2019 Franklin County ACE Survey
The survey below refers to how many Adverse Childhood Experiences (ACE) you experienced while you were growing up, during your first 18 years of life. This is an anonymous survey and the Franklin County Health Department and Franklin County Mobilizing for Action through Planning and Partnerships (MAPP) hopes to use the results from the survey and GIS mapping to identify targeted areas in Franklin County that may have higher ACE scores to develop targeted interventions, messages and education to increase the health of our community.

Instructions for completing the survey:
1. Read through the questions and for any of the 10 questions you answer yes, please add 1 to your score. If you answer no, you would add 0.
2. At the end of the survey enter the number of yes’ you had – you do not have to identify which questions you answered yes to, just the total number. For example, if you answered yes to 1, 7, 9 and 10 your ACE score would be 4 and you would enter that in the “ACE Score Total” box.
3. Provide what Elementary School district your home address is in (this may be different than the school your child attends – please choose the school district your home address is currently in).

Your feedback is invaluable and we appreciate you taking the time to complete this survey. Thank you!

Want to know more about your ACES score? Visit https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/index.html for more information.

Please note, your ACEs score does NOT define you. It is a tool to help assess your risk of developing chronic disease, increasing your risk of substance abuse disorders and other mental health issues.

Should you need more information or help regarding your ACEs score you can reach out to bluegrass.org, your local health department, your local primary care physician or mental health provider.
While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household OFTEN.....Swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
If yes add 1
2. Did a parent or other adult in the household OFTEN.....Push, grab, slab, or throw something at you? OR Ever hit you so hard that you had marks or were injured?
If yes add 1
3. Did an adult or person at least 5 years older than you EVER.....Touch or fondle you or have you touch their body in a sexual way? OR Try to or actually have oral, anal or vaginal sex with you?
If yes add 1
4. Did you OFTEN feel that.....No one in your family loved you or thought you were important or special? OR Your family didn't look out for each other, feel close to each other, or support each other?
If yes add 1
5. Did you OFTEN feel that.....You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
If yes add 1
6. Were your parents EVER separated or divorced?
If yes add 1
7. Was your mother or stepmother: OFTEN pushed, grabbed, slapped, or had something thrown at her? OR SOMETIMES OR OFTEN kicked, bitten, hit with a fist, or hit with something hard? OR EVER repeatedly hit over at least a few minutes or threatened with a gun or knife?
If yes add 1
8. Did you live with anyone who was a problem a drinker or alcoholic or who used street drugs?
If yes add 1
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
If yes add 1
10. Did a household member go to prison?
If yes add 1
Now add up your "Yes" answers and insert your number 0-10 below. This is your ACE Score *
Your answer
What Elementary School District is your home address currently located in? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy