Caregiver Form ID ___________________

Date ____________________

DOB/age ____________________

The Childhood Trust Events Survey

Children and Adolescents: Caregiver Form
Version 2.0; 10/10/2006

It is important for us to understand what may have happened to your child. The questions below describe some
kinds of upsetting experiences. Since we give these questions to everyone, we list a lot of possible events that
may have happened at any time in your child’s life. If one or more of these experiences has happened at some
time in your child’s life, please circle Y for Yes. If not, circle N for No. If you are unsure, circle DK for Don’t
Know. Thank you for completing this survey.

1. Was your child ever in a really bad accident, such as a serious car accident? Y N DK

2. Was your child ever in a disaster such as a tornado, hurricane, fire, Y N DK

big earthquake, or flood?

3. Was your child ever so badly hurt or sick that he/she had to have painful Y N DK
or frightening medical treatment?

4. Has your child ever been threatened or harassed by a bully Y N DK

(someone outside of his/her family)?

5. Has your child ever repeatedly had a parent swear at him/her, insult him/her, Y N DK
or had hurtful things said to him/her such as “You are no good,” “You will be
sent away because you are bad,” or “I wish you were never born”?

6. Was your child ever completely separated from his/her parent(s) for a long Y N DK
time, such as going to a foster home, the parent living far apart from him/her,
or never seeing the parent again?

7. Has your child ever had a family member who was put in jail or prison Y N DK
or taken away by the police?

8. Has your child ever had a time in his/her life when he/she did not have the Y N DK
right care, such as not having enough to eat, being left in charge of
younger brothers or sisters for long periods of time, or being left with an
adult who used drugs?

9. Has your child ever had a time in his/her life when he/she was living in a car, Y N DK
living in a homeless shelter, living in a battered women’s shelter, or living
on the street?

10. Has your child ever had someone living in his/her home who abused alcohol Y N DK
or used street drugs?

11. Has your child ever seen someone in the home try to hurt or kill Y N DK
himself/herself, such as cutting himself/herself or taking too many pills
or drugs?

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12. Has your child ever had a family member who was depressed Y N DK
or mentally ill for a long time?

13. Has your child ever had a family member or someone else very close to Y N DK
him/her die unexpectedly?

14. Has someone in your child’s home ever been physically violent toward Y N DK
him/her, such as whipping, kicking, or hitting hard enough to leave marks?

15. Has an adult ever said they were going to hurt your child really Y N DK
badly or kill him/her, or acted like they were going to hurt your child
very badly or kill him/her, even if this person didn’t actually do it?

16. Has your child ever seen or heard family members act like Y N DK
they were going to kill or hurt each other badly, even if they
didn’t actually do it?

17. Has your child ever seen or heard a family member being hit, punched, Y N DK
kicked very hard, or killed?

18. Has your child ever seen someone in his/her neighborhood be beaten up, Y N DK
shot at or killed?

19. Has someone ever robbed or tried to rob (jump) your child or your Y N DK
child’s family with a weapon?

20. Has someone ever kidnapped your child or has someone close to your child Y N DK
ever been kidnapped?

21. Has your child ever been badly hurt by an animal, such as attacked by Y N DK
a dog?

22. Has your child ever had a pet or animal that was hurt or killed on Y N DK
purpose by someone he/she knew?

23. Has your child ever seen a friend killed? Y N DK

24. Has someone ever touched your child’s private sexual body parts Y N DK
when he/she did not want them to?

25. Has someone ever made your child touch another person’s private sexual Y N DK
body parts?

26. Has an adult ever tied your child up, gagged him/her, blindfolded him/her, Y N DK
or locked him/her in a closet or a dark scary place?
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Total ___ ___ ___

If more than one event happened AND still seems to bother your child, put a star next to the one that you believe
bothers him/her the most.

Trauma Treatment Training Center

The Childhood Trust & The Mayerson Center for Safe and Healthy Children
Cincinnati Children’s Hospital Medical Center
3333 Burnet Ave, MLC 3008 Cincinnati, Ohio 45229-3039

This survey is a public domain document and may be freely reproduced and distributed without copyright restrictions. Please do not alter
the item wording or content or the response format and then distribute the modified version under the original name. If you feel you must
make any modifications of this survey, please rename it so that others will not be confused. For more information about this scale, please
contact Erica Pearl, Psy.D. Email: [email protected].