National Intimate Partner and Sexual Violence Surveillance System (NISVSS) - Screen

National Intimate Partner and Sexual Violence Surveillance System

DRAFT Study Questionnaire

June 2009

Table of Contents

Section	Subject	Question Numbers	Page
CF	Control Form	CF1-CF20	3
RC	Respondent Characteristics	RC1-RC9	10
H	Health	H1-H8	12
PA	Psychological Aggression		15
12PA	Twelve-Month	12PA1-12PAd	15
EPA	Lifetime (Ever)	EPA1-EPAf	17
PV	Physical Violence		19
12PV	Twelve-Month	12PV1-12PVd	19
EPV	Lifetime (Ever)	EPV1-EPVf	21
CCE	Coercive Control and Entrapment		24
12CCE	Twelve-Month	12CCE1-12CCEd	24
ECCE	Lifetime (Ever)	ECCE1-ECCEf	26
S	Stalking		28
12S	Twelve-Month	12S1-12Sd	28
ES	Lifetime (Ever)	ES1-ESf	31
SFU	Stalking Follow-Up	SFU1-SFU8	34
SV	Sexual Violence		36
12SV	Twelve-Month	12SV1-12SV16	36
	12 Month SV Follow Up	12SVa- 12SVm	38
ESV	Lifetime (Ever)	ESV1- ESV16	42
	Lifetime SV Follow Up	ESVa – ESVq	44
SVFU	Sexual Violence Follow Up	SVFU1-SVFU4	48
FU	General Follow Up Questions	FU1-FU16	50
IP	Intimate Partner Information	IP1-IP4	55
W	Wrap-Up	W1 – W4	56

Conventions used in this document are as follows:

1. Programmer instructions are in curly brackets (i.e., “{ }”).

2. Interviewer instructions to be included in the CATI instrument are in flat brackets (i.e.,

“[ ]”).

3. Text for interviewers to read is in bold font.

Section CF: Control Form

CF_INTRO

Hello, I am calling on behalf of the Centers for Disease Control and Prevention, the CDC. The CDC is doing a research study on health and injuries. My name is __________. I am an interviewer with RTI International and I am part of the research team. Let me assure you that this is not a sales call. Your phone number has been chosen randomly to represent thousands of others in the country.

Are you 18 years of age or older?

[TI: IF NO, ASK TO SPEAK TO SOMEONE OVER 18.]

1 YES {go to CF1}

2 NO {go to BREAKOFF}

98 (VOL) DK {go to CF1}

99 (VOL) RF {go to BREAKOFF}

CF1

Is this {fill: phone number}?

1 YES {go to CF2}

2 NO {go to CF1_1}

5 LANGUAGE BARRIER {go to BREAKOFF}

9 MORE CODES {go to MORE CODES}

98 (VOL) DK {go to CF1_1}

99 (VOL) RF {go to BREAKOFF}

CF1_1

I seem to have dialed the wrong number. Thank you very much for your assistance.

[TI: REDIAL NUMBER TO CONFIRM INCORRECT]

CF2

I need to ask you a few questions in order to determine your eligibility for CDC’s study.

Is this a cell phone?

1 YES {go to CF3}

2 NO {go to CF7}

98 (VOL) DK {go to BREAKOFF}

99 (VOL) RF {go to BREAKOFF}

(cell phone path = CF3 – CF6b) (landline path = CF7 – CF14)

CF3

Are you driving a vehicle at this moment?

1 YES {go to CF3_1}

2 NO {go to CF4}

CF3_1

When would be a better time to call you?

[If respondent indicates that they are willing to talk now: “I’m sorry, but for your safety we’re not able to do the interview while you’re driving. When would be a better time to call you?”]

[SET CALLBACK]

CF4

Including this one, how many working cell phones do you have?

[RECORD NUMBER OF CELL PHONES] {go to CF5}

[RANGE 1-9]

98 (VOL) DK

99 (VOL) RF

CF5

Now excluding cell phones, how many telephone numbers do you have in your household that are used for talking rather than only for machines like faxes and computers?

[RECORD NUMBER OF OTHER PHONE NUMBERS] {go to CF6}

[RANGE 0-5]

98 (VOL) DK

99 (VOL) RF

CF6

Including yourself, how many people who are 18 or older reside in your household?

[RECORD NUMBER OF PEOPLE]

[RANGE 1-9]

98 (VOL) DK

99 (VOL) RF

{go to CF15}

{end of cell phone path, beginning landline path}

CF7

Is this a private residence?

1 YES {go to CF8}

2 NO {go to CF7_1}

98 (VOL) DK {go to CF7_1}

99 (VOL) RF {go to CF7_1}

CF7_1

Thank you very much, but we are only interviewing people in private residences.

[TERMINATE INTERVIEW]

CF8

Including the number I just dialed, how many different telephone numbers do you have in your household that are used for talking, excluding cell phones or telephone lines that are used only for machines like faxes and computers?

[RECORD NUMBER OF TELEPHONE NUMBERS] {go to CF9}

[RANGE 1-5]

98 (VOL) DK

99 (VOL) RF

CF9

How many working cell phones do you have?

[RECORD NUMBER OF CELL PHONES] {if 0, go to CF10; else go to CF11}

[RANGE 0 - 9]

98 (VOL) DK

99 (VOL) RF

CF10

Does anyone else in your household have a working cell phone?

1 YES {go to CF11}

2 NO {go to CF11}

98 (VOL) DK {go to CF11}

99 (VOL) RF {go to CF11}

CF11

We need to randomly select one adult who lives in your household to be interviewed. How many adults age 18 and older live in your household?

[RECORD NUMBER OF ADULTS] {if CF11=0, go to CF11_1; if CF11=1, go to CF12; if CF11 ≥ 2, go to CF13}

[RANGE 1 – 10]

98 (VOL) DK

99 (VOL) RF

CF11_1

We are only interviewing adults age 18 and older, so those are all the questions I have for you. Thank you for your time.

[TERMINATE INTERVIEW – CODE AS INELIGIBLE AGE]

CF12

Are you the adult?

1 YES {go to CF12_1}

2 NO {go to CF13}

98 (VOL) DK

99 (VOL) RF

CF12_1

Then you are the person I need to interview.

[IF NECESSARY: Are you male or female?]

1. MALE (go to CF15}

2. FEMALE {go to CF15}

98 (VOL) DK

99 (VOL) RF

CF13

How many of these adults are men and how many are women?

[RECORD NUMBER OF MEN / NUMBER OF WOMEN] {go to CF14}

98 (VOL) DK

99 (VOL) RF

CF14

My computer will randomly select the adult from your household that will be interviewed.

The person in your household that I need to interview is the {fill: man / woman} with the most recent birthday.

Are you that person?

1 YES {go to CF15}

2 NO {go to CF17}

98 DK {go to CF19}

CF15

May I have your first name in case we get disconnected? Please do not tell me your last name, your address, or any other information that would identify you.

[RECORD RESPONDENT’S FIRST NAME ONLY]

[IF RESPONDENT REFUSES, ASK FOR A FIRST INITIAL. IF RESPONDENT STILL REFUSES, BREAK OFF AND CODE AS REFUSAL.]

CF_INTRO1

You have been randomly chosen to participate in an important study. The Centers for Disease Control and Prevention (CDC) is doing a telephone study of 10,000 people. You may have received a letter from us. Men and women age 18 and older will be asked questions about their health and injuries they may have experienced. The data we are collecting are very important, and will be used to guide national policies.

The survey will take between 20 and 25 minutes. We will do this survey over the phone right now or at another time that is better for you. Since some of the questions are personal, we suggest that you be in a private setting during the survey.

There are minimal benefits or risks to being in this voluntary study. In order to keep your information private, the answers you give us will be combined with the answers from other people who are in the survey. No information that could personally identify you will be given to anyone else. You can skip any question or stop the survey at any time.

If you complete the survey, as a token of our appreciation we will send you a check for $10 or make a donation to the United Way on your behalf, whichever you prefer. We will ask your preference at the end of the survey.

If you choose to receive the $10, I will go to a separate computer file after we finish the survey and collect your name and address so that we can mail the check to you. Your name and address will not be connected to the information you provide in the survey, and will be erased from our files at the end of this study.

If you have questions or concerns about participating in the study, you may call the Survey Manager, Susan Twiddy, at 1-877-XXX-XXXX. If you have questions about your rights as a participant, please call the CDC at 1-800-XXX-XXXX. Please leave a message with your name and phone number, and mention that you are calling about study # XXXX.

May we begin?

1. YES {go to RC_1}

2. NO {go to CF16}

98 (VOL) DK {go to CF16}

99 (VOL) RF {go to CF16}

CF16

Could you please tell me why you do not wish to participate in the study?

1 DOES NOT HAVE TIME {go to BREAKOFF, set callback}

2 INCONVENIENT NOW {go to BREAKOFF, set callback}

3 NOT INTERESTED

4 DOES NOT PARTICIPATE IN SURVEYS

5 OPPOSES GOV’T INTRUDING ON PRIVACY

6 TOO PRIVATE/SENSITIVE/EMBARASSING

7 OTHER (SPECIFY) _____________ (max 50 characters)

98 (VOL) DK

99 (VOL) RF

CF17

May I have this person’s first name in case we get disconnected?

[RECORD RESPONDENT’S FIRST NAME ONLY]

[IF RESPONDENT REFUSES, ASK FOR A FIRST INITIAL. IF RESPONDENT STILL REFUSES, BREAK OFF AND CODE AS REFUSAL.]

CF18

Is this person male or female?

1. MALE

2. FEMALE

98 (VOL) DK

99 (VOL) RF

CF19

May I speak with {fill: her/him}?

1 YES {go to CF_INTRO2}

2 NO {go to BREAKOFF}

CF_INTRO2

[WHEN SELECTED RESPONDENT COMES TO THE PHONE]

Hello, I am calling on behalf of the Centers for Disease Control and Prevention, the CDC. The CDC is doing a study on health and injuries. My name is __________. I am an interviewer with RTI International and I am part of the research team. Let me assure you that this is not a sales call.

CF_INTRO3

You have been randomly chosen to participate in an important study. The Centers for Disease Control and Prevention (CDC) is sponsoring this telephone study of 10,000 people. You may have received a letter from us. Men and women age 18 and older will be asked questions about their experiences with health and injuries. The data we are collecting are very important, and will be used to guide national policies.

The survey will take between 20 and 25 minutes. We will do this survey over the phone right now or at another time that is better for you. Since some of the questions are personal, we suggest that you be in a private setting during the survey.

There are minimal benefits or risks to being in this voluntary study. In order to keep your information private, the answers you give us will be combined with the answers from other people who are in the survey. No information that could personally identify you will be given to the CDC or anyone else. You can skip any question or stop the survey at any time.

If you complete the survey, as a token of our appreciation we will send you a check for $10 or make a donation to the United Way on your behalf, whichever you prefer. We will ask your preference at the end of the survey.

If you choose to receive the $10, I will go to a separate computer file after we finish the survey and collect your name and address so that we can mail the check to you. Your name and address will not be connected to the information you provide in the survey, and will be erased from our files at the end of this study.

If you have questions or concerns about participating in the study, you may call the Survey Manager, Susan Twiddy, at 1-877-XXX-XXXX. If you have questions about your rights as a participant, please call the CDC at 1-800-XXX-XXXX. Please leave a message with your name and phone number, and mention that you are calling about study # XXXX.

May we begin?

1. YES {go to RC_INTRO}

2. NO {go to CF20}

98 (VOL) DK {go to CF20}

99 (VOL) RF {go to CF20}

CF20

Could you please tell me why you do not wish to participate in the study?

1 DOES NOT HAVE TIME {go to BREAKOFF, set callback}

2 INCONVENIENT NOW {go to BREAKOFF, set callback}

3 NOT INTERESTED

4 DOES NOT PARTICIPATE IN SURVEYS

5 OPPOSES GOV’T INTRUDING ON PRIVACY

6 TOO PRIVATE/SENSITIVE/EMBARASSING

7 OTHER (SPECIFY) _____________ (max 50 characters)

98 (VOL) DK

99 (VOL) RF

Section RC: Respondent Characteristics

RC1

What year were you born?

[ELIGIBLE YEARS OF BIRTHS ARE: ]

[INTERVIEWER: IF YEAR OF BIRTH IS OUTSIDE ELIGIBLE RANGE, SAY: “I’m sorry, but we’re only speaking with people age 18 and older. I will have to end the interview now. Thank you for your interest, and have a nice day / evening.”]

RC2

What is the highest level of education you have completed?

1 NO SCHOOLING

2 1st‑8th GRADE

3 SOME HIGH SCHOOL

4 HIGH SCHOOL GRADUATE

5 TECHNICAL OR VOCATIONAL SCHOOL (ATTENDED OR GRADUATED)

6 SOME COLLEGE

7 4-YEAR COLLEGE DEGREE

8 POSTGRADUATE

98 (VOL) DK

99 (VOL) RF

RC3

Are you of Hispanic or {if female: Latina; if male: Latino} origin?

1 YES {go to RC3a}

2 NO {go to RC4}

98 (VOL) DK

99 (VOL) RF

RC3a

Which of these Hispanic, Latino, or Spanish groups best describes you?

1 Mexican, Mexican American, Mexicano, Chicano,

2 Puerto Rican,

3 Cuban/Cuban American,

4 Dominican [IF NECESSARY: from the Dominican Republic],

5 Central or South American, or

6 Spanish [IF NECESSARY: from Spain]

7 OTHER, SPECIFY {max 25 characters}

RC4

What is your race? You may identify more than one category. Would you say you are . . .

[CODE ALL THAT APPLY]

1 White or Caucasian

2 Black or African American

3 Asian

4 Native Hawaiian or other Pacific Islander, or

5 American Indian or Alaskan Native? {go to RC5, else go to RC6}

6 OTHER, SPECIFY {max 25 characters}

98 (VOL) DK

99 (VOL) RF

RC5

Are you a member of a tribe or village?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

RC6

Is there {fill: if RC3 = 1, another; else, an} ethnic group or culture that you identify with?

1 YES {go to RC6a}

2 NO {go to RC7}

98 (VOL) DK

99 (VOL) RF

RC6a

What ethnic group do you identify with?

[RECORD NAME OF ETHNIC GROUP] {max 25 characters}

RC7

What was the total income from ALL household members during {fill: most recently ended calendar year}, before taxes. Include income from all sources such as work, investments, child support and public assistance. Was it…

RC7a Less than $25,000? {If RC7a=2, go to RC7e; if RC7a=1, go to RC7b}

($20,000 to less than $25,000)

RC7b Less than $20,000? {if RC7b=2, go to RC8; if RC7b=1 go to RC7c}

($15,000 to less than $20,000)

RC7c Less than $15,000? {if RC7c=2, go to RC8; if RC7c=1 go to RC7d}

($10,000 to less than $15,000)

RC7d Less than $10,000? {go to RC8}

RC7e Less than $35,000? {If RC7e=2, go to RC7f; if RC7e=1, go to RC8}

($25,000 to less than $35,000)

RC7f Less than $50,000? {If RC7f=2, go to RC7g; if RC7f=1, go to RC8}

($35,000 to less than $50,000)

RC7g Less than $75,000? {If RC7g=2, go to RC7h; if RC7g=1, go to RC8}

($50,000 to less than $75,000)

RC7h $75,000 or more?

98 (VOL) DK

99 (VOL) RF

RC8

Have you been without any telephone service for more than two weeks at any point since {insert date one year before today’s date}?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

RC9 What is your zip code?

[RECORD ZIP CODE]

Section H: Health Questions

H1

The following questions are about health care and health problems.

Have you ever been told by a doctor, nurse, or other health professional that you had…

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H1A Asthma?

H1IBS Irritable bowel syndrome or IBS?

H1D Diabetes?

H1HBP High blood pressure?

H2

Do you have…

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H2FH Frequent headaches?

H2CP Chronic pain?

H2DS Difficulty sleeping?

H3

Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H4

Are any of your activities limited in any way because of physical, mental, or emotional problems?

1 YES {go to H4a}

2 NO {go to H5}

98 (VOL) DK

99 (VOL) RF

H4a

How long have you been limited in this way?

[READ IF NECESSARY]

1 Less than 1 year

2 More than 1 year but less than 3 years

3 3 or more years

98 (VOL) DK

99 (VOL) RF

H5

Do you have any health problems that require you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?

[TI INSTRUCTION: INCLUDE OCCASIONAL USE OR USE IN CERTAIN CIRCUMSTANCES.]

1 YES {go to H5a}

2 NO {go to H6}

98 (VOL) DK

99 (VOL) RF

H5a

How long have you been using this equipment?

[READ IF NECESSARY]

1 Less than 1 year

2 More than 1 year but less than 3 years

3 3 or more years

98 (VOL) DK

99 (VOL) RF

H6

Would you say that in general your physical health is…

1 Excellent,

2 Very good,

3 Good,

4 Fair, or

5 Poor

98 (VOL) DK

99 (VOL) RF

H7

Would you say that in general your mental health is…

1 Excellent,

2 Very good,

3 Good,

4 Fair, or

5 Poor

98 (VOL) DK

99 (VOL) RF

H8

Have you ever had any children under the age of 18 living with you?

1 YES {go to VIC_INTRO}

2 NO {go to VIC_INTRO}

98 (VOL) DK

99 (VOL) RF

victimization questions

VIC_INTRO

The next set of questions asks about experiences that may or may not have happened to you. There will be some questions about physical injuries, harassing behaviors and unwanted sexual activity.

Remember, you don’t have to answer any question that you don’t want to. We suggest that you be in a private setting during the survey. If, at any time, you do not feel physically or emotionally safe, you can just say “Goodbye”. I will understand and I will not call you back. You can call me back if you’d like at 1-877-XXX-XXXX.

VIC_INTROa

Do you have any questions?

1 YES [ANSWER ALL QUESTIONS] {go to VIC_INTROb}

2 NO {go to VIC_INTROb}

98 (VOL) DK

99 (VOL) RF

VIC_INTROb

The next questions ask about experiences you’ve had with romantic partners. By romantic partner, I mean any current or former spouse, boyfriend or girlfriend, or person that you have dated.

Psychological Aggression (PA)

PA

How many of your romantic partners have ever…?

[RECORD NUMBER OF PARTNERS FOR EACH ITEM]

[RANGE 0 – 9 PARTNERS]

PA1 acted very angry towards you in a way that seemed dangerous?

PA2 told you that you were a loser, a failure, or not good enough?

PA3 called you names like ugly, fat, crazy, or stupid?

How many of your romantic partners have ever…?

PA4 insulted, humiliated, or made fun of you in front of others?

PA5 told you that no one else would want you?

{if R endorses an item, ask PAa – PAh for that item, then loop back to next PA item, or if multiple perps for an item, ask PAa – PAh for each perp, then loop back to next PA item}

{once initials are collected 1^st time, for each additional endorsed item, ask PAi}

PAi

Was it {fill: 1^st set of initials}?

1 YES {go to PAb}

2 NO {if any other initials recorded, ask PAi for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to PAa}

98 (VOL) DK

99 (VOL) RF

PAa

{if 1^st time collecting initials, read: I’d like for you to tell me some way that we can refer to {fill: if any PA1 – 5 =1, this person; if any PA1 – 5 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any PA1 – 5 =1, this person; if any PA1 – 5 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any PA1 – 5 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR IP]

{if any PA1 – 5 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

PAb

{for each set of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} ever {fill: behavior}? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

PAc

{Fill: Has this person / Have any of these people} {fill: behavior} in the past three years, that is since {fill: date, 3 years ago}?

1 YES {go to PAd}

2 NO {loop back to next PA item until all are complete}

98 (VOL) DK

99 (VOL) RF

PAd

{if more than one set of initials reported at PAa: Which of these people have {fill: behavior} in the past three years?

[RECORD INITIALS FOR IP]

PAe

{for all sets of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past three years? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

PAf

{for all initials endorsed at PAd}

{Fill: Has this person / Have any of these people} {fill: behavior} in the past twelve months, that is since {fill: date, 12 months ago}?

1 YES {go to PAg}

2 NO {loop back to next PA item until all are complete}

98 (VOL) DK

99 (VOL) RF

PAg

{if more than one set of initials reported at PAd: Which of these people have {fill: behavior} in the past twelve months?

[RECORD INITIALS FOR IP]

PAh

{for all sets of initials endorsed at PAg, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past twelve months? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

{loop back to next PA item until all are complete}

Physical VIOLENCE (PV)

PV

How many of your romantic partners have ever…?

[RECORD NUMBER OF PARTNERS FOR EACH ITEM]

[RANGE 0 – 9 PARTNERS]

PV1 slapped you?

PV2 pushed or shoved you?

PV3 hit you with a fist or something hard?

How many of your romantic partners have ever…?

PV4 kicked you?

PV5 hurt you by pulling your hair?

PV6 slammed you against something?

How many of your romantic partners have ever…?

PV7 forced you to engage in sexual activity?

PV8 tried to hurt you by choking or suffocating you?

PV9 beaten you?

How many of your romantic partners have ever…?

PV10 made threats to physically harm you?

PV11 used a knife or gun on you?

{if R endorses an item, ask PVa – PVh for that item, then loop back to next PV item, or if multiple perps for an item, ask PVa – PVh for each perp, then loop back to next PV item}

{once initials are collected 1^st time, for each additional endorsed item, ask PVi}

PVi

Was it {fill: 1^st set of initials}?

1 YES {go to PVb}

2 NO {if any other initials recorded, ask PVi for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to PVa}

98 (VOL) DK

99 (VOL) RF

PVa

{if 1^st time collecting initials, read: I’d like for you to tell me some way that we can refer to {fill: if any PV1 – 11 =1, this person; if any PV1 – 11 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any PV1 – 11 =1, this person; if any PV1 – 11 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any PV1 – 11 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR IP]

{if any PV1 – 11 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

PVb

{for each set of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} ever {fill: behavior}? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

PVc

{Fill: Has this person / Have any of these people} {fill: behavior} in the past three years, that is since {fill: date, 3 years ago}?

1 YES {go to PVd}

2 NO {loop back to next PV item until all are complete}

98 (VOL) DK

99 (VOL) RF

PVd

{if more than one set of initials reported at PVa: Which of these people have {fill: behavior} in the past three years?

[RECORD INITIALS FOR IP]

PVe

{for all sets of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past three years? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

PVf

{for all initials endorsed at PVd}

{Fill: Has this person / Have any of these people} {fill: behavior} in the past twelve months, that is since {fill: date, 12 months ago}?

1 YES {go to PVg}

2 NO {loop back to next PV item until all are complete}

98 (VOL) DK

99 (VOL) RF

PVg

{if more than one set of initials reported at PVd: Which of these people have {fill: behavior} in the past twelve months?

[RECORD INITIALS FOR IP]

PVh

{for all sets of initials endorsed at PVg, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past twelve months? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

{loop back to next PV item until all are complete}

Coercive Control and Entrapment (CCE)

CCE

How many of your romantic partners have ever…?

[RECORD NUMBER OF PARTNERS FOR EACH ITEM]

[RANGE 0 – 9 PARTNERS]

CCE1 tried to keep you from seeing or talking to your family or friends?

CCE2 made decisions for you that should have been yours to make, such as the clothes you wear, things you eat, or the friends you have?

CCE3 kept track of you by demanding to know where you were and what you were doing?

How many of your romantic partners have ever…?

CCE4 threatened to hurt him or herself or commit suicide when he or she was upset with you?

CCE5 threatened to hurt you or someone you love?

CCE6 {if H8=1} threatened to take your children away from you?

How many of your romantic partners have ever…?

CCE7 kept you from leaving the house when you wanted to go?

CCE8 kept you from having money for your own use?

CCE9 said things like “If I can’t have you, then no one can”?

How many of your romantic partners have ever…?

CCE10 {if female, fill: tried to get you pregnant when you did not want to become pregnant; if male, fill: tried to get pregnant when you did not want them to get pregnant} or tried to stop you from using birth control?

CCE11 {if female} refused to use a condom when you wanted him to use one?

{if R endorses an item, ask CCEa – CCEh for that item, then loop back to next CCE item, or if multiple perps for an item, ask CCEa – CCEh for each perp, then loop back to next CCE item}

{once initials are collected 1^st time, for each additional endorsed item, ask CCEi}

CCEi

Was it {fill: 1^st set of initials}?

1 YES {go to CCEb}

2 NO {if any other initials recorded, ask CCEi for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to CCEa}

98 (VOL) DK

99 (VOL) RF

CCEa

{if 1^st time collecting initials, read: I’d like for you to tell me some way that we can refer to {fill: if any CCE1 – 10 =1, this person; if any CCE1 – 10 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any CCE1 – 10 =1, this person; if any CCE1 – 10 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any CCE1 – 10 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR IP]

{if any CCE1 – 10 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

CCEb

{for each set of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} ever {fill: behavior}? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

CCEc

{Fill: Has this person / Have any of these people} {fill: behavior} in the past three years, that is since {fill: date, 3 years ago}?

1 YES {go to CCEd}

2 NO {loop back to next CCE item until all are complete}

98 (VOL) DK

99 (VOL) RF

CCEd

{if more than one set of initials reported at CCEa: Which of these people have {fill: behavior} in the past three years?

[RECORD INITIALS FOR IP]

CCEe

{for all sets of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past three years? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

CCEf

{for all initials endorsed at CCEd}

{Fill: Has this person / Have any of these people} {fill: behavior} in the past twelve months, that is since {fill: date, 12 months ago}?

1 YES {go to CCEg}

2 NO {loop back to next CCE item until all are complete}

98 (VOL) DK

99 (VOL) RF

CCEg

{if more than one set of initials reported at CCEd: Which of these people have {fill: behavior} in the past twelve months?

[RECORD INITIALS FOR IP]

CCEh

{for all sets of initials endorsed at CCEg, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past twelve months? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

{loop back to next PV item until all are complete}

12 month non-ip psychological aggression

{if R is 56 or older, ask; else skip to S_INTRO}

12PA2_INTRO

The next questions ask about experiences you’ve had with people other than your romantic partners in the past 12 months, such as family members, friends, other people you knew, or strangers.

12PA2

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

[RECORD NUMBER OF PEOPLE FOR EACH ITEM]

[RANGE 0 – 9 PEOPLE]

12PA2_1 acted very angry towards you in a way that seemed dangerous?

12PA2_2 told you that you were a loser, a failure, or not good enough?

12PA2_3 called you names like ugly, fat, crazy, or stupid?

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

12PA2_4 insulted, humiliated, or made fun of you in front of others?

12PA2_5 told you that no one else would want you?

{if R endorses an item, ask 12PA2a – 12PA2d for that item, then loop back to next 12PA2 item, or if multiple perps for an item, ask 12PA2a – 12PA2d for each perp, then loop back to next 12PA2 item}

{once initials are collected 1^st time, for each additional endorsed item, ask 12PA2i}

12PA2i

Was it {fill: 1^st set of initials}?

1 YES {go to 12PA2b}

2 NO {if any other initials recorded, ask 12PA2i for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to 12PA2a}

98 (VOL) DK

99 (VOL) RF

12PA2a

I’d like for you to tell me some way that we can refer to {fill: if any 12PA2_1 – 5 =1, this person; if any 12PA2_1 – 5 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any 12PA2_1 – 5 =1, this person; if any 12PA2_1 – 5 > 1, these people} you’ll know who I’m talking about. Would you tell me the initials of the {fill: if any 12PA2_1 – 5 > 1, first} person who{fill: behavior} in the past 12 months?

[RECORD INITIALS FOR PERP]

{if any 12PA2_1 – 5 > 1, ask Would you tell me the initials of the {fill: if any 12PA2_1 – 5 > 1, next} person who {fill: behavior} in the past 12 months?, until # of sets of initials = number of reported people}

12PA2b

In the past 12 months, since {fill: month, year 12 mos. ago}, how often did {fill: initials} {fill: behavior}? Would you say…

1 Rarely,

2 Sometimes, or

3 Frequently?

98 (VOL) DK

99 (VOL) RF

12PA2c

What was your relationship to {fill: initials} the first time he or she {fill: behavior}?

[NON-IP CATEGORIES:

6 FAMILY MEMBER

Mother/father

Step-mother/step-father

Foster parent (male/female)

Brother/step brother

Sister/step sister

Brother/sister in-law

Uncle/Aunt

Cousin

Grandmother/grandfather

Other male relative, specify__________

Other female relative, specify__________

7 ACQUAINTANCE

First date

Someone known for less than 24 hours

Friend

Family friend

Boss/supervisor/superior in command

Teacher, professor, teaching assistant, coach

Clergy

Doctor, nurse or therapist

Other acquaintance, specify_____________

(Neighbor, classmate, roommate, neighbor, coworker, customer, client

8. STRANGER

9. other, specify {max 25 characters}

12PA2d

[IF NECESSARY]

Is {fill: initials} male or female?

1. MALE

1. FEMALE

98 (VOL) DK

99 (VOL) RF

{loop back to next 12PA2 item until all are complete}

12 month non-ip physical violence

{if R is 56 or older, ask; else skip to S_INTRO}

12PV2_INTRO

The next questions ask about experiences you’ve had with people other than your romantic partners in the past 12 months, such as family members, friends, other people you knew, or strangers.

12PV2

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

[RECORD NUMBER OF PEOPLE FOR EACH ITEM]

[RANGE 0 – 9 PEOPLE]

12PV2_1 pushed or shoved you?

12PV2_2 slapped you?

12PV2_3 hit you with a fist or something hard?

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

12PV2_4 kicked you?

12PV2_5 hurt you by pulling your hair?

12PV2_6 slammed you against something?

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

12PV2_7 forced you to engage in sexual activity?

12PV2_8 tried to choke or smother you?

12PV2_9 beaten you?

12PV2_10 threatened you with or used a knife or gun on you?

{if R endorses an item, ask 12PV2a – 12PV2d for that item, then loop back to next 12PV2 item, or if multiple perps for an item, ask 12PV2a – 12PV2d for each perp, then loop back to next 12PV2 item}

{once initials are collected 1^st time, for each additional endorsed item, ask 12PV2i}

12PV2i

Was it {fill: 1^st set of initials}?

1 YES {go to 12PV2b}

2 NO {if any other initials recorded, ask 12PV2i for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to 12PV2a}

98 (VOL) DK

99 (VOL) RF

12PV2a

I’d like for you to tell me some way that we can refer to {fill: if any 12PV2_1 – 10 =1, this person; if any 12PV2_1 – 10 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any 12PV2_1 – 10 =1, this person; if any 12PV2_1 – 10 > 1, these people} you’ll know who I’m talking about. Would you tell me the initials of the {fill: if any 12PV2_1 – 10 > 1, first} person who{fill: behavior} in the past 12 months?

[RECORD INITIALS FOR PERP]

{if any 12PV2_1 – 10 > 1, ask Would you tell me the initials of the {fill: if any 12PV2_1 – 10 > 1, next} person who {fill: behavior} in the past 12 months?, until # of sets of initials = number of reported people}

12PV2b

In the past 12 months, since {fill: month, year 12 mos. ago}, how many times did {fill: initials} {fill: behavior}?

[RECORD NUMBER OF TIMES]

[RANGE = 1 – 99]

[TI INSTRUCTION: IF RESPONDENT SAYS MORE THAN 99 TIMES, RECORD 99]

12PV2c

What was your relationship to {fill: initials} the first time he or she {fill: behavior}?

[NON-IP CATEGORIES:

6 FAMILY MEMBER

Mother/father

Step-mother/step-father

Foster parent (male/female)

Brother/step brother

Sister/step sister

Brother/sister in-law

Uncle/Aunt

Cousin

Grandmother/grandfather

Other male relative, specify__________

Other female relative, specify__________

7 ACQUAINTANCE

First date

Someone known for less than 24 hours

Friend

Family friend

Boss/supervisor/superior in command

Teacher, professor, teaching assistant, coach

Clergy

Doctor, nurse or therapist

Other acquaintance, specify_____________

(Neighbor, classmate, roommate, neighbor, coworker, customer, client

8 STRANGER

9 other, specify {max 25 characters}

12PV2d

[IF NECESSARY]

Is {fill: initials} male or female?

1. MALE

2. FEMALE

98 (VOL) DK

99 (VOL) RF

{loop back to next 12PV2 item until all are complete}

12 Month non-ip Coercive Control and Entrapment

{if R is 56 or older, ask; else skip to S_INTRO}

12CCE2_INTRO

The next questions ask about experiences you’ve had with people other than your romantic partners in the past 12 months, such as family members, friends, other people you knew, or strangers.

12CCE2

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

[RECORD NUMBER OF PEOPLE FOR EACH ITEM]

[RANGE 0 – 9 PEOPLE]

12CCE2_1 tried to keep you from seeing or talking to your family or friends?

12CCE2_2 made decisions for you that should have been yours to make, such as the clothes you wear, things you eat, or the friends you have?

12CCE2_3 kept track of you by demanding to know where you were and what you were doing?

During the past 12 months, since {fill: month, year 12 mos. ago}, how many people have…?

12CCE2_4 threatened to hurt him or herself or commit suicide when he or she was upset with you?

12CCE2_5 threatened to hurt you or someone you love?

12CCE2_6 {if H8=1} threatened to take your children away from you?

During the past 12 months, since {fill: month, year 12 mos. ago}, how many of your people have…?

12CCE2_7 kept you from leaving the house when you wanted to go?

12CCE2_8 kept you from having money for your own use?

12CCE2_9 said things like “If I can’t have you, then no one can”?

{if R endorses an item, ask 12CCE2a – 12CCE2d for that item, then loop back to next 12CCE2 item, or if multiple perps for an item, ask 12CCE2a – 12CCE2d for each perp, then loop back to next 12CCE2 item}

{once initials are collected 1^st time, for each additional endorsed item, ask 12CCE2i}

12CCE2i

Was it {fill: 1^st set of initials}?

1 YES {go to 12CCE2b}

2 NO {if any other initials recorded, ask 12CCE2i for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to 12CCE2a}

98 (VOL) DK

99 (VOL) RF

12CCE2a

I’d like for you to tell me some way that we can refer to {fill: if any 12CCE2_1 – 9 =1, this person; if any 12CCE2_1 – 9 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any 12CCE2_1 – 9 =1, this person; if any 12CCE2_1 – 9 > 1, these people} you’ll know who I’m talking about. Would you tell me the initials of the {fill: if any 12CCE2_1 – 9 > 1, first} person who{fill: behavior} in the past 12 months?

[RECORD INITIALS FOR PERP]

{if any 12CCE2_1 – 9 > 1, ask Would you tell me the initials of the {fill: if any 12CCE2_1 – 9 > 1, next} person who {fill: behavior} in the past 12 months?, until # of sets of initials = number of reported people}

12CCE2b

In the past 12 months, since {fill: month, year 12 mos. ago}, how often did {fill: initials} {fill: behavior}? Would you say…

1 Rarely,

2 Sometimes, or

3 Frequently?

98 (VOL) DK

99 (VOL) RF

12CCE2c

What was your relationship to {fill: initials} the first time he or she {fill: behavior}?

[NON-IP CATEGORIES:

6 FAMILY MEMBER

Mother/father

Step-mother/step-father

Foster parent (male/female)

Brother/step brother

Sister/step sister

Brother/sister in-law

Uncle/Aunt

Cousin

Grandmother/grandfather

Other male relative, specify__________

Other female relative, specify__________

7 ACQUAINTANCE

First date

Someone known for less than 24 hours

Friend

Family friend

Boss/supervisor/superior in command

Teacher, professor, teaching assistant, coach

Clergy

Doctor, nurse or therapist

Other acquaintance, specify_____________

(Neighbor, classmate, roommate, neighbor, coworker, customer, client)

8 STRANGER

9 other, specify {max 25 characters}

12CCE2d

[IF NECESSARY]

Is {fill: initials} male or female?

1 MALE

2 FEMALE

98 (VOL) DK

99 (VOL) RF

{loop back to next 12CCE2 item until all are complete}

Section S: Stalking

S_INTRO

I’m going to ask you some questions about times when you may have been contacted, followed or harassed on more than one occasion. When answering, please think about anyone who may have done these things to you, including romantic partners, other people you knew, or strangers. Please do not include bill collectors, telephone solicitors, or other sales people.

STALKING (S)

[TI NOTE: IF RESPONDENT REPORTS SUSPISCION OF PERSON HAVING DONE SOMETHING, BUT NO PROOF, THEY SHOULD COUNT THAT PERSON]

S

How many people have ever…?

[RECORD NUMBER OF PEOPLE FOR EACH ITEM]

[RANGE 0 – 15 PEOPLE]

S1 repeatedly made unwanted phone calls to you or left you messages? This includes hang-ups, text or voice messages.

S2 repeatedly sent you unwanted emails, instant messages, or sent messages through websites like MySpace or Facebook?

S3 repeatedly left you unwelcome cards, letters, flowers, or presents when they knew you didn’t want them to?

How many people have ever…?

S4 watched or followed you from a distance, or spied on you with a listening device, camera, or GPS [IF NECESSARY: global positioning system]?

S5 approached you or showed up in places, such as your home, workplace, or school when there wasn’t a reason for them to be there?

S6 left strange or potentially threatening items for you to find?

S7 sneaked into your home or car and did things to let you know they had been there?

{if R endorses an item, ask Sa – Sh for that item, then loop back to next S item, or if multiple perps for an item, ask Sa – Sh for each perp, then loop back to next S item}

{once initials are collected 1^st time, for each additional endorsed item, ask Si}

Si

Was it {fill: 1^st set of initials}?

1 YES {go to Sb}

2 NO {if any other initials recorded, ask Si for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to Sa}

98 (VOL) DK

99 (VOL) RF

Sa

{if 1^st time collecting initials, read: I’d like for you to tell me some way that we can refer to {fill: if any S1 – 7 =1, this person; if any S1 – 7 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any S1 – 7 =1, this person; if any S1 – 7 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any S1 – 7 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR PERP]

{if any S1 – 7 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

Sb

{for each set of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} ever {fill: behavior}? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

Sc

{Fill: Has this person / Have any of these people} {fill: behavior} in the past three years, that is since {fill: date, 3 years ago}?

1 YES {go to Sd}

2 NO {loop back to next S item until all are complete}

98 (VOL) DK

99 (VOL) RF

Sd

{if more than one set of initials reported at Sa: Which of these people have {fill: behavior} in the past three years?

[RECORD INITIALS FOR PERP]

Se

{for all sets of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past three years? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

Sf

{for all initials endorsed at Sd}

{Fill: Has this person / Have any of these people} {fill: behavior} in the past twelve months, that is since {fill: date, 12 months ago}?

1 YES {go to Sg}

2 NO {loop back to next S item until all are complete}

98 (VOL) DK

99 (VOL) RF

Sg

{if more than one set of initials reported at Sd: Which of these people have {fill: behavior} in the past twelve months?

[RECORD INITIALS FOR PERP]

Sh

{for all sets of initials endorsed at Sg, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past twelve months? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

{loop back to next S item until all are complete}

STALKING FOLLOW-UP QUESTIONS

SFU_INTRO

{establish loop for each perp initials collected, and cycle through SFU_INTRO2 – SFU4 for each perp}

Let’s talk some more about your experiences with {fill: all initials identified in S}.

SFU_INTRO2

You said that {fill: first set of initials} {fill: endorsed behaviors}.

SFU1

Overall, for how many days, weeks, months, or years did {fill: initials} do {fill: this / these things}?

[RECORD NUMBER THEN SELECT DAYS, WEEKS, MONTHS, OR YEARS]

98 (VOL) DK

99 (VOL) RF

SFU2

In general, how fearful were you when {fill: initials} did {fill: this / these things}?

Were you…

1 Very fearful,

2 Somewhat fearful,

3 A little fearful, or

4 Not at all fearful

98 (VOL) DK

99 (VOL) RF

SFU3

[TI NOTE: IF RESPONDENT SUSPECTS, BUT CANNOT PROVE, THAT THIS HAPPENED, THEY SHOULD STILL COUNT THIS AS A YES]

Did {fill: initials} ever damage your personal property or belongings, such as in your home or car?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SFU4

Did {fill: initials} ever make threats to physically harm you?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

{loop back to SFUINTRO_2 and continue with 2^nd set of initials, 3^rd set of initials, etc. until all perps have received follow-up questions SFU1 – SFU4}

Section SV: Sexual Violence

SV_INTRO

Women and men may experience unwanted and uninvited sexual situations by strangers or people they know well, such as a romantic partner, friend, teacher, coworker, supervisor, or family member. Your answers will help us learn how often these things happen. Remember, your answers are confidential, and you can skip questions you don’t want to answer.

SV

How many people have ever done any of the following things when you didn’t want it to happen? How many people have ever…

[RECORD NUMBER OF PEOPLE FOR EACH ITEM]

[RANGE 0 – 15 PEOPLE]

SV1 exposed their sexual body parts to you, flashed you, or masturbated in front of you?

SV2 made you show your sexual body parts to them? Remember, we are only asking about things that you didn’t want to happen.

SV3 made you look at or participate in sexual photos or movies?

How many people have ever…

SV4 kissed you in a sexual way? Remember, we are only asking about things you didn’t want to happen.

SV5 fondled or grabbed your sexual body parts?

Sometimes sex happens when a person is unable to consent to it or stop it from happening because they were drunk, high, drugged, or passed out from alcohol, drugs, or medications. This can include times when they voluntarily consumed alcohol or drugs or they were given drugs or alcohol without their knowledge or consent.

When you were drunk, high, drugged, or passed out and unable to consent, how many people have ever had…?

SV6 {if female} vaginal sex with you? By vaginal sex, we mean that a man or boy put his penis in your vagina.

SV7 anal sex with you? By anal sex, we mean that a man or boy put his penis in your anus.

When you were drunk, high, drugged, or passed out and unable to consent, how many people have ever…?

SV8 made you give them oral sex, meaning that they put their penis in your mouth or made you penetrate their vagina or anus with your mouth?

SV9 given you oral sex, meaning that they put their mouth on your {if male, fill: penis; if female, fill: vagina} or anus?

Some people are threatened with harm or physically forced to have sex when they don’t want to, for example, by being pinned or held down, or by using violence.

How many people have ever used physical force or threats to physically harm you to make you have…?

SV10 {if female} vaginal sex?

SV11 anal sex?

How many people have ever used physical force or threats of physical harm to…?

SV12 make you give them oral sex?

SV13 give you oral sex?

SV14 put their fingers or an object in your {if female, fill: vagina or} anus?

How many people have ever used physical force or threats of physical harm to…?

SV15 TRY to have {if female, fill: vaginal,} oral, or anal sex with you, but sex did not happen?

Sometimes unwanted sexual contact happens after a person is threatened in a nonphysical way.

How many people have ever…?

SV16 had vaginal, oral, or anal sex with you after pressuring you, for example, by threatening your job or threatening to do things like spread rumors about you or lower your school grade?

{if R endorses any 12SV6 – 12SV9, and then endorses any 12SV10 – 12SV14 and gives identical initials, ask:

SV17

Previously you told me that {fill: initials} {fill: behavior from SV6 – SV9}. Did these things happen on the same occasion?

1 YES {count follow-up questions already answered for SV6 – SV9, do not ask follow-ups for behavior endorsed from SV10 – SV14}

2 NO {continue to ask all follow-ups for behavior endorsed from SV10 – SV14}

98 (VOL) DK

99 (VOL) RF

SEXUAL VIOLENCE FOLLOW UP QUESTIONS

{if R endorses an item, ask SVa – SVn for that item, then loop back to next SV item, or if multiple perps for an item, ask SVa – SVn for each perp, then loop back to next SV item}

{once initials are collected 1^st time, for each additional endorsed item, ask SVi}

SVi

Was it {fill: 1^st set of initials}?

1 YES {go to SVb}

2 NO {if any other initials recorded, ask SVi for 2^nd set of initials; 3^rd set of initials, etc. until all have been asked; if no other initials recorded, go to SVa}

98 (VOL) DK

99 (VOL) RF

SVa

{if 1^st time collecting initials, read: I’d like for you to tell me some way that we can refer to {fill: if any SV1 – 16 =1, this person; if any SV1 – 16 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any SV1 – 16 =1, this person; if any SV1 – 16 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any SV1 – 16 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR PERP]

{if any SV1 – 16 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

SVb

{for each set of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} ever {fill: behavior}? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

SVc

{Fill: Has this person / Have any of these people} {fill: behavior} in the past three years, that is since {fill: date, 3 years ago}?

1 YES {go to SVd}

2 NO {go to SVj}

98 (VOL) DK

99 (VOL) RF

SVd

{if more than one set of initials reported at SVa: Which of these people have {fill: behavior} in the past three years?

[RECORD INITIALS FOR PERP]

SVe

{for all sets of initials, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past three years? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

SVf

{for all initials endorsed at SVd}

{Fill: Has this person / Have any of these people} {fill: behavior} in the past twelve months, that is since {fill: date, 12 months ago}?

1 YES {go to SVg}

2 NO {go to SVj}

98 (VOL) DK

99 (VOL) RF

SVg

{if more than one set of initials reported at SVd: Which of these people have {fill: behavior} in the past twelve months?

[RECORD INITIALS FOR PERP]

SVh

{for all sets of initials endorsed at SVg, fill initials 1, initials 2, etc. up to 9}

How many times did {fill: initials} {fill: behavior} in the past twelve months? Would you say…

1 One or two times,

2 Three to ten times, or

3 More than ten times?

98 (VOL) DK

99 (VOL) RF

SVj

Was {fill: initials} using alcohol, drugs or both the first time he/she {fill: behavior}?

1 ALCOHOL

2 DRUGS

3 BOTH ALCOHOL AND DRUGS

4 NEITHER ALCOHOL OR DRUGS

98 (VOL) DK

99 (VOL) RF

SVk

{if yes to any SV6 – SV9, skip SVk and go to SVl}

Were you using alcohol, drugs or both the first time {fill: initials} {fill: behavior}? Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault.

1 ALCOHOL

2 DRUGS

3 BOTH ALCOHOL AND DRUGS

4 NEITHER ALCOHOL OR DRUGS

98 (VOL) DK

99 (VOL) RF

SVl

{only ask if any SV6 – SV9 is endorsed}

Before {fill: initials} had {fill: if SV6 ≥ 1, vaginal; if SV8 or SV9 ≥ 1, oral; if SV7 ≥ 1, anal} sex with you when you were drunk, high, drugged, or passed out and unable to consent, do you think you were given drugs without your knowledge?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SVm

{only ask if any SV6 – SV9 is endorsed}

Before {fill: initials} had {fill: if SV6 ≥ 1, vaginal; if SV8 or SV9 ≥ 1, oral; if SV7 ≥ 1, anal} sex with you when you were drunk, high, drugged, or passed out and unable to consent, do you think you were given alcohol without your knowledge?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SVn

{only ask if any SV6 – SV9 is endorsed}

Before {fill: initials} had {fill: if SV6 ≥ 1, vaginal; if SV8 or SV9 ≥ 1, oral; if SV7 ≥ 1, anal} sex with you when you were drunk, high, drugged, or passed out and unable to consent, had you voluntarily used alcohol or drugs? Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault.

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

{loop back to next SV item until all are complete}

{once all gate questions have been asked, and all perps recorded, if respondent has reported more than one perpetrator total (i.e., more than one set of initials} from SV6 – SV15, ask SVo}

SVo

You’ve told me that {fill: all sets of initials} {fill: behaviors}.

Did any of these things ever involve more than one person having sex with you on the same occasion?

1 YES {go to SVp}

2 NO {go to SVFU_INTRO}

98 (VOL) DK

99 (VOL) RF

SVp

How many times has more than one person had sex with you on the same occasion?

[RECORD NUMBER OF TIMES]

SVq

How many people were involved {if 12SVl > 1, fill: the first time this happened, the second time this happened, etc.}?

[RECORD NUMBER OF PEOPLE]

SEXUAL VIOLENCE FOLLOW-UP QUESTIONS

SVFU_INTRO

{only ask SVFU questions for those who endorse any of SV6 – SV15, else skip to FU_INTRO}

{establish loop for each perp initials collected, and cycle through SVFU_INTRO2 – SFU4 for each perp}

Let’s talk some more about your experiences with {fill: all initials identified in SV}.

SVFU_INTRO2

You said that {fill: first set of initials} {fill: endorsed behaviors}.

SVFU1

Were you ever physically injured when {fill: initials} did {fill: this / any of these things}? For example, did you have bruises, vaginal or anal tears, or other internal or external injuries?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SVFU2

Did you ever get an STD or other infection when {fill: initials} did {fill: this / any of these things}? For example, did you get Chlamydia, Gonorrhea, HIV, or some other STD?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SVFU3

How old were you the first time {if only endorsed one behavior for this perp, fill: this; if endorsed more than one behavior for this perp, fill: any of these things} happened with {fill: initials}?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SVFU4

How old was {fill: initials} the first time {if only endorsed one behavior for this perp, fill: this; if endorsed more than one behavior for this perp, fill: any of these things} happened?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SVFU5

How old were you the last time {if only endorsed one behavior for this perp, fill: this; if endorsed more than one behavior for this perp, fill: any of these things} happened with {fill: initials 1}?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SECTION R: RELATIONSHIPS

R_INTRO

Let’s talk some more about your {fill: if only 1 set of initials identified, relationship; else, relationships} with {fill: all initials identified in all modules}.

You told me previously that {fill: initials 1} did {fill: this / these things}: {fill: all endorsed behaviors from all sections}.

R1

What was your relationship to {fill: initials 1} the first time {fill: this / any of these things} happened?

[INSERT REVISED LIST OF RELATIONSHIP CATEGORIES]

R2

What was your relationship to {fill: initials 1} the last time {fill: this / any of these things} happened?

[INSERT REVISED LIST OF RELATIONSHIP CATEGORIES]

R3

Do you currently have a relationship with {fill: initials 1}?

1 YES {go to R3a}

2 NO {go to R4}

98 (VOL) DK

99 (VOL) RF

R3a

What is your current relationship to {fill: initials 1}?

[INSERT REVISED LIST OF RELATIONSHIP CATEGORIES]

R4

{if R has only reported SV items, skip R4 – R6 and go to FU_INTRO}

How old were you the first time {if only endorsed one behavior for this perp, fill: this; if endorsed more than one behavior for this perp, fill: any of these things} happened with {fill: initials 1}?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

R5

How old was {fill: initials} the first time {if only endorsed one behavior for this perp, fill: this; if endorsed more than one behavior for this perp, fill: any of these things} happened?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

R6

How old were you the last time {if only endorsed one behavior for this perp, fill: this; if endorsed more than one behavior for this perp, fill: any of these things} happened with {fill: initials 1}?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

{loop back to complete relationship questions for each set of initials until all are completed}

Section FU: General follow-up Questions

FU_INTRO

Now I’d like for you to think about all of your experiences with {fill: all initials identified in all modules}.

FU1

Were you ever concerned for your safety when {fill: this / any of these things} happened with {fill: this person / any of these people}?

1 YES {go to FU1a}

2 NO {go to FU2}

98 (VOL) DK

99 (VOL) RF

FU1a

Who made you feel concerned for your safety?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU2

Were you ever fearful when {fill: this / any of these things} happened with {fill: this person / any of these people}?

1 YES {go to FU2a}

2 NO {go to FU3}

98 (VOL) DK

99 (VOL) RF

FU2a

Who made you feel fearful?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU3

Were you ever injured when {fill: this / any of these things} happened with {fill: this person / any of these people}?

1 YES {go to FU3a}

2 NO {go to FU4}

98 (VOL) DK

99 (VOL) RF

FU3a

Who caused your injuries?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU4

Did you ever need any services, such as medical, legal, or shelter services, as a result of {fill: this person / any of these people} doing {fill: this / any of these things}?

1 YES {go to FU4a}

2 NO {go to FU5}

98 (VOL) DK

99 (VOL) RF

FU4a

Who caused you to need services?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU5

Have you ever talked to your family, friends, or another romantic partner about when {fill: this / any of these things} happened with {fill: this person / any of these people}?

1 YES {go to FU5a}

2 NO {go to FU6}

98 (VOL) DK

99 (VOL) RF

FU5a

Who did you talk to your family, friends, or another romantic partner about?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU6

Have you ever talked to the police or a medical or mental health professional about when {fill: this / any of these things} happened with {fill: this person / any of these people}?

1 YES {go to FU6a}

2 NO {go to FU7}

98 (VOL) DK

99 (VOL) RF

FU6a

Who did you talk to the police or a medical or mental health professional about?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU7

Did you ever have to miss days of work or school when {fill: this / any of these things} happened with {fill: this person / any of these people}?

1 YES {go to FU7a}

2 NO {go to FU8}

98 (VOL) DK

99 (VOL) RF

98 (VOL) DK

99 (VOL) RF

FU7a

Who caused you to miss work or school?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU8

{if FU3 = Yes}

Previously, you said that {fill: 1^st set of initials from FU3a} injured you. Did those injuries include:

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

FU8_1 minor bruises or scratches?

FU8_2 cuts, major bruises, or black eyes?

FU8_3 broken bones or teeth?

FU8_4 being knocked out after getting hit, slammed against something, or choked?

FU8_5 other injuries? [SPECIFY, MAX 75 CHARACTERS]

{repeat FU8 for all initials reported at FU3a: You also said that {fill: 2^nd set of intials, 3^rd set, etc.} injured you. Did those injuries include: …}

FU9

{if FU1 or FU2 = Yes}

Previously, you said that {fill: 1^st set of initials from FU1a and/or FU2a} made you feel {if FU1 = yes, concerned for your safety; if FU2 = yes, fearful}. Throughout your relationship with {fill: initials}, when {fill: initials} did {fill: this / these things} did you ever …

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

 

FU9_1 have nightmares about it?

FU9_2 try hard not to think about it or go out of your way to avoid being reminded of it?

FU9_3 feel like you were constantly on guard, watchful, or easily startled?

FU9_4 feel numb or detached from others, your activities, or your surroundings?

{repeat FU9 for all initials reported at FU1a and/or FU2a: You also said that {fill: 2^nd set of intials, 3^rd set, etc.} made you feel {if FU1 = yes, concerned for your safety; if FU2 = yes, fearful}. Throughout your relationship with {fill: initials}, when {fill: initials} did {fill: this / these things} did you ever …}

FU10

{if FU4 = Yes}

Previously, you said that you needed services, such as medical, legal, or shelter services, as a result of {fill: 1^st set of initials from FU4a} doing {fill: this / any of these things}. Were you able to get the services that you needed?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

{if FU10 = 2}

FU10a

Which services were you not able to get? Would you say….

[CODE ALL THAT APPLY]

1 Medical services?

2 Shelter or victim’s advocate services? or

3 Police or legal services?

FU10b

Why were you not able to get the assistance that you needed when {fill: initials} did {fill: this / these things}?

[RECORD VERBATIM RESPONSE]

[MAX 250 CHARACTERS]

{repeat FU10 – FU10b for all initials reported at FU4a: You also said that you needed services, such as medical, legal, or shelter services, as a result of {fill: 2nd set of initials from FU4a, 3^rd set of initials, etc.} doing {fill: this / any of these things}. Were you able to get the services that you needed?}

Section IP: Intimate partner Questions

IP1

The last few questions are about your current relationship status.

Are you currently married, divorced, separated, widowed, or have you never been married?

1 MARRIED {go to IP4}

2 DIVORCED {go to IP2}

3 SEPARATED {go to IP2}

4 WIDOWED {go to IP2}

5 NEVER MARRIED {go to IP2}

6 OTHER (specify __________)(max 25 characters) {go to IP2}

98 (VOL) DK {go to IP2}

99 (VOL) RF {go to IP2}

IP2

Are you currently living with a man or a woman as a couple at least part of the time? By couple I mean romantically involved, not just roommates.

1 YES {go to IP4}

2 NO {go to IP3}

98 (VOL) DK {go to IP3}

99 (VOL) RF {go to IP3}

IP3

Are you currently romantically involved with someone like a boyfriend, girlfriend, or someone you are dating?

1 YES {go to IP4}

2 NO {go to W1}

8 (VOL) DK {go to W1}

9 (VOL) RF {go to W1}

IP4

{if IP3 = 1} Is the person you are romantically involved with a man or a woman?

{if IP2 = 1} Is the person you are living with as a couple male or female?

{if IP1 < 3} Is your spouse male or female?

1 MALE

2 FEMALE

98 (VOL) DK

99 (VOL) RF

Section W: Wrap-up

W1 That’s my last question in this survey. In order to mail you your check for $10, I need to collect your full name and mailing address. This information will never be connected with your answers in the survey.

[RECORD NAME AND ADDRESS]

W2 If you have any questions or concerns about participating in the survey, please feel free to call the survey manager, Susan Twiddy at 1-877-XXX-XXXX. You will hear an option to speak with a project staff member.

W3 If you or anyone you know is ever in immediate danger, call 911 or your local police. If you or anyone you know is concerned about intimate partner violence or sexual violence, you can also call confidential toll-free numbers for information. If you have a paper and pencil I can give you those numbers now. [Ask respondent what number they want and then read it slowly so he or she can get it down.]

National Domestic Violence Hotline: The number is 1-800-799-SAFE (7233).

The Rape, Abuse and Incest National Network: The number is 1-800-656-HOPE (4673).

W4 That completes the interview. Thank you for your participation.

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