Main Study Follow-up Questionnaire

Attachment K - Follow-up Measures MAIN STUDY

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

Respondent No. ___________

A. Quality of Life SF-12 Health Survey (Ware, Kisinski, & Keller, 1996)

Please see SF-12^® in Attachment L.

B. Mental Health (SRQ-20; WHO, 1994)

1. Do you often have headaches? YES NO

2. Is your appetite poor? YES NO

3. Do you sleep badly? YES NO

4. Are you easily frightened? YES NO

5. Do your hands shake? YES NO

6. Do you feel nervous, tense or worried? YES NO

7. Is your digestion poor? YES NO

8. Do you have trouble thinking clearly? YES NO

9. Do you feel unhappy? YES NO

10. Do you cry more than usual? YES NO

11. Do you find it difficult to enjoy your daily activities? YES NO

12. Do you find it difficult to make decisions? YES NO

13. Is your daily work suffering? YES NO

14. Are you unable to play a useful part in life? YES NO

15. Have you lost interest in things? YES NO

16. Do you feel you are a worthless person? YES NO

17. Has the thought of ending your life been on your mind? YES NO

18. Do you feel tired all the time? YES NO

19. Do you have uncomfortable feelings in your stomach? YES NO

20. Are you easily tired? YES NO

C. Disability

1. During the 30 days from {date from 30 days before follow-up interview to follow-up interview}, about how many days did you miss work because of an illness or injury (do not include maternity leave)?

____ days

____ Don’t remember

____ Don’t work outside my home

2. During the 30 days from {date from 30 days before follow-up interview to follow-up interview}, about how many days were you unable to do your housework tasks because of an illness or injury (do not include maternity leave)?

____ days

____ Don’t remember

D. Health Care Utilization outside Bureau and exposure to screening

1. In the past year, that is from {date from baseline interview to follow-up interview } have you been admitted to the hospital, stayed at least one night – not just in the emergency room, at a hospital other than here at County (Stroger )?

___ Yes  How many times? ____

___ No

2. In the past year, have you gone to an Emergency Room other than here at our ER room at County (Stroger)

___ Yes  How many times? ____

___ No

3. In the past year, has a doctor, nurse, or other health care provider ever asked you if you were afraid of a current or former intimate partner or if a current or former intimate partner had hurt or threatened you? By intimate partner we mean a person you date, go out with, are romantically involved with, are married to, or live with as a couple.

___ Yes

___ No

___ Doesn’t remember/Not sure

E. Positive effects of intervention

These next questions ask for your opinions about abuse by an intimate partner. Don’t worry if you’re not sure of the answer.

1. Please think about this situation: If there were 10 women sitting in a room, how many of these women would you guess have ever been physically, verbally, emotionally, or sexually threatened or harmed by an intimate partner?

________(number, 0-10)

2. How likely is it for women threatened or harmed by an intimate partner (compared to women who have not been threatened or harmed) to have problems with their physical health? More likely, less likely, or about the same?

___ More likely

___ Equally likely

___ Less likely

3. How likely is it for women threatened or harmed by an intimate partner violence (compared to women who have not) to have problems with their mental health such as anxiety, depression, or substance abuse? More likely, less likely, or about the same?

___ More likely

___ Equally likely

___ Less likely

4. Do you agree or disagree with this statement:

“Women usually get hurt by their partners because of something they (the women) did”?

___ Agree

___ Disagree

___ Not sure

5. Do you agree or disagree with this statement: “Women who are hurt by their partners can get help if they need it”?

___ Agree

___ Disagree

___ Not sure

7. Where can a woman who is being hurt by an intimate partner get help in this community? (Do not provide options)

___ HCIP

___ Name of other local IPV resource

___ Police

___ Other

F. Exposure to Intimate Partner Violence (NVAWS, 2000)

Now we would like to know about your experiences with intimate partners. Just so you know, your answers will not be shared with anyone unless you choose to share them.

Has a person you dated, or became romantically involved with, or lived as a couple with ever:

1. tried to limit your contact with family and friends? YES NO

2. been jealous or possessive? YES NO

3. insisted on knowing who you were with at all times? YES NO

4. called you names or put you down in front of others? YES NO

5. made you feel inadequate? YES NO

6. shouted or sworn at you? YES NO

7. prevented you from having access to joint income? YES NO

8. thrown something at you that could hurt? YES NO

9. pushed, grabbed, or shoved you? YES NO

10. pulled your hair? YES NO

11. slapped or hit you? YES NO

12. kicked or bitten you? YES NO

13. choked or attempted to drown you? YES NO

14. hit you with some object? YES NO

15. beat you up? YES NO

16. used or threatened you with a knife? YES NO

17. used or threatened you with a gun? YES NO

18. made you or tried to make you have vaginal, oral or anal sex? YES NO

If yes to any of the above 

19. Are you currently with a partner who has been or is violent or threatening to you?

____Yes  20a.How long have you been with this partner?

____years or ____ months or ____weeks  GO TO Section E.

____ No  20b. How long ago did you separate from the most recent partner that was violent or threatening to you?

____years or ____ months or ____weeks

21. Have you talked to anyone about these experiences?

___ NO

___ YES  Had you already talked to somebody before you joined this study?

___ YES

___ NO

G. Side effects

Now we want you to think back to when you first got involved in this study.

1. A year ago {DATE OF BASELINE} we asked you some questions on a computer survey. Do you remember this?

__ YES

__ NO  SKIP TO Q3.

2. Because of being asked these questions, did you have any small or big problems, or no problems? Interviewers remind answers are private.

a. Big problems  What were the big problems?

b. Small problems?  What were the smaller problems?

c. Both big and small problems  What were the big problems? Smaller problems?

d. No problems at all

(Instructions to interviewers for problems probe for free text to include- description of problems including who, what, when, etc)

3. Do you remember if you received a list of services from the computer that time?

___ Yes  (continue with next question)

___ No  (skip to next section)

4. Did you share this list of services with anyone?

__ Yes  who? {interviewer probe relationship}

__ No

5. Did you use the list to contact one of the services?

___ Yes

___ No

6. Did you have any small or big problems, or no problems as a result of getting this list?

___a. Big problems  What were the big problems?

___b. Small problems?  What were the smaller problems?

___c. Both big and small problems  What were the big problems? Smaller problems?

___d. No problems at all

7. Before joining this study last year, had you ever called or visited an agency that provides help to women who have been abused by their intimate partner?

___ YES

___ NO

H. Demographics

One final question so we know a little bit of the background of those who have participated in our study.

What is the highest grade in school or year of college that you have completed? Would you say…

___ Less than high school

___ completed high school /GED

___ Trade school/vocational program after high school

___ some college but without degree

___ 2-year college graduate

___ 4-year college graduate

___ Graduate degree

___ Other

___ Don’t Know/Refused