| 1) Please enter your current age |
|
| 2) Please indicate your gender: |
Male |
Female |
| 3) What is your race/ethnic origin?: |
Caucasian
African American
Hispanic
American Indian
Asian
Other
|
| 4) What is your country of citizenship? |
| 5)What is your highest level of education? |
Less than 12 years
High School Diploma
Technical training or Associates Degree
Bachelor's Degree
Graduate Degree
|
| 6) What is your employment status? |
Full-Time
Part-Time
Unemployed
|
| 7) Please indicate your current marital status |
Married
Remarried
Single (never married)
Single (divorced)
Single (widowed)
Separated
|
|
IF YOU HAVE EXPERIENCED THE ABORTION OF MORE THAN ONE GRANDCHILD, PLEASE ANSWER THE FOLLOWING QUESTIONS IN TERMS OF THE ONE ABORTION EXPERIENCE WHICH HAS BEEN THE MOST DIFFICULT FOR YOU. |
| 8a) How long ago did the abortion occur? years months |
| 8b) How many weeks pregnant was your child at the time of the abortion? weeks
|
| 8c) If you know what type of abortion was performed, identify it from the following list: |
Suction aspiration
D & C (dilation & curettage)
D & E (dilation & evacuation)
Saline induced abortion
Prostaglandin abortion
Hysterotomy
Intact dilation & extraction (partial-birth abortion)
Chemically induced abortion (RU 486)
|
| 9) When the decision to abort was made... |
| 9a. My child and I both supported the decision |
Yes |
No |
| 9b. I pressured my child into choosing abortion |
Yes |
No |
| 9c. Someone else pressured my child into choosing abortion |
Yes |
No |
| 9d. My child chose to have an abortion against my wishes |
Yes |
No |
| 9e. I left the decision to my child |
Yes |
No |
| f. I did not know about the abortion until after it occurred |
Yes |
No |
| 10) Please indicate if any of the following were reasons that influenced your child's decision to abort: |
| a. Mental Health / Emotional distress |
Yes |
No |
| b. Physical Health |
Yes |
No |
| c. Financial Concerns |
Yes |
No |
| d. School / Educational Plans |
Yes |
No |
| e. Career Plans |
Yes |
No |
| f. Family Size |
Yes |
No |
| g. Social Reasons (e.g. embarrassment) |
Yes |
No |
| 11) Has your relationship with your child changed since the abortion? |
Yes |
No |
| 12) How would you describe your relationship with your child now as compared to before the abortion? |
| It has become |
much better than before |
| It has become |
slightly better than before |
| It is |
the same as before |
| It has become |
slighlty worse than before |
| It has become |
much worse than before |
| THE FOLLOWING IS A LIST OF PROBLEMS THAT PEOPLE MAY HAVE IN RESPONSE TO STRESSFUL EXPERIENCES. PLEASE READ EACH ONE CAREFULLY AND CHOOSE THE ANSWER THAT BEST DESCRIBES HOW MUCH YOU HAVE BEEN BOTHERED BY THAT PROBLEM AS A RESULT OF THE ABORTION. IF YOU HAVE EXPERIENCED MORE THAN ONE ABORTION, PLEASE CONSIDER THE ONE MOST STRESSFUL TO YOU AS YOU ANSWER THESE QUESTIONS. |
| 13) Repeated disturbing memories, thoughts, or images of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 14) Repeated disturbing dreams of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 15) Suddenly acting or feeling as if the abortion were happening again (as if you were reliving it)? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 16) Feeling very upset when something reminded you of the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 17) Having physical reactions (e.g.heart pounding, trouble breathing, sweating)when something reminded you of the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 18) Avoiding thinking about or talking about the abortion experience or avoiding having feelings related to it? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 19) Avoiding activities or situations because they reminded you of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 20) Trouble remembering important parts of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 21) Loss of interest in activities you used to enjoy? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 22) Feeling distant or cut off from people since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 23) Feeling emotionally numb or being unable to have loving feelings for those close to you since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 24) Feeling as if your future will somehow be cut short since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 25) Trouble falling or staying asleep since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 26) Feeling irritable or having angry outbursts since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 27) Having difficulty concentrating since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 28) Being "super-alert" or watchful or on guard since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 29) Feeling jumpy or easily startled since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| CURRENT RESEARCH SUGGESTS THAT PEOPLE MAY EXPERIENCE A RANGE OF REACTIONS AFTER ABORTION. PLEASE INDICATE IF YOU HAVE PREVIOUSLY EXPERIENCED ("PAST") AND/OR IF YOU ARE CURRENTLY EXPERIENCING ("PRESENT") ANY OF THE FOLLOWING AS A RESULT OF THE ABORTION. YOU MAY CHECK BOTH "PAST" AND "PRESENT" IF APPLICABLE. |
| 30a: Anger |
Past
Present
|
| 30b: Helplessness |
Past
Present
|
| 30c: Grief or Sadness |
Past
Present
|
| 30d: Guilt |
Past
Present
|
| 30e: Relationship Problems |
Past
Present
|
| 30f: Sexual Problems |
Past
Present
|
| 30g: Isolation (either feeling alone or deliberately choosing to aovid other people) |
Past
Present
|
| 30h: Difficulty Concentrating |
Past
Present
|
| 30i: Anxiety or Excessive Worrying |
Past
Present
|
| 30j: Persistent thoughts about the baby |
Past
Present
|
| 30k: Confusion about a parent's role in society |
Past
Present
|
| 30l: Sadness at certain times of year (e.g. the month the abortion occurred or the month when the baby would have been born) |
Past
Present
|
| 30m: Difficulty sleeping |
Past
Present
|
| 30n: Disturbing Dreams or Nightmares |
Past
Present
|
| 30o: Alcohol and/or Drug Abuse |
Past
Present
|
| 30p: Increased Risk-Taking Behaviors (e.g. driving recklessly) |
Past
Present
|
| 30q: Felt Relieved |
Past
Present
|
| 30r: Felt more in control of my life |
Past
Present
|
| 30s: Felt more able to pursue my goals |
Past
Present
|
| 30t: Felt a sense of peace |
Past
Present
|
| 30u: Felt that I had regained my freedom |
Past
Present
|
| 31) Have you spoken about your abortion experience with any of the following? |
| a. Spouse |
Yes |
No |
| b. Friend |
Yes |
No |
| c. Parent |
Yes |
No |
| d. Sibling (brother or sister) |
Yes |
No |
| e. Clergyperson (priest, pastor, rabbi) |
Yes |
No |
| f. Counselor (professional or volunteer) |
Yes |
No |
| g. Other |
Yes |
No |
| If you have spoken to anyone, what made that discussion a positive experience for you? |
| |
| If you have spoken to anyone, what made that discussion a negative experience for you? |
| |
| 32) If you could go back to the time that the decision to abort was made, would you encourage your child to have an abortion? |
Yes |
No |
| 33) If your child faced another unplanned pregnancy in the future, would you encourage abortion? |
Yes |
No |
34) If you are a woman, have you yourself ever had an abortion?
OR
If you are a man, has your partner ever aborted a pregnancy you contributed to? |
Yes |
No |
| 35) Which of the following most closely describes your current position regarding abortion? |
abortion should be legal for any reason at any time during pregnancy
abortion should be legal for any reason during the first trimester of pregnancy
abortion should be legal only in cases of rape, incest, serious genetic disorders, & when the mother's physical life is threatened
abortion should be legal only in cases of rape, incest, and when the mother's physical life is threatened
abortion should be legal only when the mother's physical life is threatened
abortion should never be legal
|
| 36) Do you believe that the law should require parental notification of a minor's abortion? |
Yes |
No |
| 37) Do you believe that the law should require parental consent before a minor is allowed to obtain an abortion |
Yes |
No |
| If your views have changed from what they were prior to your child's abortion, please explain how they have changed. |
| |
| 38) Please indicate your religion: |
Christian
Jewish
Islam
Other
None
|
| 39) On a scale of one to five, please indicate how meaningful your religion is to you. |
1-Not at all Important
2
3-Somewhat Important
4
5-Very Important
|
| 40) If you blame someone other than yourself for your child's decision to abort, to what degree have you forgiven that person? |
1-not at all
2
3-in progress
4
5-completely
NA-does not apply to me
|
| 41) If you blame yourself even partially for your child's decision to abort, to what degree have you forgiven yourself? |
1-not at all
2
3-in progress
4
5-completely
NA-does not apply to me
|
| AS YOU ANSWER QUESTIONS 42-53 BELOW, PLEASE READ EACH ONE CAREFULLY AND CHOOSE THE RESPONSE THAT BEST DESCRIBES HOW YOU FEEL TODAY AFTER THE ABORTION EXPERIENCE. |
| 42) I am a person of worth |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 43) I sometimes think I am "no good" at all |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 44) I am as capable as others |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 45) I am inclined to feel that I am a failure |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 46) I feel that I don't have much to be proud of |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 47) I have a number of good qualities |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 48) I seldom feel down or depressed |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 49) I often feel sad or unhappy |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 50) I frequently get anxious or worry about things |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 51) I tend to feel calm or at peace most of the time |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 52) I often get angry or irritable for no apparent reason |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 53) I feel hopeful about the future |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 54) Have you ever suffered any of the following? |
| 54a: Child Abuse |
Yes
No
|
| 54b: Child Nelgect |
Yes
No
|
| 54c: Sexual Abuse during childhood or adolescence |
Yes
No
|
| 54d: Physical Abuse during adulthood |
Yes
No
|
| 54e: Sexual Abuse or Assault during adulthood |
Yes
No
|
| If you would like to explain the nature of the abuse, you may do so below. |
| |
| 55) Choose the number that best describes your abortion experience |
1-Low Stress
2
3
4-Moderate Stress
5
6
7-High Stress
8
9
10-Overwhelming
|
| PLEASE FEEL FREE TO SHARE ANY OTHER COMMENTS OR THOUGHTS ABOUT YOUR ABORTION EXPERIENCE. |
|
| THANK YOU FOR COMPLETING THIS SURVEY AND FOR PARTICIPATING IN OUR RESEARCH. IF YOU BELIEVE YOU MAY NEED OR BENEFIT FROM COUNSELING, CLICK "LINKS" ON THE SIDEBAR FOR REFERRAL INFORMATION. |
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