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Surveys
2015
April
M
Monthly Risk & Protective Factors Assessment
Monthly Risk & Protective Factors Assessment
0%
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How troubled or bothered are you by the medical problems in the past 30 days?
Not At All
Slightly
Moderately
Considerably
Extremely
How troubled or bothered are you by the employment/education problems in the past 30 days?
Not At All
Slightly
Moderately
Considerably
Extremely
How troubled or bothered are you by the social connectedness problems in the past 30 days?
Not At All
Slightly
Moderately
Considerately
Extremely
How troubled or bothered are you by the alcohol/drug problems in the past 30 days?
Not At All
Slightly
Moderately
Considerably
Extremely
How troubled or bothered are you by the legal problems in the past 30 days?
Not At All
Slightly
Moderate
Considerably
Extremely
How troubled or bothered are you by the familial/social problems in the past 30 days?
Not At All
Slightly
Moderately
Considerately
Extremely
How troubled or bothered are you by the psychological/emotional problems in the past 30 days?
Not At All
Slightly
Moderately
Considerably
Extremely
How troubled or bothered are you by the problems in your living environment the past 30 days?
Not At All
Slightly
Moderately
Considerately
Extremely
How troubled or bothered are you by the problems with access to service in the past 30 days?
Not At All
Slightly
Moderately
Considerably
Extremely
First Name: Last Name: Date:
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