1 -verytrue
2 - somewhat true
-
3 not true
7. Sometimes I'm not sure if1 can completely &y (count') on my W y .
1 -verytpe
-
2 somewhat true
-
3 not true
8. My f d y lets me how they tbink I'm a * (vahabZe)person.
1 -veqtrue
-
2 somewhat true
-
3 not true
.PSP dB 9. I feel very close to some of my fi-iends.
1 - very true
2 - somewhat true
3 - not true
-
1 very true
-
2 somewhat true
-
3 not true
f)*T /jf
? *
9 11. People in my family help me find solutions to my problems.
1 -verytme
2 - somewhat true
3 - not true
People who know me think I am good at what I do.

PSP/& 12.
1 - very true
2 - somewhat true
3 - not true
PSP /3 13. My fiends would take the time to talk about my problems, should I ever want to.
-
1 very true
2 - somewhat true
-
3 not true
7s P /4 14. I know my family wiU always stand by me.
1 -verytme
-
2 somewhat true
3 - not true
QSP&-- 15. Even when I am with my fiends, I f e l alone.
-
I very true
-
2 somewhat true
-
3 not true
TO
16. I have a teacher or coach who I can rely (couni) on and talk to.
1 - very true
-
2 somewhat true
-
3 not true
;\j17. I have a grandparent, uncle, or aunt that I feel close to and who helps me out.
1 - very true
-
2 somiwhat true
-
3 not true
-
1 very true
2 - somewhat true
3 - not true
19. There is an adult outside my f d y , for example, a neighbor or religious or

1 -verytrue
-
2 somewhat true
-
3 not true
1. Yes 0. No
@Yes: What is h s person's name and what is hidher re!ationship to you? (Cirde aJ that
&@&c)#b
2Oa2. 1 - Immediate Family (sibling, c u d , parent, partner)
2 - Extended Family
-
5 - School or CommUnity Memberkeader
6 - Other & d
PSPrnBA
.
i?
20bl. &--A 20b2. 1 - Immediate F d y (sibling, child, parent, partner)
First name 2 --Extended F d y
-
5 - School or Co
6 - Other
Pspomcfi
20cl. 20~2.1 - Immediate Family (sibling, child, parent, partner)
2 - Extended Family
-
6-other
z 54
Date:
mm dd yy
Subject ED:
Interviewer ID:

<$f
1. Are you planning on ~oving/leavirlghome in the next year? Y N

if "Yes,"
1a when? V C d
1b. where?
(state)
2. Do you plan on changingjobs in the near future? Y N

if "Yes,":
2a. when? 2b. new employer?
2c. new employment address: mt)
3. Do you think it is likely you will obtain work in the near future? Y w
if "Yes,":
3a when? (month/vear) 3b. employer?
3c. new employment address: bet)
law) f state1 (r&ip,
If currently in sch001, ask Question #
C:U MC1NTOS\WPDOCSWOANEW.FRM
2 61
4. Do you pian on c l k g i n g schools, or going away to school? Y w
if "Yes,"
(city) (state) (ziv)
5. Do you h o w of any reason Why YOU might not be able to participate in this Project in the
future? Y N
E,"Yes,"
1, 5a Pleaseexplainwhy:
6. Can you give me the names, addresses, and phone numbers of four dose friends or &tiva
who will always know where to find you to help us locate you in the hture?
a b.
Name:
Relationship:
Address:
City/St/Zip:
Phone:
c
Name:
Relationship:
Address:
City/St/Zip:
Phone:
2bZ
TPJto make the fulloming observations at &e close of the session

a-- annoyed b.- nemous c. bored d. afraid
e-- relaxed f. interested g. neutral h. curious
i.- cooperative j .- confused?
?.df
8. Please note any other obsemations about the respondent's demeanor:
Circle one:
1 2 3 4 5

Circle one: -
1 2 3 4 5
1Oa Please explain the reason for your assessment:
C:UMCINTOS\WDOCS\ROANNV.FRNI ROA 3
n
Interviewer H):
2.1 Was a translated version ofthe protocol used?
3. In what language(s) was the assessment conducted? . -
1.
2.
2. Paren~Guardian
3. Spousflartner
6. Other
5. How many rnezssuas were administered in a language other than English?

4. ,more than three-fourths
5. all
6. How much difficulty did the S/Pc have in understanding the language of the measures? Did
he/she find it ...
q
1. Very difficult
2. Fairiydifficult
3. Fairly easy
4. Veryeasy
7. was all of the assessment administered in private- that is, no one was actively listening to my
YES Go to-Comments Sediiod

? _ _
NQ: &to-Q8
,.- . -.
If NO, enter code(s) for the party(ies) present during the assess men^
Code.
1. Child Behavior Checklist YES NO a b. c. -
2. ContIictTactics YES NO a b. c.
3. Deviance of Peers YES NO a b. c.
4. SelfReportofOffending YES NO a-b--c.-
5. SubstanceUse YES NO a b. c.
6. Youth Self Report YES NO a- b. E.
7. Yo: gAddtSelfReprt YES NO * a b. c.
C o d i u
3 = Sibiiig 7 = Neighbor
4 = Other Adult F d y Member 8 = Other
Date:
mm dd yy
Interstiewer ID:
27"
b
2-72
s
..
273
HARVAIW SCHOOL OF PUBLIC HEALTH

ASSESSMENT
SUBJECT
COHORT: 1
FIELD COPY #2
TABLE OF CONTENTS
Age: 18 (Subject)

2. School Screen
*
3. Health Screen
4,' Family Structure & Health History
7. Vocabulary: WAIS-R
8. Deviance of Peers
10 Life History Calendar
11. Conflict Tactics Scale: PartnedSpouse
12. Substance Use: 18-24
13. WR4T: Reading
15. Self Report of Offending
16. Young Adult Self Report
19. Home (Observation of Physical Environment Only)
Demographic and Cultural Infoxmation: Subject version
2A7E
Date: ---
ashfOBd
ILM dd
7Z
yy
- Subject #: Sk&/B
Interviewer ID:
FIELD COPY 2 sauce 2E/3/0RA/s-
Time Started WEMO S T 4 M
Now I bave some general questions.
First, I will ask you about where you have lived during the past five years;
Second, I am going to ask about where you and other members of your f d y were born;
Third, I will ask about different languages youmight speak;
Fourth, I will ask for some g m d descriptive infomation about yo-
Ti,It am going to ask about your schwl backgromrd; and

Fdy,I will ask about your edmic and religious background.
ed. init. ed. date

2
Your current address is (readfiom C O M sheet):
~ Is that right?
1. Yes -
0. NO-
- - -
city SMtt zip code
'4
1. rent your home

2. own your home
4. live with someone (yourparents, guardiaus or partner) who rents this home
5. live with someone (your parents, guardians or partner) who owns this home
1A. How long in yean and months have you lived here? - -
months
Years
2. Plcase tell me all the other addresses you have had in the past fwe years, starting with
3
/ -
(street address) (state) (zip code)
2A1. Why did you move from thk address [2A]? [circle up to three]

5 = change in maritavromantic status 12 = roommates left (had to move)
6 =*paved in wl someone due to finances 13 = on vacatiodgraduated from school

Y- months
Y- months

L.a9cL;d& d u d c- ZI -
(street address) (city) (state) (zipcode)
2B1. Why did you move from this address [2B]? [circle up to three]

4 = fm/other hazardous condition 11 = wanted to live away from parents
5 = change in mariWromantic status 12 = m o m left (had to move)
6 = moved in w/someone due to ftnances 13 = on vacatiodgraduated from school
25 =other / ~ 2 *
&&
/

Y-= months
Y- months
5
4
v w r d h &md c
- -
(street address) / (city) (state) (zip code)
2C1. W h y did you move from this address [2C]? [circle up to three]
4 = firdother hazardous condition 11 = wanted to live away from parents
5 = c h e in marital/romantic status 12 = roommates left (had to move)
7 = living quarters too small/found bigger apmentmome
25 = other
/
2C2. HOWlong did YOU live at this address [2Cj?
Y- months
Y- months
2D1. W h y did you move from this address VD]? [circle up to three]

4 = fire/othcr hazardous condition 11 = wanted to live away from parents
5 = change in maritavTomantic status 12 = mmmam left (had to move)
6 = moved in w/somtollc due to finances 13 = on vacatiodgraduated from school
25 = other

Y- months
Y- months
5
2E. And where did you live before living here?
u'ae&&#k GzkCp-p d - c _ -

4 = fireiother hazardous condition 11 = wanted to live away from parents
5 ='qhange in maritavromantic status 12 = roommates left (had to move)
7 = living quarters too sdl/found bigger apartmenhome
25 =other L&+k*&i% - 6
2E2. How long did you live at this address [2EJ?

Y- months
Y== months
2F1. W h y did you movedrom tbis addrcss [m?[circle up to three]

3 = moved off-campus 10 = found a bem apartmtntmouse
4 = fireiother hazardous condition 11 = wanted to live away from parents
5 = change in maritavromautic status 12 = roommatts left (had to move)
6 = moved in wl someone due to financts 13 = on vacatiodgraduated from school
7 = living quarters too sd/found bigger apartmenthome
25 =other vW'dAfh3
2F2. How long did you live at this address [2-?
. Y- months
Ye= months
6
2Gl. W h y did you move from this address [2G]? [circle up to three]
4 = firdother hazardous condition 11 = waoxed to live away from parents
5 = c b g e in marital/romantic status 12 = roommates left (had to move)
6 = moved in w/someone due to financts 13 = on vacatiodgraduated from school
2 5 = other &.&
Y- months
2H. And where did you-live before k i n g here?

P e d & &/P& c _ - -
(strect address) (city) (-) (zip&)
2H1. W h y did you move'from this address PHJ? [circle up to three]

1 = change ofjob 8=wenttoschool
4 = fire/othcr hazardous condition 11 = wanted to liie away from parents
5 = change in marital/mmantik status 12 = roommates left (bad to move)
6=movedinw/someomduetofinaacts 13 = on vacatiodgradwtcd from school
7 = living quarters too s m a l l / f d bigger apartmenthome
2 s = other I V
2H2. How long did you live at this address [2H]?

Y- months
7
211. Why did you move from this address [21]? [circle up to three]

3 = moved off-campus 10 = found a better apanment/house
5 = Ehange in marital/romantic status 12 = roommates left (had to move)
7 = living quarters too small/found bigger apartmenaome
25 = other J L ~ x L ~ ~ ~ &
I'
212. How long did you live at this address [21]?
Y- months
2J. And where did you live befort living here?
2J 1. Why did you move from this address [a?

1 = change ofjob 8 = went toschool

3 = moved off-campus 10 = found a better apartmenthow
5 = change in maritavromantic stam 12 = roommates left (had to move)
6 = moved in w/ somtonc due to f m 13 = on vacatiodgraduated from school
7 = living quarters too small/found bigger apartmenthome J
25=
2J2. How long did you live at this address [21]?
YWS months
4
8
A. city aizz;oed. B. State

- c. country
-
IF noa born in the USA,Ask Q. 3Aand3B
8. Don't Know
8. Don't Know
Are you a U.S. citizen?
0. NO
1. YES
. ..,.....,:...........
4A Arc you (read choices) 1. y- applying,
,
..(, :...... ..
2. ptanninlr to apply,
,
Q*$
3. npt planning to become a citizen
4B. Are you registered to vote in the U.S.? 0. NO 1. YES

9
ZC,6 6. What is your marital status? Are you (Read all choices):
1. Single Go to Q. 6A
2. Separated Go $0 Q. 6A
3. Divorced Go to Q,6A
4. Married Go toQ. 6AA
5. Widowed GotoQ.6A
6. Living with Someone as a Partner Go toQ. 6Br
3 0 2 ~ 6A. Are you currently living with a partner?

3
1 . Y e s GotoQQ,6B1
0. No GotoQ.6Bz
6AA. Are you currently living with your spouse?

%C6-440
1. Yes
0. No
etting along or for some other

zc 62994/ 6AA. 1

2. Jobs iu different places
4. Other
6B1. How long have you lived with your partner/spouse?

EC64Yf XC' 6-4//'f
years months
3c ~ b ~6B2.i /Do you have any children?

0. NO
1. YES
7. What is your age? years old

10
8 8. Is your mother still living? 1. Yes 0. No 8. Don't Know
A, city A+Z:/Y~~ B. State C. Country

-F _c
If
If

'9
A. city L&;~P& B. State C. Country
uc c

-
c. country
3c7/Q& 1OA. When did she come to live in the USA? year: 19,-
8. Don't Know
1OB. How old was she when she came to l i e in the USA? age:
BC 7$z2/3(3 8. Don't Know
11. Is your father stiil living? 1. Yes 0. No 8. Don't Know

-
c.country
u-
.

.- -
A. city ASCZ-~XX B. State C. Country
11
13A. W h e n did he come to live in the USA? year: 19

8. Don't Know
8. Don't Know
What was the first language you learned?
4. Spanish 10. Other langyge (specify:)
5 . German &.&?-6jpp&
i l r
6. Lithuanian
J /
12. Two other
B. dk%Wd
What is your primary language now?
1. English . 7.Russian
2. P o h h 8. Italian
4. Spanish
5. German
6. Lithuanian
T?(spem=)
11. English AND another
12
Please note: Insert the name ofthe hnguage(s)provided in response to Q. 14 and I5

whenever the term (language(s)]appears in the text in Q. 16
''''6 Would you say that you speak mostly [languagc(s)] or do you speak mostly English, or do you speak
a. Mostly [language(s)J b. Mostly English C. Both about the same
:.I
Hand "CARD 1: LANGUAGES" to the respondent
I
I
tell me whether you use English only, mostly English,both English and Ilanguage(s)]
equally, mostly [)anguage(s)l, or [language(s)l only.
1. Englishonly 4. Mostly [language(s)l

2. Mostly English 5. [ I e ( s ) l only
3. E s d Y 6. Not applikble
16B. What language (do/did) you speak with your mother?
1. Englishonly 4. Mostly Ilanguage(s)l

2. Mostly English 5. n m 1d Y
3. Equally 6. Not applicable
16C. What language (doldid) you speak with your father?
1. English only 4. Mostly [language(s)l

2. Mostly English 5. n ( s ) l only
1. English only 4. Mostly [language@)

2. Mostly English 5. [Language(s)l only
3. Equally
13

2. Mostly English 5 . [Language(s)l only
3. Equally

2. Mostly English 5 . [LwP%e(s)l only

2. Mostly English 5. rLanguage(s)l only
1. English only 4. Mostly [language(s)l

2. Mostly English 5. [Language(s)l only
3- E q d Y 6. Not applicable
161. Do you consider your English to be.... ( r e d &ices)
1. very Good
2. pretty Good
3. Fair, or
4. Not good at all
16J. Do you consider your [language(s)] to be ... (read choices).
1. VeryGood
2. PrCttyGood
3. Fair,or
4. Not good at all
speak English well? Would you say.. . (red choices)
1. Never
2. Sometimes
3. Often, or
4. Always
I5
14
sc. c 16L. How often has it been hard to get good grades or do well at a job because of
problems understanding English? Would you say.. . (read choices)
1. Never
2. Sometimes
3. Often, or
4. Always
Now I hpve some questions about your education.
%c /g 17. Have you attended school in another country, this country (the US), or both?

2. usonly
AY /4&7 17A. How many years of school did you have? years (1 - 20)
lip[ 7v73cP; 17B. At what age did you stop ancnding school? years old

f3:ck;
0. NO
1. YES
.................
17C1. what degree did you receive? ..............
Q!$g
e:. .
.....
........
k-/g 18. Did you finish high school?
0. NO
1. YES
Re r4AO MA. And have you done any studying beyond high school?
......
0. NO
1. YES
fi&i 18A1. How many years of studying beyond high school have you done?
-Y= months
15
18A2. What is the highest degree you have reached?
1. No degree
2. Associate's degree or t e c h d degree
4. Master's degree
6. Other
18A3. Are you currently in school?
0. NO Go h
1. YES Q. I9

...........
0. NO
1. YES
18C. Have you gotten a GED or had any other schooling or training s k then?
0. NO
1. YES
16 I
1. &pi&&,idL&j -&
-
&*&g
/ d
2.
3.
-
wao 20. Do you identify with an ethnic group?

'9,
0. NO
1. YES
2 1. Which group(s) do you identify with?

1. &+a&
C'd/&S &4 Y . d
In Q. 21, cimk thc number of thc 'pwethnic

' pup.
I
22. How American or [ethnic group] arc your customs?
1. Very American
2. Mostly .American
3. Mostly [ethnic group]
4. very [ethnic group]
17
I
8c 22A. How often have you had problems with your family because you prefer American
customs? Would you say ...(read choices):
1. never
2. sometimes, or
3. often
~e.g,3 23. Are you Latino or Hispanic?
0. NO
'I 1. YES
I Hand "CARD 2: LATINO/HISPANIC"to the respondent I

WCZ 5 A 23A. Which of the following represents your origins?
1. Cuba
2. Mexico
3. hertORic0
4. Spain
5. South America
7. other &?&
I Hand "CARD3: RACE/ET"ICITY" to the respondent 1

yourself?
1. Asian
2. Pacific Islander
4. Caucasian /white
5. Native American
6. Other
%'
How often do people dislike you because of your ethnic group or race? Would you say...(read
choices)
1. never
2. sometimes, or
3. often
How often are you treated unfairly at school or work beaus- of your ethnic group or race?
yould you say.. .(read choices)
1. never
2. sometimes, OF
3. often
How often have you seen friends treated badly because of their ethnic group or race? Would
you say.. .(red &ices)
1. never
2. sometimes, or
3. often
Note that 0 . 2 8 and 29 have been intcrrtionolhr omit?d. I
2"
19
8c .Jc: 30. Do you follow or are you a member of any of the churches or religions listed here?
0. NO G o t o Q - 34-
1. YES CirclegrrrnphdkatedandGotoQ, 31
2C 3CC#L / 1. Buddhist
2. Catholic
3. Church of Christ
Y 4. Evangelical
5 . Hindu
6. Islamic
8. Jewish
~ O C M ~a. orthodox
b. Conservative
c. Reformed
d. other d k G & Q*'d
9. Mormon
10. Pentecostal
WC&?Ce 3 11. Protestant
a. Anglican
b. Baptist
2%-.%C& 1/ 1. American Baptist Association
4. southern Baptist Convention .
5. Other Baptist
c. Episcapali //
Ac c*;r.F d. Lutheran
Rc.3~ ~ & - 6 e. Methodist
1. Episcopalian
5 . Other Methodist Churches ~~+ !3@~d~
Bbc' .jCCIu-p3 f. Presbyterian
2. United Presbyterian Church in the U.S.A.
g. Seventh Day Adventist
12. other A&--&.
20
Would you say your religion provides you with.. .( R e d choices)

How often do you attend religious service? Do you attend... ( R e d choices)
I 1. almost every week or more

3. afewtimesayear
4. almost never, or
5. never
Now I have some questions about your mother.
34. What counuy(s) best represents your mother's national origin or ancestry?
1. L/G&CdLU &&&sLi&
35. Is your mother Latino or Hispanic?

'f
0. NO GatoQ. 37
1. YES GotoQ. 36
I Hand "CARD2: LATINO/HISPANIC" to the respondent

... ... .... . .. .
I
36. Which of the following represents her origins?
1. Cuba
2. Mexico
3. PuertORicQ
4. Spain
5. SouthAmerica
6. OtherCentralAmcrican
7. other dd-&d
I Hand "CARD 3: RACE/ETHNICITY"to the respondent I

37. If you were asked to put her into only one of these groups, in which one would you place her?
4. ,Asian
2. Pacific Islander
3. African American / Biack
4. Caucasian /white
5. Native American
6. Other k2GzXwd
22
38. Did your mother finish high school? Ec: .38
8840 38A. Has she done any studying beyond high school?
0. NO
1. YES
38A1. How many years of studying beyond high school has she done?
2c MA/ ,?
-Years -, months
3 ~3' 8 4 ~ . 38A2. What is the highest degree she reached?
1. Nodegree
2. Associate's degree or ttchnical degree
4. Master's degree
5. Doctoral degree (J.D., M.D., Ph.D.,D.D.S., D.O., Ed.D)
6. Other
BC 3 8 4 3 38A3. Is she currently in school?
0. NO
e
.:w;.)+$>, .........
$I&@$
1. YES Y rA
.
,
. ., %.
%' 536&4Q 38B. What is the last grade she completed? -

(1 12)
5 9 GO 38C. Has she gotten a GED or any other schaoling or training since then?
0. NO
1. YES
fa-c .%CY 38C1. What has she received? 1. GED

2. other dcgr~/ccrtificate:
3. other schooling:
38C2. Is she currently iq school or uaining?

xx 3BC;C,
0. NO
1. YES
i
23 I
i
Now I have some questions about your father.
39. What country(s) best represents your father's national origin or ancestry?
40. Is your father atino or Hispanic?
0. NO
1. YES
I Hand "CARD2: LATINO/HISPANIC"to the respondent I

4 1. Which of the following represents his origins?
I. Cuba
2. Mexico
3. PuertoRico
4. Spain
5. South America
6. Other
7. Other
Hand "CARD 3: RACEETHNICITY"to the respondent I

42. If you were asked to put him iuto only one of these groups, in which one would you piace
him? cmm::odfF
.......................................................................
................
.. ............. ..*
1. Asian
2. Pacific Islander
5. Native American
6. Other &Md
24
Did your father finish high school?
0. NO
1. YES
43A. Has he done any studying beyond high school?
1
0. NO ~ .7
1. YES
43A1. How m y years of studying beyond high school has he done?

XC4+?1' I
-Y= ,- months
K Q3 43A2. What is the highest degree he reached?
1. Nodegree
4. Master's degree
5. Doctoral degree (J.D., M.D., Ph.D., D.D.S., D.O., EA.D)
6.Other &Eaw&d * /
43A3. Is he currently in school?
0. NO
1. YES
%z4'3&J 43B. What is the last grade he completed? 3 -

-
(1 12)
@c
,y3co 43C. Has he gotten a GED or any other schooling or t h h g since then?
0. NO
1. YES
kt-c 43er 43Cl.what has he received? 1. GED

2. other degrec/cenificate:
&mzL
3. otherschooling:
fit 4 3 C & 43C2. Is he currently in school or uaining?
0. NO
1. YES
25
This interview MBy or MBy NOT end here.

Answer the following questions yourself and follow the instructions provided:
Is the subjecr married or Living with a partner?
RECORDTIME:
27
26
44. what is hisher first name? ,AWP

f 5
BCQ5 45. What is partner]'^ age?

3
3. 30 to 39 years 6.60 or above

mm
46A. When did shehe come to l i in the USA? year: 19,-.

8. Don't Know
468. How old uks she/he when sheme came to live in the USA? age:
8. Don't Know
Is [parmer('s)] mother still living? 1. Yes 0. No 8. Don't Know
-
whmwassheborn?
A. city a y f ~ d B. State C. Country

-

-
A. city 9 f p - d B. State
7
c. counay
27
A. city Y T BB.~ - State C.Country -

and 49B
=4940 49A. When did she come to live in the USA? year: 19
8. Don't Know
I;bc &ho 49B. How old was she when she came to live in the USA? age:
8. Don't Know
9
)c $0 50. Is [partner's] father still living? 1. Yes 0. No 8. Don't Know
A. city -1 -ed B. State

- c. country
-
., ,
A. city &4 B. State

-
A. city G & V ~ B. State

- c. country
x);cFAA0 52A. When did he come to live in the USA? year: 19

8. Don't Know
8c 5 & h O 52B. How old was he when he came to live in the USA? age:
8. Don't Know
25
28
&'53 53. Has [partner] attended school in another country, this country (the US), or both?
2. usonly
)aC 5 3 4 0 53A. How many years of school did Ipartner] have? -

(1 20)
ac 63A50T 53B. At what age did [partner] stop attending school? years old
7
ac 5 3 c o 53C. Did [partner] receive any type of degree?

0. NO
1. YES
53C1. What degree did [parmer] receive? h ) B d arb

Q*3
ac 54 54. Did [partner] f a h high school?
0. NO
.1. YES
BC 6'4.0MA. Has shehe done any s t u d y i i beyond high school?
0. .NO
1. , YES
-years months
54A2. what is the highest degree shehe reached?
1.No degree
4. Master's degree
5. Doctoral degrez (J.D., D., D.D.S., D.O., Ed.D)
6. Other
54A3. Is [partner] currently in school? 0. NO Go to

1. YES P*53
3Q
29
%' 5460 54B. What is the last grade [partner] completed? (1 - 12)
R".54C@ 54C. Has shehe gotten a GED or any other uaining since then?
0. NO
1. YES
54C 1. What has she received? 1. GED

&%?&5@@&d
3. other schooling:
&WHJLL
Y
54C2. Is [Partner] currently in school or train@? 0. NO Goto

1. YES o*ss
55. What country(s) best represents [parmer's] national origin or ancestry?
0. NO
1. YES
I Hand "CARD 2: LATINo/HISPANIC" to the respondent I

1 5640 56A. Which of the following represents hisher origins?
1. Cuba
2. Mexico
3. PuemRico
4. Spain
5. SouthAmerica
30
I Hand "CARD 3: RACE/ETHNICITY" to the respondent
a c e 57. If you were asked to put Cpartner] into only one of these groups, in which one would you
place himher?
cirCie0NErml;y:
1. Asian
2. Pacific Islander
5, Native Amer
6. Other
SCHOOL SCREEN
33
SCHOOL SCREEN: S [ISyear olds only]
Date: .s[:+/i
<j+/p-<"
't
mm dd yy
Interviewer ID:
..yL-w2&A&?-
,?
1. Are you currently in school?
(Code YES ifcurrently on vacation, suspension, etc. and will return to school.)
1. YES
2. NO
2. why are you not m school?

., ........>.... A . E . : e : % $ p + ! ~ ~ : . : . :
1. Graduated W:V;Q$B.
.
I
... ..... ,. .
........ . A. .,....,...
ed. init. ed. date
35
2
8. What is the name and address of the school you currently attend?
1. V&SL.&-&Lu &>&
-
Name of school
2.
Address
3b
3
13. What grade are you currently in?
-
(If during summer break and ***** is between mades code what made *****
will be entering in the fa.) Epter grade or CiFcCc 9DXin rxngnded d o &

grade
14. In the past year, were you ever truant -skipped school for the whole day without
an excuse?
~f
1. YES GOrnQd15
2.NO EoTU Q. 16
15. On the average, in the past year, how ofim did you skip school for the whole day
withoaltanexarse?
a. morethanonceawak
b. onceaweek
c. afiwtimtsamonth
d. onceamonth
e. afiwtimesayear.
16.
1. YES
2. NO
17. Onthe average, how o h d i d you skip classeswithout anexcuse?
a- everyday
b. ahtimesaweek
c. onceaweek
d. afewtimesamonth
e. onceamonth
. f afewtimesaycar.
37
4
18. Thinking back to the last year you were in high SChooY grade school were you
e ~ e ftruant-skipped school for the whole day without an excuse?
1. YES
2.NO
->$
19. How o f h did you skip school for the whole day without an excuse?
a morethanonceaweelc
b. onceaweck
d. onceamonth
e. afiwtimesayear.
1. YES
2.NO
22. Haveyoueverskippcdagrade? 1. YES 2. NO
23. Haveyou ever repeated a grade? 1. YES 2. NO
3%
5
24. Many students receive special teachmg or help in school. At any point in your
education, did have you received any help or special teaching in any of the
following areas?
(Read choices - circle all that apply.)
a. Giftedclass 1. YES 2. NO
b. Special remediation class/ tutoring program 1. YES 2. NO

(icludes summer school)
c. Learningproblems 1. YES 2. NO


LimitedEngiishspeakiog
f speechthesapy- 1. YES 2. NO
B. c~prorogramforPhysicalty 1. YES 2. NO
sight problems
h. Emotional or behavior problems 1. YES 2. NO

i Specialmusicorartschool 1. YES 2. NO
j. Specialscienceprogram 1. YES 2. NO
. -
39
6
25. W e d are you routinely involved in Cxtracunicular activities directly C O ~
with your school, such as school sports teams, school clubs, music groups, etc.
1. YES
2. NO
26. How mamy hours docs/ did this take place? hours per week
11
27. What kind of program wad is this? (Circle all that apply)

2. Artistic (music, danct, art)
3. Academic mrichment (tutoring classes)
4. other@leascspecify) VCa&&&
/ J
~~
28. Wcre/ueyou iuvolved in any other kind of after school program?

ol*his maybe at *****s but is more of an after school program *than
GxtMlKiclllaraCtivity.)
1. YES
2. NO
30. What kind of programwad is this? (Circle all that apply)

7
3 1. What schools have you attended in the past?
For RA.s only: for Elementary and High School type, use the follo
-
3 home school
b. Elementary School (including Kindergarten)

School Name I I
Address (include city,state) School type
8
c. Hi@School I
Datescnrolkd I Grades
!.
1
5. .-
9
-
2 Training program
-
3 Trade school
-
4 Technical school
5 - 2-year college (city college)
6 - 4year college
School Name Address (iclude city, state) School type Datesenrolled I Grades
1. iCZ&& cL.k&
s3 3y.a /E*
a d e n t
b. good
c. lir
d. poor
P END OFINTERVIEW RECORD TIME:

HEALTH SCREEN
4b
HEALTH SCREEN: S
',a
FIELD COPY 2 ~'(t.ci&ce
Time Started: 7YL 1-9s 77M
Now I have some questions about your health.
1. your health is d e n t , very good, good, fkir, or poor?

Would you say that in ~enaal
1. cxcellmt
2. verygood
3. good
4. - fiir
5. poor
2. Now h k m g about your physical h&b, inchrding being sick or injurtd, for how many
days during the past30 days was your physical healthnot good?
rmmber of days
3. Now tbking about your m d Mtb, which includes stress, depressi04 and problems
with emotions,for how many days during the past 30 days was your mental heahh not
good?
number ofdays
ed. init. ed. date
47
7
ys 4 4. Dunng the past 30 days, for about how many days did poor physical or mental health keep
you from doing your usual activities, such as self-care, work,or recreation (play)?
I
1
FAMILY STRUCTURE &
HEALTH HISTORY
49
1
Family Structure and Health History: Subject
PARTI: FamilyStnrctmp
Now I would like to ask some questions about your family. This year I will only be
getting a general outline of who is m your family. Next year we will come back to this
information and we will draw out a tree to camp& it.
ETrst, let me review a few details.

FC f 1. Do you have any children? (CIRCLE ONE)
1-NO
2-YES:
2
1A. For each child, I need to know hisher name, age and whether he/she is a
biological, step, foster, or adoptive child. Why don't you start with the oldest.
SONS DAUGHTERS
~
# l b name: IIS name:

living: Y N age/age died: pCJ44/' living: Y N age/age died: FCzW4
causeofdeak ~&@&&#e K/&A.5 ause of death:
s
F C ./R&1//3 FC -fR& rs
bio? step? foster bio? step? foster? adopt?
bio'l mom's nam bio'l mom's name: - d
D.O.B. &
4-
Y E
.& D.O.B. 4 L - d ,
causeofdeath: A a a e a e ?
F C fkc:L A FC?f0eEIZ S
bio? step? foster? adopt? bm? step? foster?
D.O.B. d w D.O.B.
FCfR$3A =/As. 3s
bio? step. foster? adopt? bio? step? foster? adopt?
D.O.B. D.0.B I -
3
SONS DAUGHTERS
#4b name: - 6 &e #4s name: -
2 &J
living: Y N age/age died:KjxW4'/ living: Y N age/age died: FC/ddd:

cause of dcath: FChm4A
&iy-m& 6 .
t'C-fpe.g+& h3 f R $ 4 5
bio? step? foster? adopt? bio? step. foster? adopt?
bio'l mom's name: bio'l mom's name: - 4
bio'l dad's name: bio'l dad's name: ~ &Ye Va t m w A
D.O.B.+ , D.0.B
~~
#5b name: &e@q#-e? # 5 s name: &T$ec&%e?
living: Y N age/age died:FT'I'Afl54 living: Y N agefage died: F ' c / M ~ ~

cause of death: FC 5 3 cause of death:
rA-
/ y :
E$ /AS 5 s
bio. step? foster? adopt?
bio'l .mom's name: bio'l mom's name:
bio'l dad's m e : bio'l dad's name: d w
D.O.B.
#6s name: 4z?a&@Q&

living: Y N age/%&dicd:fc/.!&$
cause of death:

bio'l mom's name:
D.O.B.
53
step, foster, or adoptive siblings.
Do you have any siblings? 2.Yes 1 .No
For each one, I need to know their m e , age, whether they are male or female,
and whether they are a biological, step, foster, or adoptive sib- of yours.
I also need to know whether your sibling has a partner and whether or not they
have children. Why don't you start with your oldest brother or sister.
1 BROTHERS
# l b name: @%+FA/
living: Y N age/age died:&&4f&/
cause of death: h-C A9W r&
d - M
bio'l mom's name:

bio'l dad's name:
12b name: 6Z%e&%wd

livii: Y N agdage diod. ./=cd.A~+j
cause of death: FC&40J&&
6da?&%L?d
Y
=R&Ezk
bio? step? foster?
bio'l mom's name:
bio'l dad's name:
NAP
5
BROTHERS SISTERS
# 3s name: d w
living: Y N age/&e died:
Y FCA443,
cause of death:
&-
FCk "p
bio? step? oster? adopt?>
FCAREZS
bio'l mom's name:
p e a &4.5
bio'l mom's name: @ -
bio'l dad's name: &2& I "
6
BROTHERS SISTERS
# 5s name: -d
L
living: Y N agehge died: X A X W ~ S
cause of death:
x
=sier 5-.s
bio'l mom's m e :
bio'l dad's name:
7
BROTHERS SISTERS
# 7 b name: L&7&ip.. # 7s name:
living: Y N age&e died:EsAA?& living: Y N agehie died: FZ'AWYS
cause of death: FC A B TI3 cause of death:
L d M J
f=CA&& 3 S J Y
bio? step? foster? @opt? bio? step? foster? adopt?
&%S
bio'l mom's name: ~ Z & - & + a w ~ bio'l mom's name:
-
bio'l dad's name: .d ? w bio'l dad's name:
NAP NAP
Fi& PA.?& FCAW/?63 FC'RPGJR TAPIQ?~ FGW/JS /=c&%?S
partner? Y N age: -gender: ME partner? Y N age: gender: M/F
Children? Y N F C . & k / ? & Children? Y N /=CdL:/?'S
# girls: - # boys : F C A / k o f ~ # g ~ ~ % .# .boys
w :sFcJ2mss
.
fr06fk&7E to /%-#5 049s
-
ifas name:
living: Y N ageli&died:K'AAABS
cause of death:
, - L
FC n a 4s'
bio? step? foster? adop
bio'l mom's name:
bio'l dad's name:
=C,Z!d??&S K.&"7'8f KAWG&'S

parmer? Y N age: gender: M/F
-ken? y N FC'~,L:/$~S
*#girls:- *#boys:-
8
Now I have some questions about your parents.

3. What are your parents' fEst names?
u *'S
4.1 What is your parents' marital status?
la marricd-stiUinvohred
lb divorced
2a nevermafricd-stillinvoIvcd
2b lltvc~marritd--M) lower involved
la married-stiUlinvohred
lb divorced
IC married, butscpamcd
2a nevermarricd-stillinvoived
2b never married-no longer invo,~ed
9
5. Has your mother ever been married to anyone else or lived with someone else as a
partner? (CIRCLE ONE)
For definitional purposes partnerhere refers to a sexual relationship with someone of the
ing of living quarters for most of the time, without
Y
1-NO: GUTOptreSonn6-
2 -YES: W T O Q . 5A
5A. How many other relationships bas she had?

# of relationships
5B. For cach of your mothers relationshrps, ....... to know whether she was
I...................
._..............,.......,...... nttd
married or living with that person mi%ZW and
&whether she is still in this
relationship]. If the relationship ended, I need to know if this was due to
divorce, separation, or death.
FC 5-k 6Q 1. Gender: M/F .1

(fmt name)
FC 5&M//
la married-still i W a l d 2a never married-still LJvolved
pararu died
2k dont know
la
lb
IC
Id
married-still involved
divorced
married, but separated
widowed .
-1 -
(frrst name)

involved
2c never married, either
10
partner died
2k don'tknow
3.Gender: M E .1
la married-still involvtd 2a never m9nied-still involved

lb diwKcad 2b never married-nolonger
IC manied, butseparated involved
Id widowed 2c ncvcrmarried,eithcr
parmcrdicd
2k don'tknow
4.Gender: M/F .I

lb d i v o r c e d 2b never married-no longer
parmcr died
2k don'tknow
11
5.Gender: MIF 1.-

(fiisC-e)

partner died
2k don'tknow
6. Gender: M/F .1

partner died
2k don'tknow
la married-still involved 2a m e r married-still imrolved

lb d i v o d 2b never married-no longer
Id widowed 2c never xnarried, either
partner died
2k don't know
12
F C 6- 6. Has your father ever been married to anyone else or lived with someone else
as a partner? (CIRCLEONE)
being married to himher at that time.
.,t -
1 NO:
2 - YES:
F C 6-40 6A. How many other relationshps has he had?

# of relationships
6B. For each of your father's relationships, I need to know whether he was married
or living with that person p m and whether he is still in this
relationship]. If lhe relationship has endcd, I need to laow if this wasdue to
divorce, separation,or dcath.
FC 6A M / la married-stillinvolved 2a never married-still imrolved

IC marricd, butseparated involved
palmer ditd
2k don't know
13
2. Gender: M/F .1
(first/&e)

lb divorced 2b never married--no longer
partner died
2k don'tknow
3.Gender: M/F .1
f a married-still involved 2a never married-still involved

partner died
2k don'tknow
4. Gender: M/F

partner died
2k don't know
14
5. Gender: M/F

parmer died
2k don'tknow
6. Gender: W F .1
la marricd-still involved 2a never married-still involved

lb divarced 2b IEVW marrkd-~)10-w
IC married, but separated invOlved
Id widowed 2c pevermarriad,either
2k dan'tkpoW
7 . G d e r M/F .1
la married-stillinvolved 2a never married-still involved

lb divmccd 2b rmrcrmarried-nolonger
Id widowed 2c nevcrmanied,either
partaerm
2k don'tknow.
15
f C 7 7. In your entire family including anyone: parents, children, siblings, aunts, uncl~,
grandparents,cousins, anyone...
Who are ypll particularly close to? YOUcan iist as many people as you want -
anyone in the family who you feel close to.

P = paternal other]
A B
FC ?-/A
.1 Name B or N
.2 Name
- /J -
/=c?--RE3
B or N M or P - Ll-
FC?-5h KJ- 3c
-3 Name - 1-
B or N MorP - I--
.4 Name - /# - fcy- 9 6
B or N
FC 3- 9c
M or P - I/ -
Fc-7-5c - -
.5 M or P .t,
K7- d/s FC ?- 6C
.6 Name
- Y-
B or N M or P
- 6t -
FL' ?- ?Ps K?-+C - f,'-
.7 Name - I&----
B or N M or P
P C L #A3 r=CX&C , -
.8 Name '--e-- BorN MorP
K 7-9/29
.9 Name - A- B or N
F C ?- mw
.10 Name - /'-- B or N
. l l Name
- &--
F C 9-///3
B or N
.12 Name - 44-

FC?-/Z A
B or N
16

8. Now, I need to lirt all the people who live in this household and Id like you to tell me
how each person is related to you. For example, I want you to tell me if the person you
list is your brother, aunt or cousin. Even if a person who lives here is not related to you,
I need you to Iist them also.
a Record fmt name and relationship to subject. Do not include *****.

I
~-
to *****
N = norbiological aunt/unclc,
A B C D
.1 Name Io. BorN MorP
- F=c-uu3 FcB-k
.2 Name BorN MorP
-
FCd- 3& F C d - 4 C -
.3 Name BorN MorP
.4 Name
- F C 8- 443
BorN
Fed-
MorP
uc -
.5 Name c
PCd- 5k3
BorN MorP
FCd-5C
-
.6 Name
- FC 5- d& fc 81- 6-c
BorN MorP
-
- FCB-Th f C & - X -
Namc BorN MorP
-
.7
- /=eg-dn F C d - B c -
.8 Name BorN MorP
.9 Name
- Fc8- 943 FCd- &7@
BorN MorP
-
- FC@-/on /=e&-/& __
.10 Name BorN MorP
. l l Name
L FCd-NA m8-K
BorN MorP
-
bb
17
Part E: Family Health History
Now, I have some questions about your family's health history...
I'm also interested in illnesses. I need to know if anyone in your immediate family has
any of the following health problems: For each person you list, please tell me how he
1* or she is related to you and whether he or she is a biological or nonbiological relation.
Fc y $
9. Diabetes: (circleone) 2.YEs 1.NO

A B C D
.2 Name
* FCY-AA
BorN
-9-Ac
MorP
.3 Name
- FC9-3&
BorN
RP-3c
MorP
7
- Fir.$?&& XA4C
.4 Name BorN MorP
I_
- i c 9-5
z3 Fc 9- 5-c -
.5 Name BorN MorP
K9Lm KY-SC
.6 Name
- BorN MorP
c__
.7 Name
- FCP-34 X 9 - X
BorN MorP
-
.8 Name
- /=cY-cf)A e9-.c
BorN MorP
-
.9 Name
- f=C9-93
BorN
/=cy-=
MorP
-
- R?9-/0A /% 9-7 4 2
-
.10 Name BorN MorP
- FcP-//A KY-d6C -
18
E /O 10. High Blood Pressure: (circle one) 2.YEs 1.NO

[Hypertension]
to *****
N = nonbiological auduncie,
19
11. Heart Problems: (circle one) 2.YEs 1.NO

/Hean Attach, COT OM^^, Arrhythmia]
to *****
.1
.2
.3
.4
.5
.6
.7
.8
.__
f% /5;4 Fc/-7Jsz; -
.15 Name BorN MorP
20
F C / A 1% Stroke: (circleone) 2.YEs 1.NO
t* *****
N = nonbiologid aunthncle,
* M = mated grandparent, child,
A . B C D
,cC y 3 a.
lTmnl
Cancer: ( M e one) 2 . m 1.NO
to *****
B = biologid [parent, sibling,
1 P = paternal self, other]
A B C D
FC /3 - 7413 /=c
/3- /c
.1 Name V&&%'dk BorN MorP k.&e-.Gh&
cx%pp-ed K/3-&% /4sN-AC
.2 Name BorN MorP
.3 Name
e/ 3 - 3 6 /r /3-3C
BorN MorP
-
FC/3-4& X f 3 . 4 ,
.4 Name BorN MorP
-
/3- && /3-6"C
.6 Name BorN MorP
F C j 5 -34 F C f 3 - Z
.7 Name BorN MorP
h
FC /5- a4 /"Cf.%&C
.8 Name BorN MorP
.9 Name
4 FC/3- 9
23 /iT/3-r9c
BorN MorP
-
j3- /0/3Jzi+-I'DC
-10 Name
. l l Name
-
BorN MorP
E @ - / f &/ccj3--/1%
BorN MorP
-
Fc f 3 - /A6 ef3- /&e
-
.12 Name BorN MorP
.13 Name
- fC f3-753
BorN MorP
ef3-13 c,
. FC /3-&73 R43446
.14 Name
.15 Name
-
BorN MorP
E/3-/5'/3
BorN
Fc r3- /5t
MorP
-
L
22
1% e,
Chronic Bronchitis or Emphysema: ( M e one) 2 . W 1.NO
[smoker's cough]
i
n to *****
$ N = nonbiological awitluncle,
23
f C i 5 % Other chronic problems (specify): (circle one) 2.Yes 1.No
B = biological [parent, s i b l q ,
* M = maternal grandparent, child,
<.
'?
.1
E
A B C D
ic>l*z& Fe {S-RC
.2 Name d BorN MorP

A B C D
K" f5- 3& FC/kL 3c
.3 Name dk4m d BorN MorP
E ILLNESS (picase specify):
A B C D
/y3f5-443 /=e/Sc--e
.4 Name d BorN MorP
A B C D
.5 Name BorN MorP
7 3
FAMILY IMENTAL REALTH &.
LEGAL HISTORY
Subject ID:
Interviewer ID:
FHdf==AA/la('
' I Now I'm going to ask you some more questions about all the people in *****'S/YOW
'" family that you've mentioned today.
1. Has drlnlung ever caused any of the people mentioned to have problems with health,
*I***

N = mnbiological aunt/mle,
P = paternal other]
a B C D
2
F M - 2. Has drug use ever caused any of the people mentioned to have problems with health,
2.YES 1.NO
to *****
B = biologipl [parent, sibling,
I P = paternal other]
3
FM3 3. Has anyone mentioned ever suffered fromdepression, h t is, they have felt so low for a
pericd of at least two week that they hardly ate or slept, or couldn't work or do whatever
they
- usually do?
2.YEs 1"
q;" grandparent, child,

4
fights,had trouble holding a job, or was a frequent discipline problem in schml?
2.YEs 1"
*****
N = nonbioiogical aunthncfe,
5
FM5- 5. Has anyone mentioned ever had probiem with their nerves or had a nervous breddown?
2.YES 1.NO

N = nonbioiogical aunt/uncle,
P = paternal other]
A B C D
Eq3=7pA
.l Name BorN
/=M9:&&
-2 Name BorN
F&f5- 3 A
-3 Name B or N
.4 Name
-5 Name BorN M or P /-/Y 5- 9-29
.6 Name
-. F H 5- &A
c -
.8 Name I , .A B or N
Y "
/=N5= 9A
.9 Name B or N
~ 4 6 6. Has anyone mentioned ever tallred to a doctor or a counselor about any emotional
2.YE-s 130

N = nonbioiogical
A B C D
.1 Name BorN MorP

F/y6-.z6 FNd- AC t 5 . g - R Rf
A B C D
.2Name BorN MorP
A B C D
.3Name BorN MorP

FWS-9~3 FWJ- +e ~ g - 9 ~ -
A B C D
.4 Name BorN MorP

FN6-ij-e 5c F/yB, 3
5%
B C D
.5 Name BorN MorP

f W+.-g& -6- 6-c FNd- d e
B C D
.6 Name BorN MorP

7
F/Y F 7. Has anyone mentioned ever been hospitdkd because of emotional prcJems, or because
2.YES 1.NO

>
N = wnbiologid aunt/uncie,
?.4s @ M = maternal grandparent, child,
P = paternat - other]
F~.z-Y/~ s;nirjve F & x B

A B C D
.lName- BorN MorP

Ffy73k3 9b9L.c F/Y.;~_&*
A B C D
.2Name BorN MorP

FM?-3.8 pv img- 3~ F / Y 7-3W
-
B C D
.3 Name BorN MorP
E Reason for treatment

/=/y2-4/ FN?-I/C FH9- w
B C D
.4 Name BorN MorP

F/Y;z - 5
% F=/Y7-5-e Frn2-52-
.5 Name BorN MorP

.6 Name BorN MorP

8
i 8 8. Have any of the people youve mentioned ever attempted suicide?
2.YEs 1.NO
Rei- to *****
B = biological , [parent, sib-,
N = nonbioiogical auuthncle,
M=lMternal grandparent, child,
P =paternal other]
9
F&f9 9. Have any of the people you've mentioned eve: cornmine0 suicide?
2.YEs 1.NO

1 '1
3
A B C I)
10
911. So, none of the people mentioned have had any problems wit31 alcohol or drugs,
(CIRCLE ONE)
1 - no one else

Hospitalizd for alcohol, emotional problems, or drugs - page 7

Fights, frequent trouble with law, trouble holding a job - page 4

lhvg use cawed problems with health, family, job, or police - page 2
Drinking c a d problems with health, family, job, or police - page 1
- 11
Now I have some q u d o n s about whether there k anyone mentioned who has had
trouble witfr the police or who has been arrested. Please do not include routine tr-&c
vioiations o r speeding tickets. '
fwfL) 10. Has anyone that you've meationed had troubie with the p o k e or been arrested? (CIRCLE
ONE)
1. NO:
c
2. YES
~ . :....f * A*...:?x.n
~....................................................................
'-;
.
.
.
.
.. ........>. ...: ? X L ............

FAffOAbL. /=&-IDA3 FiyBA4
1 2 3 4
B or N M or P
"Name Relation
/e=&' j0 ZOB. Do you know what he/she did? (CIRCLE ONE) 2 . m 1.NO
10B ;
.....&
. ............
?& ..m i &. he/&e do?
what
; v*$
F & ~ there any other reasons heishe was in trouble with the police?
~1012. ~And were
(CIRCLEONE)
2 . w 1.NO
...... ., ..............
.......................
1OC1. !EFXFS$
.......... What other offenses led to himmer having trouble with the police?
o ~1OD. Is heishe in jail or prison now? (CIRCLE ONE)

~ r ; d0 2.YEs 1.NO
-
12
F@ y/ 11. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES
?.if
f&HBL FM;/I'x13 Hff+9
1 2 3 4
B or N M or P
Relation
fHf%3U 11B. Do you know what he/she did? (CIRCLE ONE) 2.m 1 .NO
mw7"O 11 C. And were there any other reasons hekhe was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
*....>
11Cl.
.<
..*.................. What other offenses led to himmer having trouble with the police?
A
...>
....
.........
11D. Is hdshe in jail or.prison now? (CIRCLE ONE) 2 . w 1 .NO

i3
FMJYZ 12. Has anyone e!se had Double with the poiice or been arrestzd? (CIRCLE ONE)
1. NO:
2. YES
J.8
F;4//a&& F&/.243 FMAZAP
1 2 3 4
L&eL&+9& /
B or N M or P
me Relation
Ffl7znD 12B. Do you know what he/she did? (CIRCLE ONE) 2.YEs 1.NO
12B 1.
//
FH/&C(J 12C. And were there any other reasons heishe was in trouble with the police?
(CIRCLE ONE)
2.m 1.NO
..*. .
FMS/BcBO 12D. Is heishe in jail or prison now? (CIRCLE ONE) 2.YEs 1.NO
14
Fp;//3 13. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
8 END OF INTERMEW 8 RECORD TIME

I
'if
'8
~
BW3AR F7Y/3#94 f W i 3 A 9
2 3 4
B or N M or P
Relation
,z~/3 13B. Do you know what he/she did? (CIRCLE ONE) 2.m 1.NO
13B1- ........ What did he/&e do?

........... ...s ........
:;<
. .............
FH7'3 Cia 13C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . m 1.NO
.........,..
13C1.- 1 What other offenses led to himmer having trouble with the police?
mf3 BO . 13D. Is he/she in jail or prison now? (CIRCLE ONE) 2.m 1.NO
15
F H /4 14. Has anyone else had troubie with the police or been arrested? (CIRCLE ONE)
1. NO:
2. YES
14A. What is hisher name and how is hehhe related to *****?

H/WL FNAW3 FMY4A.P
1 2 3 4
B or N M or P
Relation
FW/4kW 14B. D o you know what he/she did? (CIRCLEONE) 2 . m 1 .NO
14B1. p &.&
......._,.....
x .... &
-<. !
..-2 did he/& do?
,qy i 4 0~ 14C. And were there any other reasons he/she was in trouble with the police?
(CIRCLEONE)
2.m 1.NO
14D. Is hehhe in jail or prison now? (CIRCLE ONE)

F&++%o 2.YEs 1.NO .
16
~ ~ 15. f Has5anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:
8 END OF INTERvlEW 8 RECORD

1
1
9
15A. What is his/her name and howis he/she related to *+**?
-K5?9A Fmy3-373 F#/59 9
1 2 3 4
B or N M or P
Name Relation
FMY550 15B. Do you know what heishe did? (CIRCLEONE) 2.m 1.NO
15B1. E
................ ................,...
*,.
; =
........... ..... <.-...-
AX ........
What did he/she do3
/~=lprf 5 6 0 15C. And were there any other reasons heishe was in trouble with the police?
(CIRCLEONE)
2.m 1.NO
...?..*.-
...............
15C1. What other offenses led to hi.m/her having trouble with the police?
17
FM f6 16. Has anyone else had trouble with the police or been arrested? (CIRCLE ONE)
1. NO:

fHs/Br4A /+9'/6&3 F?Y7%&4
1 2 3 4
B or N M or P
Relation
F,,,, j 6 b 0 163. Do you know what hebhe did? (CIRCLEONE) 2.YEs 1.NO
~~ ~~ ~
16C. And were there any other reasons he/she was in troubie with the police?
(CIRCLEONE)
2.m 1 .NO
....,._.._
~,...,, . ~
16C1. What other offenses led to m e r having trouble with the police?
m/6aO 16D. Is he/she in jail or prison now? (CIRCLE ONE) . 2.YEs 1.NO
- 18
17. Has anyone else had trouble with the poiice or been arrested? (CIRCLE ONE)
1. NO:
2. YES

'$
1
1 -/=WHL FNfl43 AY7G?-.Q
2 3 4
B or N M or P
Relation
fMA?&O 17B. Do you know what helshe did? (CIRCLE ONE) 2 . m 1.NO
1.
.
......, .............. ~ . : ~
what he/she do?
......A,,..k............t.
FM/+cD 17C. And were there any other reasons he/she was in trouble with the police?
(CIRCLE ONE)
2 . m 1.NO
. .....
<-
17D. Is he/she jail or prison now? (CIRCLE ONE) 2.m 1.NO

lltSM/?BO
EIIMPLOYllMENT & INCOME
95
Subject ID:
PART I: Primary CaregiverlAdult Subject Employment

q.8rs
hours each week.
- -
ed-init. &,date
1i - Working full-time in one job

--
Page 2
working fulYpart-time in additional job(s)

?'9
"I


11. Retired, working part-timejobs
12. Retired, working
15. Unemployed, looktng for work
16. Unemployed, not l o o h for work -

(NOTa homemaker)
Page 3
E1 A 2. Have you been empioyed in a paying position in tbe past 5 years? (CIRCLE ONE)
Have you done volunteer work in the past 5 years?
(CIRCLERESPONDENT'S CHOICE)
Working full-time in one job
Working full-time in one job AND

working Nypart-time in additional job(s)
On leave (temporary illness)


Working part-time in one job
Worlking part-time in two or more jobs -

On leave (temporary illness)

Temporary jobs, occasional work
11. Retired, working part-time jobs ----
17. Volunteer work only, Wpart-time

Page 4
PART: I
SECTION 1
22-3 3. How many jobs do you currently

.. hold?
... (CIRCLE
... . . . ONE)
. ..
. . ..
1. One Job,
2. Two Jobs
3. Three Jobs
4. What is your job title? 64&&4 c&&
5. What are your main responsibilities? y-dL&

1. less than 5,000

2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000a n i 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. dontknow

Y= months

hours/week
If 1 Job ONLY, GO TO Page 15, (part I) Question 45A.

art I) Question 9.
: And your other job?

;.I
4
.
7
1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. morethan5O.OOO
8. don't know

Y- months

hours/week
Page 6
lob 2 And your other job?
15. What are your main responsibilities? Y w ' d k /

-
/ '
,I
'.a

s!/6 16. Which of these numbers best fits your salary in this job? (CIRCLEONE)
1. less than5,oOo
2. between 5,000 and 9,999
3. between 10,000and 19,999
4. between 20,000and 29,999
5. between 30,000and 39,999
7. morethan50,OOO
8. don't h o w
g-7 & 17. How long have you been in this job?
Y- months
&z/ e 18. How many hours each week do you usually work?
hours/week
10%
Page 7
1 Section 2. On leave/disabilitv I
19. How many jobs did you hold before you went on leave/disability? (CIRCLE ONE)
1. One Job
2. Two Jobs
3. Three Jobs .
Of these jobs, I want you to.fKst tell me about the one you considered to be your
1
'Y 19A.
20. What was your job title? v a , d h
21. What were your main responsibilities? g-8d45 * &
1. YES
2. NO
1. lessthan5,OOo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
Page 8
22A. Do you receive your full d a r y or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
pension plan, SSI or any benefits? (CIRCLEONE)
1. lessthan5,OOO
4. between 20,000and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,000
8. don't know

Y= months
before you went on leave/disabiiity?
Y- months
If 1 Job ONLY,GO TO Page 15, @art I) Question 45A.

4
Page 9
26. What was your job title? dGL7tzcddh & ,

/
27. What were your main responsibilities? Y w k d k a

?&
$&
/
//
?>@ 1
1. YES
2. NO

28B. Which of these numbers best fit@ your N1salary in thisjob? (CIRCLE ONE)
1. less than5,OOo
3. between 10,Oooand 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
7. more than50,OOO
8. dont know
6Uslso 28A. Do you receive yoy full salary or part of your salary? (CIRCLE ONE)
1. Full
2. Partial
Page 10
2 2 A& co 28C. Which of these numbers best fit(s) your partial salary, including
1. Iessthan5,000
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
;,7
7. more than50,OOO
8. dontknow
- AQ 29. How long bad you been in this job

Years months
6730 30. How many hours each week were you usually working
hours/wtek
22-31 Y- months
If2 Jobs ONLY,GO TO Page 15, (part 9 Question &A.

If More than 2 Jobs, GO TO Next Page, (part I) Qaesb.*on32.
Page l i
iob 3; And your other job?
32. Wfiat was your job title?
~-
33. What were your main responsibilities? Ye&& &@&#.&&

/
.1,
a >.d

1. YES
2. NO

34B. Which of these numbers best fit(s) your N1 s a h y in thisjob? (CIRCLE ONE)
1. lessthan5,OOO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between.30,000and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. dont know
1. Full
2. Partial
Page 12
&/ 34CQ 34C. Which of these numbers best fit@)your partial salary, including pension
1. lessthan5,OOo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
)?. 7. more than50,OOO
8. don't know

Years months
~
&36 36. How many hours each week were you usually working
hourslweek
37. How long have you been on leave fiom this job?
Y- months

I
I od
Page 13
PAXT: I
SECTION: 3
38. What types of jobs have you done recently? Vt2seC.*d&
a 39
+,d 'f
39. About how many hours each week do you usually work? hourdweek
40 40. How much money have you earned from these jobs in the past year? (CIRCLEONE)
1. less tban5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than 50,000
8. don't know
on 45A. I
Page 14
PART: I
SECTZON: 4
v&dk
43. How many hours usually volunteer? (CIRCLEONE)
1. 1-2
2. 3-5
3. 6 - 12
-
.
4. 13 20
5. > 20

2.44 Y= months
I GO TO Page 15, (part 9 Question 45A.

Page 15
FBRT: I
-
SECTION: 5
listed during the interview, start with the primary job,
~rimary/OnlyJob]
45A. Where is your job located? (rf trave& to vanous locations, record address of main once.)
99
#4+.Z-%&*dk
address
city State zip code
45B. How far is your work fromwhere you live? (CIRCLE ONE)
0 - works at home 4-6to 1Omile~

1-lessthanamile 5 - greater than 10 d e s
2-1to2miles 6 - Varies acwrding to
1-Walk -
6 carp001
3 - bdabway -
8 commuter train
-
4 bicycle
5 - other
IllhUteS
Page 16
[Seconary job 23
46A. Where is your job located? (If travels Co vanom locations record address of m i n ofice.)
b+z2-HLdh
address
/ J
city stae zip code

$
4&. How far is your work from where you live? (CIRCLEONE)
0 - works at home 4-6tolOmil~

-
3 3 to 5 de^ work site
I-Walk 6 - v l
-
3 bU/Subway 8 - commuter train
4 - bicycle
5 - other
(using the mode of tramportation listed in Question 46C)
If there is PQ partner, go to Page 35, (part m), Qwstion 1.

Page 17
[Secondary job 31
47A. Where is your job located? @f mveh to various locm*ons,record addren of ma
n
i oficc.]
city State zip code
4%. How far is your work from where you live? (CIRCLE ONE)
1.
d
-1
3-3t05deS work site
1 -walk 6-~ p d
4 - bicycle
5 - other
minutes
i
If them is a partner, go to Page 18, (part JI) Question 1.
If there is RQ partner, go to Page 35, (part m) Question 1. I
Page 18
PART: TI
PART II: Partner Employment
work situation:
<4
%I
Page 19
2. Working full-time in one job AND -

working fiWpart-time in additional job(s)
3. On leave (temporary iilness)

?@ I
7. on leave (temporary illness)


-
15. Unemployed, lookmg for work

(NOT a homemaker)
17. Volunteer work only, fuU/part-time - 2

Page 20
2. NO: Has your parmer done volunteer work in the past 5 years?
1 -Yes
2-NO
1. YES:
:BK&
............. ...........
........................
.........
..>
..

working fWpart-time in additional job(@





fage 21
3. How many jobs does he/she currently..hold

. (CIRCLEONE)?
. .. .. . . . ...
1. One Job
2. Two Jobs
3. Three Jobs . .........,......,
i,# 1 3A. Of these jobs, I want you to first tell me about the one he/she considers to be hisher
4. What is his/her job title?
5. What are hisher main responsibilities? A=&2&&

Y U

1. lessthan5,000
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000 and 49,999
7. more than 50,000
8. don't know

Y= months
8. How many hours each week does heishe usually work? hours/week
Page 22
I 1 Job ONLY,GB TO Page 32, (part n)Question 45A

If More than 1 Job, GO TO the Next Page,(part IO Question 9.
:- And hisher other job?
9. What is hisher job title? b4+k&e&d& &

6-
t r

1. less than5,OOo
2. between 5,000 and 9,999
4. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know

Y= months
13. How many hours each week does he/she usually work? hours/wtek
If2 Jobs ONLY, GO TO Page 32, @artII')Question 45A.

Page 23
ob 3. And his/hs other job?
14. What is hisher job title? YMAd& / /
15. What are hisher main responsibilities? va*&&if&.

J J
1. less than 5,000

2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 3 9 , W
7. morethan50,OOO
8. don't know

Y- months
Page 24
PART: II
SECTION: 2
I P
t
Section 2. On leave/disab%ty
1. One Job
. v 2. Two Jobs
7
3. Three Jobs
19A. Of these jobs, I want you to first tell me about the one heishe considered to be hisher
20. What was hisher job title? P%e6-2& LzfkkWPd
21. What were hisher main responsibilities? d&d& A p &
22. Does he/she continue to receive money from this position? (CIRCLEONE)
1. YES
2. NO

Page 25
dzP&&&0 22B. Which of these numbers best fit(s>h h e r full salary in this job? (CIRCLE Olui)
1. less than 5,000

2. between 5,000 and 9,999 . .
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,.000and 49,999
7. rnorethan50,000
8. don't know
Does he/she receive his/her full salary or part of hismer salary? (CIRCLEONE)
1. Full
2. Partial
22C. Which of these numbers best fit($ hishier partial salary, including pension pian,
1. lessthan5,Ooo
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000and 49,999
7. morethan50,OO
8. don'tkuow

Y- months
How many hours each week was he/she usually worlung


YWS months
Page 26
26. What was hisher job title? k,&&&.Ld& L&ec+?p&

//
27. What were hisher main responsibilities? y-2& &H.&

/ -
I?,$ 'I
1. YES
2. NO
I Hand respondent rtspome card #2 1

28B. Which of these numbers best fit(s) his/her full salary in this job? (CIRCLE ONE)
1. lessthan5,OOO
2. between 5,000 and 9,999
3. between 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between40,000and49,999 .
7. morethan50,OOO
8. don'tknow
28A. Docs helshe of hisher salary? (CIRCLE ONE)

%F%Aix
0
1. Full
2. Partial
Page 27
2. Wh*-u of these numbers best fit(s) hidher partial salary, including pension pian, SSI or any
1. less than5,oOo
2. between 5,000 and 9,999
4. between 20,000and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
!># ,1 - 7. .more than 50,0(30
8. don't know

YWS months
30. How many hours each week was heishe usually working
Y- months
If2 Jobs ONLY, GO TO Page 32, (part II) Question 45A.

Page 28
lob 7; And hisher other job?
32. What Was hisher job title?
33. What were hisher main responsibilities? /-+d&

& a&
/ J
3%; I
- . -
1. YES
2. NO

34B. Which of these numbers best fit(s) hisher full salary in this job? (CIRCLE ONE)
1. lessthan5,000-
2. between 5,000 and 9,999
3. betwetn 10,000 and 19,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
7. morethan50,OOO
8. don't know
SIP 3&90 34A. Does he/she receive hisher full salary or part of hisher salary? (CIRCLE ONE)
1. Full
2. Partial
Page 30
PART: l3
SECTION: 3
38. What types of jobs has he/she done recentty? M,

YY
39. About how many hours each week does he/she usually work?
hours/week

40. How much money has he/she earned from these jobs in the past year? (ClRCLE ONE)
1. lcssthan5,OOO
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000and 39,999
6. between 40,000and 49,999
7. morethan50,OOO
8. don't know
1 GO TO Page 32, (part II) Question 45A. I

Page 29
si
p 0 JQCQ 34C. Wh~chof these numbers best fit($ hisher parual salary, including pension pian,
1. less than5,OOO
2. between 5,000 and 9,999
4. between 20,000 and 29,999
5. between 30,000 and 39,999
6. between 40,000 and 49,999
8. dont know

before heishe went on leave/disabiiity?
36 36. How many hours each week was heishe usually workjng
QPa7 37- How long has heishe been on leave from this job?
months
GO TO Page 32, (part IX) Question 45A.

1
Page 31
PART: II
SECTION: 4
Section 4. Voiunteer work
u w * dLiz. &*D 4
43. How many hours each week does heishe usuaUy volunteer? (CIRCLEONE)
1. 1-2
2. 3-5
3. 6 -12
4. 13 - 2 0
5. > 20

Y-
~
months
Page 32
PART: 11
SECTION: 5
-/Only Job]
45A. Where is your partner's job located? (7ftrtrveh to vanow locmions, record address of main
oflce.)
~
Y w ' d h dfi@??#e&e
address
city State zip code
1fiP&j-- 45B. How far is hisher work from where you live? (CIRCLEONE)
0 - works at home 4-6t010miles

1-lessthanamile -
I :F/P46c-o 45C. How does he/she usually get to work? (CIRCLEall that apply)
l-W& 6-carp001
2 - drive myself -
3 - budsubway -
8 commuter train
4 - bicycle
5 - other
If 1Job ONLY, GO TO Page 35, (part III) Question 1.

s a r t II) Question 46A.
I m?
Page 33
[Secondary job 23
46A. Where is hisher job located? @f ?ravels to various locations, record d r e s s of main office.)
city State zip code
/PoY6/30 ,,46J3. How far is his/her work fkom where youJive? (CIRCLEONE)
9
?//.96CO 46C. How does he/she usually get to work? (CIRCLEall that apply)
1-Walk 6-c~p001
-
4 - bicycle
-
5 other
?/PO630
minutes
If 2 jobs ONLY,GO TO Page 35, (part m)Question 1.

If More than 2 Jobs, GO TO Next Page, (part n)Question 47A.
Page 34
[Secondary job 31
47A. where is hisher job located? flf navels to various locations, record d r e s s of main ofice.)
P&l'db
address
city Sfate zip code
4*. - is hisher work ftom where you &e? (CIRCLE ONE)

How far
-
0 works at home -
4 6 to 10 miles
2-1to2miies 6 - Varies according to
3-3to5des work site
47c. How does he/she usually get to work? (CIRCLE all that apply)
1-walk 6-yrpo0l
-
4 - bicycle
5 - other
47D. On the average, how long does it take him/her to get to work?
minutes
I GO TO NEXT PAGE, (part III) Question 1.

Page 35
PART III.
soufces in the past tax year. Have you recemed....(r ead each choice and circle all that apply)


f. money from relatives (NOT partner or spouse) 1. YES 2. NO

5 federal grant, financial aid, scholarships 1. YES 2. NO

(please specify) kzbedd& hfld
Now I am g o b to ask 3011some questions abut your total income. First, I w i l l ask about your
personal income, and then I wiU ask about your total household income.
?,
t
2A. From these sources of income AND the income from any jobs you had in the last tax year,
1. lessthan55,Ooo
2. between $5,000 and $9,999
3. between $10,000 and $19,999
4. between $20,000 and $29,999
5. between $30,000 and $39,999
6. between W , OO and $49,999
O
7. more than$SO,OOO
8. don'tlcnow
28. From these choices, what was your total household income in the last tax year before taxes?
household.
1. lessthan$5,000
2. between $5,OOO and $9,999
3. between $10,000 and $19,999
4. between $20,000 and $29,999
5. between $30,000 and $39,999
6. between $40,000and $49,999
8. don't know
8 END OF INTERVIEW 8 REc.oRDTIME I

,
133
1
WAIS-R
Only ask the following questions of subjects who speak either Enghsh or Spanish. DOnot
You should answer the nut set of questions in the language you know the best, that is, the
lahuage you know the most words in.
1. Which language do you know ,$hcbest? - -. .,flc-.B$h3

- __ -- I
__
.... .. . . . .
135
Arrangement Order Correct or
Acceptable Order I (Circle)
Arrangement Order Correct or
Acceptable Order
Score
(Circle)-
1. House 60" ' 1 ' CAP 2 6.Escape 90" HUNT 0 2

-
& 7. Hill 90" HELPS 0 2
JANET 2
2. Flirt 60' JNAET or AJNET 0 1 8. Fish 90" ANGLER or ARNGLE 2
AGNLER 0 1
3.Romeo 60' --------GxGZF
SHADE
LUNCH 0 2
4. Louie 60 ARGUES 0 2 SAMUEL or AMUELS 2
OPENS 10. Taxi 120" SALMUE 0 1
5. Enter 90' OENSP 0 1 - Max=2O
5. VOCABULARY Dlrcontlnue after 5 consecutive fallurer.

score '
2, 1, or 0
1. Bed
2. Shid
3 Pennv
4. Winter I 1
5. Breakfast t l
6.Repair
7. Fabric
8. Assemble
9. Enormous
10. Conceal
11. Sentence
12. Consume
13. Regulate
14. Terminate
15. Commence
16. Domestic
17. Tranquil
18. Ponder
I
19. Designate
20. Reluctant I
21. Obstruct
22. Sanctuary
23. Compassion
124. Evasive
~~ ~
25. Remorse I .
26. Perimeter
27. Generate
28. Matchless
29. Fortitude
r
v c 30 30. Tangible
I/ C3 3 '31. Plagiarize
v~ 3,$5 32. Ominous
vc 3 3 33. Encumber
i/c 3 4 34. Audacious
v c 3 5- 35. Tirade Max=70
Note: Be sure to include scores for Items 1-3 in Total.
Tobl
i
E W C E OF FEERS
Deviance of Peers
mm COPY 2
I
t ,I
Time Started: ;BOPS 7/&
Y$.
Now 1 a m going t o ask you some questions about your Mends and people you spend time
with. All of these questions are about things these people have done in the past year,
that is since ...
During the past year, how many of the people you spend t h e w i t h have done each of the
following things. Choosing from,
3. Allofthean
2. -Some of them
1. Noneofthem
1A. Are any of your friends and/or people you spend time with in school?
1. YES
2 . NO
1. Have been involved in school activities, not including sports? Would you say.. . Bp f,+
3 2 ' 1
ed. init. ed. date

2
Deviance of Peers --.
I
During the past year, how m a y of the people who you spend time with.. .
!
..
. .
I
.- -_.
Have been involved in school athletics/sp.drts?

~
2.
'4
3 2 1
of them Some ofthem None of them
.)
plll
3. How many have gotten along. well with teachers and adults at school?
3 2 1
4. How many have been thought of as a good student?
3 2 1
5. How many have obeyed school rules? 3-
3 2 1
6. How many have slupped school without an excuse?
3 2 I
3 2 1
_..
3
Oeviance of Peers
During the past year, how m y of the people who you spend time with.. .
1.t
'f
am?
3 2 1
9. How many have been involved in religious activities or church groups?
- 3 2 1
3 2 1
3 2 1
3 2 1
13. How many have been'generally honest and told the truth?
3 2 1
79.3
4
Deviance of Peers
*
14. Have lied, disobeyed, or talked back to adults, such as parents, teachers or others?
3 2 1 BP Y.4
15. HOWmany have purposely damaged or destroyed property that did not belong to them?
3 2 1
' 16. How many have stolen somethulg worth $5 or less?
3 2 1
17. How many have stolen something worth more than $5 but less than $500?
3 2 1
la. How many have stolen sometlung worth more than $500?
3 2 1
19. How many have gone into or tried to go into a building to steal something?
- 3 2 1
AU of them Some of them None of them
5
Deviance of Peers
During the past year, how anany of the people who you spend time with.. ,
20. Have taken a motor vehicle, such as acar or motorcycle, for a ride or drive without &e
owner's permission?
BPD
Lj d 3 2 1
21. How many have gotten into physical (fist) fights with schoolmates/co-workers or Bp& f
friends?
3 2 1
22. How many have hit someone with the idea of hurting them? BP3h
3 2 1
23. How many have attacked someone with a weapon with the idea of seriously hurting 3
them?
3 2 1
24. How many have used a weapon or force tc get money or things from people? BflAQ
3 2 1
25. How many have sold drugs, such as heroin, cocaine, crack, or LSD (other than p ~ f j -
marijuana).
-- 3 2 1
6
Deviance of Peers
During the past year, how many of the people who you spend time with ...
?;?:
26. How many have used marijuana or pot?
3 2 1
27. How many have used any form of alcohol, including wine, liquor, or beer?
3 2 1
28. How many have used drugs, such as heroin, cocaine, crack, or LSD (other than a p 2 8
marijuana)?
3 2 1
29. How many have used tobacco?

-..- ..;..
....... .,.,
.
3 2 1 :k .:I
I
30. How many have had sexual intercourse? -.*...

. .
(Record don't understand" if applicable)
3 ' 2. 1
I .
i
Hand Subject response card #2 n
7
Deviance of Peers
During the past year, how often have people you spend t i m e with done the following?
Choosing from (1) Never, (2)QndTwice, (3) Several Times or (4) Often. !
31. How often have they asked you to go drinking with them? Would you say.... BP 3/
I
1 2 3 4
Never OnceiTwice Several Times Often
32. How often have they put pressure on you to drink? BP 3d5
1 2 3 4
33. How often have they said that you have to get drunk to have a good time? l7%P33
1 2 3 4
34. How often have they offered (gave or sold) marijuana or pot to you? 8P34
1 2 3 4
35. How often have they said that you have to get high on drugs to have a good t h e ?
ap35-
1 2 3 4
W36
1 2 3 4
Never Once/Tw ice Several Times Often
d

1
EASI Temperament Survey: Subject Version
Interviewer ID:
EAS/';RA1%
Now I am going to read some statements about what you might be like.
I Hand response card and point to response scale 1

For each one, try to rate yourself on a d e h m 1to 5, with 1 being uncharacteristic or
not at all like you and 5 being characteristic or v e q much like you.
1. i feel happiest in familii surroundings.
1- Uncharacteristic (NOT at all like you)

2- Somewhat Uncharacttristic (NOT very much like you)
3- Neither Uncharacteristic nor Characteristic
4- Somewhat Charactcritic (sort of like you)
5- Characteristic (very much like you)
2. I often act on the spur of the moment.

2- Somewhat Uncharacteristic (NOT very much like you)
4- Somewhat Characteristic (sort of like you)
ed. init. ed. date

2
EZ3 3. I am something of a loner.

EZLt 4. I sometimes do "crazy" things just to be different.
1- Uncharacteristic (NOT at all like you) -

&25 5. I like to be with people.

E? b 6. I have trouble resisting temptation.

3 1 7. I find people more stimulating than anything else.

2- Somewhat Uncharacteristic (NOTvery much like you)
3
8. Unfinished tasks really bother me.

9. I cry easily.
,1
3- Neither Uncharacteristic nor characteristic
10. I make friends easily.
1- Uncharacteristic (NOTat all likc you)

2- Somewhat Uncharacteristic (NOTvery much likc you)
5- characteristic (very much like you)
11. I tend to be somewhat emotional.
1- Uncharacteristic (NOTat all like you)

2- Somewhat Uncharacteristic (NOT vcry much l i i you)
5- characteristic (very much l i you)
12. I am off and Nnning as soonas I wake up in the morning.

4- Somewhat characteristic (sort of like you)
I 53
4
E? 13 13. I generally seek new and exciting experiences and sensations.

14A. I like to spend my money right away rather than save it for long range goals.

15. I can tolerate frustration better than most.

16A. I frequently get distressed.

217 17. I get upset easily.

5
E2 fcf 18. I tend to hop from one interest to another quickly.

2 19 19. I take a long time to warm up to strangers.

?
EZXO 20. I prefer quiet activities to more active ones.

5- Characteristic (very much likc you)
E 2 zi 21. I often say the first thing that comes into m y head.
1- uncharactens' tic (NOTat all like you)
2- Somewbat Uncharactwistic (NOTvery much like you)

3- Neither Uncharacteristic nor Chatacteristic
4- Somewhat characteristic (sort of iike you)
5- characteristic (very much l i i you)
22. I tend to be shy.

222
6
23. I tend to get bored easily.

223 24. Usually I can not stand waiting.

Z 25 25. I have trouble controlling my impulses.

326 26. I am always on the go.

7
I am very friendly with strangers.

E2 22 27.

E 2 28 28. I always like to make detailed plans before I do something.

*#
E2 2 9 29. I generally like to see things through to the end.

30. I often have trouble making up my mind.

E 2 30
2- Somewhat Uncharacteristic (NOT vcry much lib you)
5- charactuistic (very much like you)
31. I prefer being with others rather than being alone.

2 31
1- UQcharacteristic (NOTat all like you)
8
EE32 32. I am very sociable.

Characteristic (very much like you)
I
5-
E233 33. When alone, I feel isolated.

a39 34. I react intensely when upset.

235 35. I am very energetic.

3- Neither Uncharacteristicsor Characteristic
EZ3L 36. I tend to give up easily.

5- Characteristic (very much like YOU)
9
E2 3? 37. When I move about, I usually move slowly.

E 2 38 38. I like to plan things way ahead of time.

d
39. Once I get going on something, I hate to stop.

EL 39
1- Uncharacteristic (NOTat all likc you)
3- Neither Uncharacttristic nor Characteristic
5- characttristic (very much like you)
/Qq0 40. Iwillayanythingonce.
1- uncharacteristic (NOT at all l

ib you)
2- Somewhat Uncharacteristic (NOT very much likt you)
3- Neither Unchactcristic nor characttristic
8 END OF INTERVIEW 8
RECORD TIME:
'9
1
LIFE HISTORY CALENDAR

Life History Calendar
Date:,, --.
mm dd yy
Subject ID:
FIELD COPY 2 Interviewer ID:
t
Prior to the appointment, highlight the respondent's birth month for the past 5 years and
write hisher age above each column highlighted. In addition, drawing a heavy line at
the present month and this same month 5 years ago gives a concrete parameter for
gatheringinformation. lkmmme the respondent's age five ycars ago and usc this to
anchor the respondent to the time frame of the Life History Calendar. The Calendar you
have should cover 5 years (61 months). That k,if you are interviewing in October
of 1994, the calendar should extend back to October of 1989. If there are extra months
on tither end of the Calendar block them out prior to beginning.
We are going to be using this chart to fill in information about different things that have
happened to you in the past 5 years, that is since!:
I Rcad-1 year] in 1st Wlumn of calmdar. I

SpecificauJr I will be asking questions about about whether or not certain things have
hapjmedinthepast5years. Pleasebear withmesothat this calendar canbeas
complete and acunate as possible.
These colored lines (point to them) mark the month of your birthday. Across the top of the
calendar I have labeled both the year and how old you were. We will begin from the
present and work back u n a [e.g. name month, year of lst column of calendar].
NOTE TO INTERVIEWER. This measure starts with # 21 on purpose.

PAGE IS MISSING
23. In the past 5 years, has there been a time when you had an illness, injury, or emotional
problem and you were unable to work or carry out your normal activities for a periad
of a month or more?
Y
23A. Was this because of an
l=illncss
2 = injury
3 = emotional difficulties
23B. Whcnwastbat?
23C. How long did this period last?
Code on-row, usel, 2 or3 ineachmonthof disabling illness or injury.
23D. Were there any other times?
24. Have you bccn the victim of acrime in the past five ycars?
C i e NO
24A. When did this happen?
I65
i .
4
PAGE IS MISSING
late:
,UBID:
i t ID:
LIFE HISTORY CALENDAR: W o n 5 - Other Events March 1996
ime Started:
1995 1996
1991 1993
I
-
LIFE HISTORY CALENDAR:
sedion 5 Wer Events
3s 3 g d$Sl k P I r e IC P i
PAGE IS MISSING
Date:
SUBID:
Int ID:
LIFE HISTORY CALENDAR: sedion 5 - Other Events April 1996
Time Started:
1891 1993

-
Sodon 5 Other Events
liPS459liPC
,-
PAGE IS MISSING
Date:
SOBID:
ilnt ID:
LIFE HISTORY CALENDAR: Section 5 - Other Events May 1886
/lime Started:
1 T i e Stopped:
1994

Sedion5- OthsrEvenb
PAGE IS MISSING
1. Are you currently involved with someone? CT i/
1. YES
0. NO
g .
; t~ :.: . ~ , ! : : ~ ; ~
.. .......... . ... ..
.... . . ..:. -.
....._._....
_. .. ._.... ..-
A. Are you married to, engaged to, or dating this person? C 7/ A 0

1. married
2. engaged
3. dating
B. Are you currently living with this person?

1. Yes
0. No
C. How long have you been in the relationship? C77CO
-
Y- months
I 1
I BEGIN INTERVIEW I
(If more than one person, select most significantrelationship) C7-+.&
1. YES
0. NO
A. Were you married to, engaged to,or dating this person? @TARO
1. married
2. engaged
3. dating
B. Were you living with this person? c7xr30

1. Yes
2. No
1
I
t
BEGIN INTERVEW 1
3. Have you dated anyone at all in the past year? 0-3
1. YES
For this interview,I would like you to think of all your dating
0. NO 4
736
l.
Date: C7&-PB#/-.
mm dd yy
No matter how well a couple gets dong, there are times when they disagree, get annoyed with
the other person, or just have fights because theyre in a bad mood or tired or for some other
reason. They also &e many different ways of trying to settie their differences. Im going to
read some thingsthat you and your partner might have done when you had an argument in
...
Refer to fmt month on the time line
these responses.
R Hand respondent the response card, and read choices 1 to 6
ed. init. ed. date

2
1A. How many times have you discussed an issue calmly? CT 7 4

0 1 2 3 4 5 6
'1
"Q

0 1 2 3 4 5 6
IC. as this ever happened? CT YG 1 =Yes 0 = No
2A. How many times have you gotten information to back up your side of things? CTL.4
0 1 2 3 4 5 6
never O W twice 3-5 610 11-20 more than
2B. How many times has he/she gotten information to back up hisher side of things? T.,&&
0 1 2 3 4 5 6
2C. Has this ever happened? 1 =Yes

3
0 1 2 3 4 5 6
11
9
3B. How many times AS hehhe "rought in or triec, to bring in someone else to help settle things?
0 1 2 3 4 5 6
c73c 3C. Has this ever happened? 1 = Yes 0 = No
C7-4M 4A. How many times have you insulted or swore at himher?
0 1 2 3 4 5 6
4B. How many times has heishe insulted or swore at you?

C 74 4
0 1 2 3 4 5 6

4
5A. How many times have you sulked and/or refused to talk about an issue?
0 1 2 3 4 5 6
? !'
'8
5B. How many times has he/she sulked and/or refused to talk about an issue?
0 1 2 3 4 5 6
6A. How many times have you stomped out of the room, house or yard?
0 1 2 3 4 5 6
0 1 2 3 4 5 6
never O W twice 3-5 6-10 11-20 more than
6C. Has this ewer happened? 1 =Yes 0 = No

5
When you had an argirment with your partner in the past year,
1 74 7A. How many times have you cried?

0 1 2 3 4 5 6
'>$ r
I CGv3 7B. How many times has he/she cried?
0 1 2 3 4 5 6
8A. ' How m y times have you done or said something to spite him/her?
0 1 2 3 . 4 5 6
0 1 2 3 4 5 6

m8c
6
c/ gf+ 9A. How many times have you threatened to hit or throw somettmg at him/her?
0 1 2 3 4 5 6
never once , twice 3-5 6-10 11-20 more than
$
?q
i
37-96 9B. How many times has he/she threatened to hit or throw something at you?
0 1 2 3 4 5 6
never Oflce twice 3-5 6-10 1 1-20 more than
1OA. How many times have you thrown, smashed, hit, or kicked w?
0 1 2 3 4 5 6
times times times 20 timts
10B. How many times has heishe thrown,smashed, hit, or kicked w ?
0 1 2 3 4 5 6
1OC. Has this ever happened? 1 =Yes . O=No

7
11A. How many times have you thrown something af W h e r ?
0 1 2 3 4 5 6
t
1 1B. How many times has he/she thrown something iU you?
0 1 2 3 4 5 6'
12A. How many times have you pushed, grabbed, or shoved m e r ?
0 1 2 3 4 5 6
0 1 2 3 4 5 6

8
13A. How many times have you slapped himher?
0 1 2 3 4 5 6
' 'I
?'i9

0 1 2 3 4 5 6
...
13C. Has this ever happened? l=Yes 0 = No
14A. How many times have you kicked, bit, or hit himmer
0 1 2 3 4 5 6
14B. How many times has helshe kkkcd, bit, or hit you m?
0 1 2 3 4 5 6
. ...
14C. Has this ever happened? 1=Yes 0 = No

15A. How many times have you hit or k e d to hit him/her ?
0 1 2 3 4 5 6
Q, $
I
0 1 2 3 4 5 6
0 1 2 3 4 5 6
16B. How many times has hdshe beat you up?
0 1 2 3 4 5 6
16C. Has this ever happened? 1 = Yes . O =No
I85
10
C7/7t4 17A. How many times have you choked himlher?
0 1 2 3 4 5 6
?,#"

c7 /?&
0 1 2 3 4 5 6
never Ollce twice 3-5 6-10 1 1-20 more than

C777C
mf&4 18A. How many times have you thrcate!ned m e r with a M e or gun?
0 1. 2 3 4 5 6
27/86 18B. How many times has he/she threatened you with a knife.or gun?
0 1 2 3 ' 4 5 6
never OnrX twice 3-5 610 11-20 more than
.. .. ............
.... ..

When you had an argumen with your parfner in the past year,
19A. How many times have you used a knife or fired a gun?
0 1 2 3 4 5 6
1
tiB)
19B. How many times has he/she used a knife or fued a gun?
0 1 2 3 4 5 6

SUBSTANCE USE
Substance Use Interview
-
[18 24 Year Old Subjects]
Date: .
mm dd yy
Subject ID:
herviewerm
&m COPY 2
Timestaltd
This questionnaire is about your use of Cigarettes, alcohol, marijuana and other drugs.
Remember, at the begidug of the study, I told you about the special protection to
ensure your privacy? The Federal Certificate of CoIlfidentinlity makes it illegal for
anyone,even your parents or people at school, to see or find out what your answers are
m this study. No one except our research staf'fwiIl ever see them. Your answers can
never be seen by police, the mutts, your parents, or anyone clse.
If you don't b o w the meaning of a word just ask me.
llsed them m your entire life- choa6ing from one of these &oices...
1 Hand snbject respome card # l,to these choices for Wetime use.
refer I
These are the choices for telling me how many times you have used aiwhol or a drug in
your whole life. The choices are: 0. Never, 1. 1-2 Days,2.3-5 Days, 3. 6-11 Days,
4. 12-24 Days, 5. 25-50 Days, 6. 51-99 Days, 7. 100-199 Days, or 8. 200 or more Days.
ed. init. ed. date

Page 2
have used them in the past year, that is since... .
Hand subject response card #2, refer to these choices for past year use.
In thinking about the past year, the choices are the same, however, there is some extra

1. 1-2days
2. 3-5days
3. 6 - 11 days.. ...........means every other month
4. 12 - 24 days.. .........means 1 or 2 times each month
5. 25 - 50 days ...........means several times each month
6. 51 - 99 days ...........means 1 or 2 days each week
7. 100 - 199 days.. ......means 3 - 4 days each week
8. 200+ days.. ...........means almost every day
have used them in the past month, that is since....
In thinking about the past month, the choices are a little M e r e n t and here is some extra I

1. 1 -2days
2. 3 - 5 days..............means once each week
3. 6 .9 days ..............means twice each week
4. 10 .14 days ...........means three times each week
5. 15 - 20 days.. .........means four times each week
6. 21 + days.. ............means almost every day
Page 3
The following questions are about cigarette smoking.
1A. Have you EVER smoked cigarettes? (CIRCLE ONE ANSWER)

sw7xo NO....0 - Goto Q.'s
Yes...l
A
1
#
1B. About how old were you when you first smoked a cigarette?
S# f450
Years Old
How many days have you smoked cigarettes...

3-5 6-11 12-24 25-50 51-99 100- 200+

Days Days Days Days Days 199 Days
Days
2 1 3 6 7 8
2 1 3 4 5 6 7 8
10-14
SM/EO
Never 1-2
Days
3-5
Days
69
Days Days
15-20
Days Days 1
4 1 5
r
1E. Duringthe 0 1 2 3
last 30 dam?
Page 4
sw IF 0 1F. During the past 30 days, how many cigarettes did you smoke on an average day?
(CIRCLE ONE ANSWER)
2 - 1 - 5 cigarettes a day
3 - About 1/2 pack a day (6 - 15 cigarettes)
swk1 1-Did you use what was in the house?..................................... 1. Yes 0. No

5 w 16 2 2-Did you buy it from friends, family, or other people you know?. .. 1. Yes 0. No
SWIG3 3-Did you buy it from a store?............................................... 1. Yes 0. No
sw 16 'f 4-Did others share it with you? ............................................... 1. Yes 0. No
sw 16 5 5 -Did others give it to you?.................................................. 1. Yes 0. No
SW I6 6 6 -Did you trade goods for it? (trade something for it?) ................. 1. Yes 0. No
s w 1 67 7 -Did you trade services for it? (do something for it?). ................. 1. Yes 0. No
SW I G 9 8 -Did you steal it?.. ........................................................... 1. Yes 0. No
sw I(; q 9 .Did you get it by scam, fraud, or con?................................. 1. Yes 0. No

sw 1 6 IO 10-Did someone else buy it for you?. ........................................ 1. Yes 0. No
Page 5
1W. During the past 12 months, when you smoked cigarettes, what have been your m ~ s t
? -

-
3 Was it to feel good or get high?.......I.................................... 1. Yes 0. No
4 - Was it to have a good time with your friends?.. ........................ 1. Yes 0. No
, 5 - Was it to fit in with a group you like?................................... 1. Yes 0. No
'P
6 .Was it to get away fromyour problems or troubles?.; ................ 1. Yes 0. No
9 - Was it to help yourself fall aslctp?....................................... 1. Yes 0. No
10 .Was it to help yourselfstay awake? ..................................... 1. Yes .O. No
13 - Was it to end a pregnancy?.............................................. 1. Yes 0. No
14 - Was it to make sex better?............................................... - 1. Yes 0. No
15 - Was it for any other reason? (specify:)................................ 1. Yes 0 . No
I A.
Page 6
sw 2A 0 2A. Have you EVER taken or used smokeless tobacco? Other names for this are snuff,
plug, dipping tobacco, or chewing tobacco. (CIRCLE ONE ANSWER)
NO....0 -
Yes ...1
Sw28 0 2B. About how old were you when you first used Smokeless tobacco?
Years Old
How many days have you used smokeless tobacco.. .

I Never 1-2
Days
1 1
I2C. Ever in I
last 12 months?
I I Never 1-2
Davs
3-5
Days
SWXO 2E. Duringthe

last 30 days?
0 1 2
3 1 4 1 5
tbe
Page 7
zk. How dld you get any smokeless tobacco you used during the iaSt 30 days?
SWAFd 1-Did you use what was in the house?..................................... 1. yes 0. No
1
3-Did you buy it from a store? ............................................... 1. Yes 0. No
CDid others share it with you?................:.............................. 1. Yes 0. No
6.-Did you trade goods for it? (aade something for it?) ................. 1. Yes 0. No
7 -Did you trade services for it? (do something for it?)..................
'B
1. Yes 0. No
8 -Did you steal it?.............................................................. 1. Yes 0. No
sdZFf0 10-Did someone else buy it for you?......................................... 1. Yes 0. No
2G. Durhg the past 12 months, when you used smokeless tobacco, what have been your
1 .Was it for fim, kicks, or excitement? ..................................... 1. Yes 0. No

2 .Was it to relax or relieve tension? ........................................ 1. Yes 0. No
3 .Was it to feel good or get high? ............................................ 1. Ycs 0. No
4 .Was it to have a good time with your friends? ........................... 1. Yes 0. No
5 .Was it to fit in with a group you k? ................................... 1. Ycs 0. No
7 .Was it because of bondom, nothing else to do? ....................... 1. Yes 0.No
8 .Was it bccause of anger or hmation? .................................. 1. Yes 0 ,No
9 .Was it to help yourself fall aslecp? ....................................... 1. Yes 0. No
10 .Was it to help yourself stay awake? ..................................... 1. Yes 0. No
11 .was it to help manage your weight? .................................... 1. Yes 0. No
13 .Was it to end a pregnancy?.............................................. 1. Yes 0.No
14 .Was it to make sex better? ............................................... 1. Yes 0. No
A.
B.
[ 57
Page 8
The following questions are about drinking alcoholic beverages, including BEER, WINE,
WINE COOLERS, and LIQUOR. A drink means a 12 oz. can or bottle of beer, a 4 02.
glass of wine, a 12 oz. wine cooler, or a shot glass of hard liquor (like scotch, gin,
vodka). Liquor also includes a mixed drink.
I I
SW3A 0 3A. Have you EVER had a drink of beer or wine cooler, or hard liquor - not just a sip
or taste? (CIRCLE ONE ANSWER)
NO....0 -
Yes.. .1
SM 3Bl-l 3B.1 About how old were you when you first drank beer -- not just a sip or a taste?
(CIRCLE 'NEVER TRIED' OR RECORD AGE)
0. Never Tried
SW361-2 Years Old
sw362-1 3B.2 About how old were you when you first drank wine or wine cooler -- not just a sip or a
taste? (CIRCLE 'NEVER TRIED' OR RECORD AGE)
0. Never Tried SW3B2-2 Years Old
s w 3% I 3B.3 About how old were you when you first drank a mixed drink or shot of hard liquor --
not just a sip or a taste? (CIRCLE 'NEVER TRIED' OR RECORD AGE)
0. Never Tried SW3B3,2 Years Old

Page 9
How many days you had alcoholic beverages to drink - not just a sip or taste...
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

S"N 3co Days
% 3C. Ever in 1 2 3 4 5 6 7 8
your whole life?
3b. Duringthe 0 1 2 3 4 5 6 7 8
I last12months?
Nc~er 1-2 3-5 69 10-14 15-20 21+

5-w3 E O Days Days Days Days Days Days
3E. Duringthc 0 1 2 3 4 5 6
last 30 dam?
Page 10
31. On those days when you drank beer, wine, wine coolers, or liquor, about how many
sw310 drinks did you have?
Usual number of drlnks per day on the days you drank in the past 30 days:
SW3JO 35. During the last 30 days how many times have you had 5 or more drinks in a row?
(CIRCLE ONE ANSWER)
0 - None
1 - Once
2 - Twice
3 - 3-5 times
4 - 6-9 times
5 - 10 or more times
3K. How did you get any beer, wine, wine coolers, or liquor you drank during the last 30
days?
sN3K I 1-Did you use what was in the house? ..................................... 1. Yes 0. No
s ld 3 K 2 2-Did you buy it from friends, family, or other people you know?. .. 1. Yes 0. No
s w3 K3 3-Did you buy it from a store?. .............................................. 1. Yes 0. No
S W 3 )c L) 4-Did others share it with you?. .............................................. 1. Yes 0. No
5 W 3 K $ 5 -Did others give it to you? .................................................. 1. Yes 0. No
s W 3 K b 6 -Did you trade goods for it? (trade something for it?)................. 1. Yes 0. No
S 3K7 7 -Did you trade services for it? (do something for it?). ................. 1. Yes 0. No
3w 3K 8 8 -Did you steal it? ............................................................. 1. Yes 0. No
S W 3 K q 9 - Did you get it by scam, fraud, or con? ................................. 1. Yes 0. No
3 w3 KlO 10-Did someone else buy it for you?. ........................................ 1. Yes 0. No
Page 11
3L. During the past 12 months, when you drank beer, wine, wine coolers, or liquor what
. .
have been your for drlnklllg?
-
1 Was it for fun,kicks, or excitement?..................................... 1. Yes 0. No
2 .Was it to relax or relieve tension?........................................ 1. Yes 0.No
3 .Was it to feel good or get high? .....I.....................................
. 1. Yes 0. No
-
4 Was it to have a good time with your friends?.......................... 1. Yes 0. No
.>,4 -
5 Was it fit in with a group you l i ?................................... 1. Yes 0. No
7 .Was it because of boredom,nothing else to do?....................... 1. Yes 0. No
8 .Was it b-e of anger or frusaation?.................................. 1. Yes 0. No
9 .Was it to help yourself fall asltep?. ...................................... 1. Yes 0.No
12 .Was it to help get rid of a bangover?. .................................. 1. Yes 0. No
13 .was it to end a pregnancy?.............................................. 1. Yes 0. No
14 .Was it to make sex better?............................................... 1. Yts 0.No
3 &' 3 i ,/3- 15 .Was it for any other reason? (specify:)................................ 1. Yes 0.No
A.
B.
3M. During the past 12 months, about how many times have you gotten drunk or very higb on
alcoholic beverages?
Number of times drunk or very high in the past l2 months:

Page 12
The following questions are about other drugs.
SW4Al) 4A. Have you EVER used marijuana or hashish? Other names for this are grass, pot,
hash, or hash oil. (CIRCLE ONE ANSWER)
NO.,..^ -
Yes.. .1
SW bo 4B. About how old were you when you first used marijuana or hash, even once?
Years Old
How many days have you used marijuana or hash ...

r
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 2OO-t

Days
4C. Ever in 1 2 3 4 5 6 7 8
your whole life?
4D. Duringthe 0 1 2 3 4 5 6 7 8
, last 12months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SwYED 4E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 13
4F. How did you get any marijuana that you used during the last 30 days?
.sp.cY
/ Fi 1-Did you use what was in the house?..................................... 1. Yes 0. No
2-Did you buy it from ffiends, family, or other people you know?... 1. Yes 0. No
0.No
3 5 -Did others give it to you?.................................................. 1. Yes 0. No
6?-Didyou trade goods for it? (trade something for it?)................. 1. Yes 0. No
1
0. No
0. No
0. No
4G. During the past 12 months, when you used marijuana, what have been your
? -
Sd46i 1 .Was it for fun, kicks, or excitement? ..................................... 1. Yes 0. No

3 .Was it to feel good 01 get high? ............................................ 1. Yes 0. No
1
4 .Was it to have a good time with your friends? .......................... 1. Yes 0. No
5 .Was it to fit in with a group you like? ................................... 1. Yes 0. No
7 .Was it because of boredom, nothing elst to do? ....................... 1. Yes 0. No
8 .Was it because of anger or frustration? ...............
;.................. 1. Yes 0. No
9 .Was it to help yourself fall asleep? ....................................... 1. Ycs 0. No
10 .Was it to help yourself stay awake? ..................................... 1. Yes 0. No
13 .Was it to end a p r e g n a q ? ............................................... 1. Yes 0. No
14 -Was it to make SUI. better?............................................... 1. Yes 0. No
s iJ L.16 15 .Was it for any other reason? (specify:) ................................ 1. Yes 0. No
A.
B.
Page 14
SW5AO 5A. Have you EVER used Cocaine or Coke in any form, such as powder (or Snow),
NO....0 -
Yes ...1
5B. About how old were you the first time you used cocaine, in any form?
Yeais Old
How many days have you used cocaine -- powder cocaine, crack, freebase or cocoa paste ...
Never
5C. Ever in
vow whole life?
*
5D. Duringthe 0
last 12 months?
I 10-14 I 15-20 21 +
p
Never 6-9
Da s Da s Davs
last3Oda s?
0
l I 2 6
Page 15
5F. How did you get any cocaine that you used during the last 30 days?
sn/3-Fd 1-Did you use what was in the house?..................................... 1. Yes 0. No

2-Did you buy it from friends, family, or other people you know?... 1. Yes 0.No
4Did others share it with you?................................................ 1. Yes 0. No
5 -Did others give it to you?.................................................. Yes 0. No
z
1.
6 -Qid you goods for it? (tradc something for it?)................. 1. Yes 0.No
7 -Did you trade services for it? (do some- for it?).................. 1. Yes 0. No
8 -Did you s a it?............................................................. 1. Ye 0. No
Sk/'$/!=/Q 10-Did someone else buy it for you?......................................... 1. Yes 0. No
5G. During the past 12 months, when you used Cocaine, what have been your
9 1 .Was it for fun, kicks, or excitement? ..................................... 1. Yes 0. No

3 .Was it to feel good or get high? ............................................ 1. Yes 0. No
4 .Was it to havc a good time with your friends? .......................... 1. Yes 0. No
.
5 Was it to fit in with a group you like? ................................... 1. Yes 0. No
7 .Was it because of boredom,nothing else to do? ....................... 1.Y- 0. No
8 .Was it because of anger or frustration? .................................. 1. Yes 0. No
9 .Was it to help yourself fall asleep? ....................................... 1. Yes 0. No
11 .Was it to help manage your weight? .................................... 1. Yes 0. No
12 .Was it to he4 get rid of a hangover? ................................... 1.Yes 0. No
14 .Was it to makc sex better? ............................................... 1. Yes 0.No
s /v' sg f3- 15 .Was it for any other reason? (specify:) ................................ 1. Yes 0. No
A.
B.
Page 16
These questions are just about crack. Crack is cocaine in rock or chunk form.
I
6A. Have you EVER used Crack?
(CIRCLE ONE ANSWER)
NO....0 -
Yes.. .1
SWbBO 6B. About how old were you when you first used crack even once?
Years Old
How many days have you used crack ...
r
Never 1-2 I 3-5 I 6-11 12-24

Days
25-50
Days
200+
Days
6C. Ever in
your whole life?
4 5
6 1 7 8
6D. Duringthe
last 12 months?
0
l I 2 l 3 4 5
6 1 7 8
Never 1-2 3-5 6-9 10-14 15-20 21+

5wloEO I6E. During: 0 1 2 3 4 5 6
last 30 da s?
Page 17
6F. How did you get any crack that you used during the last 30 days?
sw6"F-L 1-Did you use what was in the house?..................................... I. Yes 0. No

2-Did you buy it from friends, famiiy, or other people you know?... 1. Yes 0. No
3-Did you buy it froma dealer?.............................................. 1. Yes 0. No
4-Did others share it with you?................ .............................. 1. Yes 0. No
r
6 -!lid you trade goods for it? (trade somettung for it?)................. 1. Yes 0. No
7 -Did you trade services for it? (do somcttung for it?) .................. 1. Ycs 0. No
*& 6Ffo 10-Did someone eise buy it for you?......................................... 1. Yes 0. No
6G. During the past 12 months, when you used crack,what have been your
W?
'M661 1 .Was it for fun, kicks, or excitement? ..................................... 1.Yes 0. No

2 .Was it to relax or relievc tension?........................................ 1. Yes 0.No
3 .Was it to ftel good or get high?............................................ 1. Yes 0. No
4-Wasittohpveagoodtimewithy~ufriends?.......................... 1. Yes 0. No
5-Wasittofitinwithagroupyoulike? ................................... 1.Yes 0.No
6 .Was it to get away from your probkms or troubles?.................. 1. Yes 0. No
7 .Was it because of boredom, nothing else to do?....................... 1.Yes 0. No
8 -Was it because of auger or frustration?.................................. 1. Yes 0. No
9 .Was it to help yourself fall aslap?....................................... 1. Yes 0. No
10 .Was it to help yourself stay awakc?..................................... 1. Yes 0. No
13 .Was it to end a pregnancy?.............................................. 1.Yes 0. No
14 .Was it to make sex bettd ............................................... 1. Yes 0. No
s - g&f5
~
A.
B.
Page 18
7A. Have you EVER lnhaled or sniffed any substance like glue, gasoline, paint or
markers to get high? (CIRCLE ONE ANSWER)
NO....0 -
Yes ...1
7B. About how old were you when you first inhaled or sniffed a spray or liquid, even once?
Years Old
How many days have you lnhaled or sniffed anything to get high...
Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

Days
7C. Ever in 1 2 3 4 5 6 7 8
your whole life?
7D. Duringthe 0 1 2 3 4 5 6 7 8
last12months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SW7EO 7E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 19
I
8A. Have you EVER used any psychedelic drugs or hallucinogens, like LSD,PCP,
Angel dust, Ecstasy, or psychedelic mushrooms? (CIRCLEONE ANSWER)
NO....0 -
XM&BO Yes.. -1
d
8B. About how old were you when you fmt used psychedelic drugs or hallucinogens, even
O m ?
Years Old
How many days have you used psychedelic drugs or hallucinogens...

Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

ShJ8L-L~ Days
8C. Ever in 1 2 3 4 5 6 7 8
your whole life?
8D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
1-2 3-5 6-9 10-14 15-20 21+

s/**8#E(> Never
8E. Duringthe 0 1 2 3 4 5 6
& last 30 days?
Page 20
L
s\rJ 4 A 0 9A. Have you EVER used Heroin? Other names for heroin are smack or dope.
(CIRCLE ONE ANSWER)
NO....0 -
Yes.. .1
SLJ q g 0 9B. About how old were you when you first used heroin even once?
Years Old
How many days have you used heroin...

~ ~
Never 1-2 3-5 6-11 12-24

Days Days Days Days
9C. Ever in 1 2 3 4
your whole life? ~
9D. Duringthe 0 1 2 3 4
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SmEO 9E. Duringthe 0 1 2 3 4 5 6
c last 30 days?
Page 21
Mow we would like to ask you about other drvgs that doctors can prescribe but that you
may have plsed on your own to get high.
"he following questions are about Barbiturates.
Barbiturates are sometimes prescribed by doctors to help people relax or get to sleep.
They are sometimes called downers, goofballs, yellows, red, blues, and rainbows.
I I
1OA. Have you EVER used barbiturates without a doctor's prescription, or in a manner
r not prescribed by a doctor? (CIRCLEONE ANSWER)
NO....0 -
SW/D&O Yes...l
S-Ld /&hO
1OB. About how old were you when you first used barbiturates, even once?
Years Old
How many days have you used barbiturates...
(CIRCLEONE AN= FOR EACH ROW)
Nevtr 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

S$iOCO Days
. 1OC. Ever in 1 2 3 4 5 6 7 0
your whole life?
1OD. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 . 21+

$# 1.oEd Days Days Days Days Days Days
10E. Duringthe 0 1 2 3 4 5 6
- last3Odavs?
Page 22
The following questions are about Tranquilizers.
Tranquilizers are sometimes prescribed by doctors to calm people down, quiet their
nerves, or relax their muscles. Librium, Valium, Xanax, Halcion and Dalmane are all
I
tranquilizers,
I
11A. Have you EVER used any kind tranquilizers without a doctor's prescription or in a
SWJIAO manner not prescribed by a doctor? (CIRCLE ONE ANSWER)
NO....0 -
Yes.. .1
$w 11 c?; 0 11B. About how old were you when you first used tranquilizers, even once?
Years Old
How many days have you used tranquilizers.. .

Never 1-2 3-5 6-11 12-24 25-50 51-99 100- 200+

b
Days I
swllco 11C. Ever in 1 2 3 4 5 6 7 8

your whole life?
$wl[DO 11D. Duringthe 0 1 2 3 4 5 6 7 8
last 12 months?
Never 1-2 3-5 6-9 10-14 15-20 21+

SwlrEo 11E. Duringthe 0 1 2 3 4 5 6
last 30 days?
Page 23
The following questions are about Amphetamines.
Amphetamines have been prescribed by doctors to help people lose weight or m give
people more energy. They are sometimes called uppers, ups, speed, bennies, dexies, pep
pills, and diet pills. Amphetamines do NOT include any non-prescription drugs, such as
over-the-counter diet pills (like Dexatrim) or stay-awake pills (like No-Doz), or any mail-
order drugs.
I I
12A. Have you EVER used any kind of amphetamines without a doctors prescription or
f in a manner not prescribed by a doctor? (CIRCLE ONE ANSWER)
NO....0 -
.92//&A i3 Yes...l
r s w fi0
12B. About how old were you when you first used amphetamines, even once?
Years Old
How many days have you used amphetamines.. .

N C V ~ 1-2 3-5 6-11 . 12-24 25-50 51-99 100. 200+

,x&h//&
co Days
12C. Ever in 1 2 3 4 5 6 7 8
your whole He?
12D. Duringthe 0 1 2 3 4 5 6 7 8
I iast12months?
Never 1-2 3-5 6-9 10-14 15-20 21+

S4vfdLCO Days Days Days Days Days Days
12E. Duringthe 0 1 2 3 4 5 6
- last 30 days?
Page 24
I
The following questions are about Steroids.
I
SW 13A 0 13A. Have you EVER used any kind of steroids without a doctor's prescription or in a
manner not prescribed by a doctor? (CIRCLE ONE ANSWER)
NO....0 -
Yes.. .1
g\FJ 13 80 13B. About how old were you when you first used steroids, even once?
Years Old
How many times have you used steroids...

Never 1-2 3-5 6-1 1 12-24 25-50 51-99 loo- 200+

Days
13C. Ever in 1 2 3 4 5 6 7 8
your whole life?
I
$NI3DO 13D. Duringthe 2 3 4 6 7 8
last 12 months?
Never 1-2
Days
10-14
Days
15-20
Days
I1 Days
21+
L last30 days? I
0 1
2 1 3 4 1 5 6
Page 25
ever injected any drug through your skin or into a vein without a doctor's
prescription or in a m e r not prescribed by a doctor?
(CIRCLE ONE ANSWER) ' I
,I
14A. 1 About how old were you when you injected a drug,- even once?
Years Old
14A.2 Please tell me the names of the drugs that you have injected.
1.
2:
14B. How many times have you EVER injecttd a drug through your skin or into a vein?
sy/ W & O 1-2 timts ........ ............. 1
3-5 timts ............ ......... 2
6 9 times ............ ...... 3
................... 4
*.
10-19 times
20-39 times ................... 5
&99 times .-.................6
100 or more times ............7
14C. In the past 12 months, how many times have you injected a drug through your skin or
into a vein?
0 times.............*.......... 0
1-2 times...................... 1
sv %& 0 3-5 times...................... 2
6-9 times ............*.........3
10-19 times 4
20-39 times................... 5
......I............
40-99 times................... 6
100 or more times........... 7
Page 26
Answer the following question yourself and follow the instructions provided:
I Has the respondent reported ANY substance use?
NO -->
Yes -->
All the questions on the next few pages refer to the past 12 months. That is, since...
Refer to first month on the time line. 7

15. During the past 12 months, have you had a period of a month or more when you
of any of the following drugs or alcohol, m, or eettlng
(CIRCLE YES or NO FOR 15aa - 150
SwlFAA 0 aa. cigarettes........................ 1. Yes 0. No

SW I SAO a. alcohol............................ 1. Yes 0. No
5 J 5 6 0 b. marijuana (or hashish). ........ 1. Yes 0. No
SW5C.O c. cocaine........................... 1. Yes 0. No
SW 1500 d. "crack"........................... 1. Yes 0. No
1( tJ 15E 0 e. inhalants (such as glue). ....... 1. Yes 0. No
S W I F F 0 f. other drugs...................... 1. Yes 0. No
16. Have you used any of the following drugs or alcohol -more often or in
during the past 12 months?
S W I bAA 0 aa. cigarettes.. ...................... 1. Yes 0. No

s WlbA 0 a. alcohol............................ 1. Yes 0. No
5wlbgO b. marijuana (or hashish) ......... 1. Yes 0. No
s\rJIbCo c. cocaine........................... 1. Yes 0. No
sw d. "crack"........................... 1. Yes 0. No
.W I b E O e. inhalants (such as glue)........ 1. Yes 0. No
SdIbFO f . other drugs...................... 1. Yes 0. No
Page 27
17. 'During the past 12 months, haw you experienced tolerance for alcohol or any of the
following drugs, so that using the^?
SW r+jq/4cj aa. cigarettes........................ 1. Yes 0. No
sd 1 a. alcohol............................. 1. Yes 0. No
1) 53c//?/5B b. marijuana (or hashish)......... 1. Yes 0. No
S M K Z co c.cocaine ........................... 1.Yes 0:No
J-.W:y-7 JFo d. "crack"............................ 1. Yes 0. No
spv. 93 E O . e. inhalants (s'u~has glue) ........ 1. yes 0. No
Sk.t/ ly FC> f. other drugs...................... 1. Yes 0.No
18. Have you often lzccu~& the effects or

ro- a -d . . .
was threatcncd (such as ridmg a bike or car,using h a y
machinery, or swimming) during the past 12 months?
j M/@,+A. aa. cigarcues........................

L) 1. Yes 0.No
SW //CF#-O a. alcohol............................ 1. Yes 0.No
5 w f & b b.matl'juana(orhashinh)
~ ......... 1 . b 0. No
svt/ A?co
c.cocainc ........................... 1.Yes 0. No
d. "crack"........................... 1. Yes 0. No
5 L z / A!+*
e* ixhahts (such as glue)........ 1. Yes 0. No
LE/ /p E 0
,=of. other drugs...................... 1. Yes 0. No
19. During the past 12 montbs, did your use of alcohol or a drug cause you to have
s-
or to wv- or
m?
(CIRCLE YES OT NO FOR 1% - 19f)
SW fgrQ/y-Q aa. cigarettes........................ 1. yes 0. No
s w 7'9 rCFc a. alcohol............................ 1. YCS 0. No
J W +g 0 b. marijuana (or hashish)......... 1. YCS 0.No
svt/ {5 c 0 c. cocaitlt........................... 1. YCS 0. No
s u/ ~9 Bt> d. "Crack"........................... 1. YCS 0. No
SW
- /YE0 e. inhalants (such as glue)........ 1. Yes 0.No
f. other drugs...................... 1. Yes 0. No
siz/ Y q F D
Page 28
20. 21.
During the past 12 months, have you During the past 12 months, were you
wanted to cut down or stop using any able to stop your use of this every time
of the following drugs or alcohol? you wanted to?
(CIRCLE YES or NO FOR 20aa - 200 (CIRCLE YES or NO FOR 21aa - 210
SW2OAA 0 0
aa. cigarettes.................. 1. Yes: aa. cigarettes................ 1. Yes S W U A A
0. No 0. No
$WZOffD Yes . ........................ai a. alcohol .................... SlJZlAO
a. alcohol.. ..................... . 1. Yes
*::. f & k $
.,:.
.......................
.:
:
...................
0. No 0. No
SN20BD
b. marijuana (or hashish) .... 1. Yes: b. marijuana (or hashish). 1. Yes Sw2160
0. No 0. No
p2MO
c. cocaine...................... 1. Yes: c. cocaine................... I. Yes Swzl LO
0. No 0. No
SH1261)O
d. "crack"..................... 1. Yes: d. "crack".................. 1. Yes ~ ~ D O2 1
0. No 0. No
sW2OEO
e. inhalants (such as glue). .. 1. Yes: e. inhalants .............. 1.Yes ~ ' ' 1 ' '
0. No 0. No
SVVZOFO s\Rj21FO
f. other drugs ................. 1. Yes: f. other drugs.............. 1. Yes
0. No 0. No
Time stopped:
WWT: READING
x
CAUTION: EXAMINER USE ONLY!
A B O S E R T H U P I V Z J Q * 5:
. . . .
3 milk :was
milk U'UL
-_. . -
h
-then -jar 7 letter 6 city
hen jahhr let-er sit-KC
- _.
. . . . . _........... . . . . .
'4
- between cliff !.stalk :;grunt
hi-tween klli scawk grunt
.- ....... . . . . . . . .
huge
hycxq
- plot :. sour - humidity
plot sowr hyoo-mid-i-[CK
- -. .
.clarify residence (+urge rancid

k Iar - - t i
:a-
rez-1-dEns "TI ran-cid

__ - - - ._- - - -~
L conspiracy __deny _.quarantine -2 deteriorate
kvn-spir-i-see di-nT kwor-in-teen di-teer-i-o-rajt
- -.-
-. .......... -. . __ -__
:5 rudimentary :t mosaic 2- rescinded :e audacious

rtw-di -men - ti-- rcc moh-zay-ik ri -sind -cJ
-_ . _____ a w - d-a-
y-
-shk
:cmitosis 2,:. protuberance 31 longevity 32 predilection

mTtoh-sis proh- too- &-rim Inn-jev- i - tee pred-i-lck-shGn
.... ---___-- . . . ~ ............... ~ __.__
z regime 2: beatify :5 internecine 2~ regicidal

re-zhe e m - bi -at -7- fi in-trr-nee-seen. -nes-ecn rej-i-sT&i
-- . - .- -. - .- - - .. - . -- ....... -
i7puerile lc.factitious 3; lucubration

pycw-i-ril fak-tish-6s
-loo--k__
-- yuu-bray-shh
........ . _. - .______
epithalamion 2. inefficacious 2: synecdoche

rp-i-thi-Isy-rni-Gn in-ef-i-kay-shk si-nek-do-kee
5/10 RULES
OBSERVATIONSIREMARKS:
- Photocopying of this test is 8 viohtion of copyright i8W.
\H<
COPYRlGrlTO 1993 by Jaslak Associates
A OIVISON OF WIDE RANGE. INC
All rtgnts fesemed Prinlea In U.S A
1937 1946.1965.1976.1978.l984.1993 WIDE R A N G E
' 5 Ashley Place. Suite 1A. Wilmingroo. DE 19804-1314
1

Date: s/-k<-
=*
2h4-&
- M u
Interviewer ID:
&7PS R*AJRY
Im going to ask you some questions about violence and how it may have affected you or
1. Are you afraid you might be hurt by violence in your neighborhood?
1 .- YES 2-. NO
2. Arc you afraid you might be hurt your apartment building or house?
-1. YES 2. NO
3. Are you afraid you might be hurt your apartment building or house?
1 .- YES 2. NO
.4. Arc you afraid you might be hurt by violence at school or work?
-1. YES 2. NO
ed. init. ed. date

2

....
1. YES 2. NO
1. YES 2. NO
6. Have any of your family members been killed by a violent act? SA 6 .-
1. YES 2. NO
1. YES 2. NO
1. YES 2. NO
9. At what age do you think a child is affected by observing violence? (circle one) 54 Q
infancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
3
The questions 111be asking you now have to do with acts of violence that you may have
&A 10. Have you ever seen or been present when somebody was shoved, kicked or punched?
...
1. YES
2. NO
1. Withinlastweek
2. Withinlastmonth
3. Withinlastyear
4. More than OM ycar ago
12. Whcre did that happen?

2/45PA
1. Inyourhome
3. In front of your housdbuilding
6. At your schooYday care
7. Inoroutsidebar
25. -(specify) v&&)4de &Lqpp.C?G$
Y
13. Did you know thc: pcrsonor people who this happened to?
1. YES
2. NO
4
13A. Who was it? (MARK ALLTHAT APPLY)
14. How badly was the pcrson or people injured?

(MARK &THAT APPLY)
15. Did you know the jwrson or people who did thk?
1. YES
2. NO
5
gfi &5 16. Have you seen this more than once?
1. YES Go To Q. 16A
2. NO Go TO Q*x7
16A. How many times have you seen this in the past year?
225 f6AV
. a 3 i6-fm
16B. How many times have you ever seen this? ,-,
.I
17. Have you ever seen or been present whensomeone was attacked with a knife?
S& /?
1. YES
2. NO
Z h /4? 18. When was the last time you saw that?
1. W i t h i n l a s t d ..
2. Withinlastmonth
3. within last year
4. Morttbanontycarago
1. In your home
3. In front of your hoUSC/bUildiDg
25. m=(specify) &-
&
6
253 so 20. Did you know the person or people who this happened to?
1. YES llGoTop..aA
2. NO GO TUQ31
t'n m.4 20A. Who was it? (MARK ALL THAT APPLY)
'1 1. p a r e n t
8.888
2-.
3.,-Friend
4-. Neighbor
5 . ~ i b hSg
6-. other Relative (Spec
2 5 . - (Specify)
InA9 21. Haw badly was the pcrson or pwplc injured?

(MARK &THAT APPLY)
22. Did they die?
2& A5 23. Did you know the person or people who did this?
1. YES
2. NO
7
s,3 2 3k'c 23A. Who was it? (MARK THAT APPLY)

1. Parent
2-. *****
3. Friend
4-. Neighbor
5 .~-Sibimg
. .
6. Other Rclative(Speclfy) d'L&.&&&
B.-Othm (Specify) &7ZC.&<fi~
/ Y
$
24. Have you seen this more than once?.
225 29
1. YES
2. NO
24 2WkO 24A. How many times have you s e n this in the past year?
24B. How many times haw you ever seen this?
2% &e
245 R 5-
1. YES
2. NO
26. Whenwasthelasttimeyouhcardthat?
1. within k t week
2. within last month
3. Withinlastycar
4. Martthanoncyearago
. -
23.1
8
22?2-F 27. Where did that happen?
1. In your home
2. In your ballway or building
3. In front of your house/building
6. At your schwl/day care
'I
Z. m e r (specify) ~&CGHM-L.X~
245 $ 8 28. Have you heard a gun shot more tban oncc?
1. YES
2. NO
1. YES
2. NO
ENDOFINTERVIEW
RECORDTIME:
9
s23 3 8 30. When was the last time you saw that?
1. Withinlastweek
2. Withinlastmonth
3. Withinlastycar
4. More than one ycar ago
253 3 / 3 1. Where did that happen?
'I 1. In your home

3. In front of your housc/building
6. At your schooUday carc
25. (specify)
si3 3+L 32. Did you know the person or people who got shot?
1. YES
2. NO
233
10
1.- YES 2-. NO 8..-,Don't Know
2-534 34. Did you know the person or people who did this?
1. YES
2. NO ...
34A. Who was it? (MARK-& THAT APPLY)
... .. .
2. NO
23 4
Date: sieoE ? 7
?6
mm dd yy
Subject ID:
of the study, I told you about the special protection to ensure your privacy? The Federal
school, to see or find out what your answers are in this study. No one except our
your parents, or anyone else.
I am going to describe some things that people do. First, tell me if you have done
any of these things. Then I will ask how many times you have done-the thing during the
I
I1 . II
ed. init. ed. date

..
1
SRO -- 7
. .,
i .,
SECTION I.
. ..
You vou
staved awav o v m
pastr
1A. Run away from home and stayed away 1c. How old were you
overnight? sa /I90 you did this? S& f C Q

lnfhe-? S& /50 S&/BM S&B$
month year - ..
: ,
# of times

S& /so
1. alone
2. with others

this? C& -/Fo
1. Yes
0. No
.-
2
SRO
2 Are you still in grade school/high

school? S& 23
1. Yes -
T ,'1~ 0. NO -
e vou ever b a you did this? $4 yi: A 3
. ... .
S&AAf
. . . .. .
1. Yes - 2A4. Whenwas- YOU

0. NO - were absent from school without
an excuse?
2A2. How many times have you done this in --
S~AfWM su4y
e?
SiRZAb month year
# of times
were YQlUY!x: 2B3. How old were you

!B 1. Absent from gradehigh school without you did this? S&A65
an excuse? soeZAf
2B4. Whenwas- YOU

were absent from gradehigh
!B2. How many times in your school without an excuse?
did you do this? &&&34w SAJ&9
month year
s%?tx3
2.d
# of times
3
SRO
.,<'>f
11
3A. Carried a hidden weapon? 3c. How old were you
sua 34u you did this? SA dc o
1. Yes -
0. N O -
3B. HOWmany times have you done this 3D. When was YOU
?- m i e d a hidden weapon?
sR 5/30
# of times
4
SRO
4Ai,#;fCaused trouble in a public place so that

people complained about it, such as
being loud or disorderly? 4c. How old were you
SA 440 you did h?&g 4CO
1. Yes -
0. NO-
4B. How many times have you done this 4D. When was you did
m?
Se 4/30
this?
Sk4fltV SR4B9
month year
# of times

this? S
Be 4255
1. Yes
0. No
5
SRO
e vou ever;
'\I
5A. Purposely damaged or destroyed

to you? (for example, breaking, cutting you did this? Se 5 C O
S& 5A 0
..... .
1. Yes -
0. N O -
this?
5B. HOWmany times have you done this s 4 3 - x JBZ?Y
?- month year
SX 5 / 3 0
# of tiges

sa 520
1. alone
2. with others

this? $5& 5j=o
1. Yes
0. No
6
SRO
car, or vacant lot? &2 680 you did this? Sg 6-CO
1. Yes - Agd
0. N O -
w.
HOWmany times have you done this this?
l2 months? $22 6 A O S&?BA/Y S%?B/BY
month year
# of times

6s-0
1. alone
2. with others

this? $46 F O
1. Yes
0. No
7
SRO
7A. Entered or broke into a building to steal 7C. How old were you
something? .s& 240 you did this? g 2CO
s
1. Yes -
0. N O -

?- sbe-7830
--
sk?-3m S Z n Y
month year
# of times

SR 7C?o
1. alone
2. with others

phis? . S& ?PO
1. Yes
0. No
8
-
SRO

8A. Stolen something from a store? you did this? bC0
1. Yes -
sa 8/90
0. NO-

t 12- ? S&CJT5@Y JZx3Y
CA 8/3 0 month year

items you stole? SRBeo
$-,------

sa BFO
1. done
2. with others

guards talk to you about this?
Ge 660
1. Yes
0. No
9
SRO
1
ver;
I ~
you from any member of your- you did this? Sk 9Lo
household? s& 9AO
Age
1. Yes -
0. N O -
9B. Whenwas- * you did
this?
9B. HOWmany times have you done this S&.B/Y JxWZY
?- month year
S& 9/50
# of tjEnes
9E. Were you done or with others?

$& 9 I O
1. alone
2. with others

this?, S& 9FO
1. Yes
0. No
10
SRO
10. Have you ever had a job?

5ie 70
1OC. How old were you
you did this? r& ; / o C O
10A. Taken something that did not belong to

you from your place of work or your
employer?
...................................
7D40
1. Yes -
0. NO-
sk!fQ20
IOB. How many times have you done this 1. alone
12 e? 2. with others
J22 -rO&U
10F. Did your supervisor find out
# of times about this? $% / O F 0
10G. Did he/she call the

police? s& -80 60
1. Yes
0. No
11
SRO
edou e v E
11A. Snatched someone's purse or wallet or 11C. How old were you
picked someone's pocket? you did this? JL
... . ...... .. .........
sa YfAO
1. Yes-
0. N O - . . .. .....

11B. HOWm y times have you done this this?
m? S& //AN SAf/Ag
SL /4&0 month year
# of times

SA /i%o
1. alone
2. with others

thls? s&2H F O
1. Yes
0. No
12
SRQ
in the
t be& to vqy
C vou e v a
you from a car? sa@ you did this? sg CQ
1. Yes -
0. N O -

?- S&ib&AM S / A W
$#.e/& 430 month year
# of times

S& b L 6 0
1. alone
2. with others

this? . SI@f A F O
1. Yes
0. No
13
SRO
-d
?#
. '
232 ;/3t40 you did this? s22 f 3 C O
1. Yes -
0. N O -
13B. HOWm ~ times

y have you done this 13D.
V?
r-92 -/3/30
-~ ~
# of-times

SR Y 3 S O
1. alone
2. with others

this? c94 Y3FO
1. Yes
0. No
...
14
SRO
l-8
sell? 5-23 72940 you did this? g~
1. Yes -
0. N O -
14D. When was & last a you did

W? s&3/4Jws&/.By
s#e7.4430 month year
# of times

3
627.420
1. alone
2. with others

this? SJe/&J=O
1. Yes
0. No
15
SRO
You evou
m
something? s4 f5#0 you did this? sk /.--Q

1p the?-
4-d Y5AO
# of times

this? s4 73-so
1. Yes
0. No
.A
16
SRO
vou e v z
16A. Used credit or bank cards without the 16C. How old were you
owner's permission? Si
e 9B#D did this? s2?f6CO
. ....... .
16D. When was & last you did

V? S&246AW S&/.a/Oy
6-4A5430 month year
# of times
16E. Did the police talk you about

this? Le /6SO
1. Yes
0. No
17
SRO
You in vou
..
17A. Sold marijuana or pot? y2Ao 17C. How old were you
you did this? gg /yCc,
1. Yes -
0. N O -

V? 17D. When was you did
*
s
8e /7/30 this?
--
sZ?fl&'wY S&/77/i34.'
month year
# of times

232 7720
1. alone
2. with others
17F. Did the police tallc to you about

this? Sk?77FO
1. Yes
0. No
18
SRO
78. 1
18A. Sold cocaine or crack? jg 48140 18C. How old were you
you did this? sg ~3y-o
1. Yes -
0. NO-
18B. HOWmany time have you done this in 18D. Whenwas- you did
12 months? this?
$4 +&A0 $g /8KW S4%E?Y
month year
# of times

S&/8&0
1. alone
2. with others

this? Ck?@FO
1. Yes
0. No
19
SRO
past;
19A. $old heroin? 4?#0

1. Yes- you did this? s2?&CO
0. NO-
19B. HOWmany times have you done this in

19D. Whenwas- * youdid
this?
- S&?/QaY
sx!Y9XYy -

S R f9dO
1. alone
2. with others

this? S4.e /@FO
1. Yes
0. No
20
SRO
You in the past vou
e YOU ever;
-
2
4
.$
20A. Hit someone gvith vdurn vou 1i v d with you did this? ~4
SLO&U&O
1. Yes -
0. NO- 20D. Whenwas- you did
this?
--
J ~ L 0 3 wSgLDB9
V?
SRDAO
# of times 20E. Who did you hit? 0
(CIRCLEALL THAT APPLY)
3. father 4. child
5. partner 6 . roommate
7. other (specify):
a. SA &ED#
b. S& 0 S O A
C. seAw&oc

doctor? s-4 m a
1. Yes
0. No

this?
S& m 6 0
1. Yes
0. No
21
SRO

21A:ifHit someone y&h whQIll you did not live you did this? gg ~ { I C O
with the idea of hurting them?
-
S&d.i130
21D. Whenwas- you hit

them?
21B. How many times have you done this S&Pz/B& CTR2mY
1~ the -months? month year
S&A/43O . .
# of times 21E. Who did you hit? SAe&?~&O
3. father 4. child
9. acquaintance
a. S& ee f P 0 4
b. s&?LrfQa
C. &eLesoc
21F. Was anyone you hit h t

doctor? SA2 & f L O
1. Yes
0. No
0. No
22
SRO
d -s
aw
- in the
you did this? g~ ~ 5 ~ 0
2 2 4 I Attacked someone with a weapon?
1. Yes -
this?
.5&#.?5zmY 'SZuBy
t 12 months?
of
S&&&&O
22E. 1. Who did you attack? s 4 A.8 6 /
#of times (CIRCLE ALL THAT APPLY)
3. father 4. child
9. acquaintance
a. SLe R&S:i/OA
b. S&uu sa%3
C. sdeAc 2 7.0c

1. alone SRALLC
2. with others

1. Yes S R a z F O
0. No
0. No
-
23
SRO
vou -used a we-

or
e YOU ever;
23A:>;''Used a weapon or force to get money or 23C. How old were you
things from people? S&J3 40 you did this?&- . ,
1. Yes - Age
0. NO-
this?
S&od3J244S22232IY
12 mQ&s? month year
S& A 3 A 0
# of times
1. school
2. playground
3. street
4. business
5 . bar
6. car
7. other ~45A320

SA?a 3FO
1. alone
2. with others
23G. Did the police tallc to you about

this? Sib?A330
1. Yes
0. No
24
SRO
e vou e=
a,$ ,I
24A. Thrown objects, such as rocks or bottles, 24C. How old were you
at people (other than events you have you did t h ~ ~ ? s~e
already mentioned)? gk ~44.40
....... ... .......... .

this?
24B. How many times have you done this J&&&n&
m?
S&L&B?
month year
s8ea94o
# of times

S
PQR e o
1. alone
2. with others

this? SQ G d YFO
B
1. Yes
0. No
25
SRO
vou e v m
someone was hurt or threatened with you did this? sg
harm? S & R5640
.. .. ...... Age
1. Yes -
0. N O -
this?
JzAs-Bw <&yz3-&y
~3 the past 12 m? month year
SLR5fiL3
# of times
25E. Were weapons used?

Sje J 5SO
1. Yes
0. NO
25F. Was anyone hurt seriously

$4 A 5 F O
1. Yes
0. No
26
SRO

YOU did this? J~ 0
with someone against their will?
1. Yes- 26D. Whenwas- you did

0. NO- this?
SedGnL.sgaa9
month year
1. done g g A 8 1 O
2. with others
# of times
this? SdeiabFO
1. Yes
0. No

1. Yes $ ~ ? A 6 4 0
0. No
or same sex? g~ &,gfi~
1. same sex
0. opposite sex

1. Yes s&&6/0
0. No
27
SRU
vou ever;
27A.. a Been paid by someone for having sexual

"'
relations with them?
1. Yes -
.... ..
?Bo
you did this?
-
sg 2 7 0~
Age
0. N O -
this?
27B. HOWmany times have you done this S&22Bfl S&ZJ&Y
month year
# of times

this? SR Yz320
1. Yes
0. No
28
SRO
28A. Used a false name or alias to try to

obtain something you were not entitled 28C. How old were you
?y Y
to, such as a job or bank loan? you did this? se 2 . 8 ~ 0
... ... ... . . SRA8J;ZO
1. Yes -
0. NO-

?-
SL i%&O
# of times of

- $de. zag (3
1. Yes
0. No
29
SRO
ve vou e v z
* '7
29A." Given false information (other than a 29C. How old were you
false name) on an application for a job, you did this? sg A QC 0
a tax form, or an application for a loan
or bank account? SAZbZQAO Age
1. Yes -
this?

V?
&5LQAO
# of times
S&89lO
1. Yes
8. No
30
SRO
e vou ever;
30A. Obtained welfare benefits or

'
unemployment checks that you were not 30C. How old were you
sd 3 ~ 8 0
'f
entitled to? J k 3LWo you did this?
1. Yes - Age
0. NO-
30D. When was thel;isttlme you did
30B. HOWmany times have you done thu this?
aqt 12 months? J&-JQB/Y
2?& 3QA 0 month year
# of times

562 3020
1. Yes
0. No
31
SRO
vou
. .
had been uiven a
t for a d r m in the
31A. Been given a ticket for a driving

offense? L-4 3 i # O 31C. How old were you
,,it
YOU did this? sk 3j c 0
1. Yes-
0. N O -
31B. How many times has this happened in 31D. When was * this
7- spe 3/AO happened?
S3il.T& S&3j/&Sjll
month year
# of times:
. . 31E. Have you had your drivers

d-4 37-20
3 1B1. Did any of these driving offenses involve 1. Yes
alcohol? - 0. No
$*le 3/Ai
1. Yes
0. No
32
SRO
You that vou -m v

vou
e or after v w
e YOU ever;
32&f Driven a motor vehicle when you did not 32C. How old were you
have a drivers license or after your you did this? ~ S ; 3~
R cc,
drivers license had been suspended?
1. Yes -
0. N o -

* the?- S&3a /so
S&-32mM C.2424Y
month year
# of times last
32E. Did the police tallc to you about

tbs? S6-e 322u
1. Yes
0. No
1 1

column.
33
SRO
33, How old were you the first time in your whole life that you were in trouble with the
police: (Circle Never or record age) -
'$,
:,ai
0. Never Sd3346)
33
34. As a result of any.police contact in YOUP life, have any of the following things ever
happened to you?
34.1. Were you ever warned and released? 0. No 1. Yes S g 39- 7'
34.2. Were you held in jail for some time? 0. No 1.Yes ~4 34AaZ
34 -3. Were your parents ever told? 0.No 1. Yes S& 34- 3
J-4 39- 4
34.5. Were you ever referred for counseling? 0. No 1. Yes 95&34--5

34.6. Were you ever sent to a treatment program? S& 34i-
0. NQ
1. Yes
34.6A. What treatment programs have you been sent to?
1.
2.
3.
- 4.
34.7. Did you ever go to juvenile or adult court after being in lrouble with the police?
s4 3 4 - 3
0. No
...... ... ...
1. Yes
34
SRO
34.7A. Were you ever on probation? 0. No 1. Yes
34.7C. Did you ever have to make restitution?

34.7D. Have you had to do community service? 0. No 1. Yes
34.7E. Have you lived in a juvenile or correctional. center?
O.NO -
1. Yes -
34.7F. How many times have you lived in a juvenile or correctional 59.--?EO
center?
1. Only once
2. More than once
34-76. What juvenile or correctional centers have you lived in?
35. Of the contacts you have had with the police over the past 12 months, on how many
occasions were you arrested or charged with an offense? sa3 5-
-
# of times
36. For each time you were arrested or charged in the P;ist vear, please tell me what you
did, when and where it happened and whether you went to court.
742-1
35
SRO
I6 what month and year did this happen? &z36.-

7 t
3 6 . h . month (circle one): 1. Jan 4.Apr 7. Jul 10. Oct
36.1C. year (circle one): 2. 1995 3. 1996 J-4

3x-{CLJ

2. Other:
36.1E.state: 1. Illinois
2. Other: c
.4236- A50
36.1F. Did you go to court because of this? $E 36-

O.NO -
1. Yes -

2. Adult
3. Family
4. Traffic -
5. Other $25 36-
O.NO - m m !
1. Yes -
36
SRO
In what month and year did this happen? Sk!?3 6 - A / 3 0

Tb@ 4
2 . Feb 5. May 8. Aug 11. Nov
36.2C. year (circle one): 2. 1995 3. 1996 SK 3 6 -

2. Other: Sk 5 6 - 4 3 0

2. Other: r&36-&czo

36 - AJ=Q
0. NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5. Other 36-RGO
0. NO - @Ef@@3
1. Yes -
37 .. .
SRO -_
Ia what month and year did this happen? S1.Q36- 3 6 0

"?
36.&. month (circle one): 1. Jan 4.Apr 7. Jul 10. Oct
3. Mar 6. Jun 9. Sep 12.Dec
36.3C. year (circle one): 2. 1995 3. 1996 Sk5 36-3c0

2. Other: 36-52379

2. Other: JZ 3c-3Cw
O.No -
1. Yes -

2. Adult
3. Family
4. Traffic
5 . Other SR 3 6 - 3GO
O.NO -
1. Yes -
38
SRO

1
#,'
Sk38- 430 2. Feb 5. May 8. Aug 11. Nov
36.4C. year (circle one): 2. 1995 3. 1996 S&? 3'6- QtCo

2. Other: cs@ 36- 4238

2. Other: cS.& 36- 920
36.4F.Did you go to court because of this? SK 36- -Cf/=Ll

O.NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5 . Other Jk3 36 -460
36.4H. Have you been arrested or charged for anything else? SE 36- 4HO
O.No -
1. Yes -
39
SRO
I6what month and year did this happen?

1-2

sle 36- 3-450 2. Feb 5. May 8. Aug 11. Nov
36.5C. year (circle one): 2. 1995 3. 1996 36- 5-co


2. Other: 3 6 - 5-a~

2. Other: sR 36- 5-20
36.5F. Did you go to court because of this? && 36- 5R2

O.NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5. Other s%53&- 5- 0
O.NO -
1. Yes -
*
4 r
s4? 3 6 - C&U 2. Feb 5. May 8. Aug 11. Nov
3. Mar 6. Jun 9. Sep 12.Dec
36.6C. year (circle one): 2. 1995

2 . Other: Sg36- 62372

2. Other: Jz36.-da
O.NO -
1. Yes -

2. Adult
3. Family

41
SRO
Irl what month and year did this happen?

r l
36.7B. month (circle one): 1. Jan 4.Apr 7. Jul
2. Feb 5. May 8. Aug
3. Mar 6. Juri 9. Sep
36.7C. year (circle one): 2. 1995 3. 1996

:--a
?< J
36.7D. city: 1. Chicago * .
sg3.6.-7m
-J
2. Other:

2. Other: sk 36- 320
L. .
O.NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5 . Other S& 3 6 + - 9 S O

42
SRO
*
Sx?36-dao
,I
4.Apr
1,
36.8B. month (circle one): 1. Jan 7. Jul 10. Oct
2. Feb 5 . May 8. Aug 11. Nov
3. Mar 6. Jun 9. sep 12. Dec
36.8C. year (circle one): 2 . 1995 3. 1996

2. Other:

2. Other: S& 36- 620
O.NO -
1. Yes-

2. Adult
3. Family
4. Traffic
5. Other S& 36 - cf'dD
36.9H. Have you been arrested or charged for anything else? se 3&-8W
O.NO -
1. Yes -
43
SRO
.-
36.9A.What did you do? --
' _
I$ what month and year did this happen?

>
36.98. month (circle one): 1. Jan 4. Apr 7. Jul 10. Oct SZ.36- 9/30-_
2. Feb 5 . May 8. Aug 11. Nov 7' 3
3. Mar 6. Jun 9. Sep 12. Dec ..
36.9C. year (circle one): 2. 1995 3. 1996 , S&36-QGU'

I -

3 ~ 3 6J7-*
O.No -
1. Yes -

2. Adult
3. Family
4. Traffic
5. Other s
pe 36- 9so
O.NO -
1. Yes -
44
SRO

1,@3
36.10B. month (circle one) 1. Jan 4. Apr 7. Jul 10. Oct S@ 36-
3. Mar 6. Jun 9.Sep 12. Dec
36.10C. year (circle one): 2. 1995 3. 1996 &k? 36-/QC


2. Other: S& 36.- /5W

2. Other: S&36 - /G, t
O.NO -
1. Yes -

2. Adult
3. Family
4. Traffic
5. Other 36/i6 0
45
SRO
RECORD TIME: S O & 7/M -
Y dl
37. For each time you went to court please tell me the reason for your appearance and what
type of court you went to. J& 3+
37.1B. What type of court did you go to? 1. Juvenile sg3-;2-

2. Adult
3. Family
4. Traffic
5. Other S-/W
about? se337-L
1. Yes - W Q -
0.NO - F e
3 7 . 2 A . n ~were you in court?

- 2. Adult
3. Family
4. Trafflc
5 . Other sa 3-7-.23&0
46
SRO
about?
1. Yes -
sz 3.3-3
0. NO -
r
ir
11 RECORD TIME: s--277m 1
Ii
'.# i
37.3B. What type of court did you go to? 1. Juvenile .SA2 3-7- 3/50
2. Adult
3. Family
4. Traffic
5 . Other s
pe 3-7- 3/30
about? S&3;7- 4
1. Yes -
0. NO -
37.4B. V h t type of court did you go to? 1. Juvenile

2. Adult
3.'Family
4. Traffk
5 . Other sk?3-3- Y / 3 d
47
SRO
Have you been court in the past year for anything other than what you've already told me
about? JK 3% 5-
1. Yes -
O.NO -
1
1
II
RECORD TIME: Srn&r//y
?Y? It
3 7 . 5 A . W ~were you in court?

2. Adult
3. Family
4. Traffic
5 . Other 32- 3230
about?
1. Yes -
O.NO -
3 7 . a . What type of court did you go to? 1. Juvenile $4 3'9-6.130

2. Adult
3. F d y
4.
5.
A
Have you been in court in the past year for anything other than what you 've already told me
about?
1. Yes -
I
O.NO -
I
II
I1 s
a277M
I
RECORD TIME:
37.7B. What type of court did you go to? 1. Juvenile J Z 32L7fiO

2. Adult
3. Family
4. Traffic
5. Other JE 37- 7/30
about?
1. Yes -
O.NO -
37.8B. What w e of court did you go to? 1. Juvenile

2. Adult
3. Family
4. Traffk
5 . Other J-E 3f-923-a
YOUNG ADULT SELF REPORT
?
Young Adult Self Report
I am going to read a list of items that describe people.
I Hand Subject Responsecprd1 I

For eacb item that describesy m ~ or
w .. if the item
plcrrse say w2w
is very- item is sanewhat or somdmes trw, 01
or oftentme of you, wlwiftk if the
itan is not true of you.
O=Noth
l=SOmewbatorS~Troc
2=VcryTrmorOitmTrm.
YA =7 0 1 2 1. Iacttooyoungformyage
9.4z -0 1 2 2. ImalrcgooduscofmyopporounitieJ
XA s -0 1 2 3. Iarguealot
$A+ -0 1 2 4. I work up to my ability
94 5 -0 1 2 5. I act like the opposite sex
346 -0 1 2 6. I get along well with most people
.YA4 -0 1 2 7. Ibrag
init.ed. ed.date
8. I have trouble concentrating or paying attention
9. I can't get my mind off certain thoughts
10. I have trouble sitting still
11. I am too dependent on others
12. I feel lonely
13. I feel confused or in a fog
14. Icryalot
15. I am prew honest
16. I am mean to others
17. I daydream a lot
18. Ideliberately try to hurt or kill myself
19. I try to get a lot of attention
20. Idesuoymythings
21. I destroy things belonging to others
22.Iwomyalxmtmyfuwe
23. IbreaLrolesatrchmlmwOISr
24. Idon'tcataswcllasIshould
22. I don't get along with others
26. I don't feel guilty aftu doing something I shouldn't
27. I am jealous of others
28. Iam willing to help others when they nad help
29. I am afraid of certain animals, situations, or places
30. I worry about my relations with dre apposite sex
31. I am afraid I might think or do something bad
32. I feel that I have to be perfect
33. I feel that no one loves me
34. I feel that others are out to get me
35. I feel wonhless or inferior
36. I accidentally get hurt a lot
37. I get in m y fights
38. I get wed a lot
39. I hang around with others who get in trouble
40. I hear sounds or voices that other people think aren't Lere
4 1. I act without stopping to think
42. I would nther be alone than with others
43. I lie or cheat
44. I bite my fmgernaiis
45. I am nervous or tense
46. Pam of my body witch or makc nervous movements
47. I have nightmares
48. Iamnotlilredbyothus
49.1candocertainthingsbetterthanothupeople
50.Iamtoofcarfuloranxious
51. I feel
52. I feel too guilty
53. I eat too much
54. I feel overtired
55. I am overweight
a. Aches or pains (not headaches)
b. Headaches
c. Nausea, feel sick
d. Problems with eyes
f. Stomach aches or cramps
g. vomiting, throwing up
h. Other physical problems without known medical cause
57. I physically attack people
58. I pick my skin or other p m of my body
59. I am able to make friends easily
60.11ikctotryncw*
61. My school work or job performance is p r
62. I am poorly coordinated or clumsy
63. I would rather be with Older people than with pwple of my own age
64. I would rather be with younger people than with people my own age
65. Ircfusetotalk
66. Irepeatccrtainactionswerandover
67. I lose friends q u a y
68.Iscnamalot
69. I amsemtiveorkeep things to myself
70.IseethhgsthatothcrpeoplethiaLann'tthere
71. I am selfumAous or casity embanassed
72.Isetfirej
73. I meet m y responsibilities to my family
74. Ishowofforclown
75.I am shy
76. I have trouble fauiug aslecp
77. I sleep more than most others during day and/or night
78. Iwakeuptooearly
79. I have a speech problem
80. I stand up for my rights
81. I worry about my job or school work
82. I steal
83. I storeup things I don't need
84. I do things other people think are strange
85. I have thoughts that other people would think are suange
86. I am stubborn
87. My moods or feelings change suddenly
88. I enjoy being with other people
89. I am suspicious
90. I drink too much alcohol
91. I think about killing myself
92.IliketomaLtotherslaugh
93. I talk too much
94. I tcase others a lot
95. I have a hot temper
%.IthinLaboutswtoomuch
97. I threatcn to hurt people
98. I like to help others
99.Iam~concermdaboutbeingmatorclean
100. I have trouble sleeping
101. I have trouble f- things I should do
1Cn. I don't have much energy
103. I am unhappy, sad, or depressed
104. I am louder tban others
105. I do things that may cause me trouble with the law
106. I l r y t o b e f a i r t o o t h e ~
107. I enjoy a good joke
108. I like to takt life easy
109. I try to help other people when I can
110. I wish I were of the opposite sex
111. I keep from getting involved with others
112. I worry a lot
113. I am too concerned about how I look
If you have a paid job (or bad a paid job within the past 6 months), piwe m e r &
following questions:
$f&//$-0 1 2 117. I have trouble getting my work done
- 12
*
Y4 ,mf 0 118. I am satisfied with my job situation
921 -0 1 2
r;/G 119. I do things that might cause me to lose my job
'Yd#fK 0 1 2 120. I stay away from my job even if I'm not sick
-0 1 2
.Y.4/idA 122. I am satisfied with my school situation
-0 1 2 123. I have trouble getting dong with my teachem
-
"-9A/J$ 0 1 2 128. My partner and I disagree about what to do when we arc together
-
-hW75L0 1 2 132. I have trouble with my partner's family
In the itam below, lldrhk" means a glass of Wine, shot of liquor, or a can or bottle of beer.
c9d, ~ 33 133. How often did you drink alcohol in the last 6 months?
I Hand Subject Response Card 2

I
1. Never in the last 6 months WTOQ- US
2. Less than 1 drhk per week, on avetage
3. 1-7 drinks per week, on average
6. More than21 per week
$4y3.y 134. How often have you been drunk in the last 6 months?
I Hand subject Rcspomecard3 I

1. Never in the last six months
2.1or2times
3.3or4tim#
4.Sor6times
5. More tban 6
9A r.5 9- 135. Are you wocerotd about the amount of alcohol you drink?
0. No 1. Yes
*s;;./7.46 136. Are your family or friends concerned with the amount of alcohol
you drink? 0, No 1. Yes
~@7;z 137. In the b t 6 months, how often did you use drugs for nonmedical purposes?
I Refer to Response Card 3 I

1. Never in the last six months Ed
2.1or2timeS
3.3or4tinzcs
4.5 or 6 times
S. More than 6 times
34 r.5 J+ 137A. About how many times?
Did you use marijuana? 0. No 1. Yes
ampktamincs? 0. No 1. Yes -
hashish? 0. No 1. Yes
e? 0. No 1. Yes
crack? 0. No 1. Ye
pcpl 0. No 1. Yes
I
heroin? 0. No 1. Yes
LSD? 0. No 1. Yes
other? 0. No 1. Yes
I RECORD TIME: I
F d y Environment Scale: Short Version
Interviewer ID:
false for most members. If the members are evenly divided, decide what is the stronger
1. T 2. F
1. T 2. F
1. T 2. F
ed. init. ed. date

2
Family members rarely become openly angry
1. T 2. F
We don't say prayers in our family
1. T 2. F
'I6.
2 There are very few rules to follow in our family
1. T 2. F
Family members sometimes get so angry they throw things
1. T 2. F
1. T 2. F
62 9 9. There is one family member who makes most of the decisions
1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
1.. T 2. F
19.
1. T 2. F

'J P
1. T 2. F
1. T 2. F
1. T 2. F
P-
1. T 2. F
1. T 2. F
1. T 2. F
1. T 2. F
1.' T ' 2. F
4
/=& ,+ 24. Rules are pretry inflexible in our household
1. T 2. F
,zz 2.5 25. In our family, we believe you don't ever get anywhere by raising your voice
1. T 2. F
.26. Family members believe that if YOU sin you will be punished
F2A6 '8
1. T 2. F
Fz 2 7 27. You can't get away with much in our family

1. T 2. F
I HAND SUBJECT RESPONSE CARD
F&.-&f 28.- When you answered these questions, who did you have in mind?
1. Siblings
2. Parent
3. Roommate
6. SpousePartuer
7. ChildKhildren
END OF INTERVIEW
c
RECORD TIME: F%sI7/N
3 4
Date:
m m dd yy
Subject ID: 3u.3
/A-
Interviewer ID:
Time Started: I
I Hand Respondent the Response Card and Read Choices I

For each of the statements I read, please use phis s d c and tell me the answer that best
I= verytme
2= somewhattrue
3= nottrue
/gTss1 1. When Ihwith my f i i d I feel complctely &ie to relax and be mys&
1 -verytrue
-
2 somewhat true
-
3 not true
P5s 2, 2. I share the same approach to H e that msny of my fiiends do.
1 -verytrue
-
2 somewbat true
-
3 not true
ed. bit. ed. date
a
3. People who h o w me trust me and respect me. /?ys .3
-
1 very true
-
2 somewhat true
-
3 not true
4. No matter what happens, I know that my f d y d atways be there for me should I need
them. * p.ss$/
-
1 very true
-
2 somewhat true
-
3 not true
5. When I want to go out to do things, I know that many of my fiends would (ZZh)
p:d.s 3-
-
1 very true
-
2 somewhat tme
-
3 not true
6. I have at least one fiend that I could tell anything to. ps-s 4r
1 -vcrytrue
-
2 somewhat true
-
3 not true
7. Sometimes rm not sure if1 can completely (countj on my fkdy. /ex-s +
1 -verytrue
-
2 somewhat true
-
3 not true
8. My f d y lets me know they think plm a (valuable)perSon.
1-vaytrue
-
2 somewhat true
-
3 not true
9. I feel very close to some of my hends.
-
1 very true
-
2 somewhat true
-
3 not true
10. People in my family have confidence in me. p33So

-
1 very true
-
2 somewhat true
P
-
3 not true
11. People in my f d y help me find solutions to my problems. f J . 3;dj4

1 -verytrue
-
2 somewhat true
3 - not true
12. People who h o w me thinlr I am good at what I do. pJ-5 /&

1 -vcrytrue
-
2 somewhat true
3 - not true
13. My fiendswould take the time to talc about my problems, should I ever want to.
1-vaytrue
-
2 somewhat true
-
3 not true
14. I h o w my family will always stand by me.
1 -wrytrue
-
2 somewhat true
-
3 not true
15. Even when I am with my fiends,I fetl alone. ps s

1 -verytrue
-
2 somewhat true
-
3 not true
TU Q. 20
16. I have a teacher or coach who I can rgly (counr) on and talk to. PJS .iig
1 -verytrue
-
2 somewhat true
-
3 not true
17. ' I have a grandparent, uncle, or aunt that I feel close to and who helps me out. pss /?
1 -verytrue
-
2 somewhat true
-
3 not true
18. I have a brother, a sister or a cousin who h t n s to me and understands my problems.
1 -vuytrue
PJS A?+
-
2 somewhat true
-
3 not true
19. There is an adult outside my h d y , for orample, a neighbor or religious or

community member, who I cango to for help ifIneed it. /=Js
1 -verytrue
-
2 somcwhat tnre
-
3 not true
1. Yes 0. No
3438
sELrY+s: what is this person's name and what is M e r relationship to you? (Circle all that
apply)
20al. 20a2. 1 - Immediate Family (sibling, child, parent, partner) Y S S D

~
First name -
2 Extended Family
-
-
-
6 Other
206 1.
- 2Ob2. 1 L Immediate Family (sibling, child, parent, partner)
First name -
2 Extended Family
I
-
-
5 School or Community Memberkader y s 2~
6-m~
20cl.
4
-
20c2. 1 Immediate F d y (sib- child, parent, partner)
First name -
2 Extmded F d y
-
-
4 Church Member/Leada
/?3rmca
-
5 School or Community Mcnnber/Leader
6-0th~
Y
HOME
311
mm dd yy
OBS SCALE vm.PHYSICAL EwvIRoNMEm IN THE HOME?

W R I O R OF HOME] (CIRCLE ONE]
** 1. House or apartment is fiee of potentially a. YES
dangerous structural or health hazards. b.NO
(exposed outlets, broken winhvs, windows
without screens or guar&, leakmg r d a t o r ,
pots h @ n g over edge of stove)
** 2. House or apartment has as least 100 square a. YES -
feet of living space per person. b. NO
of the home are reasonably clean and b. NO
** 4. In terms of availablem, the rooms a. YES
are not overcrowded with firnitwe. b.NO
** 5. The interior of the house or apartment is not a YES
dark or perceptually monotonous. b.NO
or other types of art work on the walls. b.NO
** 7. -
House or apartment is not overly noisy firom a. YES
noise in the house. b.NO
(television, shouts of chihiken, radio)
** 8. House or apartment is not overly noisy - fiom a. YES
noise outside the house. b.NO
(train, cars, people. music)
#/A 8-9 b. NO
home.
bottles)
TIME ENDED
SCALE K.PHYSICAL ENVIRONMENT
-OR OF HOME]
Date: - .-
w
- ,
mm dd
Dayofweek: M Tu W Th F- Sa Su
* (CIRCLEONE)
T-of day: Entcrcd home: - AM PM
brmin
2. -
Through curved
3. H-laymt
4. T-layout
5. L-layout
6. cul&-Sac
7. Boulevard
8. Divided Highway
9. other
2. How would you cbaractck the land use on this fke-block, based on m t - l e v d
frontage? -+/A 9-A
2. primarily wmmercial
6. Rimarily vacant lots and open space
9. Other
I
3. How would you rate the general condition of m ~ s of
f the housing units or other buildings
~
in the face-block? .9q& 9-25

2. Fair condition
4. Do any of the fronts of residential or Commercial units have metal security blinds, gates,
or iron bars or grills?
#H 9-3
1. None
2. Some
3. At leasthalf
4. Most
5. How would you rate the volume of aaffic on the face-block? -f//4 9- 5
1. Notrafflicpermitted
2. Verylight
3. Lidt
4. Modcrate
5. . Heavy
6. Vcryluavy
6. How would you rate the condition of tht street in the fixe-block? +/x 9- 6
2. Modcrate - evidence kept in good repair
3. -
Fair &or repairs needed, but not rough surface
4. -
Poor potholes and other evidence of neglect
7. Is there garbage, Iittcr, or broken glass (except beedliquor bottles) in the street or on the
sidewalk?
7
949-7
3. Yes, quite a bit
8. Are there drug-related paraphernalia, condoms, beer or liquor containers or pachging,
cigareue butts or discarded cigarette packages in the street or on the sidew&?
-MA-9-
.p
1. . Nonc, or almost none
3. Yes, quite a bit
I +/A 9-9
M g , or behaving in any kind of hostile or threatening way?
.;p) ~ . - ~
1. No persons observed in thc street or sidewaIk

3. Yes,one or two behaving in a hostile manner
11. How did you fed parking, walking, or waiting at the door in the face-block?
1. Vcry comfortable: can imagine living/working/shopping here 74fl +9-
5. I felt afraid for my personal safcty
1. Are you planning on movingfleaving home m the next yea? Y N
if'YcS,"
la. when? {monthhear)
lb. where? [!am!)
. .I
I&*) (state)
2. Do you plan on changingjobs m the near fixture? Y N

if 'Yes,":
2a whm? Ip2oothlvear\ 2b. new employer?
2c. new employment address /street)
fcitv] (!3tatel (Zm't
4. Do you plan on changing schook, or going away t o school? Y N

if'YeS/
. 4b. new school address:: [stret)
[city) (state) ( ~ )
C:\WPWINGO\CHIP\DOC\ROANEW.FRhA
frrtllrc? Y W
I$ 'Ye?+''
Sa. Please explain why:
6. . Can you give me the names, addresses, and phone n d c of~four close friards or relatiyes
who win always b o w where to h d you to help us locate you m the Kmm?
a. b.
Name:
"9
Relationship:
Address:
ChylStmp:
Phone:
c d
ROA 2
9%
8. Please note any other obsnvations about the respondtnrs demeanor:
?'f *
Circle on=
1 2 3 4 5
10. Using the scale below, make yaur best asstssmcnt of thc d S d y we wiJIhave in locating this
Cide one:
1 2 3 4 5
10a Please explain the reason for your assessment:
ROA 3
Subject ID:
Interviewer D:
9
-
1- Was the entire assessment administered in English?
YES Go.to'Q.6
NO Gotop'2
- -
YES Ga to Q'2-I- Spe'cirylanguage

-'
NO 606Q-3
YES. Go to Q 5
NO G o t 0 4 4
1.
2.
2. ParentlGuardian
3. SpouseRPartner
6 . Other
5 . How many measures were administered in a language other than English?

3. between one-halfand three-fourths
4. more thanthree-fourths
5. all
6. How much difficulty did the SPC have in widerstanding the language of the measures? Did
hdshe find it ...
'8
1. very difficult
2. Fairlydifficult
3. Fairly easy
4. Very easy

NO- G o t o Q S
8, Were the following measures administered in private?
IfNO, enter code(s) for the party(ies) present during the assessment.
Code
2. Conflict Tactics YES NO a b. c.
3. Deviance of Peers YES NO a b. E.
4. Self Report of Offending YES NO a b. c.

7. Young Adult SelfReport YES NO * a b. c.
C o d i w
2 = Spousflartner 6 = Friend
Comments Section:
PLEASE RCORD ANY ADDITIONAL COMMENTS:
323
Date:
mal old yy
Interviewer PI):

0001 Questionnaire

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0001 Questionnaire

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ICPSR 13599 Project on Human Development

Questionnaires for Wave 1 Longitudinal

Inter-university Consortium for

Project on Human Development

1. Demographic & Cultural Information

Now I have some general questions.

Third, I will ask about different languages you might speak;

Fifth, I am going to ask about your school background; and

Finally, I will ask about your ethnic and religious background.

street addrkss apt. # ... ,

city state zip code --!

1. rent your home

2. own your home

IF at current address for 2 5 years Go to Q. 3

IF at current address for less than 5 years, Go to Q. 2.

Calculate Cumulative Total

2B. And where did you live before living here?

1 = change of job 8 = went to school

2B2. How long did you live at this address [2B]?

Calculate Cumulative Total

2C. And where did you live before living here?

Calculate Cumulative Total

2D. And where did you live before living here?

(street ad&&) (city) (state) (zip code)

Calculate Cumulative Total

2E. And where did you live before living here?

2E2. How long did you live at this address [2E]?

Calculate Cumulative Total

2F. And where did you live before living here?

2F2. How long did you live at this address [2F]?

2G. And where did you live before living here?

2H. And where did you live before living here?

(street addreg)' (city) (state) (zip code)

Calculate Cumulative Total

21. And where did you live before living here?

Calculate Cumulative TOM

27. And where did you live before living here?

251. Why did,you move from this address [a?

272. How long did you live at this address [a?

Calculate Cumulative Total

(street address) (city) (zip code)

1 = change in custody/shared custody 7 = child hospitalized (medical)

4A2. How long did ***** live at this address [4A]?

4B. And where did ***** live before living here?

4B2.How long did ***** live at this address [4B]?

4C. And where did ***** live before living here?

1 = change in custody/shared custody 7 = child hospitalized (medical)

4D. And where did ***** live before living here?

4D2. How long did ***** live at this address [4D]?

4E. And where did ***** live before living here?

Calculate Cumulative Total

5. Where was ***** born?

A. city B. State c. country -

6. Where were you born?

8. Where was she born?

12.1 Where does he live now?

Now I have some other questions about you.

13. Are you a U.S.citizen? rn Y 3

13A. Are you (read choices) 1. currently applying, Go To

13B. Are you registered to vote in the U.S.? 0. NO 1. YES

15. What is your marital status? Are you (Readall choices): m f5

15A. Are you currently living with a partner? Ab3 f 5 H O

1. Not getting along Record and mv5-mU