Revised Adverse Childhood Experiences
Prior to your 18th birthday...
1.
Did a parent or adult in the household
often or very often...
Swear at you, insult you, put you down, or humiliate you?
or
Act in a way that made you feel afraid that you might be physically hurt?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
2.
Did a parent or other adult in the household
often or very often...
Push, grab, slap, or throw something at you?
or
Ever hit you so hard that you had marks or were injured?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
3.
Did an adult or person at least 5 years older than you
ever...
Touch or fondle you or have you touch their body in a sexual way?
or
Attempt or actually have oral, anal, or vaginal intercourse with you?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
4.
Did you
often or very often
feel that...
No one in your family loved you or thought you were important or special?
or
Your family didn't look out for each other, feel close to each other, or support each other?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
5.
Did you
often or very often
feel that...
You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?
or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
6.
Was a biological parent
ever
lost to you through divorce, abandonment, or other reason?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
7.
Was your mother or stepmother:
Often or very often
pushed, grabbed, slapped, or had something thrown at her?
or
Sometimes, often, or very often
kicked, bitten, hit with a fist, or hit with something hard?
or
Ever
repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
8.
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
9.
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
10.
Did a household member go to prison?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
11.
Did other kids, including brothers or sisters,
often or very often
hit you, threaten you, pick on you or insult you?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
12.
Did you
often or very often
feel lonely, rejected or that nobody liked you?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
13.
Did you live for
2 or more years
in a neighborhood that was dangerous, or where you saw people being assaulted?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
14.
Was there a period of
2 or more years
when your family was very poor or on public assistance?
Yes
No
If you would like to expand on your answer about how this has impacted you in the workplace please use the text box below:
15.
Over the
last two weeks
, how often have you been bothered by the following problems about work?
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge about work
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying about work
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about work
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing at work
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it's hard to sit still at work
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable because of work
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid, as if something awful might happen related to work
Not at all
Several days
More than half the days
Nearly every day
16.
How difficult have these problems made it for you to work, take care of things at home, or get along with other people?
Not difficult at all
Somwhat difficult
Very difficult
Extremely difficult
17.
Please provide your email address for a free report. If you've taken our Toxic/Adverse Work Experiences or other surveys, providing your email address can help us understand how Adverse Childhood Experiences relate other workplace experiences.