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PSS-SR: Part 1

Many people have lived through or witnessed a very stressful and traumatic event at some point in their lives. Below is a list of traumatic events. Put a check next to ALL of the events that have happened to you or that you have witnessed.

(Q1) Serious accident, fire, or explosion (for example, an industrial, farm, car, plane, or boating equipment)

(Q2) Natural disaster (for example, tornado, hurricane, flood, or major earthquake)

(Q3) Non-sexual assault by a family member or someone you know (for example, being mugged, physically attacked, shot, stabbed, or held at gunpoint)

(Q4) Non-sexual assault by a stranger (for example, being mugged, physically attacked, shot stabbed, or held at gunpoint)

(Q5) Sexual assault by a family member or someone you know (for example, rape or attempted rape)

(Q6) Sexual assault by a stranger (for example, rape or attempted rape)

(Q7) Military combat or war zone

(Q8) Sexual contact when you were younger than 18 with someone who was 5 or more years older than you (for example, contact with genitals, breasts)

(Q9) Imprisonment (for example, prison inmate, prisoner of war, hostage)

(Q10) Torture

(Q11) Life-threatening illness

(Q12) Other traumatic event

(Q13) If you marked Item 12, specify the traumatic event below (type your answer below).

IF YOU MARKED ANY OF THE ITEMS ABOVE (Q1-Q13), CONTINUE. IF NOT, STOP HERE.

PSS-SR Part 2

(Q14) If you marked more than one traumatic event in Part 1, CHECK the event that bothers you the most. If you marked only one traumatic event in Part 1, mark the same below.

Accident

Disaster

Non-sexual assault/someone you know

Non-sexual assault/stranger

Sexual assault/someone you know

Sexual assault/stranger

Combat

Sexual contact under 18 with someone 5 or more years older

Imprisonment

Torture

Life-threatening illness

Other

On the lines (box) below, briefly describe the traumatic event you marked above (type your answer below).

Below are several questions about the traumatic event you just described above.

 (Q15) How long ago did the traumatic event happen? (CHECK ONE)

Less than 1 month

1 to 3 months

3 to 6 months

6 months to 3 years

3 to 5 years

More than 5 years

For the following questions, CHECK Y for Yes or N for No.

During the traumatic event:

(Q16) Were you physically injured? Y N

(Q17) Was someone else physically injured? Y N

(Q18) Did you think that your life was in danger? Y N

(Q19) Did you think that someone else’s life was in danger? Y N

(Q20) Did you feel helpless? Y N

(Q21) Did you feel terrified? Y N

PSS-SR Part 3

Below is a list of problems that people sometimes have after experiencing a traumatic event. Read each one carefully and using the options after each question, SELECT the statement that best describes how often that problem has bothered you IN THE PAST MONTH. Rate each problem with respect to the traumatic event you described in Item 14.

(Q22) Having upsetting thoughts or images about the traumatic event that came into you head when you didn't want them to.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q23)Having bad dreams or nightmares about the traumatic event.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q24)Reliving the traumatic event, acting or feeling as if it were happening again.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q25) Feeling emotionally upset when you were reminded of the traumatic event (for example, feeling scared, angry, sad, guilty, etc.).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q26) Experiencing physical reactions when you were reminded of the traumatic event (for example, breaking out in a sweat, heart beating faster).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q27) Trying not to think about, talk about, or have feelings about the traumatic event.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q28) Trying to avoid activities, people, or places that remind you of the traumatic event.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q29) Not being able to remember an important part of the traumatic event.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q30) Having much less interest or participating much less often in important activities.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q31) Feeling distant or cut off from people around you.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q32) Feeling emotionally numb (for example, being unable to cry or unable to have loving feelings).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q33) Feeling as if your future plans or hopes will not come true (for example, you will not have a career, marriage, children, or a long life).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q34) Having trouble falling or staying asleep.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q35) Feeling irritable or having fits of anger.

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q36) Having trouble concentrating (for example, drifting in and out conversation, losing track of a story on television, forgetting what you read).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q37) Being overtly alert (for example, checking to see who is around you, being uncomfortable with your back to the door, etc.).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q38) Being jumpy or easily startled (for example, when someone walks up behind you).

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q39) How long have you experienced the problems that you reported above?

• Not at all or only one time
• Once a week or less/once in a while
• 2 to 4 times a week/half the time
• 5 or more times a week/almost always

(Q40) How long after the traumatic event did these problems begin? (CHECK ONE)
less than 1 month 1 to 3 months More than 3 months Less than 6 months 6 or more months

PSS-SR Part 4

Indicate below if the problems you rated in Part 3 have interfered with any of the following areas of your life DURING THE PAST MONTH. CHECK Y for Yes or N for No.

(41) Work Y N

(42) Household chores and duties Y N

(43) Relationships with friends Y N

(44) Fun and leisure activities Y N

(45) Schoolwork Y N

(46) Relationships with your family Y N

(47) Sex life Y N

(48) General satisfaction with life Y N

(49) Overall level of functioning in all areas of you life Y N

THE END OF THIS QUESTIONNAIRE

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