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Thank you for taking the time to fill out this survey! It will take only about 5 minutes. All answers are anonymous.

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FASS-S

 

The items in this questionnaire refer to things and experiences that may cause fear or other unpleasant feelings.

 

1. Please imagine yourself in each situation below and rate how much the object or situation DISTURBS you using the scale below:

 

Not at all       A little      A fair amount      Much      Very much

1------------------2------------------3------------------4------------------5

 

"I am disturbed by ________."

 

Note that the FASTEST way to fill out this form is by using the NUMERIC KEYPAD and the TAB key to go to the next item!

 

 

 

Item #

"I am disturbed by ________."

Rating

1

Witnessing Surgery

2

Rodents

3

Taking part or speaking in a meeting or class

4

Birds

5

Injections

6

Writing while someone watches

7

Acting on a stage

8

Snakes

9

Open wounds

10

Eating or drinking where someone could watch you

11

Going to a party or other social outing

12

Dogs

13

Blood

14

Dead People

15

Insects

 

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>>>PLEASE NOTE<<<

 

 

The next two questionnaires have items that are similar to those on the previous questionnaire. However, they are different in an important way: they ask about “WHY” you are fearful of the object or situation. It is very important that you read the directions and answer the questions accordingly!

 

 

One questionnaire asks you to imagine yourself in each situation below and rate how much the object or situation disturbs you BECAUSE of a fear or concern that something dangerous could happen that would cause harm (like a building collapsing, a fire, being attacked, car accident, etc.).

 

For example, “I am disturbed by __elevators__ BECAUSE of a fear or concern that something dangerous could happen that would cause harm (like the elevator falling).”

 

The other questionnaire asks you to imagine yourself in each situation and rate how much the object or situation disturbs you BECAUSE of a fear that you might not be able to get help or get away quickly if you experience intense fear, dizziness, nausea, or panic.

 

For example, "I am disturbed by __elevators__ BECAUSE I might not be able to get help or get away quickly if I experience intense fear, dizziness, nausea, or panic."

 

 

Please keep the differences in these instructions in mind as you answer the questions.

 

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Please imagine yourself in each situation below and rate how much the object or situation DISTURBS you BECAUSE of a fear that you might not be able to get help or get away quickly if you experience intense fear, dizziness, nausea, or other uncomfortable bodily sensations using the scale below (CIRCLE the number that applies):

 

Not at all       A little      A fair amount      Much      Very much

1------------------2------------------3------------------4------------------5

 

"I am disturbed by _________ BECAUSE I might not be able to get help or get away quickly if I experience intense fear, dizziness, nausea, or other uncomfortable bodily sensations."

 

Item #

 

Rating

16

Storms

17

Traveling in a bus

18

Being in enclosed places

19

Tunnels

20

Large open spaces

21

Thunder or lightning

22

Traveling in an automobile

23

Being outside the home alone

24

Heights

25

Standing in a line

26

Being in still water like a swimming pool

27

Elevators

28

Being on a bridge

29

Being in a crowd

30

Traveling in a train

31

Dirt

 

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Please imagine yourself in each situation below and rate how much the object or situation DISTURBS you BECAUSE of a fear or concern that something dangerous could happen that would cause harm (like a building collapsing, a fire, being attacked, car accident, etc.) using the scale below (CIRCLE the number that applies):

 

Not at all       A little      A fair amount      Much       Very much

1------------------2------------------3------------------4------------------5

 

"I am disturbed by _________ BECAUSE of a fear or concern that something dangerous could happen that would cause harm (like a building collapsing, a fire, being attacked, car accident, etc.).”

 

Item #

 

Rating

32

Storms

33

Traveling in a bus

34

Being in enclosed places

35

Tunnels

36

Large open spaces

37

Thunder or lightning

38

Traveling in an automobile

39

Being outside the home alone

40

Heights

41

Standing in a line

42

Being in still water like a swimming pool

43

Elevators

44

Being on a bridge

45

Being in a crowd

46

Traveling in a train

47

Dirt

 

 

 

Thanks for helping out!!!

 

A description of the theory behind the development of this questionnaire will be made available at http://hanshananigan.tripod.com/fearstudydebriefing.html, as well as the results of the pilot data, when available.