Somatic Mindfulness Training for a Healthy Workforce: Student Pilot Sample
Phase: NA
Conditions: Occupational-based Secondary Trauma
Sponsor: Montana State University

Official Title: Somatic Mindfulness Training for a Healthy Workforce: Student Pilot Sample 
NCT Number: NCT04122534 
Document Date: 08/08/2019 
 
COVER PAGE  

Official Title: Somatic Mindfulness Training for a Healthy Workforce: Student Pilot Sample 
NCT Number: NCT04122534 
Document Date: 08/08/2019 
 
STUDY PROTOCAL  
Includes:  
1. Approval for Modification 
2. Modification Request 
3. IRB Study Protocol 
4. Consent  
5. Survey Items  
 
 

 
 
 
 
    Montana State University 
   Institutional Review Board 
Request for Minor Modifications/Amendments 
 
Instructions:  E-mail completed form and all revised and/or new study documents to: 
cherylj@montana.edu 
 
Note:  The project’s IRB-approved Research Protocol must be kept current and followed throughout the 
life of the project with yearly renewals. Protocols approved in the Exempt category do not require yearly 
renewals. All study documents are subject to review. 
 
1. IRB approval number: CE080819 
 
2. Project Title: Somatic Mindfulness Training for a Healthy Workforce 
 
3. Principal Investigator: Colter Ellis and Kelly E. Knight  
Contact information (phone/e-mail): kelly.knight3@montana.edu; colter.ellis@montana.edu  
Address (where you want approval letter sent): Department of Sociology and 
Anthropology, Wilson Hall 2-118 
  
4. Requesting modification/amendment to: 
□ Research protocol  
□ Consent form  
□ Recruitment materials  
□ Survey instrument, interview questions X 
□ Research personnel  
□ Other, please explain: 
 
 
 
5. Describe the modification being requested: 
Note: with each requested change, provide a detailed description of where within 
the study documents (e.g. Research protocol, survey instrument, etc.) the changes are 
reflected (e.g., section, question #, etc.). 
 
We want to add the “Self-Compassion Scale” to the survey. This is a commonly used 26 
item measure. Participants respond on a five point scale. The questions are included with 
this document.  
 
6. Have these requested changes been initiated? 
□  No X  
 
7. How will the proposed modification(s) affect study participants? N/A 
Note: Federal regulations require IRB approval prior to changing a research procedure or deviating 
from IRB approved documents unless it is in the best interest of or for the safety of study participants. 
 
 

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I try to be understanding and patient towards those aspects of my personality I
don't like.
I'm kind to myself when I'm experiencing suffering.
When I'm going through a very hard time, I give myself the caring and tenderness I
need.
I'm tolerant of my own flaws and inadequacies.

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I try to be loving towards myself when I'm feeling emotional pain.
When I see aspects of myself that I don't like, I get down on myself.
When times are really difficult, I tend to be tough on myself.

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I can be a bit cold-hearted towards myself when I'm experiencing suffering.
I'm disapproving and judgmental about my own flaws and inadequacies.
I'm intolerant and impatient towards those aspects of my personality I don't like.
When I'm feeling inadequate in some way, I try to remind myself that feelings of
inadequacy are shared by most people.

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I try to see my failings as part of the human condition.
When I'm down and out, I remind myself that there are lots of other people in the
world feeling like I am.
When things are going badly for me, I see the difficulties as part of life that
everyone goes through.

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When I fail at something that's important to me I tend to feel alone in my failure.
When I think about my inadequacies it tends to make me feel more separate and
cut off from the rest of the world.
When I'm feeling down I tend to feel like most other people are probably happier
than I am.
When I'm really struggling I tend to feel like other people must be having an easier
time of it.

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When something upsets me I try to keep my emotions in balance.
When I'm feeling down I try to approach my feelings with curiosity and openness. 
When something painful happens I try to take a balanced view of the situation.
When I fail at something important to me I try to keep things in perspective.

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When something upsets me I get carried away with my feelings.
When I'm feeling down I tend to obsess and fixate on everything that's wrong.
When something painful happens I tend to blow the incident out of proportion.

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When I fail at something important to me I become consumed by feelings of
inadequacy.

 
1
Full Committee Review   
Expedited Review   
 
 
MONTANA STATE UNIVERSITY 
 
Institutional Review Board Application for Review 
 
(revised 06/01/15) 
 
*********************************************************************************************************************** 
THIS AREA IS FOR INSTITUTIONAL REVIEW BOARD USE ONLY. DO NOT WRITE IN THIS AREA 
          Application Number:   
 
 
 
Approval Date: 
          Disapproved:   
 
 
 
 
IRB Chair's Signature: 
********************************************************************************************************************** 
 
Date:  
 
I. Investigators and Associates (list all investigators involved; application will be filed under name of first 
    person listed) 
  
    NAME: Dr. Colter Ellis 
 
 
 
TITLE:  Assistant Professor 
    DEPT: Sociology and Anthropology   
 
PHONE #: (406) 994-4219 
    COMPLETE ADDRESS: P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: colter.ellis@montana.edu 
    DATE TRAINING COMPLETED: ______03.01.2017__________  [Required training: CITI Training; see website for link] 
 
SIGNATURE (PI or ADVISOR): _______________________________ 
 
    NAME: Dr. Kelly E. Knight 
 
 
 
TITLE:  Assistant Professor  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: (406) 994-7224 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: kelly.knight3@montana.edu 
    DATE TRAINING COMPLETED: _____03.01.2017___________  [Required training: CITI Training; see website for link] 
 
    NAME: Amy Talcott    
 
 
 
TITLE:  Research Associate III  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: amyktalcott@gmail.com 
    DATE TRAINING COMPLETED: _______06.28.2018_________  [Required training: CITI Training; see website for link] 
 
    NAME: Leah Helfrich  
 
 
 
TITLE:  Undergraduate Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: leahlouisehelfrich@gmail.com>  
    DATE TRAINING COMPLETED: _______05.18.2017_________  [Required training: CITI Training; see website for link] 
     
    NAME: Stephanie Zappone 
 
 
 
TITLE:  Undergraduate Research Assistant 
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: stephanie.zappone@student.montana.edu 
    DATE TRAINING COMPLETED: _______12.22.2018_________  [Required training: CITI Training; see website for link] 
 
    NAME: Lauren Samuel 
 
 
 
TITLE:  Undergraduate Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: laurenlizsamuel@gmail.com 
    DATE TRAINING COMPLETED: _______1.19.2019_________  [Required training: CITI Training; see website for link] 
    
    NAME: Emma Sundeen 
 
 
 
TITLE:  Undergraduate Research Assistant 
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: emma.sundeen@gmail.com 
    DATE TRAINING COMPLETED: _______2.7.2019_________  [Required training: CITI Training; see website for link] 
 
 

 
2
    NAME: Madison Loft  
 
 
 
TITLE:  Undergraduate Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: themadisonloft@gmail.com 
    DATE TRAINING COMPLETED: _______1.8.2018_________  [Required training: CITI Training; see website for link] 
    
    NAME: Tristian Miller  
 
 
 
TITLE:  Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: tmiller1296@gmail.com 
    DATE TRAINING COMPLETED: _______6.12.2019_________  [Required training: CITI Training; see website for link] 
    
    NAME: Joshua Neu  
 
 
TITLE:  Undergraduate Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: joshuaneu2010@gmail.com 
    DATE TRAINING COMPLETED: _______3.13.2019_________  [Required training: CITI Training; see website for link] 
    
    NAME: Brenna Scott  
 
 
TITLE:  Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: bren0316@gmail.com 
    DATE TRAINING COMPLETED: _______9.09.2018_________  [Required training: CITI Training; see website for link] 
 
NAME: Andrew Z. Hassanali  
 
TITLE:  Research Assistant  
    DEPT: Sociology and Anthropology 
 
 
PHONE #: N/A 
    COMPLETE ADDRESS:  P.O. Box 172380, Bozeman, MT 59717-2380 
    E-MAIL ADDRESS: andrew.hassanali@icloud.com 
    DATE TRAINING COMPLETED: _______6.20.2019_________  [Required training: CITI Training; see website for link] 
 
    (repeat for additional investigators if needed; or delete extra if not necessary) 
 
Do you as PI, any family member or any of the involved researchers or their family members have consulting agreements, management 
responsibilities or substantial equity (greater than $10,000 in value or greater than 5% total equity) in the sponsor, subcontractor or in 
the technology, or serve on the Board of the Sponsor? _____ YES ___X_ NO  
 
If you answered Yes, you will need to contact Kellie Peterson, Assistant Legal Counsel-JD at 406-994-3480. 
 
II. 
Title of Proposal:  Somatic Mindfulness Training for a Healthy Workforce. 
 
III. Beginning Date for Use of Human Subjects: August 15, 2019 
 
IV. Type of Grant and/or Project (if applicable)  
 
Research Grant: X 
 
Contract: 
  
Training Grant: 
  
Classroom Experiments/Projects: 
Thesis Project: 
 
Other (Specify):  
 
V. 
Name of Funding Agency to which Proposal is Being Submitted (if applicable):  
 
We have submitted a proposal to MSU’s Center for American Indian and Rural Health Equity (CAIRHE) which 
is funded by the National Institutes of Health. 
 
 
 
 
 
 
 
 

 
3
VI. Signatures  
 
 
Submitted by Investigator  
 
 
Typed Name: Colter Ellis, Joint-PI 
 
 
Signature:  
 
  
 
 
 
Date: 7/24/19 
 
 
 
Faculty sponsor (for student)  
 
 
Typed Name: Kelly Knight, Joint-PI 
 
 
Signature:  
 
 
 
 
 
Date: 7/24/19 
 
VII. Summary of Activity. Provide answers to each section and add space as needed. Do not refer to an 
accompanying grant or contract proposal.  
 
A. RATIONALE AND PURPOSE OF RESEARCH.  (What question is being asked?)  
 
Victims of sexual assault, intimate partner violence, child neglect, and other forms of abuse depend on service 
providers to help them find safety, access resources, and seek justice. This work is critically important to 
survivors but often has negative consequences for individuals who assist them. As a result, a burgeoning body 
of literature has tried to document the emotional strain of this work (see Elwood, Mott, Lohr, & Galovski, 2011; 
Molnar et al., 2017; Sabin-Farrell & Turpin, 2003, for reviews). We define “secondary trauma” as the result of 
repeated empathetic engagement with traumatized populations. When workers burnout, it increases operating 
costs for organizations and decreases the quality of services provided (Powell and York 1992; Ullman and 
Townsend 2007). The scholarship, however, has yet to fully theorize the occupational hazards of victim service 
provision and there are few theoretically and empirically driven solutions (Bercier & Maynard, 2015). This 
research seeks to develop, pilot, and evaluate an intervention response that will help mitigate the 
negative impacts of secondary trauma.   
 
 
B. 
RESEARCH PROCEDURES INVOLVED. Provide a short description of sequence and methods of 
procedures that will be performed with human subjects. Include details of painful or uncomfortable procedures, 
frequency of procedures, time involved, names of psychological tests, questionnaires, restrictions on usual life 
patterns, and follow up procedures.  If you are planning on posting flyers, posters, etc. anywhere on Campus, 
you must check with the building managers and/or departments located in MSU buildings and obtain their 
approval prior to the posting. 
 
This proposed research will develop and pilot a somatically-oriented mindfulness curriculum designed to 
reduce the symptoms of occupational-based secondary trauma (ST) among victim service providers working in 
Montana. The content of the curriculum will be based on our previously published text Secondary Trauma in 
the Workplace: Tools for Awareness, Self-Care, and Organizational Response in Montana we wrote with a 
group of seven local victim service providers. The curriculum for this intervention, however, will be expanded to 
more fully include mindfulness meditation and somatic-based trauma resolution techniques.  
 
The intervention curriculum will be developed and tested with three cohorts.  
 
For the first cohort, Drs. Knight and Ellis will pilot the curriculum in an undergraduate course in the Fall of 
2019 (n= approximately 15 students). Dr. Knight will be the instructor of record. The content and effectiveness 
of the course will be evaluated using a survey. The complete survey and consent form are included in this 
application. There will be three waves of survey data collected. For the first two waves, students will be asked 
to complete the survey during the semester (wave one, during the first few weeks of class and wave two during 
the final few weeks of class). Students can choose not to complete the survey with no penalty. If at least 85% 

 
4
of the students in each class participate in data collection waves one and two, all students will be eligible for 
some form of extra credit and/or participation in some kind of celebration (such as pizza on the last day of 
class). All students will be eligible, even if they themselves did not participate. A third wave may also be 
collected approximately one month after the course. Participation for this final wave of data collection will be 
incentivized by a $20 e-gift card. Students’ participation will be strictly optional. 
 
The second cohort will occur in the Spring of 2020. Drs. Knight and Ellis will, again, pilot the intervention in an 
undergraduate course (n=35). Dr. Ellis will be the instructor of record.  Again, the content and effectiveness of 
the course will be evaluated using a survey. Just as before, there will be three waves of survey data collected. 
For the first two waves, students will be asked to complete the survey during the semester (wave one, during 
the first few weeks of class and wave two during the final few weeks of class). Students can choose not to 
complete the survey with no penalty. If at least 85% of the students in each class participate in data collection 
waves one and two, all students will be eligible for some form of extra credit and/or participation in some kind 
of celebration (such as pizza on the last day of class). All students will be eligible, even if they themselves did 
not participate. A third wave may also be collected approximately one month after the course. Participation for 
this final wave of data collection will be incentivized by a $20 e-gift card. Students’ participation will be strictly 
optional. 
 
After preliminary analysis of the first two student-cohorts is complete, the content will be modified as necessary 
and the curriculum will be piloted with a third cohort. This cohort will comprise of a small sample of local 
victim service providers. By victim service providers we mean any profession or volunteer position that involves 
interacting with victims of crime. These positions include, but are not limited to, law enforcement, attorneys, 
child protective services, healthcare providers, victim advocates, and religious clergy. Our goal is to have a 
small sample of 5-20 victim service providers willing to meet once a week for 15 weeks. During these 
meetings, we will implement our curriculum. The intervention will be evaluated by asking participants to 
complete the survey three times (before the training begins, at the end of the training, and then a third time one 
to three months post-training). Participation in this program will be incentivized with three $20 e-gift cards, sent 
after each of the three surveys.  
 
All the measures included in the survey are well established in the literature. Table 1 provides a list of 
measures included.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
5
Table 1: Names of Survey Questionnaires  
Measurement Name 
Abbreviation  
Number of Items  
Basic Demographics, VSP* 
BD 
11 
Basic Demographics, Student* 
BDS 
12 
Work Demographics*  
WD 
7 
Maslach Burnout Inventory – General Version* 
MBI-G 
16 
Maslach Burnout Inventory – General Student Version* 
MBI-GS 
17 
Maslach Burnout Inventory – Student Version* 
MBI-S 
16 
Secondary Traumatic Stress Scale 
STSS 
18 
The PTSD Checklist for DSM-5 
PCL-5 
20 
Body Mass Index 
BMI 
2 
Health Related Quality of Life  
HRQoL 
4 
Autoimmune Diagnosis  
AD 
1 
Patient Health Questionnaire – Somatic Symptom Severity  
PHQ-15 
15 
AUDIT Alcohol Questionnaire 
AUDIT 
10 
Tobacco, Alcohol, Prescription and Other Substance Use Tool 
TAPS 
4 
Jenkins Sleep Scale 
JSS 
4 
Generalized Anxiety Disorder 
GAD-7 
7 
Patient Health Questionnaire – Depression 
PHQ-8 
8 
Mental Health Specialist 
MHS 
1 
Interpersonal Reactivity Index 
IRI 
28 
BRFSS Adverse Childhood Experience (ACE) Module 
BRFSS ACE 
11 
Brief Resilience Scale 
BRS 
6 
Experiences in Close Relationships - Relationship Structures 
ECR-RS 
9 
Multidimensional Assessment of Interoceptive Awareness  
MAIA 
37 
Five Facets of Mindfulness Questionnaire 
FFMQ 
20 
Trauma Exposure and Training 
TE 
4 
Feedback  
FE 
2 
 Note: *All items may not actually appear in each survey.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
6
C. DECEPTION - If any deception (withholding of complete information) is required for the validity of this 
activity, explain why this is necessary and attach debriefing statement.  
 
No deceptive practices will be used.  
 
 
D. SUBJECTS    
 
 
1. Approximate number and ages 
 
 
 
How Many Subjects: 65 
 
 
 
Age Range of Subjects: 18 years and older 
 
 
 
How Many Normal/Control: n/a   
 
 
 
Age Range of Normal/Control: 18 years and older 
 
 
 
2. Criteria for selection:  
 
Study participants must be either students at MSU or working or volunteering in a victim service profession or 
organization. All participants must be 18 years or older. 
 
 
 
3. Criteria for exclusion:  
 
For the first two cohorts, those who are not undergraduate students at Montana State University will be 
excluded from data collection. For the third cohort, study participants not working or volunteering in a victim 
service profession or organization will be excluded from data collection. Anyone who is not 18 years or older 
will be excluded from all parts of the study.  
 
 
 
4. Source of Subjects (including patients):  
 
For cohorts one and two, study participants will be recruited in the classroom. Both Drs. Ellis and Knight are 
popular teachers who attract students interested in issues of trauma and mindfulness. For cohort 3, community 
contacts, victim service organizations, and community advisory board members will help with recruitment.  
 
 
 
5. Who will approach subjects and how?  Explain steps taken to avoid coercion.  
 
Students who choose to enroll in the class will be required to read and work with the content of the course, 
however, they will not be required to participate in the evaluation survey. We will emphasize in the syllabus and 
verbally in class, that participation, or nonparticipation, in the survey is absolutely optional and will not count 
towards their grade in anyway. Victim service providers will be free not to participate and can end participation 
at any time.  
 
6. Will subjects receive payments, service without charge, or extra course credit?     X Yes   or   No  
(If yes, what amount and how? Are there other ways to receive similar benefits?)  
 
For the first two cohorts, if at least 85% of the students in each class participate in data collection waves one 
and two, all students will be eligible for some form of extra credit and/or participation in some kind of 
celebration (such as pizza on the last day of class). All students will be eligible, even if they themselves did not 
participate. Students who participate in data collection wave three (approximately1 month after class has 
ended) will receive a $20 e-gift card. Victim service providers who participate in cohort three will be eligible for 
MSU continuing education credits and $20 e-gift cards for each survey.  
 
 
 
 
7. Location(s) where procedures will be carried out.  
 
Cohorts one and two will be carried out in a classroom on campus. Cohort three will be held at a time and 
place convenient for all the participating victim service providers.  
 
 
 
 

 
7
 
E. RISKS AND BENEFITS (ADVERSE EFFECTS) 
 
 
 
1. Describe nature and amount of risk and/or adverse effects (including side effects), substantial 
stress, discomfort, or invasion of privacy involved.  
 
Some of the questions on the survey will ask about personal and potentially emotional topics. While these 
questions may cause some discomfort, a list of resources will be provided should participants feel they need to 
seek help.  
 
While it is not the focus of the study, the survey will ask about alcohol and other drug use. We ask these 
questions because respondents may be using substances to cope with secondary trauma. To protect 
participants, identifying information will be separated from their responses and all information will be 
deidentified when presented or published.  
 
 
 
2. Will this study preclude standard procedures (e.g., medical or psychological care, school 
attendance, etc.)? If yes, explain.  
 
No. 
 
 
 
3. Describe the expected benefits for individual subjects and/or society.  
 
Survey data will document the prevalence of ST and its correlates. If successful, the intervention will be a 
useful tool for improving the work lives and psychological health of victim service providers. 
 
 
F. ADVERSE EFFECTS 
 
1. How will possible adverse effects be handled? 
 
No adverse effects are expected. If participants become upset during the survey, a list of resources is provided 
in the consent form.  
 
 
 
 
By investigator(s):   
 
NA   
 
 
 
 
Referred by investigator(s) to appropriate care: 
 
N/A 
 
 
 
Other (explain):  
 
N/A 
 
 
 
2. Are facilities/equipment adequate to handle possible adverse effects?   X Yes   or   No 
 
 
 
(If no, explain.)  
 
2. Describe arrangements for financial responsibility for any possible adverse effects.  
 
None. In our view, there is no reasonable concern that a participant would experience any adverse effects.  
 
 
 
 
MSU compensation (explain): NA 
 
 
 
Sponsoring agency insurance: NA 
 
 
 
Subject is responsible: NA 
 
 
 
Other (explain): NA  
 
 
G. CONFIDENTIALITY OF RESEARCH DATA 
 
 
 
1. Will data be coded?    X Yes   or   No  

 
8
 
 
 
2. Will master code be kept separate from data?     X Yes   or   No  
  
 
 
3. Will any other agency have access to identifiable data?    Yes   or   X No 
 
 
 
(If yes, explain.)  
 
Workplaces will not have access to providers’ data. 
 
 
 
4. How will documents, data be stored and protected?  
 
 
 
Locked file: 
 
Yes, all physical files will be locked in a cabinet and in a locked office on campus.  
 
 
 
 
Computer with restricted password:  
 
Yes, all de-identified digital files will be kept on password-protected computers or stored on a secured server.  
 
 
 
 
Other (explain): N/A 
 
 
VIII. Checklist to be completed by Investigator(s)  
 
 
A. Will any group, agency, or organization be involved?      Yes   or   X No 
 
 
(If yes, please confirm that appropriate permissions have been obtained.) 
 
 
 
B. Will materials with potential radiation risk be used (e.g. x-rays, radioisotopes)?    Yes   or   X No  
 
 
 
1. Status of annual review by MSU Radiation Sources Committee (RSC).     Pending   or   Approved 
 
 
 
(If approved, attach one copy of approval notice.)  
 
 
 
2. Title of application submitted to MSU RSC (if different).  
 
 
C. Will human blood be utilized in your proposal?      Yes   or   X No  
 
 
(If yes, please answer the following) 
 
1. Will blood be drawn?     Yes   or   X No 
 
(If yes, who will draw the blood and how is the individual qualified to draw blood?  
 
What procedure will be utilized?) 
 
 
 
2. Will the blood be tested for HIV?    Yes   or   X No 
 
 
 
3. What disposition will be made of unused blood?  
 
 
 
4. Has the MSU Occupational Health Officer been contacted?    Yes   or   X No 
 
 
D. Will non-investigational drugs or other substances be used for purposes of the research? Yes or X No 
 
 
 
 
 
Name: 
 
 
Dose: 
 
 
Source: 
 
 
How Administered: 
 
 
Side effects:  
 
 
 
 
 
 

 
9
 
E. Will any investigational new drug or other investigational substance be used?    Yes   or   X No  
[If yes, provide information requested below and one copy of: 1) available toxicity data; 2) reports of animal studies; 3) 
description of studies done in humans; 4) concise review of the literature prepared by the investigator(s); and 5) the drug 
protocol.] 
 
 
 
Name: 
 
 
Dose: 
 
 
Source: 
 
 
How Administered: 
 
 
IND Number: 
 
 
Phase of Testing: 
 
 
F. Will an investigational device be used?   Yes   or   X No 
 
 
(If yes, provide name, source description of purpose, how used, and status with the U.S. Food and Drug 
Administration FDA). Include a statement as to whether or not device poses a significant risk. Attach any 
relevant material.)  
 
 
G. Will academic records be used?   Yes   or   X No  
 
 
H. Will this research involve the use of: 
 
 
Medical, psychiatric and/or psychological records   Yes   or  X No 
 
 
Health insurance records      Yes   or   X No 
 
 
Any other records containing information regarding personal health and illness    Yes   or   X No 
 
 
 
If you answered "Yes" to any of the items under "H.", you must complete the HIPAA worksheet.     
 
 
I. Will audio-visual or tape recordings or photographs be made?    Yes   or   X No  
 
 
J. Will written consent form(s) be used?  (X Yes or No. If no, explain.)   (Please use accepted format 
from our website. Be sure to indicate that participation is voluntary. Provide a stand-alone copy; do 
 
 
List of Attachments  
 
There are two versions of our evaluation survey, one for MSU Students and another of victim service 
providers. Full copies of both of these surveys are included as electronic attachments in this application.  
 
02 
MBTHW Student Survey Final 07.24.2019  
03 
MBTHW VSP Survey Final 07.24.2019 

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Consent, Montana VSPs
Hello!
 
This survey has been developed by Associate Professors from Montana State University to
study secondary trauma. 
The purpose of this study is to better understand the personal histories and experiences of
victim service providers, or those considering becoming victim service providers, in Montana. 
Any insights you could offer are greatly appreciated! 
Before we begin, however, we need to review this consent form. This insures that your rights
are protected as a participant this study. 
     
Kelly Knight, PhD, and Colter Ellis, PhD  
Principal Investigators 
 
Questions? We have answers:
 
 
Why am I being asked to participate?
You are being asked to participate in a research study because of your involvement in, or
knowledge of, services in your area.
 
 
 
Why is this research being done?
This survey is being conducted to evaluate a new educational program. The program is
intended to teach people strategies for managing the negative consequences of
secondary trauma. Your participation will help us better understand how the personal histories
and experiences of service providers impact their work and mental and physical health.
 
 
How long will it take me to participate?
This survey should take approximately 30-45 minutes to complete.
 
 
 
Will I be compensated for participation?
You will receive a $20 eGift Card when you have completed the surveys.
 
Please allow one week for us to email you the eGift Card. Thanks for your patience with us!
 
 
 
What will I be asked to do?
Your participation in this research is voluntary and completely your choice. If you agree, you

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will be asked to answer a number of questions about your personal history, your work, your
physical and psychological health, and your resilience. You will also be asked to complete
some basic demographic questions. You can choose to not answer any questions you do not
want to answer. Also, you can stop at any time with no consequences.
 
 
 
Are there any benefits to me if I participate in this study?
This study is of no direct benefit to you. However, the information gained will inform the
development of a data-driven intervention to lessen the impacts of secondary trauma on
service providers.
 
 
 
Will my information be kept private?
Everything you tell us will be kept confidential. Your answers will be separated  from your
name and contact information (which we need to give you your eGift Card). 
All data collected will be secured on a password-protected and firewalled computer in a locked
office on Montana State University’s campus or stored on a secure server. No one but the
official research staff will have access to the information. Your results will be grouped with
other participants’ data when results of this study are published. Your identity will remain
anonymous.
An exception to confidentiality is the indication of imminent harm to yourself or others.  
 
Who should I contact if I have questions?
You can contact the principal investigators about the study: Kelly E. Knight, PhD, (406) 994-
7224, kelly.knight3@montana.edu, or Colter Ellis, PhD, (406) 994-4219,
colter.ellis@montana.edu. They can also be reached by mail at: Montana State University,
Department of Sociology and Anthropology, PO Box 172380, Bozeman, MT, 59817.
 
In addition, you can contact MSU’s institutional review board chairperson: Mark Quinn, PhD,
(406) 994-4747, mquinn@montana.edu. He can also be reached by mail at Montana State
University, IRB, PO BOX 173610, Bozeman, MT, 59817.
 
 
 
What happens if I change my mind?
Participation is strictly voluntary and you can stop at any time. Participation or non-
participation will not affect your current or future relationship with Montana State University.
 
 
 
Are there any risks to me if I participate in this study?
We do not foresee any significant physical or psychological risks as a result of your
participation. However, some of the questions are personal and may provoke an emotional
response. Below is a list of resources should you be worried or need support after the survey.
Resource List: 
 
1.    Montana Suicide Prevention Lifeline: (800) 273-8255

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Agree
Female
Male
Other
 
2.    MSU Voice Center: (406) 994-7069
 
3.    Counseling and Psychological Services, MSU: (406) 994-4531
 
4.    HELP Center Crisis and Referral Line: (406) 586-3333 or just dial 2-1-1
 
5.    Haven Domestic Violence Program: (406) 586-4111
 
6.    Alcohol and Drug Services of Gallatin County: (406) 586-5493
 
7.    Bozeman Health Deaconess Hospital: (406) 414-5000
 
8.    Bridger Care, Reproductive & Sexual Healthcare & Education: (406) 587-0681
 
9.    Child and Family Services: (866) 820-5437
 
10.  Gallatin Valley Mental Health Center: (406) 556-6500 
ELECTRONIC CONSENT:  
 
You voluntarily agree to participate.
You are 18 years of age or older. 
 
 
Demographics
What is your age?
What is your sex/gender?

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Did not complete high school
High school or equivalent
Some college or post high school training
Associate's or 2-year degree
Bachelor's degree
Graduate/professional degree
American Indian
Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian, Other Pacific Islander
White
Other
Married
Living with partner (but not married)
Divorced/separated
Single
Widowed
Other
What is the highest level of education that you have completed?
What race do you consider yourself? Check all that apply. 
What is your current marital status?
Which category best describes your current income from all sources before taxes?

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Own
Rent
No
ADHD/ADD
Learning disability
Psychological disability
Traumatic brain injury
Other
No
Yes
Which category best describes your total 2018 household income from all sources before
taxes?
Do you own or rent your home?
How long have you lived in this area?
Do you have a documented disability? Check all that apply. 
Do you consider yourself to be a veteran? 

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Community and social services occupations (e.g., social workers, counselors, therapists, clergy)
Education, training, and library occupations (e.g., teachers, librarians)
Healthcare practitioners and technical occupations (e.g., physicians, nurses, paramedics)
Healthcare support occupations (e.g., home health aides, massage therapists)
Legal occupations (e.g., lawyers, judges, paralegals)
Protective service occupations (e.g., police officers, fire fighters, correctional officers)
Other
Architecture and Engineering Occupations
Arts, Design, Entertainment, Sports, and Media Occupations
Building and Grounds Cleaning and Maintenance Occupations
Business and Financial Operations Occupations
Computer and Mathematical Occupations
Construction and Extraction Occupations
Farming, Fishing, and Forestry Occupations
Food Preparation and Serving Related Occupations
Installation, Maintenance, and Repair Occupations
Life, Physical, and Social Science Occupations
Management Occupations
Office and Administrative Support Occupations
Personal Care and Service Occupations
Production Occupations
Sales and Related Occupations
Transportation and Material Moving Occupations
Other
Work Demographics, VSPs
Using these U.S. Department of Labor categories, which best describes your occupation?
Please select other occupational category.
How long have you worked in your general profession? 

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Front-line staff
Supervisor
Management (First-level)
Management (Intermediate)
Management (Senior)
Other
Overall, how long have you worked at your current organization? 
What is your current job title?
How long have you worked in your present position?
Is your position considered: (Please select one)
MBI (Burnout)
On this page are statements of job-related feelings. Please read each statement carefully and
decide if you ever feel this way about your job.

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Never
A few
times a
year or
less
Once a
month or
less
A few times
a month
Once a
week
A few
times a
week
Every day
I feel emotionally drained from my work.
  
I feel used up at the end of the workday.
  
I feel tired when I get up in the morning and have to
face another day on the job.
  
Working all day is really a strain for me.
  
I can effectively solve the problems that arise in my
work.
  
I feel burned out from my work.
  
I feel I am making an effective contribution to what
this organization does.
  
I have become less interested in my work since I
started this job.
  
Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all
media. Published by Mind Garden, Inc., www.mindgarden.com
On this page are statements of job-related feelings. Please read each statement carefully and
decide if you ever feel this way about your job. 
 
  
Never
A few times a
year or less
Once a
month or less
A few times a
month
Once a week
A few times a
week
Every day
I have become less enthusiastic
about my work.
  
In my opinion, I am good at my
job.
  
I feel exhilarated when I
accomplish something at work.
  
I have accomplished many
worthwhile things in this job.
  
I just want to do my job and not be
bothered.
  
I have become more cynical about
whether my work contributes
anything.
  
I doubt the significance of my
work.
  
At my work, I feel confident that I
am effective at getting things
done.
  

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Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all
media. Published by Mind Garden, Inc., www.mindgarden.com
STSS (Secondary Traumatic Stress Scale)
The following is a list of statements made by persons who have been impacted by their work
with traumatized clients (or other potentially traumatized populations, e.g., patients, students,
customers, or anyone to whom you provide services). 
 
In the past seven days, how frequently was the statement true for you:
 
  
Never
Rarely
Occasionally
Often
Very often
I felt emotionally numb.
  
My heart started pounding when I thought about my work with clients.
  
It seemed as if I was reliving the trauma(s) experienced by my client(s).
  
I had trouble sleeping.
  
I felt discouraged about the future.
  
Reminders of my work with clients upset me.
  
I had little interest in being around others.
  
I felt jumpy.
  
I was less active than usual.
  
I thought about my work with clients when I didn’t intend to.
  
I had trouble concentrating.
  
I avoided people, places, or things that reminded me of my work with clients.
  
I had disturbing dreams about my work with clients.
  
I wanted to avoid working with some clients.
  
I was easily annoyed.
  
I expected something bad to happen.
  
I noticed gaps in my memory about client sessions.
  
Please select 'Very often' for this response.
  
PCL-5 (PTSD)
Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then indicate how much you have been
bothered by that problem in the past month.
 

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In the past month, how much were you bothered by:
 
  Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing, and unwanted memories of the stressful
experience?
  
Repeated, disturbing dreams of the stressful experience?
  
Suddenly feeling or acting as if the stressful experience were actually
happening again (as if you were actually back there reliving it)?
  
Feeling very upset when something reminded you of the stressful
experience?
  
Having strong physical reactions when something reminded you of the
stressful experience (for example, heart pounding, trouble breathing,
sweating)?
  
Avoiding memories, thoughts, or feelings related to the stressful
experience?
  
Avoiding external reminders of the stressful experience (for example,
people, places, conversations, activities, objects, or situations)?
  
Trouble remembering important parts of the stressful experience?
  
Having strong negative beliefs about yourself, other people, or the world
(for example, having thoughts such as: I am bad, there is something
seriously wrong with me, no one can be trusted, the world is completely
dangerous)?
  
Blaming yourself or someone else for the stressful experience or what
happened after it?
  
Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then indicate how much you have been
bothered by that problem in the past month.
 
In the past month, how much were you bothered by:
 
  Not at all
A little bit
Moderately
Quite a bit
Extremely
Having strong negative feelings such as fear, horror, anger, guilt, or
shame?
  
Loss of interest in activities that you used to enjoy?
  
Feeling distant or cut off from other people?
  
Trouble experiencing positive feelings (for example, being unable to feel
happiness or have loving feelings for people close to you)?
  
Irritable behavior, angry outbursts, or acting aggressively?
  
Taking too many risks or doing things that could cause you harm?
  
Being “superalert” or watchful or on guard?
  
Feeling jumpy or easily startled?
  
Having difficulty concentrating?
  
Trouble falling or staying asleep?
  
BMI (Body Mass Index)

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Excellent
Very good
Good
Fair
Poor
Don't know/not sure
What is your height (in feet and inches)?
What is your weight (in pounds)? (If pregnant, please use pre-pregnancy weight.)
HRQoL (Health Related Quality of Life)
Would you say that in general your health is —
Now thinking about your physical health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health not good?
Now thinking about your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not good?

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No
Yes, I have been diagnosed with:
During the past 30 days, for about how many days did poor physical or mental health keep
you from doing your usual activities, such as self care, work, or recreation?
AD (Autoimmune Disease)
Has a doctor, nurse, or other health professional ever diagnosed you with an autoimmune
disease?        
(e.g., rheumatoid arthritis, hashimoto's disease, Sjogren's syndrome, multiple sclerosis, type 1
diabetes, systemic lupus erythematosus)
PHQ-15 (Somatic Symptoms Survey)
During the past four weeks…
 
How much have you been bothered by any of the following problems?
 
  
Not bothered at all
Bothered a little
Bothered a lot
Stomach pain
  
Back pain
  
Pain in your arms, legs, or joints (knees, hips, etc.)
  
Menstrual cramps or other problems with your periods [Women only]
  
Headaches
  
Chest pain
  
Dizziness
  
Fainting spells
  
Feeling your heart pound or race
  
Shortness of breath
  
Pain or problems during sexual intercourse
  
Constipation, loose bowels, or diarrhea
  
Nausea, gas, or indigestion
  
Feeling tired or having low energy
  

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Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
Trouble sleeping
  
AUDIT (Alcohol)
The following are questions about your alcohol use in the past 12 months.
 
 
  How often do you have one drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?
  
 
  
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often do you have four or more drinks on one occasion?
  
How often during the last year have you found that you are not able to stop
drinking once you have started?
  
How often during the last year have you failed to do what was normally
expected from you because of drinking?
  
How often during the last year have you needed a first drink in the morning to
get yourself going after a heavy drinking session?
  
How often during the last year have you had a feeling of guilt or remorse after
drinking?
  
How often during the last year have you been unable to remember what
happened the night before because you had been drinking?
  

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 In the past 12 months...
 
  
No
Yes, but not in the
last year
Yes, during the last
year
Have you or someone else been injured as a result of your drinking?
  
Has a relative or friend or doctor or health worker been concerned about your
drinking or suggested you cut down?
  
TAPS (Substance Use)
The following are questions about other substance use.
 
 
In the past 12 months, how often have you...
 
  
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Used any tobacco product (for example, cigarettes, ecigarettes, cigars, pipes, or
smokeless tobacco)?
  
Used marijuana?
  
Used any prescription medications just for the feeling, more than prescribed or that
were not prescribed for you?
  
Used any other drugs including cocaine or crack, heroin, meth, hallucinogens,
ecstasy/MDMA?
  
JSS (Sleep Disturbance)
In the past month, did you…
 
  Not at all
1-3 days
4-7 days
8-14 days
15-21 days 22-31 days
Have trouble falling asleep?
  
Wake up several times per night?
  
Have trouble staying asleep (including waking far too early)?
  
Wake up after your usual amount of sleep feeling tired and worn
out?
  
GAD-7 (Anxiety)

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Over the last two weeks, how often have you been bothered by the following problems?
 
Indicate how often you have experienced…
 
  
Not at all
Several days
More than half the
days
Nearly every day
Feeling nervous, anxious or on edge.
  
Not being able to stop or control worrying.
  
Worrying too much about different things.
  
Trouble relaxing.
  
Being so restless that it is hard to sit still.
  
Becoming easily annoyed or irritable.
  
Feeling afraid as if something awful might happen.
  
PHQ-8 (Depression)
Over the last two weeks, how often have you been bothered by any of the following
problems?
 
Indicate how often any of the following problems have bothered you.
 
  
Not at all
Several days
More than half
the days
Nearly every
day
Little interest or pleasure doing things.
  
Feeling down, depressed, or hopeless.
  
Trouble falling or staying asleep, or sleeping too much.
  
Feeling tired or having little energy.
  
Poor appetite or overeating.
  
Feeling bad about yourself - or that you are a failure or have let yourself or
your family down.
  
Trouble concentrating on things, such as reading the newspaper or
watching television.
  
Moving or speaking so slowly that other people could have noticed. Or the
opposite - being so fidgety or restless that you have been moving around a
lot more than usual.
  
MHS (Mental Health Specialist)
In the past month, have you talked to a mental health specialist, such as a psychiatrist,
psychologist, or specially trained social worker, about emotional problems, your nerves, or the

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No
Yes
way you were feeling or behaving?  
IRI (Empathy)
For each item, indicate how well it describes you. 
 
  
Does not
describe
me well
2
3
4
Does
describe
me well
I daydream and fantasize, with some regularity, about things that might happen to me.
  
I often have tender, concerned feelings for people less fortunate than me.
  
I sometimes find it difficult to see things from the "other person's" point of view.
  
Sometimes I don't feel very sorry for other people when they are having problems.
  
I really get involved with the feelings of the characters in a novel.
  
In emergency situations, I feel apprehensive and ill-at-ease.
  
I am usually objective when I watch a movie or play, and I don't often get completely caught up in it.
  
I try to look at everybody's side of a disagreement before I make a decision.
  
When I see someone being taken advantage of, I feel kind of protective towards them.
  
I sometimes feel helpless when I am in the middle of a very emotional situation.
  
I sometimes try to understand my friends better by imagining how things look from their perspective.   
Becoming extremely involved in a good book or movie is somewhat rare for me.
  
When I see someone get hurt, I tend to remain calm.
  
Other people's misfortunes do not usually disturb me a great deal.
  
For each item, indicate how well it describes you. 
 
  
Does not
describe
me well
2
3
4
Does
describe
me well
If I'm sure I'm right about something, I don't waste much time listening to other people's arguments.
  
After seeing a play or movie, I have felt as though I were one of the characters.
  
Being in a tense emotional situation scares me.
  
When I see someone being treated unfairly, I sometimes don't feel very much pity for them.
  
I am usually pretty effective in dealing with emergencies.
  
I am often quite touched by things that I see happen.
  

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I believe that there are two sides to every question and try to look at them both.
  
I would describe myself as a pretty soft-hearted person.
  
When I watch a good movie, I can very easily put myself in the place of a leading character.
  
I tend to lose control during emergencies.
  
When I'm upset at someone, I usually try to "put myself in his shoes" for a while.
  
When I am reading an interesting story or novel, I imagine how I would feel if the events in the story
were happening to me.
  
When I see someone who badly needs help in an emergency, I go to pieces.
  
Before criticizing somebody, I try to imagine how I would feel if I were in their place.
  
BRFSS Adverse Childhood Experiences (ACEs)
Next are some questions about events that happened during your childhood. This
information will allow us to better understand problems that may occur early in life and may
help others in the future. Trigger warning. This is a sensitive topic and some people may feel
uncomfortable with these questions. Please keep in mind that you can skip any question you
do not want to answer. All questions refer to the time period before you were 18 years of age. 
 
Now, looking back before you were 18 years of age---
 
  No
Yes
Don't
know/not
sure
Did you live with anyone who was depressed, mentally ill, or suicidal?
  
Did you live with anyone who was a problem drinker or alcoholic?
  
Did you live with anyone who used illegal street drugs or who abused prescription medications?
  
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
  
Now, looking back before you were 18 years of age---
 
  No
Yes
Don't
know/not
sure
Parents
not
married
Were your parents separated or divorced?
  
Now, looking back before you were 18 years of age---
 
  Never Once
More
than
once

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How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?
  
How often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include
spanking.
  
How often did a parent or adult in your home ever swear at you, insult you, or put you down?
  
How often did anyone at least 5 years older than you or an adult, ever touch you sexually?
  
How often did anyone at least 5 years older than you or an adult, try to make you touch sexually?
  
How often did anyone at least 5 years older than you or an adult, force you to have sex?
  
BRS (Resilience)
Please respond to each item by selecting one response below.
 
  
Strongly
disagree
Disagree
Neutral
Agree
Strongly
agree
I tend to bounce back quickly after hard times.
  
I have a hard time making it through stressful events.
  
It does not take me long to recover from a stressful event.
  
It is hard for me to snap back when something bad happens.
  
I usually come through difficult times with little trouble.
  
I tend to take a long time to get over set-backs in my life.
  
ECR-RS (Experiences in Close Relationships - Relationship Structures)
Please read each of the following statements and rate the extent to which you believe each
statement best describes your feelings about close relationships in general.
 
  
Strongly
disagree
2
3
4
5
6
Strongly
agree
It helps to turn to people in times of need.
  
I usually discuss my problems and concerns with
others.
  
I talk things over with people.
  
I find it easy to depend on others.
  
I don't feel comfortable opening up to others.
  
I prefer not to show others how I feel deep down.
  
I often worry that other people do not really care for
me.
  
I'm afraid that other people may abandon me.
  

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I worry that others won't care about me as much as I
care about them.
  
MAIA (Interoceptive Awareness)
Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life:
 
  
Never
1
2
3
4
Always
When I am tense I notice where the tension is
located in my body.
  
I notice when I am uncomfortable in my body.
  
I notice where in my body I am comfortable.
  
I notice changes in my breathing, such as whether it
slows down or speeds up.
  
I ignore physical tension or discomfort until they
become more severe.
  
I distract myself from sensations of discomfort.
  
When I feel pain or discomfort, I try to power
through it.
  
I try to ignore pain.
  
I push feelings of discomfort away by focusing on
something.
  
When I feel unpleasant body sensations, I occupy
myself with something else so I don’t have to feel
them.
  
When I feel physical pain, I become upset.
  
I start to worry that something is wrong if I feel any
discomfort.
  
Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life:
 
  
Never
1
2
3
4
Always
I can notice an unpleasant body sensation without
worrying about it.
  
I can stay calm and not worry when I have feelings
of discomfort or pain.
  
When I am in discomfort or pain I can’t get it out of
my mind.
  
I can pay attention to my breath without being
distracted by things happening around me.
  
I can maintain awareness of my inner bodily
sensations even when there is a lot going on around   

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me.
When I am in conversation with someone, I can pay
attention to my posture.
  
I can return awareness to my body if I am distracted.   
I can refocus my attention from thinking to sensing
my body.
  
I can maintain awareness of my whole body even
when a part of me is in pain or discomfort.
  
I am able to consciously focus on my body as a
whole.
  
I notice how my body changes when I am angry.
  
When something is wrong in my life I can feel it in
my body.
  
I notice that my body feels different after a peaceful
experience.
  
Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life:
 
  
Never
1
2
3
4
Always
I notice that my breathing becomes free and easy
when I feel comfortable.
  
I notice how my body changes when I feel happy /
joyful.
  
When I feel overwhelmed I can find a calm place
inside.
  
When I bring awareness to my body I feel a sense
of calm.
  
I can use my breath to reduce tension.
  
When I am caught up in thoughts, I can calm my
mind by focusing on my body/breathing.
  
I listen for information from my body about my
emotional state.
  
When I am upset, I take time to explore how my
body feels.
  
I listen to my body to inform me about what to do.
  
I am at home in my body.
  
I feel my body is a safe place.
  
I trust my body sensations.
  
FFMQ (Five Facets of Mindfulness)
Choose the best response that describes your opinion of what is generally true for you.

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Never
or very
rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
When I’m walking, I deliberately notice the sensations of my body moving.
  
I’m good at finding words to describe my feelings.
  
I criticize myself for having irrational or inappropriate emotions.
  
I perceive my feelings and emotions without having to react to them.
  
When I do things, my mind wanders off and I’m easily distracted.
  
When I take a shower or bath, I stay alert to the sensations of water on my body.
  
I can easily put my beliefs, opinions, and expectations into words.
  
I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise
distracted.
  
I watch my feelings without getting lost in them.
  
I tell myself I shouldn’t be feeling the way I’m feeling.
  
I notice how foods and drinks affect my thoughts, bodily sensations, and emotions.
  
It’s hard for me to find the words to describe what I’m thinking.
  
I am easily distracted.
  
Please select 'Very often' for this response.
  
Choose the best response that describes your opinion of what is generally true for you.
 
  
Never
or very
rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
I believe some of my thoughts are abnormal or bad and I shouldn’t think that way.
  
I pay attention to sensations, such as the wind in my hair or sun on my face.
  
I have trouble thinking of the right words to express how I feel about things.
  
I make judgments about whether my thoughts are good or bad.
  
I find it difficult to stay focused on what’s happening in the present.
  
When I have distressing thoughts or images, I “step back” and am aware of the thought or
image without getting taken over by it.
  
I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing.
  
In difficult situations, I can pause without immediately reacting.
  
When I have a sensation in my body, it’s difficult for me to describe it because I can’t find the
right words.
  
It seems I am “running on automatic” without much awareness of what I’m doing.
  
When I have distressing thoughts or images, I feel calm soon after.
  
I tell myself that I shouldn’t be thinking the way I’m thinking.
  
I notice the smells and aromas of things.
  

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A great deal
A lot
A moderate amount
A little
None at all
A great deal
A lot
Choose the best response that describes your opinion of what is generally true for you.
 
  
Never
or very
rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
Even when I’m feeling terribly upset, I can find a way to put it into words.
  
I rush through activities without being really attentive to them.
  
When I have distressing thoughts or images I am able just to notice them without reacting.
  
I think some of my emotions are bad or inappropriate and I shouldn’t feel them.
  
I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light
and shadow.
  
My natural tendency is to put my experiences into words.
  
When I have distressing thoughts or images, I just notice them and let them go.
  
I do jobs or tasks automatically without being aware of what I’m doing.
  
When I have distressing thoughts or images, I judge myself as good or bad, depending what
the thought/image is about.
  
I pay attention to how my emotions affect my thoughts and behavior.
  
I can usually describe how I feel at the moment in considerable detail.
  
I find myself doing things without paying attention.
  
I disapprove of myself when I have irrational ideas.
  
TE (Trauma Exposure and Training Questions)
Overall, how much of your work involves (directly or indirectly) engaging with traumatized
individuals or traumatic material? 
How much training have you received on primary or secondary trauma (including topics like
vicarious trauma, secondary traumatic stress, burnout, and moral distress)?

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A moderate amount
A little
None at all
Extremely effective
Very effective
Moderately effective
Slightly effective
Not effective at all
Definitely yes
Probably yes
Might or might not
Probably not
Definitely not
Altogether, how effective were your trainings on primary or secondary trauma (including topics
like vicarious trauma, secondary traumatic stress, burnout, and moral distress)?
Do you want more training on secondary trauma (including topics like vicarious trauma,
secondary traumatic stress, burnout, and moral distress)?
FE (Feedback)
Are there any factors affecting your answers that we should know about (e.g., a health issue
or language barrier)?
Please provide any other feedback you would like to share.

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Identifiers
Thank you for participating in our survey. We would like to email you an Amazon.com eGift
Card. To do so, we need you to complete the following questions.
 
Please allow one week for us to email you the eGift Card. Thanks for your patience with us!
 
 
What is your first name?
What is your last name?
What is your phone number (e.g., XXX-XXX-XXXX)?
What is your email address? (This is where we will send your e-gift card.)

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Please verify your email address.

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Consent, MSU Students
Hello!
 
This survey has been developed by Associate Professors from Montana State University to
study secondary trauma. 
The purpose of this study is to better understand the personal histories and experiences of
victim service providers, or those considering becoming victim service providers, in Montana. 
Any insights you could offer are greatly appreciated! 
Before we begin, however, we need to review this consent form. This insures that your rights
are protected as a participant this study. 
     
Kelly Knight, PhD
Principal Investigator
Questions? We have answers:
 
 
Why am I being asked to participate?
You are being asked to participate in a research study because of your current or future
involvement in, or knowledge of, services in your area.
 
 
 
Why is this research being done?
This survey is being conducted to evaluate a new educational program. The program is
intended to teach people strategies for managing the negative consequences of
secondary trauma. Your participation will help us better understand how the personal histories
and experiences of service providers impact their work and mental and physical health.
 
 
 
How long will it take me to participate?
This survey should take approximately 30-45 minutes to complete.
 
 
 
Will I be compensated for participation?
No, you will not be compensated for your involvement. You will, however, receive an e-gift
card if you complete this survey a third time. 
 
 
 
What will I be asked to do?
Your participation in this research is voluntary and completely your choice. It will in no way
impact your grade in this class or your relationship with your professors. If you agree, you

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will be asked to answer a number of questions about your personal history, your work, your
physical and psychological health, and your resilience. You will also be asked to complete
some basic demographic questions. You can choose to not answer questions you do not want
to answer. Also, you can stop at any time with no consequences.
 
 
 
Are there any beneﬁts to me if I participate in this study?
This study is of no direct beneﬁt to you. However, the information gained will inform the
development of a data-driven intervention to lessen the impacts of secondary trauma on
service providers.
 
 
 
Will my information be kept private?
Everything you tell us will be kept conﬁdential. Your answers will be separated from your
name and contact information (which will be used for tracking purposes only). 
All data collected will be secured on a password-protected and ﬁrewalled computer in a
locked oﬃce on Montana State University’s campus or stored on a secure server. No one but
the oﬃcial research staﬀ will have access to the information. Your results will be grouped with
other participants’ data when results of this study is published. Your identity will remain
anonymous.
 
An exception to conﬁdentiality is the indication of imminent harm to yourself or others.  
Who should I contact if I have questions?
You can contact the principal investigator about the study: Kelly E. Knight, PhD, (406) 994-
7224, kelly.knight3@montana.edu. They can also be reached by mail at: Montana State
University, Department of Sociology and Anthropology, PO Box 172380, Bozeman, MT, 59817.
 
In addition, you can contact MSU’s institutional review board chairperson: Mark Quinn, PhD,
(406) 994-4747, mquinn@montana.edu. He can also be reached by mail at Montana State
University, IRB, PO BOX 173610, Bozeman, MT, 59817.
 
 
 
What happens if I change my mind?
Participation is strictly voluntary and you can stop at any time. Participation or non-
participation will not aﬀect your current or future relationship with Montana State University.
 
 
 
Are there any risks to me if I participate in this study?
We do not foresee any signiﬁcant physical or psychological risks as a result of your
participation. However, some of the questions are personal and may provoke an emotional
response. Below is a list of resources should you be worried or need support after the survey.
 
 
Resource List: 
 
1.    Montana Suicide Prevention Lifeline: (800) 273-8255
 

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Agree
Female
Male
Other
Married
Living with partner (but not married)
Divorced/separated
2.    MSU Voice Center: (406) 994-7069
 
3.    Counseling and Psychological Services, MSU: (406) 994-4531
 
4.    HELP Center Crisis and Referral Line: (406) 586-3333 or just dial 2-1-1
 
5.    Haven Domestic Violence Program: (406) 586-4111
 
6.    Alcohol and Drug Services of Gallatin County: (406) 586-5493
 
7.    Bozeman Health Deaconess Hospital: (406) 414-5000
 
8.    Bridger Care, Reproductive & Sexual Healthcare & Education: (406) 587-0681
 
9.    Child and Family Services: (866) 820-5437
 
10.  Gallatin Valley Mental Health Center: (406) 556-6500 
ELECTRONIC CONSENT:  
 
You voluntarily agree to participate.
You are 18 years of age or older. 
 
 
BDS (Basic Demographics, Student)
What is your sex/gender?
What is your current marital status?

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Single
Widowed
Other
American Indian
Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian, Other Pacific Islander
White
Other
Freshman
Sophomore
Junior
Senior
What race do you consider yourself? Check all that apply. 
What is your age?
What is your major?
Major:
Second major (if applicable):
What is your class status?

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Graduate student
Professional student
Continuing education student
Yes
No
Yes
No
How many hours/week do you work for pay OFF campus?
How many hours/week do you work for pay ON campus?
How many hours/week of volunteer work?
Do you consider yourself to be a veteran?
Do you consider yourself to be an NCAA athlete?
Do you consider yourself to be a student with a documented disability? Check all that apply. 

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No
ADHD/ADD
Learning disability
Physical disability
Psychological disability
Traumatic brain injury
Other:
MBI-S (Maslach Burnout Inventory - Student Version)
Below are 17 statements of university-related feelings. Please read each statement and
decide if you ever feel this way about your academic work.  If you have had this feeling,
indicate how often you feel it by indicating the choice that best describes how frequently you
feel that way.
 
  
Never
A few
times a
year or
less
Once a
month or
less
A few times
a month
Once a
week
A few
times a
week
Every day
I feel emotionally drained by my studies.
  
I feel used up at the end of the day at the university.
  
I feel tired when I get up in the morning and have to
face another day at the university.
  
Attending classes all day is really a strain for me.
  
I can effectively solve the problems that arise in my
studies.
  
I feel burned out from my studies.
  
I feel I am making an effective contribution in class.
  
I have become less interested in my studies since my
enrollment.
  
Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all
media. Published by Mind Garden, Inc., www.mindgarden.com
On this page are statements of job-related feelings. Please read each statement carefully and
decide if you ever feel this way about your job. 
A few times a
Once a
A few times a
A few times a

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Yes, I currently work either for a wage or as a volunteer.
No, I do not currently work or volunteer.
 
  
Never
year or less
month or less
month
Once a week
week
Everyday
I have become less enthusiastic
about my studies.
  
In my opinion, I am a good
student.
  
I feel exhilarated when I
accomplish something at the
university.
  
I have accomplished many
worthwhile things in my studies.
  
I just want to get my work done
and not be bothered.
  
I have become more cynical about
whether my university work
contributes to anything.
  
I doubt the significance of my
studies
  
While working at the university, I
feel confident that I am effective at
getting things done.
  
Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all
media. Published by Mind Garden, Inc., www.mindgarden.com
MBI-GS (Maslach Burnout Inventory - General Student Version)
Do you currently work (for a wage or as a volunteer)?
On this page are statements of job-related feelings. Please read each statement carefully and
decide if you ever feel this way about your job.
 
  
Never
A few
times a
year or
less
Once a
month or
less
A few times
a month
Once a
week
A few
times a
week
Every day
I feel emotionally drained from my work.
  
I feel used up at the end of the workday.
  
I feel tired when I get up in the morning and have to
face another day on the job.
  

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Working all day is really a strain for me.
  
I can effectively solve the problems that arise in my
work.
  
I feel burned out from my work.
  
I feel I am making an effective contribution to what
this organization does.
  
I have become less interested in my work since I
started this job.
  
Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all
media. Published by Mind Garden, Inc., www.mindgarden.com
On this page are statements of job-related feelings. Please read each statement carefully and
decide if you ever feel this way about your job. 
 
  
Never
A few times a
year or less
Once a
month or less
A few times a
month
Once a week
A few times a
week
Every day
I have become less enthusiastic
about my work.
  
In my opinion, I am good at my
job.
  
I feel exhilarated when I
accomplish something at work.
  
I have accomplished many
worthwhile things in this job.
  
I just want to do my job and not be
bothered.
  
I have become more cynical about
whether my work contributes
anything.
  
I doubt the significance of my
work.
  
At my work, I feel confident that I
am effective at getting things
done.
  
Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all
media. Published by Mind Garden, Inc., www.mindgarden.com
STSS (Secondary Traumatic Stress Scale)

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The following is a list of statements made by persons who have been impacted by their work
with traumatized clients (or other potentially traumatized populations, e.g., patients, students,
customers, or anyone to whom you provide services). 
 
In the past seven days, how frequently was the statement true for you:
 
  
Never
Rarely
Occasionally
Often
Very often
I felt emotionally numb.
  
My heart started pounding when I thought about my work with clients.
  
It seemed as if I was reliving the trauma(s) experienced by my client(s).
  
I had trouble sleeping.
  
I felt discouraged about the future.
  
Reminders of my work with clients upset me.
  
I had little interest in being around others.
  
I felt jumpy.
  
I was less active than usual.
  
I thought about my work with clients when I didn’t intend to.
  
I had trouble concentrating.
  
I avoided people, places, or things that reminded me of my work with clients.
  
I had disturbing dreams about my work with clients.
  
I wanted to avoid working with some clients.
  
I was easily annoyed.
  
I expected something bad to happen.
  
I noticed gaps in my memory about client sessions.
  
Please select 'Very often' for this response.
  
PCL-5 (PTSD)
Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then indicate how much you have been
bothered by that problem in the past month.
 
In the past month, how much were you bothered by:
 
  Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing, and unwanted memories of the stressful
experience?
  
Repeated, disturbing dreams of the stressful experience?
  
Suddenly feeling or acting as if the stressful experience were actually
happening again (as if you were actually back there reliving it)?
  
Feeling very upset when something reminded you of the stressful
experience?
  

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Having strong physical reactions when something reminded you of the
stressful experience (for example, heart pounding, trouble breathing,
sweating)?
  
Avoiding memories, thoughts, or feelings related to the stressful
experience?
  
Avoiding external reminders of the stressful experience (for example,
people, places, conversations, activities, objects, or situations)?
  
Trouble remembering important parts of the stressful experience?
  
Having strong negative beliefs about yourself, other people, or the world
(for example, having thoughts such as: I am bad, there is something
seriously wrong with me, no one can be trusted, the world is completely
dangerous)?
  
Blaming yourself or someone else for the stressful experience or what
happened after it?
  
Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then indicate how much you have been
bothered by that problem in the past month.
 
In the past month, how much were you bothered by:
 
  Not at all
A little bit
Moderately
Quite a bit
Extremely
Having strong negative feelings such as fear, horror, anger, guilt, or
shame?
  
Loss of interest in activities that you used to enjoy?
  
Feeling distant or cut off from other people?
  
Trouble experiencing positive feelings (for example, being unable to feel
happiness or have loving feelings for people close to you)?
  
Irritable behavior, angry outbursts, or acting aggressively?
  
Taking too many risks or doing things that could cause you harm?
  
Being “superalert” or watchful or on guard?
  
Feeling jumpy or easily startled?
  
Having difficulty concentrating?
  
Trouble falling or staying asleep?
  
BMI (Body Mass Index)
What is your height (in feet and inches)?

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Excellent
Very good
Good
Fair
Poor
Don't know/not sure
What is your weight (in pounds)? (If pregnant, please use pre-pregnancy weight.)
HRQoL (Health Related Quality of Life)
Would you say that in general your health is —
Now thinking about your physical health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health not good?
Now thinking about your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not good?
During the past 30 days, for about how many days did poor physical or mental health keep
you from doing your usual activities, such as self care, work, or recreation?

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No
Yes, I have been diagnosed with:
AD (Autoimmune Disease)
Has a doctor, nurse, or other health professional ever diagnosed you with an autoimmune
disease?        
(e.g., rheumatoid arthritis, hashimoto's disease, Sjogren's syndrome, multiple sclerosis, type 1
diabetes, systemic lupus erythematosus)
PHQ-15 (Somatic Symptoms Survey)
During the past four weeks…
 
How much have you been bothered by any of the following problems?
 
  
Not bothered at all
Bothered a little
Bothered a lot
Stomach pain
  
Back pain
  
Pain in your arms, legs, or joints (knees, hips, etc.)
  
Menstrual cramps or other problems with your periods [Women only]
  
Headaches
  
Chest pain
  
Dizziness
  
Fainting spells
  
Feeling your heart pound or race
  
Shortness of breath
  
Pain or problems during sexual intercourse
  
Constipation, loose bowels, or diarrhea
  
Nausea, gas, or indigestion
  
Feeling tired or having low energy
  
Trouble sleeping
  
AUDIT (Alcohol)
The following are questions about your alcohol use in the past 12 months.

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Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
 
 
  How often do you have one drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?
  
 
  
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often do you have four or more drinks on one occasion?
  
How often during the last year have you found that you are not able to stop
drinking once you have started?
  
How often during the last year have you failed to do what was normally
expected from you because of drinking?
  
How often during the last year have you needed a first drink in the morning to
get yourself going after a heavy drinking session?
  
How often during the last year have you had a feeling of guilt or remorse after
drinking?
  
How often during the last year have you been unable to remember what
happened the night before because you had been drinking?
  
 In the past 12 months...
 
  
No
Yes, but not in the
last year
Yes, during the last
year
Have you or someone else been injured as a result of your drinking?
  
Has a relative or friend or doctor or health worker been concerned about your

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drinking or suggested you cut down?
  
TAPS (Substance Use)
The following are questions about other substance use.
 
 
In the past 12 months, how often have you...
 
  
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Used any tobacco product (for example, cigarettes, ecigarettes, cigars, pipes, or
smokeless tobacco)?
  
Used marijuana?
  
Used any prescription medications just for the feeling, more than prescribed or that
were not prescribed for you?
  
Used any other drugs including cocaine or crack, heroin, meth, hallucinogens,
ecstasy/MDMA?
  
JSS (Sleep Disturbance)
In the past month, did you…
 
  Not at all
1-3 days
4-7 days
8-14 days
15-21 days 22-31 days
Have trouble falling asleep?
  
Wake up several times per night?
  
Have trouble staying asleep (including waking far too early)?
  
Wake up after your usual amount of sleep feeling tired and worn
out?
  
GAD-7 (Anxiety)
Over the last two weeks, how often have you been bothered by the following problems?
 
Indicate how often you have experienced…
 
  
Not at all
Several days
More than half the
days
Nearly every day
Feeling nervous, anxious or on edge.
  

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No
Yes
Not being able to stop or control worrying.
  
Worrying too much about different things.
  
Trouble relaxing.
  
Being so restless that it is hard to sit still.
  
Becoming easily annoyed or irritable.
  
Feeling afraid as if something awful might happen.
  
PHQ-8 (Depression)
Over the last two weeks, how often have you been bothered by any of the following
problems?
 
Indicate how often any of the following problems have bothered you.
 
  
Not at all
Several days
More than half
the days
Nearly every
day
Little interest or pleasure doing things.
  
Feeling down, depressed, or hopeless.
  
Trouble falling or staying asleep, or sleeping too much.
  
Feeling tired or having little energy.
  
Poor appetite or overeating.
  
Feeling bad about yourself - or that you are a failure or have let yourself or
your family down.
  
Trouble concentrating on things, such as reading the newspaper or
watching television.
  
Moving or speaking so slowly that other people could have noticed. Or the
opposite - being so fidgety or restless that you have been moving around a
lot more than usual.
  
MHS (Mental Health Specialist)
In the past month, have you talked to a mental health specialist, such as a psychiatrist,
psychologist, or specially trained social worker, about emotional problems, your nerves, or the
way you were feeling or behaving?  

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IRI (Empathy)
For each item, indicate how well it describes you. 
 
  
Does not
describe
me well
2
3
4
Does
describe
me well
I daydream and fantasize, with some regularity, about things that might happen to me.
  
I often have tender, concerned feelings for people less fortunate than me.
  
I sometimes find it difficult to see things from the "other person's" point of view.
  
Sometimes I don't feel very sorry for other people when they are having problems.
  
I really get involved with the feelings of the characters in a novel.
  
In emergency situations, I feel apprehensive and ill-at-ease.
  
I am usually objective when I watch a movie or play, and I don't often get completely caught up in it.
  
I try to look at everybody's side of a disagreement before I make a decision.
  
When I see someone being taken advantage of, I feel kind of protective towards them.
  
I sometimes feel helpless when I am in the middle of a very emotional situation.
  
I sometimes try to understand my friends better by imagining how things look from their perspective.   
Becoming extremely involved in a good book or movie is somewhat rare for me.
  
When I see someone get hurt, I tend to remain calm.
  
Other people's misfortunes do not usually disturb me a great deal.
  
For each item, indicate how well it describes you. 
 
  
Does not
describe
me well
2
3
4
Does
describe
me well
If I'm sure I'm right about something, I don't waste much time listening to other people's arguments.
  
After seeing a play or movie, I have felt as though I were one of the characters.
  
Being in a tense emotional situation scares me.
  
When I see someone being treated unfairly, I sometimes don't feel very much pity for them.
  
I am usually pretty effective in dealing with emergencies.
  
I am often quite touched by things that I see happen.
  
I believe that there are two sides to every question and try to look at them both.
  
I would describe myself as a pretty soft-hearted person.
  
When I watch a good movie, I can very easily put myself in the place of a leading character.
  
I tend to lose control during emergencies.
  
When I'm upset at someone, I usually try to "put myself in his shoes" for a while.
  
When I am reading an interesting story or novel, I imagine how I would feel if the events in the story
were happening to me.
  

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When I see someone who badly needs help in an emergency, I go to pieces.
  
Before criticizing somebody, I try to imagine how I would feel if I were in their place.
  
BRFSS Adverse Childhood Experiences (ACEs)
Next are some questions about events that happened during your childhood. This
information will allow us to better understand problems that may occur early in life and may
help others in the future. Trigger warning. This is a sensitive topic and some people may feel
uncomfortable with these questions. Please keep in mind that you can skip any question you
do not want to answer. All questions refer to the time period before you were 18 years of age. 
 
Now, looking back before you were 18 years of age---
 
  No
Yes
Don't
know/not
sure
Did you live with anyone who was depressed, mentally ill, or suicidal?
  
Did you live with anyone who was a problem drinker or alcoholic?
  
Did you live with anyone who used illegal street drugs or who abused prescription medications?
  
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
  
Now, looking back before you were 18 years of age---
 
  No
Yes
Don't
know/not
sure
Parents
not
married
Were your parents separated or divorced?
  
Now, looking back before you were 18 years of age---
 
  Never Once
More
than
once
How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?
  
How often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include
spanking.
  
How often did a parent or adult in your home ever swear at you, insult you, or put you down?
  
How often did anyone at least 5 years older than you or an adult, ever touch you sexually?
  
How often did anyone at least 5 years older than you or an adult, try to make you touch sexually?
  
How often did anyone at least 5 years older than you or an adult, force you to have sex?
  

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BRS (Resilience)
Please respond to each item by selecting one response below.
 
  
Strongly
disagree
Disagree
Neutral
Agree
Strongly
agree
I tend to bounce back quickly after hard times.
  
I have a hard time making it through stressful events.
  
It does not take me long to recover from a stressful event.
  
It is hard for me to snap back when something bad happens.
  
I usually come through difficult times with little trouble.
  
I tend to take a long time to get over set-backs in my life.
  
ECR-RS (Experiences in Close Relationships - Relationship Structures)
Please read each of the following statements and rate the extent to which you believe each
statement best describes your feelings about close relationships in general.
 
  
Strongly
disagree
2
3
4
5
6
Strongly
agree
It helps to turn to people in times of need.
  
I usually discuss my problems and concerns with
others.
  
I talk things over with people.
  
I find it easy to depend on others.
  
I don't feel comfortable opening up to others.
  
I prefer not to show others how I feel deep down.
  
I often worry that other people do not really care for
me.
  
I'm afraid that other people may abandon me.
  
I worry that others won't care about me as much as I
care about them.
  
MAIA (Interoceptive Awareness)

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Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life:
 
  
Never
1
2
3
4
Always
When I am tense I notice where the tension is
located in my body.
  
I notice when I am uncomfortable in my body.
  
I notice where in my body I am comfortable.
  
I notice changes in my breathing, such as whether it
slows down or speeds up.
  
I ignore physical tension or discomfort until they
become more severe.
  
I distract myself from sensations of discomfort.
  
When I feel pain or discomfort, I try to power
through it.
  
I try to ignore pain.
  
I push feelings of discomfort away by focusing on
something.
  
When I feel unpleasant body sensations, I occupy
myself with something else so I don’t have to feel
them.
  
When I feel physical pain, I become upset.
  
I start to worry that something is wrong if I feel any
discomfort.
  
Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life:
 
  
Never
1
2
3
4
Always
I can notice an unpleasant body sensation without
worrying about it.
  
I can stay calm and not worry when I have feelings
of discomfort or pain.
  
When I am in discomfort or pain I can’t get it out of
my mind.
  
I can pay attention to my breath without being
distracted by things happening around me.
  
I can maintain awareness of my inner bodily
sensations even when there is a lot going on around
me.
  
When I am in conversation with someone, I can pay
attention to my posture.
  
I can return awareness to my body if I am distracted.   
I can refocus my attention from thinking to sensing
my body.
  
I can maintain awareness of my whole body even
when a part of me is in pain or discomfort.
  
I am able to consciously focus on my body as a
  

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whole.
I notice how my body changes when I am angry.
  
When something is wrong in my life I can feel it in
my body.
  
I notice that my body feels different after a peaceful
experience.
  
Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life:
 
  
Never
1
2
3
4
Always
I notice that my breathing becomes free and easy
when I feel comfortable.
  
I notice how my body changes when I feel happy /
joyful.
  
When I feel overwhelmed I can find a calm place
inside.
  
When I bring awareness to my body I feel a sense
of calm.
  
I can use my breath to reduce tension.
  
When I am caught up in thoughts, I can calm my
mind by focusing on my body/breathing.
  
I listen for information from my body about my
emotional state.
  
When I am upset, I take time to explore how my
body feels.
  
I listen to my body to inform me about what to do.
  
I am at home in my body.
  
I feel my body is a safe place.
  
I trust my body sensations.
  
FFMQ (Five Facets of Mindfulness)
Choose the best response that describes your opinion of what is generally true for you.
 
  
Never
or very
rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
When I’m walking, I deliberately notice the sensations of my body moving.
  
I’m good at finding words to describe my feelings.
  
I criticize myself for having irrational or inappropriate emotions.
  
I perceive my feelings and emotions without having to react to them.
  

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When I do things, my mind wanders off and I’m easily distracted.
  
When I take a shower or bath, I stay alert to the sensations of water on my body.
  
I can easily put my beliefs, opinions, and expectations into words.
  
I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise
distracted.
  
I watch my feelings without getting lost in them.
  
I tell myself I shouldn’t be feeling the way I’m feeling.
  
I notice how foods and drinks affect my thoughts, bodily sensations, and emotions.
  
It’s hard for me to find the words to describe what I’m thinking.
  
I am easily distracted.
  
Please select 'Very often' for this response.
  
Choose the best response that describes your opinion of what is generally true for you.
 
  
Never
or very
rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
I believe some of my thoughts are abnormal or bad and I shouldn’t think that way.
  
I pay attention to sensations, such as the wind in my hair or sun on my face.
  
I have trouble thinking of the right words to express how I feel about things.
  
I make judgments about whether my thoughts are good or bad.
  
I find it difficult to stay focused on what’s happening in the present.
  
When I have distressing thoughts or images, I “step back” and am aware of the thought or
image without getting taken over by it.
  
I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing.
  
In difficult situations, I can pause without immediately reacting.
  
When I have a sensation in my body, it’s difficult for me to describe it because I can’t find the
right words.
  
It seems I am “running on automatic” without much awareness of what I’m doing.
  
When I have distressing thoughts or images, I feel calm soon after.
  
I tell myself that I shouldn’t be thinking the way I’m thinking.
  
I notice the smells and aromas of things.
  
Choose the best response that describes your opinion of what is generally true for you.
 
  
Never
or very
rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
Even when I’m feeling terribly upset, I can find a way to put it into words.
  

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A great deal
A lot
A moderate amount
A little
None at all
A great deal
A lot
A moderate amount
A little
None at all
I rush through activities without being really attentive to them.
  
When I have distressing thoughts or images I am able just to notice them without reacting.
  
I think some of my emotions are bad or inappropriate and I shouldn’t feel them.
  
I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light
and shadow.
  
My natural tendency is to put my experiences into words.
  
When I have distressing thoughts or images, I just notice them and let them go.
  
I do jobs or tasks automatically without being aware of what I’m doing.
  
When I have distressing thoughts or images, I judge myself as good or bad, depending what
the thought/image is about.
  
I pay attention to how my emotions affect my thoughts and behavior.
  
I can usually describe how I feel at the moment in considerable detail.
  
I find myself doing things without paying attention.
  
I disapprove of myself when I have irrational ideas.
  
TE (Trauma Exposure and Training Questions)
Overall, how much of your work involves (directly or indirectly) engaging with traumatized
individuals or traumatic material? 
How much training have you received on primary or secondary trauma (including topics like
vicarious trauma, secondary traumatic stress, burnout, and moral distress)?
Altogether, how effective were your trainings on primary or secondary trauma (including topics

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Extremely effective
Very effective
Moderately effective
Slightly effective
Not effective at all
Definitely yes
Probably yes
Might or might not
Probably not
Definitely not
like vicarious trauma, secondary traumatic stress, burnout, and moral distress)?
Do you want more training on secondary trauma (including topics like vicarious trauma,
secondary traumatic stress, burnout, and moral distress)?
FE (Feedback)
Are there any factors affecting your answers that we should know about (e.g., a health issue
or language barrier)?
Please provide any other feedback you would like to share.
Identifiers

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Thank you for participating in our survey. We would like to email you an Amazon.com eGift
Card. To do so, we need you to complete the following questions.
 
Please allow one week for us to email you the eGift Card. Thanks for your patience with us!
 
 
What is your first name?
What is your last name?
What is your phone number (e.g., XXX-XXX-XXXX)?
What is your email address? (This is where we will send your e-gift card.)
Please verify your email address.

Official Title: Somatic Mindfulness Training for a Healthy Workforce: Student Pilot Sample 
NCT Number: NCT04122534 
Document Date: 08/08/2019 
 
STATISTICAL ANALYSIS PLAN 
 
For each outcome measure (i.e., STSS, PCL-5), most analyses will simply involve calculating 
descriptive statistics for each wave of data collection. We are pilot testing materials using a 
small sample and findings will help inform future statistical designs and power needs.