SOCIAL SUPPORT QUESTIONNAIRE

PLEASE READ ALL DIRECTIONS

ON THIS PAGE BEFORE STARTING

Please list each significant person in your life on the right. Consider all
the persons who provide personal support for you or who are important
to you.

Use only first names or initials, and then indicate the relationship, as in
the following example:

Example:
First Name or Initials Relationship

1. Mary T friend
2. Bob brother
3. M.T. mother Note: Before use, pages 1-4 should be
4. Sam friend
5. Mrs. R. neighbor
cut along the dashed center line to allow
etc. the response lines for Questions 1-6 to
align with the Personal Network list on
Use the following list to help you think of the people important to you, page 5.
and list as many people as apply in your case.

- spouse or partner
- family members or relatives
- friends
- work or school associates
- neighbors
- health care providers
- counselor or therapist
- minister/priest/rabbi
- other

You do not have to use all 24 spaces. Use as many spaces as you have
important persons in your life.

WHEN YOU HAVE FINISHED YOUR LIST, PLEASE TURN TO PAGE 2.

© 1980 by Jane S. Norbeck, DNSc

University of California, San Francisco
Page 1 Revised 1982, 1995
For each person you listed, please answer the following questions by writing in the
number that applies.
0 = not at all
1 = a little
2 = moderately
3 = quite a bit
4 = a great deal

Question 1: Question 2:

How much does this person How much does this person
make you feel liked or loved? make you feel respected or
admired?

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7. Note: Before use, pages 1-4 should be
8. 8. cut along the dashed center line to allow
9. 9. the response lines for Questions 1-6 to
10. 10. align with the Personal Network list on
11. 11. page 5.
12. 12.
13. 13.
14. 14.
15. 15.
16. 16.
17. 17.
18. 18.
19. 19.
20. 20.
21. 21.
22. 22.
23. 23.
24. 24.
[EMO1] [EMO2]

Page 2 GO ON TO NEXT PAGE

 0 = not at all
1 = a little
2 = moderately
3 = quite a bit
4 = a great deal

Question 3: Question 4:

How much can you confide in How much does this person
this person? agree with or support your
actions or thoughts?

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7. Note: Before use, pages 1-4 should be
8. 8. cut along the dashed center line to allow
9. 9. the response lines for Questions 1-6 to
10. 10. align with the Personal Network list on
11. 11. page 5.
12. 12.
13. 13.
14. 14.
15. 15.
16. 16.
17. 17.
18. 18.
19. 19.
20. 20.
21. 21.
22. 22.
23. 23.
24. 24.
[EMO3] [EMO4]

Page 3
GO ON TO NEXT PAGE
 0 = not at all
1 = a little
2 = moderately
3 = quite a bit
4 = a great deal

Question 5: Question 6:

If you needed to borrow $10, If you were confined to bed

a ride to the doctor, or some for several weeks, how much
other immediate help, how could this person help you?
much could this person
usually help?

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7. Note: Before use, pages 1-4 should be
8. 8. cut along the dashed center line to allow
9. 9. the response lines for Questions 1-6 to
10. 10. align with the Personal Network list on
11. 11. page 5.
12. 12.
13. 13.
14. 14.
15. 15.
16. 16.
17. 17.
18. 18.
19. 19.
20. 20.
21. 21.
22. 22.
23. 23.
24. 24.
[AID5] [AID6]

Page 4
GO ON TO NEXT PAGE
 Number _________________
[IDNO]
Question 7: Question 8: Date _________________

How long have you known How frequently do you

this person? usually have contact with this
person? (Phone calls, visits,
or letters)
PERSONAL NETWORK
1 = less than 6 months 5 = daily
2 = 6 to 12 months 4 = weekly
3 = 1 to 2 years 3 = monthly
4 = 2 to 5 years 2 = a few times a year First Name or Initials Relationship
5 = more than 5 years 1 = once a year or less

1. 1. 1. [SOU1]
2. 2. 2. [SOU2]
3. 3. 3. [SOU3]
4. 4. 4. [SOU4]
5. 5. 5. [SOU5]
6. 6. 6. [SOU6]
7. 7. 7. [SOU7]
8. 8. 8. [SOU8]
9. 9. 9. [SOU9]
10. 10. 10. [SOU10]
11. 11. 11. [SOU11]
12. 12. 12. [SOU12]
13. 13. 13. [SOU13]
14. 14. 14. [SOU14]
15. 15. 15. [SOU15]
16. 16. 16. [SOU16]
17. 17. 17. [SOU17]
18. 18. 18. [SOU18]
19. 19. 19. [SOU19]
20. 20. 20. [SOU20]
21. 21. 21. [SOU21]
22. 22. 22. [SOU22]
23. 23. 23. [SOU23]
24. 24. 24. [SOU24]
[DURATION] [FREQCON]

Page 5

PLEASE BE SURE YOU HAVE RATED EACH PERSON ON

EVERY QUESTION. GO ON TO THE LAST PAGE.
9. During the past year, have you lost any important relationships due to moving, a job change, divorce or separation, death, or some other
reason?

0. No
1. Yes [LOSS]

IF YOU LOST IMPORTANT RELATIONSHIPS DURING THIS PAST YEAR:

9a. Please indicate the number of persons from each category who are no longer available to you.
spouse or partner [LOSS1]
family members or relatives [LOSS2]
friends [LOSS3]
work or school associates [LOSS4]
neighbors [LOSS5]
health care providers [LOSS6]
counselor or therapist [LOSS7]
minister/priest/rabbi [LOSS8]
other (specify) [LOSS9]

[LOSSNO]

9b. Overall, how much of your support was provided by these people who are no longer available to you? [LOSSAMT]
0. none at all
1. a little
2. a moderate amount
3. quite a bit
4. a great deal

Page 6