ACE Survey

I invite you to fill in your information and take the survey. At the end, once you see your ACE score, you will have the option of sending me your score or opting out. Please choose either option and click the "Submit" button when you are finished.

Fields marked with a blue asterisk (*) are required. If you get an error, it is probably because you left out a required field.

Note that javascript must be enabled in your browser in order to take this survey.

First name: *      Last name: *     Email:
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Which class are you in?:     A block Honors Physics 2 B block Honors Physics 1 E block Honors Physics 1 F block CP1 (Regular) Physics 1 G block CP1 (Regular) Physics 1 other or N/A * [Required]

Adverse Childhood Experiences (ACE) Survey

This survey will calculate your Adverse Childhood Experiences (ACE) score. The number of questions that you answer "yes" provides an estimate of the kinds of childhood traumatic experieces you have experienced.

There are 10 types of childhood trauma measured in the ACE Study. Five are personal: physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. The other five are related to other family members: a parent who is an alcoholic, a parent who is a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death, deportation or abandonment.

1. Did a parent or other adult in the household often or very often do either or both of the following:
   • Swear at you, insult you, put you down or humiliate you?
   • Act in a way that made you afraid that you might be physically hurt?
   yes     no
   
   
2. Did a parent or other adult in the household do either or both of the following:
   • Often or very often push you, grab you, slap you, or throw something at you?
   • Ever hit you so hard that you had marks or were injured?
   yes     no
   
   
3. Did an adult or person at least 5 years older than you ever do either (or both) of the following:
   • Touch or fondle you or have you touch their body in a sexual way?
   • Attempt or actually have oral, anal, or vaginal intercourse with you?
   yes     no
   
   
4. Did you often or very often feel that either (or both):
   • No one in your family loved you or thought you were important or special?
   • Your family didn't look out for each other, feel close to each other, or support each other?
   yes     no
   
   
5. Did you often or very often feel that either (or both):
   • You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?
   • Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
   yes    no
   
   
6. Was a parent ever lost to you through divorce, abandonment, death or another reason?
   yes     no
   
   
7. Did any of the following happen to your mother, stepmother, or another adult in your household?
   • They were often or very often pushed, grabbed, slapped, or had something thrown at them.
   • They were sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard.
   • They were ever repeatedly hit for at least a few minutes or threatened with a gun or knife.
   yes     no
   
   
8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
   yes     no
   
   
9. Was a household member depressed or mentally ill, or did a household member attempt or commit suicide?
   yes     no
   
   
10. Did a household member get deported or go to prison, or is a household member going to court to avoid deportation?
    yes     no
    
    
11. Have you experienced other significant trauma not listed above, such as watching a sibling being abused, losing a primary caregiver other than a parent (grandparent, aunt/uncle, etc.), being homeless, surviving and recovering from a severe accident, etc.?
    yes     no