1.  Have you ever been in a serious disaster (for example, an earthquake, hurricane, large fire, explosion)

__Yes __No

2.  Have you ever seen a serious accident (for example, a bad car wreck or an on-the-job accident)

__Yes __No

3.Have you ever had a very serious accident or accident-related injury (for example, a bad car wreck or an on-the-job accident)

__Yes __No

4.Was a close family member ever sent to jail

__Yes __No

5.Have you ever been sent to jail

__Yes __No

6.Were you ever put in foster care or put up for adoption

__Yes __No

7.Did your parents ever separate or divorce while you were living with them

__Yes __No

8.Have you ever been separated or divorced

__Yes __No

9.Have you ever had serious money problems (for example, not enough money for food or place to live)

__Yes __No

10. Have you ever had a very serious physical or mental illness (for example, cancer, heart attack, serious operation, felt like killing yourself, hospitalized because of nerve problems)

__Yes __No

11. Have you ever been emotionally abused or neglected (for example, being frequently shamed, embarrassed, ignored, or repeatedly told that you were "no good")

__Yes __No

12. Have you ever been physically neglected (for example, not fed, not properly clothed, or left to take care of yourself when you were too young or ill)

__Yes __No

13. WOMEN ONLY: Have you ever had an abortion or miscarriage (lost your baby)

__Yes __No

14. Have you ever been separated from your child against your will (for example, the loss of custody or visitation or kidnapping

__Yes __No

15. Has a baby or child of yours ever had a severe physical or mental handicap (for example, mentally retarded, birth defects, can't hear, see, walk)

__Yes __No

16. Have you ever been responsible for taking care of someone close to you (not your child) who had a severe physical or mental handicap (for example, cancer, stroke, AIDS, nerve problems, can't hear, see, walk)

__Yes __No

17. Has someone close to you died suddenly or unexpectedly (for example, sudden heart attack, murder or suicide)

__Yes __No

18. Has someone close to you died (do NOT include those who died suddenly or unexpectedly)

__Yes __No

19. When you were young (before age 16). did you ever see violence between family members (for example, hitting, kicking, slapping, punching)

__Yes __No

20. Have you ever seen a robbery, mugging, or attack taking place

__Yes __No

21. Have you ever been robbed, mugged, or physically attacked (not sexually) by someone you did not know

__Yes __No

22. Before age 16, were you ever abused or physically attacked (not sexually) by someone you knew (for example, a parent, boyfriend, or husband, hit, slapped, choked, burned, or beat you up

__Yes __No

24. Have you ever been bothered or harassed by sexual remarks, jokes, or demands for sexual favors by someone at work or school (for example, a coworker, a boss, a customer, another student, a teacher.

__Yes __No

23. After age 16, were you ever abused or physically attacked (not sexually) by someone you knew (for example, a parent, boyfriend, or husband hit, slapped, choked, burned, or beat you up)

__Yes __No

25. Before age 16, were you ever touched or made to touch someone else in a sexual way because he/she forced you in some way or threatened to harm you if you didn't

__Yes __No

26. After age 16, were you ever touched or made to touch someone else in a sexual way because he/she forced you in some way or threatened to harm you if you didn't

__Yes __No

27. Before age 16, did you ever have sex (oral, anal, genital) when you didn't want to because someone forced you in some way or threatened to hurt you if you didn't

__Yes __No

28. After age 16, did you ever have sex (oral, anal, genital) when you didn't want to because someone forced you in some way or threatened to harm you if you didn't

__Yes __No

29. Are there any events we did not include that you would like to mention

__Yes __No

30. Have any of the events mentioned above ever happened to someone close to you so that even though you didn't see it yourself, you were seriously upset by it

__Yes __No