Spinal Cord Injury Research Questionnaire

Part I. General Spinal Cord Injury Information

Please fill in all fields.

1.       Do you have a spinal cord injury?    Yes No

If you answered "Yes" to the previous question, please continue to question 2. If you answered "No," thank you for your participation but this questionnaire is only for spinal cord injured persons.

2.       If known, please provide your spinal cord injury level or area on your spinal cord that was injured (cervical, thoracic, lumbar, or sacral area)?

3.       When and how did you acquire a spinal cord injury? Please provide the year and if possible, the month that this occurred.

4.       How long was your recovering hospital stay?

5.       Have you sought out rehabilitation since your injury? If you went to an inpatient rehabilitation facility, how long was your stay? If you went to an outpatient rehabilitation facility, how frequently were your visits?

6.       Do you live with anyone or do you live alone?  

7.       Do you work or attend college? If so, what is your major?

8.       Do you own a ramp van? If so, do you drive yourself?

9.       Optional: Would you like to share any struggles or difficulties you face being spinal cord injured?

10.       Optional: What do you miss most from life without a spinal cord injury?

________________________________________________________

11.       Are you male or female?    Male Female

12.       What is your age?     

13.       What is your marital status?     

14.       What is place of residence?     

 

Part II. Mood Scale

Please read the following statements and select the best answer for how you have felt over the last month.

 

1.       Have you felt hopeless, down, or depressed?     

 

2.       Have you felt tired and had a lack of energy?     

 

3.       Do you feel satisfied with your life?     

 

4.       Are you usually in good spirits?     

 

5.       Do you laugh and still find humor in things?     

 

6.       Do you live a healthy lifestyle?     

 

7.       Do you feel that your life has value?     

 

8.       Do you easily get upset?     

 

9.       Do you find interest and enjoyment in doing things?     

 

10.       Do you feel happy?     

 

11.       Are you positive for the most part?     

 

12.       How often do you worry?     

 

13.       How often do you feel angry?     

 

14.       Do you feel regret?     

 

15.       Do you prefer to stay home?     

 

16.       How often do you have fun?     

 

17.       Do you ever feel helpless?     

 

18.       Have you felt suicidal or wished you were not alive?     

 

19.       Have you felt stressed or annoyed?     

 

20.       Do you enjoy life?     

 

21.       Do you feel hopeful about the future?     

 

Part III. The 14-Item Resilience Scale™ (RS-14™)

Please read the following statements. To the right of each you will find seven numbers, ranging from "1" (Strongly Disagree) on the left to "7" (Strongly Agree) on the right. Circle the number which best indicates your feelings about that statement. For example, if you strongly disagree with a statement, circle "1". If you are neutral, circle "4", and if you strongly agree, circle "7", etc.

 

  Strongly
Disagree 		  Strongly
Agree
  1. I usually manage one way or another.

1

2

3

4

5

6

7
  1. I feel proud that I have accomplished things in life.

1

2

3

4

5

6

7
  1. I usually take things in stride.

1

2

3

4

5

6

7
  1. I am friends with myself.

1

2

3

4

5

6

7
  1. I feel that I can handle many things at a time.

1

2

3

4

5

6

7
  1. I am determined.

1

2

3

4

5

6

7
  1. I can get through difficult times because I've experienced difficulty before.

1

2

3

4

5

6

7
  1. I have self-discipline.

1

2

3

4

5

6

7
  1. I keep interested in things.

1

2

3

4

5

6

7
  1. I can usually find something to laugh about.

1

2

3

4

5

6

7
  1. My belief in myself gets me through hard times.

1

2

3

4

5

6

7
  1. In an emergency, I'm someone people can generally rely on.

1

2

3

4

5

6

7
  1. My life has meaning.

1

2

3

4

5

6

7
  1. When I'm in a difficult situation, I can usually find my way out of it.

1

2

3

4

5

6

7
© 1987 Gail M. Wagnild & Heather M. Young. Used by permission. All rights reserved.  "The Resilience Scale" is an international trademark of Gail M. Wagnild & Heather M. Young.
 

NOTE: By clicking the Submit button below, you agree to allow us to use your ANSWERS ONLY in future published studies on Resilience, which we hope you will find useful and beneficial. We will keep your responses in a large database and will only report aggregate data; we do not keep data to identify you.

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Created February 26, 2011

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