Professional Documents
Culture Documents
Pro2013002733
4/25/2013
This survey is to help gather information about the effect of unemployment on physical and
mental health among New Jersey labor force. The survey will take approximately 5-10 minutes.
Thank you for your time. Your participation is greatly appreciated.
DEMOGRAPHICS:
1. Age as of your last birthday:
2. Gender (please check one):
Male
Female
11. Annual household income before unemployment: (including if applicable, income from
spouse, partner, parents and children)
< $19,999
$20,000 - 39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 or more
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13. Since unemployment, what is your current annual household income: (including if
applicable, income from spouse, partner, parents and children)
< $19,999
$20,000 - 39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 or more
14. Please tell us who is living in your household? (check all that apply)
Yourself
Spouse/Partner
Children (how many and ages)
Other: (please explain)
15. Do you currently have health insurance coverage?
Yes
No
If YES, what type of insurance?
Private insurance associated with Spouse/ Partner
COBRA/ former employer
Medicare (elderly and person with disability)
Individually purchased health insurance
Medicaid (resources for low income individuals)
Other
16. Do you currently have health insurance coverage for your child(ren)?
Yes
No
Not applicable (no dependent children)
17. Would you say that in general your overall health is:
Excellent
Very good
Good
Fair
Poor
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Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
No
HEALTH BEHAVIOR
19. Do you exercise/ participate in physical activities? ......................... Yes
No
If yes, since being unemployed, have you made any changes in the frequency of physical
activity?
I exercise less
I exercise more
No change in physical activities/ exercise
20. Do you drink alcohol? ...................................................................... Yes No
If yes, since being unemployed, would you say you drink less, drink more or about the
same?
Drink less
Drink more
Drink about the same
21. Do you smoke cigarettes?...... Yes No
If yes, since being unemployed, would you say you smoke less, smoke more or about the
same?
Smoke less
Smoke more
Smoke about the same
22. Has financial stress caused any health problems since being unemployed?
Yes; please list/explain
No
Dont know/ not applicable
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care
while
being
unemployed,
has
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
No
MENTAL HEALTH
(Please remember that your responses are anonymous and the responses you provide cannot be
traced back to you)
25. In the past 30 days (please check all that applies)
Never
1 or 2
days
3 or 4
days
5 or more
days
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26. Since being unemployed, did you begin to take medicine or receive treatment from a
doctor or other health professional for any type of mental health condition or emotional
problem?
Yes
No, did not begin and I am not taking any medication/treatment now.
No, did not begin however I was taking medication/treatment prior to
unemployment
27. Has a doctor or other healthcare provider EVER told you that you have an anxiety
disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessivecompulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social
anxiety disorder)?
Yes; Before becoming unemployed
Yes; After becoming unemployed
No; Never
28. Since being unemployed, are you easily irritated, angry over minor incidents or hostile?
Yes
No
29. In the past 30 days, have you (please check all that applies)
NO
1 or 2 times
3 or 4times
5 or more times
30. Are you familiar with the NJ Family Care Health Insurance Plan?
Yes
No
31. Are you aware of any free medical services where you live?
Yes, which one(s)
No
32. What is your greatest area of concern during this period of unemployment? (please use
this space to also add anything or make any suggestions on this questionnaire)
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