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Effects of Racism on Mental Health Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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1

Have you experienced racism?

Select an option that best describes your experience.
2

Rate the impact of racism on mental health (1 - Not impactful, 10 - Very impactful)

Rate the impact of racism on mental health using a star rating scale.
3

How has racism affected your mental health?

Please describe how experiences of racism have affected your mental health.
4

Do you feel comfortable seeking help for mental health issues related to racism?

Select an option that best represents your feelings towards seeking help for mental health issues related to racism.
5

Have you noticed any physical symptoms due to experiences of racism?

Select all physical symptoms you have experienced due to racism.
6

Rate your overall mental health (1 - Very Poor, 5 - Excellent)

Rate your overall mental health using a star rating scale.
7

In your opinion, does the society adequately address mental health issues caused by racism?

Select an option that reflects your opinion on society's approach to addressing mental health issues caused by racism.
8

How often do you feel anxious or stressed due to experiences of racism?

Select the frequency that best represents how often you feel anxious or stressed due to experiences of racism.
9

Have you sought professional help for mental health issues related to racism?

Select an option that indicates whether you have sought professional help for mental health issues related to racism.
10

What coping mechanisms do you utilize to deal with mental health issues related to racism? (Select all that apply)

Select all coping mechanisms that you use to deal with mental health issues related to racism.
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