Self Administered Questionnaire On Factors Influencing Suicidal Behavior Tool

SELF ADMINISTERED QUESTIONNAIRE ON FACTORS
INFLUENCING SUICIDAL BEHAVIOR
TOOL
SECTION: - A: DEMOGRAPHIC DATA
INSTRUCTION: Dear respondent listed below are few statements. Please read each
one carefully and select the best response by using tick ( ) mark.
Code no.
1. Age in years ( )
a. 18-20years
b. 20-22 years
2. Gender ( )
a. Male
b. Female
3. Religion ( )
a. Hindu
b. Christian
c. Muslim
d. Other (specify)-----------------------------------------
4. Education ( )
a. First Year
b. Second Year
5. Occupation of father ( )
a. Agriculture
b. Business
c. Private service
d. Government service
e. Unemployed
6. Occupation of mother ( )
a. Agriculture
b Business
c. Private Service
d. Government service
e. Housewife
7. Monthly income of the family (specify……………………..) ( )
a. Below Rs 2000
b. Rs 2001-4000
c. Rs 4001-5000
d. Rs 6001 and above
8. Type of family ( )
a. Nuclear family
b. Joint family
c. Extended family
d. Single parent family
9. Source of information about suicidal behavior. ( )

a. Television
b. Radio
c. Newspaper
d. Movies
e. Magazine
f. Book
g. Other (specify)------------------------------------------------
10. Family history of mental illness. ( )
a. Depression
b. Schizophrenia
c. Mania
d. Any other (specify)----------------------------------------------------
e. None of the above
11. Family history of substance abuse. ( )

a. Drug abuse
b. Smoking
c. Alcohol dependence
d Any other (specify)------------------------------------------------------
e. None of the above
12. Area of living ( )

a. Urban
b. Rural
SECTION B: SELF-ADMINISTERED QUESTIONNAIRES ON FACTORS
INFLUENCING SUICIDAL BEHAVIOR.
Instruction: Dear respondent listed below are few statements. Please read each one
carefully and select the best response by using tick ( ) mark.
SR. STATEMENT YES NO

NO.
I SOCIOECONOMIC FACTORS
1. Do you have frequent trouble with your colleagues?
2. Do you have break up with your close friend?
3. Do you ever feel socially isolated?
4. Do you have any cultural or religious belief that suicide is

noble resolution of personal dilemma?
5. Do you have easy access to any lethal means of suicide?
6. Has any of your friend committed suicide?
7. Do you feel influenced by the media about suicidal

behavior?
8. Do you have peer group pressure or self-destructive peer

acceptance?
9. Have you ever suffered from rejection or provocative

behavior from college mates?
10. Does your family have long-term financial crisis?
11. Do you feel like taking revenge on someone?
II PSYCHOLOGICAL FACTORS
12. Have you ever been diagnosed previously with any mental
disorder?
13. Have you ever attempted for suicide?
14. Do you have continuous thought of committing suicide?
15. Do you feel low self-esteem?

16. Do you have feeling of hopelessness and guilt?
17. Are you addicted to alcohol and drugs?
18. Do you have feeling of loneliness?
19. Do you have lack of social support?
III FAMILY FACTORS
20. Is there continuous quarrel between the members of your

family?
21. Are you suffering from physical/ emotional abuse in your

family?
22. Has any of your family members committed suicide?
23. Are you facing poor communication in your family?
24. Do you have frequent quarrel with your parents?
25. Does your parents have very high expectation from you?
26. Does your parents have excessive authority on you?
27. Do you feel neglected by parents?
III PHYSICAL FACTORS
28. Are you suffering from any serious physical illness?
29. Are you handicapped?
30. Are you suffering from chronic pain?
31. Do you have physical fights with your friends?
32. Are you a victim of sexual abuse?
33. Are you satisfied with your present body image?
IV ACADEMIC FACTORS
34. Do you have any fear about your college life?
35. Do you feel you have poor coping abilities during stress?
36. Do you have excessive burden of exams?
37. Are you worried about poor academic performance?
38. Do you have lack of confidence in studies?
39. Are you a case of academic failure?
40. Are you a victim of corporal punishment?
41. Are you a victim of a bullying (being teased repeatedly or

say or do unpleasant thing)?
V MAJOR LIFE EVENTS
42. Have you suffered from parental loss?
43. Are you suffered from loss of any closed one?
44. Do you ever have problem of love failure?
45. Are you involved in any antisocial activities?

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SELF ADMINISTERED QUESTIONNAIRE ON FACTORS

INFLUENCING SUICIDAL BEHAVIOR

SECTION: - A: DEMOGRAPHIC DATA

7. Monthly income of the family (specify……………………..) ( )

9. Source of information about suicidal behavior. ( )

11. Family history of substance abuse. ( )

12. Area of living ( )

carefully and select the best response by using tick ( ) mark.

SR. STATEMENT YES NO

1. Do you have frequent trouble with your colleagues?

2. Do you have break up with your close friend?

3. Do you ever feel socially isolated?

4. Do you have any cultural or religious belief that suicide is

5. Do you have easy access to any lethal means of suicide?

6. Has any of your friend committed suicide?

7. Do you feel influenced by the media about suicidal

8. Do you have peer group pressure or self-destructive peer

9. Have you ever suffered from rejection or provocative

11. Do you feel like taking revenge on someone?

14. Do you have continuous thought of committing suicide?

15. Do you feel low self-esteem?

18. Do you have feeling of loneliness?

19. Do you have lack of social support?

III FAMILY FACTORS

20. Is there continuous quarrel between the members of your

21. Are you suffering from physical/ emotional abuse in your

22. Has any of your family members committed suicide?

23. Are you facing poor communication in your family?

24. Do you have frequent quarrel with your parents?

26. Does your parents have excessive authority on you?

27. Do you feel neglected by parents?

III PHYSICAL FACTORS

28. Are you suffering from any serious physical illness?

29. Are you handicapped?

30. Are you suffering from chronic pain?

31. Do you have physical fights with your friends?

32. Are you a victim of sexual abuse?

33. Are you satisfied with your present body image?

34. Do you have any fear about your college life?

37. Are you worried about poor academic performance?

38. Do you have lack of confidence in studies?

39. Are you a case of academic failure?

40. Are you a victim of corporal punishment?

41. Are you a victim of a bullying (being teased repeatedly or

V MAJOR LIFE EVENTS

42. Have you suffered from parental loss?

43. Are you suffered from loss of any closed one?

44. Do you ever have problem of love failure?

45. Are you involved in any antisocial activities?

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