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Instrument 2. A: A Political Poll

Instrument 2. A: A Political Poll

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Instruments and Social Inquiry

45

is usually rotated in polls; for example, a political poll might list Democrat as the
first choice on half of the questionnaires and Republican as the first choice on
the other half. Notice that the response choices vary in order to match the question;
it would not be appropriate to use a single response scale, such as strongly disagree to
strongly agree, as that does not fit all the items. Lastly, notice that the demographic
questions are limited to essential information and that given an adequate sample
size and appropriate mode of administration it would be difficult to identify the
respondent.

INSTRUMENT 2.A: POLITICAL OPINION POLL.

We’re interested in how you view current events. Please place a check in the box ᮀ
that best describes how you feel about the question. It should take no more than
10 minutes to complete the following fourteen items.
Do you approve or disapprove
of the way the President is handling
his job?

Approve

Disapprove

Unsure

Do you approve or disapprove
of the way Congress is handling
its job?

Approve

Disapprove

Unsure

Do you think the Congress is in
touch with what is going on in the
country?

In touch

Not in touch

Unsure

Wrong track

Unsure

Generally speaking, would you say
things in this country are heading
in the right direction, or are they
off on the wrong track?

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Right
direction

Do you think America is ready to
elect a woman president, or not?

Ready

Not ready

Unsure

In general, do you believe that
members of Congress are honest
and trustworthy in their conduct?

Honest

Not honest

Unsure

When it comes to who pays what
in taxes, do you think the federal
income tax system is basically fair
or basically unfair?

Fair

Unfair

Unsure

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Designing and Constructing Instruments for Social Research and Evaluation

Do you think the federal government
should guarantee health insurance
for all Americans, or isn’t this the
responsibility of the federal
government?

Should
guarantee

Not their
responsibility

Unsure

Please tell me whether you favor or
oppose a constitutional amendment
to allow voluntary prayer in public
schools.

Favor

Oppose

Unsure

Do you consider the amount of
federal income tax you have to pay
as too high, about right, or too low?

Too high

About right

Too low

Do you approve or disapprove of
the way Congress is handling ethics
in government?

Approve

Disapprove

Unsure

Which party do you believe is doing
a better job of handling the nation’s
business?

Repub.

Democratic

Neither

Do you think the federal government
should or should not require labels
on food saying whether it has
been genetically modified or
bio-engineered?

Should

Should not

Unsure

Right now, do you think the quality
of the environment in the country
as a whole is getting better or
getting worse?”

Getting
better

Getting
worse

Same

Which of the following do you think is the most important problem facing this
country today? (check one)
National defense
Economy/jobs
Highways and transportation infrastructure
Environment
Energy
Social Security
Drug abuse
Health care
Other: ________________________________

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Instruments and Social Inquiry

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Your Gender:
Female

Male

Your Age:
Under 21
21 to 30
31 to 40
41 to 50
51 to 60
61 to 70
71 and older

Instrument 2.B: Mental Health Screening Form
As explained in this chapter, one of the primary reasons for constructing a questionnaire is to produce information for decision making. The Mental Health
Screening Form-III is presented to clients upon admission to a hospital unit or center for substance abuse treatment. These individuals may also have co-occurring
mental health problems, such as depression, phobias, or thought disorders, which
can influence treatment. The purpose of the questionnaire is to screen for mental
health problems so that therapy can be provided holistically.
The first page of the instrument provides information to treatment providers
and is not presented to the client filling out the form. This page describes the purpose of the questionnaire, how items should be scored, and how the results should
be interpreted. For example, some items cluster together, and if a respondent
answers in the affirmative it is an indicator that further evaluation and assessment
should be considered.
The instrument that the client completes begins on a new page. The title
is clearly indicated at the top of the page and the instructions section explains
the purpose of the instrument. The instructions do not specifically state that the
respondent is to circle the appropriate response, but the layout supports
that mode of recording the response. The yes responses are totaled, and the higher the
score the more likely the individual is to need more intensive evaluation and
the more aware the treatment provider should be of the potential for a co-occurring
disorder. The questionnaire does not include demographic items, such as age,
gender, ethnic group, weight, and so forth, because that information is available from other sources in the client’s medical record. Additionally, demographic
information may not be essential because this questionnaire is used for screening and

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Designing and Constructing Instruments for Social Research and Evaluation

not diagnostic purposes. However, because medications are often prescribed
and adjusted based on such factors as gender, weight, and age, an instrument
used diagnostically probably would ask about these characteristics.

INSTRUMENT 2.B: MENTAL HEALTH SCREENING FORM-III.
Guidelines for Using the Mental Health Screening Form-III
The Mental Health Screening Form-III (MHSF-III) was initially designed as a rough
screening device for clients seeking admission to substance abuse treatment
programs. Each MHSF-III question is answered either “yes” or “no.” All questions
reflect the respondent’s entire life history; therefore all questions begin with the
phrase “Have you ever . .”
The preferred mode of administration is for staff members to read each item to the
respondent and get their “yes” and “no” responses. Then, after completing all
18 questions (question 6 has two parts), the staff member should inquire about any
“yes” response by asking “When did this problem first develop?”; “How long did it
last?”; “Did the problem develop before, during, or after you started using
substances?”; and,
“What was happening in your life at that time?” This information can be written
below each item in the space provided. There is additional space for staff member
comments at the bottom of the form.
The MHSF-III can also be given directly to clients for them to complete, providing
they have sufficient reading skills. If there is any doubt about someone’s reading
ability, have the client read the MHSF-II instructions and question number one to the
staff member monitoring this process. If the client can not read and/or comprehend
the questions, the questions must be read and/or explained to him/her.
Whether the MHSF-III is read to a client or s/he reads the questions and responds
on his/her own, the completed MHSF-III should be carefully reviewed by a staff
member to determine how best to use the information. It is strongly recommended
that a qualified mental health specialist be consulted about any “yes” response to
questions 3 through 17. The mental health specialist will determine whether or
not a follow-up, face-to-face interview is needed for a diagnosis and/or treatment
recommendation.
The MHSF-III features a “Total Score” line to reflect the total number of “yes”
responses. The maximum score on the MHSF-III is 18 (question 6 has two parts).
This feature will permit programs to do research and program evaluation on the
mental health-chemical dependence interface for their clients.

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