African American Male Mini Mental Health Survey- Faith Edition

African American Male Mini-Mental Health Survey: Faith Edition

Thank you for participating in our survey. The goal of this survey is to assist Male Behavioral Health to better understand male well-being by examining areas demonstrated to impact the health and well-being of men and boys.

Anonymity: This questionnaire does not require personal identifying information such as name, address, or date of birth . Answers will always remain anonymous .

Time: This brief survey will takes approximately 4 minutes to complete.

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* 1. What is your gender?

Female

Male

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* 2. What city do you currently live in?

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* 3. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 4. How often do you attend church or other religious meetings?

More Than Once A Week

A Few Times A Month

A Few Times A Year

Once A Week

Once A Year Or Less

Never

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* 5. The following section contains 3 statements about religious belief or experience. Please mark the
extent to which each statement is true or not true for you.

	Definitely not true	Tends not to be true	Unsure	Tends to be true	Definitely true of me
In my life, I experience the presence of the Divine	In my life, I experience the presence of the Divine Definitely not true	In my life, I experience the presence of the Divine Tends not to be true	In my life, I experience the presence of the Divine Unsure	In my life, I experience the presence of the Divine Tends to be true	In my life, I experience the presence of the Divine Definitely true of me
My religious beliefs are what really lie behind my whole approach to life	My religious beliefs are what really lie behind my whole approach to life Definitely not true	My religious beliefs are what really lie behind my whole approach to life Tends not to be true	My religious beliefs are what really lie behind my whole approach to life Unsure	My religious beliefs are what really lie behind my whole approach to life Tends to be true	My religious beliefs are what really lie behind my whole approach to life Definitely true of me
I try hard to carry my religion over into all other dealings in life	I try hard to carry my religion over into all other dealings in life Definitely not true	I try hard to carry my religion over into all other dealings in life Tends not to be true	I try hard to carry my religion over into all other dealings in life Unsure	I try hard to carry my religion over into all other dealings in life Tends to be true	I try hard to carry my religion over into all other dealings in life Definitely true of me

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* 6. How often do you spend time in private religious activities, such as prayer, meditation or Bible
study?

Daily

A few times a month

More than once a day

Once a week

Rarely or Never

Two or more times a week

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* 7. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 8. Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

In a domestic partnership or civil union

Single, but cohabiting with a significant other

Single, never married

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* 9. Please answer one of the following

	not at all	somewhat	quite a bit	a great deal
I looked for a stronger connection with God	I looked for a stronger connection with God not at all	I looked for a stronger connection with God somewhat	I looked for a stronger connection with God quite a bit	I looked for a stronger connection with God a great deal
I sought God's love and care.	I sought God's love and care. not at all	I sought God's love and care. somewhat	I sought God's love and care. quite a bit	I sought God's love and care. a great deal
I sought help from God in letting go of my anger.	I sought help from God in letting go of my anger. not at all	I sought help from God in letting go of my anger. somewhat	I sought help from God in letting go of my anger. quite a bit	I sought help from God in letting go of my anger. a great deal
I tried to see how God might be trying to strengthen me in this situation.	I tried to see how God might be trying to strengthen me in this situation. not at all	I tried to see how God might be trying to strengthen me in this situation. somewhat	I tried to see how God might be trying to strengthen me in this situation. quite a bit	I tried to see how God might be trying to strengthen me in this situation. a great deal
I asked forgiveness for my sins.	I asked forgiveness for my sins. not at all	I asked forgiveness for my sins. somewhat	I asked forgiveness for my sins. quite a bit	I asked forgiveness for my sins. a great deal
I focused on my religion to stop worrying about my problems.	I focused on my religion to stop worrying about my problems. not at all	I focused on my religion to stop worrying about my problems. somewhat	I focused on my religion to stop worrying about my problems. quite a bit	I focused on my religion to stop worrying about my problems. a great deal
I wondered whether God had abandoned me.	I wondered whether God had abandoned me. not at all	I wondered whether God had abandoned me. somewhat	I wondered whether God had abandoned me. quite a bit	I wondered whether God had abandoned me. a great deal
I felt punished by God for my lack of devotion.	I felt punished by God for my lack of devotion. not at all	I felt punished by God for my lack of devotion. somewhat	I felt punished by God for my lack of devotion. quite a bit	I felt punished by God for my lack of devotion. a great deal
I wondered what i did for God to punish me.	I wondered what i did for God to punish me. not at all	I wondered what i did for God to punish me. somewhat	I wondered what i did for God to punish me. quite a bit	I wondered what i did for God to punish me. a great deal
I questioned God's love for me.	I questioned God's love for me. not at all	I questioned God's love for me. somewhat	I questioned God's love for me. quite a bit	I questioned God's love for me. a great deal
I wondered whether my church had abandoned me.	I wondered whether my church had abandoned me. not at all	I wondered whether my church had abandoned me. somewhat	I wondered whether my church had abandoned me. quite a bit	I wondered whether my church had abandoned me. a great deal
I decided the devil made this happen.	I decided the devil made this happen. not at all	I decided the devil made this happen. somewhat	I decided the devil made this happen. quite a bit	I decided the devil made this happen. a great deal
I questioned the power of God.	I questioned the power of God. not at all	I questioned the power of God. somewhat	I questioned the power of God. quite a bit	I questioned the power of God. a great deal

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* 10. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 11. What is your ethnicity? (Please select all that apply.)

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White / Caucasian

Prefer not to answer

Other (please specify)

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* 12. Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge	Feeling nervous, anxious or on edge Not at all	Feeling nervous, anxious or on edge Several days	Feeling nervous, anxious or on edge More than half the days	Feeling nervous, anxious or on edge Nearly every day
Becoming easily annoyed or irritable	Becoming easily annoyed or irritable Not at all	Becoming easily annoyed or irritable Several days	Becoming easily annoyed or irritable More than half the days	Becoming easily annoyed or irritable Nearly every day
Feeling afraid as if something awful might happen	Feeling afraid as if something awful might happen Not at all	Feeling afraid as if something awful might happen Several days	Feeling afraid as if something awful might happen More than half the days	Feeling afraid as if something awful might happen Nearly every day
Trouble relaxing	Trouble relaxing Not at all	Trouble relaxing Several days	Trouble relaxing More than half the days	Trouble relaxing Nearly every day
Not being able to stop or control worrying	Not being able to stop or control worrying Not at all	Not being able to stop or control worrying Several days	Not being able to stop or control worrying More than half the days	Not being able to stop or control worrying Nearly every day
Being so restless that it is hard to sit still	Being so restless that it is hard to sit still Not at all	Being so restless that it is hard to sit still Several days	Being so restless that it is hard to sit still More than half the days	Being so restless that it is hard to sit still Nearly every day
Worrying too much about different things	Worrying too much about different things Not at all	Worrying too much about different things Several days	Worrying too much about different things More than half the days	Worrying too much about different things Nearly every day

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* 13. Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several Days	More than half the days	Nearly everyday
Little interest or pleasure in doing things	Little interest or pleasure in doing things Not at all	Little interest or pleasure in doing things Several Days	Little interest or pleasure in doing things More than half the days	Little interest or pleasure in doing things Nearly everyday
Feeling down, depressed, or hopeless	Feeling down, depressed, or hopeless Not at all	Feeling down, depressed, or hopeless Several Days	Feeling down, depressed, or hopeless More than half the days	Feeling down, depressed, or hopeless Nearly everyday
Trouble falling or staying asleep, or sleeping too much	Trouble falling or staying asleep, or sleeping too much Not at all	Trouble falling or staying asleep, or sleeping too much Several Days	Trouble falling or staying asleep, or sleeping too much More than half the days	Trouble falling or staying asleep, or sleeping too much Nearly everyday
Feeling tired or having little energy	Feeling tired or having little energy Not at all	Feeling tired or having little energy Several Days	Feeling tired or having little energy More than half the days	Feeling tired or having little energy Nearly everyday
Poor appetite or overeating	Poor appetite or overeating Not at all	Poor appetite or overeating Several Days	Poor appetite or overeating More than half the days	Poor appetite or overeating Nearly everyday
Feeling bad about yourself - or that you are a failure or have let yourself or your family down	Feeling bad about yourself - or that you are a failure or have let yourself or your family down Not at all	Feeling bad about yourself - or that you are a failure or have let yourself or your family down Several Days	Feeling bad about yourself - or that you are a failure or have let yourself or your family down More than half the days	Feeling bad about yourself - or that you are a failure or have let yourself or your family down Nearly everyday
Trouble concentrating on things, such as reading the newspaper or watching television	Trouble concentrating on things, such as reading the newspaper or watching television Not at all	Trouble concentrating on things, such as reading the newspaper or watching television Several Days	Trouble concentrating on things, such as reading the newspaper or watching television More than half the days	Trouble concentrating on things, such as reading the newspaper or watching television Nearly everyday
Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual	Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual Not at all	Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual Several Days	Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual More than half the days	Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual Nearly everyday
Thoughts that you would be better off dead or of hurting yourself in some way	Thoughts that you would be better off dead or of hurting yourself in some way Not at all	Thoughts that you would be better off dead or of hurting yourself in some way Several Days	Thoughts that you would be better off dead or of hurting yourself in some way More than half the days	Thoughts that you would be better off dead or of hurting yourself in some way Nearly everyday

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* 14. If you would like to have the "Key Findings" from the survey sent to you or if you would like to participate in future African American Male Mini-Mental Health Surveys, please enter your email address.

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* 15. THIS LAST QUESTION IS OPTIONAL. Meaning do not have to answer this question to conclude with the survey. Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18th
birthday.

Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had
no one to protect or take care of you?

Did you lose a parent through divorce, abandonment, death, or other reason?

Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Did you live with anyone who had a problem with drinking or using drugs, including
prescription drugs?

Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Did you live with anyone who went to jail or prison?

Did a parent or adult in your home ever swear at you, insult you, or put you down?

Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Did you feel that no one in your family loved you or thought you were special?

Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal
intercourse/penetration)?

African American Male Mini Mental Health Survey- Faith Edition