Norbeck Social Support Questionnaire
The Norbeck social support questionnaire was created by Dr. Jane S Norbeck, a professor in UCSF School of nursing. The questionnaire also known as NSSQ, is an important social support questionnaire that measures several components related to the functional properties of social support. These properties include emotional and tangible support, loss of supportive relationships, support from other sources etc.
Norbeck Social Support Questionnaire Sample
Name of the individual: _______________________________________
Sex: _______ Age: _________ Marital Status: ____________________
Address: ___________________________________________________
City: ________________ State: ______________ Zip: ______________
Telephone: ____________________ Fax: ________________________
Q1. Please list the name of significant people in your life and the relationship you share with them?
Note: Relationship includes: friend, brother, sister, mother, neighbor, father, colleague, classmate, healthcare provider, counselor, therapist, priest, others
First name Relationship
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Rate Q2- Q7 according to this scale: “0″ – Not at all; “1″ – a little; “2″ – moderately; “3″ – quite a bit; “4″ – a great deal
Q2. How much has each of these people made you feel loved or liked?
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q3. How much has each of these people made you feel admired or respected?
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q4. How much can you confide in each of them?
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q5. How much each of these people agree with or support your thought?
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q6. How much would each of these people help if you needed to borrow money, or a ride to a hospital or any other help?
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q7. If you were hospitalized and confined to bed, how much could each of them help you?
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q8. How long have you known each one of them?
“1″ – less than 6 months; “2″ – 6 to 12 months; “3″ – 1 to 2 years; “4″ – 2 to 5 years; “5″ – more than 5 years
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Q9. How frequently do you contact each one of them?
“5″-Daily / “4″-weekly / “3″-monthly / “2″-few times in a year / “1″-once a year or less
First name Rating
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Mr./Ms.
Category: Social Questionnaire