Black Womxn and Femmes: Mini Quality of Life Survey

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Hey y'all! A super mini version of the longer QLS. The larger survey is intended for black identifying womxn and femmes, but anyone may take this mini version.

So, If you want: pick a quiet spot, tune into yourself, and spend 10-15 minutes in your feelings about your lived experiences.

Responses can be anonymous, and you can skip any question, for any reason.

Feel free to reach out to me, Desiree, at nanacsapothecary@gmail.com.

So much gratitude for you!

Name

Gender (all inclusive)

Race (all inclusive)

Age

Zip code

I believe that the following factors lead to a happy (content or fulfilling) life--check up to SEVEN factors.

adequate housing

food security

financial stability

romantic relationship(s)

free time

spiritual connection

meaningful friendships

service to others

raising/nurturing children (legacy)

education

mobility

physical fitness

ability to travel

exploring creative passions

a career or calling that i love

Other:

On a scale of 0-10, I consider myself a happy, content or satisfied person.

extremely unhappy

extremely happy

Clear selection

I enjoy my life:

not at all

a little

some of the time

most of the time

a lot!

I don't know

Clear selection

I am hopeful about my future.

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

I don't know

Clear selection

I have three or more people that I can go to for help if:

yes

I don't know

not applicable

I'm sick

I'm having trouble paying my bills

I'm having emotional problems

I Need someone to watch my children

I Need someone to help with my elderly parents

I need a hug or physical touch

Clear selection

I Feel comfortable in my body.

yes

sometimes

I don't know

Clear selection

In the past three months, I've:

Not at all

a bit less than usual

no more than usual

a bit more than usual

much more than usual

I don't know

Been able to concentrate on what I'm doing

Lost sleep over worrying

Felt under pressure or strain

Felt I couldn't overcome my difficulties

Been feeling unhappy or depressed

Been losing confidence in myself

Clear selection

If I or someone in my household had to make an unexpected payment of $5,000 today, I would (check all that apply):

Use savings

borrow from relatives

borrow from friends

borrow from a financial institution (bank, credit union)

borrow from informal lenders (check cashing, pay day loans)

sell an asset (car, house, jewelry)

I have no way of getting that amount of money

Other:

My overall quality of life might improve if I: (please share whatever tool, skill, resource or circumstances that YOU feel you would need)

Submit

Clear form

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