Women in Transition HOPE Survey

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Women in Transition HOPE Survey - page 1

INSTRUCTIONS: The purpose of this survey is to better understand your views and attitudes, helping us measure the overall impact of our program on the client population that we are serving. All responses will remain confidential and there is no obligation for you to take the survey, it is voluntary. It is important that you answer all of the questions, otherwise the survey analysis results could be invalidated. Please read each item and select the best response that reflects your answer.

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Date *

First Name *

Last Name *

City *

State *

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DEMOGRAPHIC INFORMATION

Age *

Educational Background *

Less than 12th grade

High School/GED

Technical

Some College

College Graduate

Race/Ethnicity *

White

Black or African American

American Indian

Asian

Hispanic or Latino

Other

WELL-BEING

Below are eight statements with which you may agree or disagree. Using the scale below, indicate your agreement with each item by indicating that response for each statement.

1. I lead a purposeful and meaningful life. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

2. My social relationships are supportive and rewarding. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

3. I am engaged and interested in my daily activities. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

4. I actively contribute to the happiness and well-being of others. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

5. I am competent and capable in the activities that are important to me. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

6. I am a good person and live a good life. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

7. I am optimistic about my future. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

8. People respect me. *

Strongly Disagree

Disagree

Slightly Disagree

Neither Agree nor Disagree

Slightly Agree

Agree

Strongly Agree

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Women in Transition HOPE Survey - page 2

QUESTIONS ABOUT GOALS

Read each item carefully. Using the scale shown below, please mark the space that best describes YOU.

1. I can think of many ways to get out of a jam. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

2. I energetically pursue my goals. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

3. I feel tired most of the time. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

4. There are lots of ways around any problem. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

5. I am easily downed in an argument. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

6. I can think of many ways to get the things in life that are important to me. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

7. I worry about my health. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

8. Even when others get discouraged, I know I can find a way to solve the problem. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

9. My past experiences have prepared me well for my future. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

10. I've been pretty successful in life. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

11. I usually find myself worrying about something. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

12. I meet the goals that I set for myself. *

Definitely False

Mostly False

Somewhat False

Slightly False

Slightly True

Somewhat True

Mostly True

Definitely True

FEELINGS ABOUT SELF AND OTHERS

For each of the following statements please choose the response that best indicates the extent of your agreement or disagreement as it describes your persoal experience.

1. I feel isolated from people. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

2. I am unable to talk with people about myself. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

3. I am connected to people in meaningful ways. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

4. There are people who I can talk with about my life. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

5. I feel a sense of connectedness. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

6. There is no one I can talk with about what's going on in my life. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

7. There are few people who I am close with. *

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

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Women in Transition HOPE Survey - page 3

PERSONAL FEELINGS

Please think about what you have been doing and experiencing during the past 4 weeks. Then report how much you experieced each of the following feelings, using the scale below.

1. Positive *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

2. Negative *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

3. Good *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

4. Bad *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

5. Pleasant *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

6. Unpleasant *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

7. Happy *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

8. Sad *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

9. Afraid *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

10. Joyful *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

11. Angry *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

12. Contented *

Very rarely or rarely

Rarely

Sometimes

Often

Very often or always

DEALING WITH STRESS

The following items ask you to indicate what you generally do and feel when you experience stressful events. Different events bring out somewhat different responses, but think about what you usually do when you are under stress. Then respond to each item by marking your answer below.

1. I turn to work or other substitute. *