1. What is your Zip or Postal Code?

2. Are you pregnant?

• Yes   No
  Week of pregnancy

3. Have you had a baby within the last 6 months?

• Yes   No

4. Your age?

5. Which best describes your ethnic group(s)?

• African American/Black (non-Latino)
  American Indian or Alaskan Native
  
  Asian or Asian American
  • Chinese
    Korean
    Filipina
    Japanese
    Other:
  
  Latino or Hispanic
  • Mexican/Chicana or Mexican American
    Central American
    Caribbean Latina
    South American
    Spanish or Spanish American
    Black or African American Latina
  
  Multi-ethnic or mixed
  Pacific Islander or Native Hawaiian
  White
  Don't Know
  Other:

6. What is the most common language spoken in your home?

• --select-- English Spanish Mardarin Other
  Other:

7. Select the highest grade or year you completed in regular school, vocational school, college, or graduate professional training.

• Grade School: --select-- 1 2 3 4 5 6 7 8
  High School: --select-- 9 10 11 12
  College: --select-- 13 14 15 16
  Graduate School: --select-- 17 18 19 20 21 22 >22

8. Select what best describes your current employment status.

• Employed Full-time
  Employed Part-time
  Self-employed
  Retired
  Unemployed
  Disability / Sick Leave
  Student
  Other (specify):

9. What is your sexual orientation?

• Bisexual
  Heterosexual
  Lesbian/Gay
  Other (specify):

10. What is your family annual income before taxes?

• less than 10,000
  10,000-19,999
  20,000-29,999
  30,000-39,999
  40,000-49,999
  50,000-59,999
  60,000-69,999
  70,000-79,999
  80,000-89,999
  90,000-99,999
  100,000-or more

11. Have you suffered any recent losses or upsets?

• none
  loss of job
  loss of significant other
  loss of parent(s)
  other:

12. Your height (in inches)

13. Your current weight

14. Are you in a committed relationship?

• Yes   No (skip to question 15)
  

• If your partner would like to complete this survey as well, please have her enter your unique study number in question 14a. Your unique study number is: 787

14a. (Optional) Partners reference number (if your partner filled out the survey and gave you her unique study number):

14b. Please indicate your relationship with your partner:

• Married
  Domestic Partnership-registered with the state
  Living Together/ Domestic Partner (not registered)
  Girlfriend
  Boyfriend
  Fiancé

14c. How much support do you get from your partner?

• None = 0	1	2	3	4	5	6	7	8	9	10 = As much as I need

14d. How much control do you feel your partner has on your life?

• None = 0	1	2	3	4	5	6	7	8	9	10 = As much as I need

You have completed 20% of the survey..

15. In the past, have you ever had a period of 2 weeks or more where on most days and for most of the day you experienced (1) a depressed mood or (2) a loss of interest or pleasure in daily activities?

• Yes   No

• If yes, please select any other symptoms you had:
  Weight loss
  Recurrent thoughts of death or suicide
  Difficulty sleeping or sleeping all the time
  Agitation and/or restlessness
  Tiredness
  Feeling worthless
  Difficulty thinking or concentrating

16. Now, have you had a period of 2 weeks or more or more where on most days and for most of the day you experienced (1) a depressed mood or (2) a loss of interest or pleasure in daily activities?

• Yes   No

• If yes, please select any other symptoms you had:
  Couldn't gain enough weight
  Recurrent thoughts of death or suicide
  Difficulty sleeping or sleeping all the time
  Agitation and/or restlessness
  Tiredness
  Feeling worthless
  Difficulty thinking or concentrating

17. If you have been treated for depression, were you treated with: (Please check all that apply)

• Treatment	In the past	Now
  Psychotherapy
  Medication
  Herbs
  Hospitalization
  Other

• If you answered other above, please describe:
  

18. Have you ever been the victim of intimate partner violence?

• Yes   No

19. Were you ever the victim of sexual violence/assault during your childhood?

• Yes   No

20. Were you ever the victim of physical violence/assault during your childhood?

• Yes   No

21. Have you been the victim of sexual violence/assault during your teen years?

• Yes   No

22. Have you been the victim of physical violence/assault during your teen years?

• Yes   No

For questions 23 through 32, Please indicate the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today:

23. I have been able to laugh and see the funny side of things.

• As much as I always could
  Not quite so much now
  Definitely not so much now
  Not at all

24. I have looked forward with enjoyment to things.

• As much as I ever did
  Rather less than I used to
  Definitely less than I used to
  Hardly at all

25. I have blamed myself unnecessarily when things went wrong.

• Yes, most of the time
  Yes, some of the time
  Not very often
  No, never

26. I have been anxious or worried for no good reason.

• No, not at all
  Hardly ever
  Yes, sometimes
  Yes, very often

27. I have felt scared or panicky for not very good reason.

• Yes, quite a lot
  Yes, sometimes
  No, not much
  No, not at all

28. Things have been getting on top of me.

• Yes, most of the time I haven't been able to cope at all
  Yes, sometimes I haven't been coping as well as usual
  No, most of the time I have coped quite well
  No, I have been coping as well as ever

29. I have been so unhappy that I have had difficulty sleeping.

• Yes, most of the time
  Yes, sometimes
  Not very often
  No, not at all

You have completed 40% of the survey..

30. I have felt sad or miserable.

• Yes, most of the time
  Yes, quite often
  Not very often
  No, not at all

31. I have been so unhappy that I have been crying.

• Yes, most of the time
  Yes, quite often
  Only occasionally
  No, never

32. The thought of harming myself has occurred to me.

• Yes, quite often
  Sometimes
  Hardly ever
  Never

33. In your life, have you experienced discrimination?

• Yes   No

• If yes, please explain:
  

For questions 34 through 42, please indicate how often on a daily basis you experience the following because of things such as your race, ethnicity, gender, age, religion, physical appearance, sexual orientation, or other characteristics.

34. People act as if they think you are not as good as they are.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

35. People act as if they think you are not smart.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

36. You are treated with less respect than other people.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

37. You are treated with less courtesy than other people.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

38. People act as if they are afraid of you.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

39. You get poorer service than others do at restaurants or stores.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

40. People act as if they think you are dishonest.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

41. You are called names or are insulted.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

42. You are threatened or harassed.

• Never
  Rarely
  Sometimes
  Often

• If you have experienced this, what do you believe is/are the reason(s) for the discrimination? (click on all that apply)
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

For questions 43 through 55, please indicate how many times in your life you have experienced the following because of things such as your race, ethnicity, gender, age, religion, physical appearance, sexual orientation, or other characteristics.

43. Not hired for a job

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

44. Not given a job promotion

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

45. Fired from your job

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

You have completed 60% of the survey..

46. Discouraged by teacher from continuing education

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

47. Denied a scholarship

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

48. Prevented from renting or buying a home

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

49. Denied a bank loan

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

50. Forced out of neighborhood by your neighbor(s)

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

52. Denied or given inferior services (e.g. by plumber, mechanic)

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

53. Hassled by police

• Times in life

• If you have ever experienced this, what do you believe is/are the reason(s) for the discrimination?
  
  age
  race
  sex
  ethnicity/nationality
  religion
  height or weight
  other physical characteristics
  physical disability
  sexual orientation
  other

54. To what extent has discrimination interfered with having a full and productive life?

• Not at all A little Some A lot

55. To what extent has discrimination made your life harder?

• Not at all A little Some A lot

For questions 56 through 75, please indicate how often have you felt this way during the past week:

56. I was bothered by things that usually don't bother me.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

57. I did not feel like eating; my appetite was poor.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

58. I felt that I could not shake off the blues even with help from my family or friends.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

59. I felt that I was just as good as other people.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

60. I had trouble keeping my mind on what I was doing.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

You have completed 80% of the survey..

61. I felt depressed.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

62. I felt that everything I did was an effort.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

63. I felt hopeful about the future.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

64. I thought my life had been a failure.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

65. I felt fearful.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

66. My sleep was restless.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

67. I was happy.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

68. I talked less than usual.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

69. I felt lonely.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

70. People were unfriendly.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

71. I enjoyed life.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

72. I had crying spells.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

73. I felt sad.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

74. I felt that people disliked me.

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

75. I could not get "going".

• Rarely or none of the time (less than 1 day/week)
  Some or a little of the time (1-2 days/week)
  Occasionally or a moderate amount of time (3-4 days/week)
  Most or all of the time (5-7 days/week)

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