Anda di halaman 1dari 3

APPENDIX 1: Survey Questions and Consent Form

Group Members: Hyo Jin Lee, Xiangyu Wu, Linghao Wei


Research Question: What mental health problems/challenges do international students
face at Mason?
Mental Health of International Students at Mason
This research is being conducted to investigate mental health issues among
international students at Mason. If you agree to participate, you will be asked to
(Answer 23 questions about personal experience. we estimate the survey will take
about 15 mins.)
This survey may cause participants feeling uncomfortable talking about difficult
emotions. There are no benefits to you as a participant among international students at
Mason. The data in this study will be confidential. The survey will not collect any
names, email addresses, or information that can identify you. While it is understood
that no computer transmission can be perfectly secure, reasonable efforts will be
made to protect the confidentiality of your transmission.Your participation is
voluntary, and you may withdraw from the study at any time and for any reason. If
you decide not to participate or if you withdraw from the study, there is no penalty.
There are no costs to you or any other party.
This research is being conducted by the Summer 2016 PROV 106: Research Methods
class at George Mason University under the supervision of Dr. Sharon DoetschKidder. She may be reached at 703-993-1160 for questions or to report a researchrelated problem. You may contact the George Mason University Office of Research
Integrity & Assurance at 703-993-4121 if you have questions or comments regarding
your rights as a participant in the research.
I have read this form, and I agree to participate in this study.
yes
no
Survey questions:
1. Gender: Female / Male
2. Age: 18-21
22-25
26-29
other______
3. Where are you from?
* U.S
* China
* Saudi Arabia
* Korea
* Canada

* Russia
* Japan
* France
* South Africa
* Other [
]
* Prefer not to answer.
4. How would you rate your mental health level?
1 2 3 4 5
(poor) (not good)
(fair) (good)(excellent)
5. Do you adapt to to American life?
1 2 3 4 5
(poorly)
(fine)
(very well)
6. Do you think what is most important mental health issue for international students
at Mason?
__anxiety
__isolation
__autism
__suicide thought
__depression
__rage
other _________________________
7. How often do you lose your sleep?
1 2 3 4 5
(not at all)(barely have)(sometimes)(very often always)
8. How often do you have homesick or missing someone?
1 2 3 4 5
(not at all)
(sometime)
(often)
9. How often do you hang out with your friends?
1 2 3 4 5
(not at all)
(sometime)
(often)
10. When you are working, how about your efficiency?
1 2 3 4 5
(low)
(normal)
(high)
11. Have you been gaining or losing much weight since you came to U.S?
1 2 3 4 5
(little)
(never change)
(much)
12. How many friends you have made in here?
1 2 3 4 5
(barely have)
(some)
(a lot)
13. Which stress level of academic work do you have?
1 2 3 4 5
(barely have)
(some)
(a lot)
14. When you feel you have stress, what will you do?
__Sleep
__Traveling
__Exercise
__Shopping
__Chanting
__Hang out
Other_______________

15. Have you ever taken any of mental care medicines?


1 2 3 4 5
(not at all)
(sometime)
(often)
16. How often do you go outside of resident?
1 2 3 4 5
(not at all)
(sometime)
(often)
17. How often do you feel too bored or too emotional?
1 2 3 4 5
(not at all)
(sometime)
(often)
18. How stressful you are when you meet a non mother language speaker?
1 2 3 4 5
(Bad)
(good)
(very good)
19. Which level you satisfied of your current life?
1 2 3 4 5
(Bad)
(good)
(very good)
20. How often do you miss your family or country?
1 2 3 4 5
(not at all)
(sometime)
(often)
21. Have you heard Counseling and Psychological Services?
1 2 3 4 5
(never)
(sometime)
(usually)
22. How often do you visited Counseling and Psychological Services ever?
1 2 3 4 5
(never)
(sometime)
(usually)
23. Do you think the Counseling and Psychological Services is helpful and useful to
you?
1 2 3 4 5
(barely have)
(some)
(a lot)