Electrical Injury Survey Form

(Part II)

University of San Diego
Department of Electrical Engineering
Broad Study of Electrical Injury
(030203.2 Update)

 
Instructions:

Please read instructions for each item carefully before you answer. This research survey is voluntary, anonymous, and should take about 10 minutes to complete. There are no right or wrong answers to the questions. Just answer the questions the way you feel about them. Most questions can be answered by "clicking" a ready-made answer or by filling in a blank or writing in a brief description. Although you can choose not to answer some questions, it limits the helpfulness of the questionnaire so please answer as many questions as you can.

The information you provide will not be linked to you in any way. You may provide your e-mail address so we can provide you with survey results but your survey, once submitted will not be linked in any way to your email address.

All information will be kept confidential to the full extent provided by law

 
Please Enter Your E-mail Address (Optional):

(Your email address will only be used to provide you with updates on the status of this project)

 

Thank you very much for your time!

General Information:

Enter your Zipcode here:   

Preliminary Information: :

Date of injury (MM/DD/YY): 
(Please use this exact format for date)

Race:
Caucasion
African-American
Asian/Pacific Islander
Hispanic
Native American/Alaskan
Other
Age at the time of your electrical injury:
Gender:
Female
Male

 

Your age Today:

 

Highest level of education you have completed

Less then 12th grade
High school or GED
Some college / technical school
Bachelor's degree
Graduate degree (masters or doctoral)

Characterize your electrical contact

My contact was with:

Less than 1000 Volts

More than 1000 Volts

 

Select any statements that are true:

 

The current entered or exited through my head, face, or neck

I suffered loss of consciousness

I hit my head on something during or immediately after the shock

 

 

 

1. Prior to your electrical contact, had you ever had an experience that caused you to fear you would be killed or injured?


Yes No
Serious accident
Natural disaster
Threatened with a weapon
Molested / raped
Fire , flooding, or collision at sea

2. During the electric shock and immediately afterwards did you?


Yes No
Feel in physical danger
Fear you would die
Get injured
Lose consciousness

 

3. During the electric shock and immediately afterward did you feel:


Not at all A little bit Moderately Quite a bit Extremely
Frightened
Helpless
Anxious
Horrified
Hopeless

 

4. Please select the choice that best describes your experiences and reactions DURING the electric shock and immediately afterward (if an item does not apply to your experience, please select “not at all true")


Not at - all true Slightly - true Somewhat - true Very - true Extremely - true
I had moments of losing track of what was going on - I “blanked out” or “spaced out” or in some way felt that I was not part of what was going on
I found that I was on “automatic pilot'' - I ended up doing things that I later realized I hadn't actively decided to do
My sense of time changed - things seemed to be happening in slow motion
What was happening seemed unreal to me - like I was in a dream or watching a movie or play
I felt as though I were a spectator watching what was happening to me - as if I were floating above the scene or observing it as an outsider
There were moments when my sense of my own body seemed distorted or changed. I felt disconnected from own body, or that it was unusually large or small
I felt as though things that were actually happening to others were happening to me - like I was being trapped when I really wasn't
I was surprised to find out afterward that a lot of things had happened at the time that I was not aware of, especially things I ordinarily would have noticed
I felt confused; that is, there were moments when I had difficulty making sense of what was happening
I felt disoriented; that is, there were moments when I felt uncertain about where I was or what time it was

5. Since the incident how many times have you visited a psychiatrist, psychologist,social worker, or other mental health care provider?

Not at all
Once
2 - 3 times
More than 3 times

6. Over the Last Two Weeks, how often have you been bothered by any of the following problems?

 


Not at all Several days More than - half the days Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thought that you would be better off dead or of hurting yourself in some way

 

7a. The following is a list of difficulties people sometimes have after stressful events. Read each item and select how distressing each difficulty has been for you DURING THE PAST 7 DAYS with respect to the electric shock. How much were you distressed or bothered by the following:


Not at all A little bit Moderately Quite a bit Extremely
Any reminder that brought back feelings about it
I had trouble staying asleep
Other things kept making me think about it
I felt irritable and angry
I avoided letting myself get upset when I thought about it or was reminded of it
I thought about it when I didn't mean to
I felt as if it didn't happen or wasn't real
I stayed away from reminders of it
Pictures of it popped into my mind
I was jumpy and easily startled
I tried not to think about it

7b.


Not at all A little bit Moderately Quite a bit Extremely
I was aware that I still had a lot of feelings about it but didn't deal with them
My feelings about it were kind of numb
I found myself acting or feeling like I was back at that time
I had trouble falling asleep
I had waves of strong feelings about it
I tried to remove it from my memory
I had trouble concentrating
Reminders of it caused me to have physical reactions such as sweating, trouble breathing, nausea, or a pounding heart
I had dreams about it
I felt watchful and on guard
I tried not to talk about it

8. In the year prior to your electrical accident had you felt any of the following?


Yes No
Felt you needed to cut back on your drinking
Felt annoyed at anyone who suggested you cut back on your drinking
Felt you needed an “eye-opener” or early morning drink
Felt guilty about your drinking

9. Please compare your current use of alcohol to your use before the electrical shock incident:

Use more since the incident
No change
Use less than before the incident

10. In the time since your electrical accident had you felt any of the following?


                                 
Yes No
Felt you needed to cut back on your drinking
Felt annoyed at anyone who suggested you cut back on your drinking
Felt you needed an “eye-opener” or early morning drink
Felt guilty about your drinking

 

Thank you for your time and effort in completing this survey. Your submission will be completely anonymous.

 

You must press the SUBMIT button  below if you want your survey entered into the database.

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