All of the following questions refer to experiences since you were born. Now, looking back on your childhood…
Questions:
1. How often has your family experienced serious financial problems?
- Never
- Rarely
- Sometimes
- Often
- Very Often
2. How often have you been hungry because your family could not afford food?
- Never
- Rarely
- Sometimes
- Often
- Very Often
3. How often have you been homeless?
(This means having to stay somewhere like a transitional housing program, a shelter, a hotel/motel paid by voucher, someone else’s home, a car or other vehicle, an abandoned building, anywhere outside, or anywhere else not meant for people to live.)
- Never
- Rarely
- Sometimes
- Often
- Very Often
4. How often has a parent or adult in your home ever swore at you, insulted you, or put you down?
- Never
- Rarely
- Sometimes
- Often
- Very Often
5. How often have you been you bullied or severely teased by other children or adolescents?
(This refers to bullying or teasing by children or adolescents of any age. It does not include experiences with adults or with siblings.)
- Never
- Rarely
- Sometimes
- Often
- Very Often
6. How often has there been an adult in your household who tried hard to make sure your basic needs were met? By “basic needs” we mean food, shelter, clothing, and medical care.
(This could be any adult in the household, not just a parent.)
- Never
- Rarely
- Sometimes
- Most of the Time
- Always
7. How often has there been an adult in your household who made you feel safe and protected?
- Never
- Rarely
- Sometimes
- Most of the Time
- Always
8. How often has a parent or adult in your home ever hit, beat, kicked, or physically hurt you in any way? Do not include spanking.
- Never
- Once
- More Than Once
9. How often have your parents or adults in your home ever slap, hit, beat, kicked, or physically hurt each other?
- Never
- Once
- More Than Once
10. How often has an adult, or anyone at least 5 years older than you, touched you sexually, tried to make you touch them sexually, or forced you to have sex?
- Never
- Once
- More Than Once
11. Have you lived with anyone who was depressed, mentally ill, or suicidal?
- Yes
- No
12. Have you lived with anyone who was a problem drinker or alcoholic?
- Yes
- No
13. Have you lived with anyone who used illegal street drugs or who abused prescription medications?
- Yes
- No
14. Have you lived with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
- Yes
- No
15. Are your parents separated or divorced?
- Yes
- No
16. Have either one of your parents been absent from your life for a long period of time? Do not include absence due to death of parent.
- Yes
- No
17. Have you experienced the death of a parent, caregiver, or sibling?
- Yes
- No
18. Have you ever been the victim of a violent crime? This refers to any violent act that was perpetrated by someone other than a parent or household family member.
- Yes
- No
19. Have you ever been the victim of a violent crime? This refers to any violent act that was perpetrated by someone other than a parent or household family member.
- Not at All
- Slightly
- Moderately
- Very
- Extremely
Adapted from Centers for Disease Control and Prevention. (2012). Behavioral Risk Factor Surveillance System Survey Questionnaire: Adverse Childhood Experiences Module. Atlanta, Georgia: Author.
For further information about this measure, contact: Dr. Joshua Mersky, University of Wisconsin-Milwaukee, mersky@uwm.edu