Study / Date Completed / Assessor / Subject ID / Study ID
M / M / D / D / Y / Y / Y / Y / # / # / # / # / # / # / # / # / # / # / # / # / # / # / # / #
Assessment: 1 Baseline
Reach Social Support Scale
Now I would like to ask you some questions about your friends and family
1. Overall, how satisfied have you been in the past month with the help you have received from family, friends, or neighbors?ssatis / Not at all
0 / A little
1 / Moderately
2 / Very
3 / Unknown
997 / Refused
998
2. How many relatives, friends, neighbors, other than (CR) do you see of hear from at least once a month?
ssee / None
0 / One
1 / Two
2 / Three or Four
3 / Five to Eight
4 / Nine or more
5 / Unknown
997 / Refused
998
3. How many relatives, friends, neighbors, other than (CR) do you feel close to? That is, how many do you feel at ease with, can talk to about private matters, or can call on for help?
sshelp / None
0 / One
1 / Two
2 / Three or Four
3 / Five to Eight
4 / Nine or more
5 / Unknown
997 / Refused
998
4. How many relatives, friends, neighbors, other than (CR) do you feel you can call on for help with chores, transportation, etc.?
sscall / None
0 / One
1 / Two
2 / Three or Four
3 / Five to Eight
4 / Nine or more
5 / Unknown
997 / Refused
998
5. When other people you know have an important decision to make, do they talk to you about it?
sstalk / Never
0 / Seldom
1 / Sometimes
2 / Often
3 / Very Often
4 / Always
5 / Unknown
997 / Refused
998
6. In the past month, how often has someone, such as a family member, family or neighbor, other than (CR), provided transportation, pitched in to help you do something that needed to get done, like household chores or yardwork, and/or helped you with shopping?
sschore / Never
0 / Once in a While
1 / Fairly
Often
2 / Very Often
3 / Unknown
997 / Refused
998
7. Overall, how satisfied have you been in the past month with the help you have received with transportation, housework, yardwork and shopping?
ssyard / Not At All
0 / A Little
1 / Moderately
2 / Very
3 / N/A
888 / Unknown
997 / Refused
998
8. In the past month, how often has someone been there with you (physically) in a stressful situation, provided comfort to you, or expressed concern about your wellbeing?
sscomf / Never
0 / Once in a While
1 / Fairly
Often
2 / Very Often
3 / Unknown
997 / Refused
998
9. In the past month, how satisfied have you been with the support, comfort, interest and concern you have received from others?
ssupp / Not At All
0 / A Little
1 / Moderately
2 / Very
3 / N/A
888 / Unknown
997 / Refused
998
10. In the past month, how often has someone given you information and guidance on some action? For example, they made a difficult situation clearer and easier to understand or told you what they did in a similar situation?
ssguid / Not At All
0 / A Little
1 / Moderately
2 / Very
3 / N/A
888 / Unknown
997 / Refused
998
11. Overall, how satisfied in the past month have you been with the suggestions, clarifications, and sharing of similar experiences you have received from others?
ssexp / Not At All
0 / A Little
1 / Moderately
2 / Very
3 / N/A
888 / Unknown
997 / Refused
998
I’d like to ask you a few more questions about your relationships with others. Remember, when the term “others” is used, it includes friends, neighbors, or family members other than (CR).
12. In the past month, how often have others made too many demands on you?
ssdem / Never
0 / Once in a While
1 / Fairly
Often
2 / Very Often
3 / Unknown
997 / Refused
998
13. In the past month, how often have others been critical of you?
sscrit / Never
0 / Once in a While
1 / Fairly
Often
2 / Very Often
3 / Unknown
997 / Refused
998
14. In the past month, how often have others pried into your affairs?
ssaffa / Never
0 / Once in a While
1 / Fairly
Often
2 / Very Often
3 / Unknown
997 / Refused
998
15. In the past month, how often have others taken advantage of you?
ssadvan / Never
0 / Once
in a While
1 / Fairly
Often
2 / Very Often
3 / Unknown
997 / Refused
998
16. In the past six months, do you feel the amount of help and support that you receive from others has improved?
ssotimp / No
0
go to table 16.2 / Yes
1
go to table 16.1 / Unknown
997 / Refused
998
16.1 Was the improvement minimal or substantial?
ssimpr / Minimal Improvement
1 / Substantial Improvement
2 / Unknown
997 / Refused
998
16.2 Was there no change, minimal decline or substantial decline?
ssdecli / No change
1 / Minimal Decline
2 / Substantial Decline
3 / Unknown
997 / Refused
998
ReachSSS/ Form Page 1 of 3 Primary Entered by: ______Date: __/____/____
Version 1, 5/31/2006
Secondary Entered by: ______Date: ____/____/____