Phase II Questionnaire - attachment 11

Testing of Sexual Violence Definitions and Recommended Data Elements in Three Different Racial/Ethnic Minority Communities

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Testing of Sexual Violence Definitions and Recommended Data Elements in Three Different Racial/Ethnic Minority Communities (Phase 2- Main Survey)

OMB: 0920-0796

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Section 0: Respondent Characteristics


Appendix 11: Phase II Questionnaire


Form Approved

OMB No. 0920-0796

Exp. Date 01/31/2012


Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information , including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd NE, MS E-11, Atlanta, GA 30333; ATTN: PRA (0920-0796).



Thank you very much for agreeing to participate in our study. The questions I will ask during the interview will be very specific. Please feel free to ask questions any time during the interview. As we mentioned in the informed consent, you can contact the project manager, Angela DeBello, at any time. We look forward to working with you on this important research.


To ensure that I capture your responses accurately, I would like to record this interview. The recording will only be accessible by NORC and CDC project staff and will not contain any identifying information. After we have concluded this study, the recording will be destroyed. Do I have your permission to record the interview?

  1. Yes (Start recording and state the respondent’s ID number)

  2. No


The first section of the questionnaire focuses on general health-related issues that women experience in their daily lives. Again, if anything is unclear, please let me know. Now, let’s get started.


Section 0: Respondent Characteristics:


  1. What year were you born? __________________


  1. Are you Latina or of Hispanic origin?

    1. Yes

    2. No (Skip to Q0.4)

    3. DON’T KNOW (Skip to Q0.4)

    4. REFUSED (Skip to Q0.4)


  1. 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: ______________________________________________________)



  1. What is your race?


(GIVE GREEN SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. American Indian / Alaska Native

    2. Asian (Skip to Q0.7)

    3. Black or African American (Skip to Q0.7)

    4. Native Hawaiian / Pacific Islander (Skip to Q0.7)

    5. White or Caucasian (Skip to Q0.7)

    6. Other (Specify: __________________________________________) (Skip to Q0.7)

    7. DON’T KNOW (Skip to Q0.7)

    8. REFUSED (Skip to Q0.7)


  1. Are you affiliated or enrolled with a tribe or village?

    1. Yes (Specify: ______________________________________________)

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. Have you ever lived within reservation boundaries or in an Alaska Native Village?

    1. Yes

    2. No (Skip to Q0.8)

    3. DON’T KNOW (Skip to Q0.8)

    4. REFUSED (Skip to Q0.8)


  1. Have you lived within reservation boundaries or in an Alaska Native Village within the past 12 months?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. Which of the following best describes your current living situation?

    1. I live in some form of permanent housing (e.g., house or apartment I own or rent)

    2. I live in some form of temporary housing (e.g., house or apartment of a family member or friend; a mission or shelter)

    3. I do not have regular housing; (e.g., I sleep in places like an all-night movie theater, in an abandoned building, in a car or other vehicle, or on the street)

    4. DON’T KNOW

    5. REFUSED


  1. How many times have you moved in the last 3 years? _________


  1. During the next 12 months, do you plan to:

    1. Staying in your current home or apartment?

    2. Moving to a different home or apartment in the same neighborhood?

    3. Moving to a different neighborhood in the same city?

    4. Moving to a different city?

    5. Moving to a different state?

    6. Moving out of the country?


  1. 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 or equivalent (e.g., GED)

    5. Some college

    6. Associates (2-year) college degree

    7. Bachelors (4-year) college degree

    8. Post-graduate degree

    9. DON’T KNOW

    10. REFUSED


  1. What is your current marital status? (BE SURE TO READ ALL OPTIONS)

    1. Single/Never married

    2. Married

    3. Separated

    4. Divorced

    5. Widowed

    6. Other (specify): ____________________

    7. DON’T KNOW

    8. REFUSED


  1. What was the total income before taxes from ALL household members during 2008? Include income from all sources such as work, investments, child support, public assistance, and selling drugs. If you are not living in a home or apartment you own or rent, please report only YOUR total income.


(GIVE RED SHOW CARD TO R, THEN CODE RESPONSE.)


  1. Less than $1,000

  2. $1,000 to $2,999

  3. $3,000 to $4,999

  4. $5,000 to $7,499

  5. $7,500 to $10,000

  6. $10,000 to $11,999

  7. $12,000 to $14,999

  8. $15,000 to $19,999

  9. $20,000 to $24,999

  10. $25,000 to $34,999

  11. $35,000 to $49,999

  12. $50,000 to $74,999

  13. $75,000 to $99,999

  14. $100,000 to $149,999

  15. $150,000 or more

  16. DON’T KNOW

  17. REFUSED

Section 1: Health-Related Questions


The next set of questions is about your health care and health problems you may have experienced.


    1. In general, how would you describe your overall health?

  1. Excellent

  2. Very Good

  3. Good

  4. Fair

  5. Poor

  6. DON’T KNOW

  7. REFUSED

ACCESS TO HEALTH CARE FROM PEMS


    1. Has a doctor, nurse, or other health professional EVER told you that you have diabetes?


[IF R SAYS ‘PRE-DIABETES’ OR ‘BORDERLINE DIABETES,’ CODE AS ‘C.’]


a) Yes

  1. No (Skip to STEM 1.1)

c) No, but pre-diabetes or borderline diabetes (Skip to STEM 1.1)

d) DON’T KNOW (Skip to STEM 1.1)

e) REFUSED (Skip to STEM 1.1)


  1. Was this only when you were pregnant?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


STEM 1.1: Have you ever been told by a doctor, nurse, or other health professional that you had …

      1. Yes

      2. No

      3. DON’T KNOW

      4. REFUSED


  1. Asthma?

  2. Coronary heart disease?

  3. Irritable bowel syndrome or IBS?

  4. High blood pressure?


STEM 1.2: Do you have…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. Frequent headaches?

  2. Chronic pain?

  3. Difficulty sleeping?


  1. A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?

    1. Yes

    2. No (Skip to Q1.13)

    3. DON’T KNOW (Skip to Q1.13)

    4. REFUSED (Skip to Q1.13)


  1. How long has it been since you last had a pap smear?

    1. Within the past year (anytime less than 12 months ago)

    2. Within the past 2 years (1 year but less than 2 years ago)

    3. Within the past 3 years (2 years but less than 3 years ago)

    4. Within the past 5 years (3 years but less than 5 years ago)

    5. More than 5 years ago


  1. A mammogram is an x-ray of each breast to look for cancer. Have you ever had a mammogram?

    1. Yes

    2. No (Skip to Q1.15)

    3. DON’T KNOW (Skip to Q1.15)

    4. REFUSED (Skip to Q1.15)


  1. How long has it been since you last had a mammogram?

    1. Within the past year (anytime less than 12 months ago)

    2. Within the past 2 years (1 year but less than 2 years ago)

    3. Within the past 3 years (2 years but less than 3 years ago)

    4. Within the past 5 years (3 years but less than 5 years ago)

    5. More than 5 years ago


  1. 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

    3. DON’T KNOW

    4. REFUSED


STEM 1.3: In the past 12 months, would you have had the following kinds of help if you had needed them?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED

  1. Someone to loan you $50?

  2. Someone to help you if you were sick and needed to be in bed?

  3. Someone to take you to the clinic or doctor’s office if you needed a ride?

  4. Someone to talk with about your problems?


Introduction to Sex-Related Questions


I now want to ask you about experiences you may have had with unwanted sex. Women may experience unwanted and uninvited sexual experiences by strangers or people they know well, such as a romantic or sexual partner, friend, teacher, coworker, supervisor, or family member. It can happen anywhere, such as a home, a car, at a job, or in another public place. She could be awake or asleep, unconscious, drunk, or high. She could be unable to give consent for some other reason when it happens. Women do not always report unwanted sex to the police. They often do not discuss it with friends or family members. Please keep this information in mind as we go through the survey. Your information will help us learn how often these things happen.



Some of the language we will use is explicit, but it is important that I ask the questions this way so that you are clear about what I mean. I will explain all the terms I use. I can always repeat the definitions if you need to be reminded. Your answers will be kept private. Remember, you don’t have to answer any question that you don’t want to.

Section 2: Gateway Questions – Unwanted Sexual Situations


The first set of questions relates to unwanted sexual situations that happened in your lifetime. These unwanted situations do not involve touching, sexual intercourse, or attempted sexual intercourse. By unwanted, we mean that the situations happened after you said or showed you didn’t want them to happen. It also would be unwanted if they happened without your consent.


STEM 2.1: During your lifetime how many times has someone ever done any of the following things when you didn’t want it to happen? How many times has someone ever…


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. 11-25 times in my lifetime

    6. 26-50 times in my lifetime

    7. More than 50 times in my lifetime

    8. DON’T KNOW

    9. REFUSED


  1. said unwanted sexual or offensive comments or jokes to you? This could be when someone talked about his or her own sexuality or sexual conduct. It also could be about your or other people’s sexuality or sexual conduct.

  2. made unwanted sexual or offensive gestures or looks at you? By this I mean such things as thrusting their hips in your direction. It also might mean looking at you in a sexual way.

  3. exposed their sexual body parts to you, flashed you, or masturbated in front of you? Remember, we are only asking about things you didn’t want to happen.

  4. shown or given you unwanted sexual pictures, messages, or notes? These are times when you did not agree to see, listen, or read them.

  5. watched or tried to watch while you undress, were nude, or in a sexual act. That is, been watched by a ‘Peeping Tom?’

  6. harassed you in some other sexual way while you were in a public place in a way that made you feel unsafe?

Section 3: Gateway Questions – Unwanted Sexual Contact


The next questions are about your experiences of unwanted sexual contact during your lifetime. This unwanted contact, however, does not include sexual intercourse or attempted sexual intercourse.


STEM 3.1: During your lifetime, how many times has someone ever done any of the following things when you didn’t want it to happen? How many times has someone ever…


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. 11-25 times in my lifetime

    6. 26-50 times in my lifetime

    7. More than 50 times in my lifetime

    8. DON’T KNOW

    9. REFUSED


  1. kissed you in a sexual way?

  2. touched, grabbed, or fondled your sexual body parts in a sexual way? Include times even if it was done through your clothing.

  3. made you touch or fondle his or her genitals in a sexual way? Include times even if it was done through their clothing.

  4. rubbed up against you in a sexual way?. Remember, we are only asking about things you didn’t want to happen.

  5. removed or tried to take off your clothing?

Section 4: Gateway Questions – Unwanted Sex


Now, we are going to talk about your experiences with unwanted sex. Some of the questions will be about times when the sex actually occurred when you did not want it to happen or without your consent. Other questions will be about times when someone tried to have sex with you when you did not want him or her to or without your consent, but the sex did not occur. Remember, some of the language I will use is explicit, but it’s important that I ask the questions this way so that you are clear about what I mean. Please remember that your answers will be kept private.


Some people are threatened with harm or are physically forced to have sex when they don’t want to, for example, by being pinned or held down, or by the use of a weapon. It may also include things such as threatening to hurt them or someone close to them.


STEM 4.1: During your lifetime, how many times has someone ever used physical force or threats of physical harm to …


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. make you have unwanted vaginal sex with them? By vaginal sex we mean when someone puts a penis, finger, or object into your vagina.

  2. make you have unwanted oral sex with them? By oral sex we mean when someone’s mouth or tongue touches your vagina or anus. It also can mean when your mouth or tongue are made to touch someone else’s genitals or anus.

  3. make you have unwanted anal sex with them? By anal sex we mean when someone puts a penis, finger, or object into your anus.


STEM 4.2: During your lifetime, how many times has someone ever used physical force or threats of physical harm to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. TRY to make you have unwanted vaginal sex with them, but sex did not happen?

  2. TRY to make you have unwanted oral sex with them, but sex did not happen?

  3. TRY to make you have unwanted anal sex with them, but sex did not happen?



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 when they were given drugs or alcohol without their knowledge or consent. Please remember that even if someone uses alcohol or drugs, every person has the right not to be sexually assaulted.


STEM 4.3: During your lifetime, how many times has someone ever GIVEN you alcohol or drugs to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. make you have unwanted vaginal sex with them?

  2. make you have unwanted oral sex with them?

  3. make you have unwanted anal sex with them?


STEM 4.4: During your lifetime, how many times has someone ever GIVEN you alcohol or drugs to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. TRY to make you have unwanted vaginal sex with them, but sex did not happen?

  2. TRY to make you have unwanted oral sex with them, but sex did not happen?

  3. TRY to make you have unwanted anal sex with them, but sex did not happen?


I now want to ask you about times other than when someone gave you alcohol or drugs on purpose to have sex with you.


STEM 4.5: How many times during your lifetime, when you were unable to consent, such as when you were passed out, asleep, drunk, high, or drugged, has someone ever had…


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. unwanted vaginal sex with you?

  2. unwanted oral sex with you?

  3. unwanted anal sex with you?


STEM 4.6: How many times during your lifetime, when you were unable to consent, such as when you were passed out, asleep, drunk, high, or drugged, has someone ever…


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. TRIED to make you have unwanted vaginal sex with them, but sex did not happen?

  2. TRIED to make you have unwanted oral sex with them, but sex did not happen?

  3. TRIED to make you have unwanted anal sex with them, but sex did not happen?



Sometimes unwanted sex happens after a person is pressured in non-physical ways.


STEM 4.7: During your lifetime, how many times has someone ever done things like telling you lies, making promises about the future they knew were untrue, threatening to end your relationship, or threatening to spread rumors about you to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. make you have unwanted vaginal sex with them? Remember, by unwanted I mean when you said or showed you didn’t want it to occur. It also could mean without your consent.

  2. make you have unwanted oral sex with them?

  3. make you have unwanted anal sex with them?


STEM 4.8: During your lifetime, how many times has someone ever done things like telling you lies, making promises about the future they knew were untrue, threatening to end your relationship, or threatening to spread rumors about you to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. TRY to make you have unwanted vaginal sex with them, but sex did not happen?

  2. TRY to make you have unwanted oral sex with them, but sex did not happen?

  3. TRY to make you have unwanted anal sex with them, but sex did not happen?


STEM 4.9: During your lifetime, how many times has someone ever tried to wear you down by repeatedly asking for sex, or showing you they were unhappy to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. make you have unwanted vaginal sex with them?

  2. make you have unwanted oral sex with them?

  3. make you have unwanted anal sex with them?


STEM 4.10: During your lifetime, how many times has someone ever tried to wear you down by repeatedly asking for sex, or showing you they were unhappy to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. TRY to make you have unwanted vaginal sex with them, but sex did not happen?

  2. TRY to make you have unwanted oral sex with them, but sex did not happen?

  3. TRY to make you have unwanted anal sex with them, but sex did not happen?


STEM 4.11: During your lifetime, how many times has someone ever tried to use their influence or authority over you, for example, your boss or your teacher to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. make you have unwanted vaginal sex with them?

  2. make you have unwanted oral sex with them?

  3. make you have unwanted anal sex with them?


STEM 4.12: During your lifetime, how many times has someone ever tried to use their influence or authority over you, for example, your boss or your teacher to:


RECORD BEST GUESS #; IF CANNOT GET EXACT NUMBER THEN USE THE FOLLOWING RESPONSES


    1. Never

    2. 1 time in my lifetime

    3. 2-5 times in my lifetime

    4. 6-10 times in my lifetime

    5. More than 10 times in my lifetime

    6. DON’T KNOW

    7. REFUSED


  1. TRY to make you have unwanted vaginal sex with them, but sex did not happen?

  2. TRY to make you have unwanted oral sex with them, but sex did not happen?

  3. TRY to make you have unwanted anal sex with them, but sex did not happen?


Section 5: Severe Detail Questions - FIRST EXPERIENCE


IF R DID NOT REPORT ANY UNWANTED SEXUAL EXPERIENCE THAT INCLUDES ORAL, VAGINAL, OR ANAL SEX, SKIP TO SECTION 7: MENTAL HEALTH.


IF R REPORTED MORE THAN 1 UNWANTED SEXUAL EXPERIENCE FILL = [FIRST]:


Up to this point, I have been asking you some basic questions about your various experiences of unwanted sex. Now, I want to ask more detailed questions about your first experience of unwanted vaginal, oral, or anal sex. Some women may find these questions upsetting, but it is important that I ask them this way so that you are clear about what I mean. Remember, your information will be kept private.


Please think about your [FIRST] experience of unwanted sex. Did vaginal, oral, or anal sex occur?

    1. Yes (In Section 5, FILL = “SEX”; Skip to Q5.1)

    2. No


During your [FIRST] experience of unwanted sex, did someone TRY to have vaginal, oral, or anal sex with you, but sex did NOT occur?

    1. Yes (In Section 5, FILL = “ATTEMPTED SEX”; Skip to Q5.1)

    2. No


Please tell me what happened during your [FIRST] experience of unwanted sex?


______________________________________________________________________________


______________________________________________________________________________


{INTERVIEWER TO PROBE WHY R INDICATED UNWANTED SEX IN SECTION 4, BUT IS NOT REPORTING IT HERE}


  1. Which of the following happened to you the [FIRST] time you experienced unwanted [sex / attempted sex]? (MARK ALL THAT APPLY)

    1. Vaginal sex

    2. Oral sex

    3. Anal sex


  1. How old were you when you [FIRST] experienced unwanted [sex / attempted sex]?


BEST GUESS AGE ________ [IF CANNOT GET EXACT AGE THEN USE THE FOLLOWING RESPONSES]


    1. < 12 years old

    2. 13 to17 years old

    3. 18 to 29 years old

    4. 30 to 44 years old

    5. 45 to 59 years old

    6. 60 to 64 years old

    7. > 65 years old

    8. DON’T KNOW

    9. REFUSED


  1. Where did your [FIRST] experience of unwanted [sex / attempted sex] take place?

(GIVE WHITE SHOW CARD TO R, THEN CODE RESPONSE)


    1. In your home

    2. In the home of the [person/people] who did this to you

    3. In a home you share(d) with the [person/people] who did this to you

    4. In a friend or relative’s home where you were staying at the time

    5. In a group living institution

    6. At your workplace

    7. At the workplace of the [person/people] who did this to you

    8. In a public place, for example, the grocery store, a dress store, a shopping mall or the library

    9. In a car

    10. In a parking lot or garage

    11. Outdoors (specify)______________________________________________

    12. Other (specify)_________________________________________________

    13. DON’T KNOW

    14. REFUSED


  1. Did your [FIRST] experience of unwanted [sex / attempted sex] happen ON or NEAR a reservation an Alaska Native village?

    1. On

    2. Near

    3. Neither

    4. DON’T KNOW (GO TO NOTE 5.1)

    5. REFUSED (GO TO NOTE 5.1)


  1. Was more than one person involved in unwanted [sex / attempted sex] with you during your [FIRST] experience?

    1. Yes

    2. No (GO TO NOTE 5.1)

    3. DON’T KNOW (GO TO NOTE 5.1)

    4. REFUSED (GO TO NOTE 5.1)


  1. How many people engaged in unwanted [sex / attempted sex] with you during your [FIRST] experience?


BEST GUESS # ________ [SKIP TO NOTE 5.2]



NOTE 5.1

IF Q5.6=1, SAY:

Next, I want to ask you some questions about the person who did this to you.

[SKIP TO Q5.7]


NOTE 5.2

IF Q5.6 IS MORE THAN 1, SAY:

Next, I want to ask you questions about the people who did this to you. I will ask the next set of questions about the first person. Then, I will ask the questions again for each additional person who was involved. That is, the next set of questions will ask about the FIRST person who engaged in unwanted [sex / attempted sex] during your [FIRST] experience. Then, I’ll ask you about the SECOND person and so on. Let’s start with the first person who did this to you.


FOR SECOND/THIRD … PERPERTRATOR SAY:

Now, I want to ask you about the [second, third…] person involved in your [FIRST] experience with unwanted [sex / attempted sex].


  1. Was this person male or female?

    1. Male

    2. Female

    3. DON’T KNOW

    4. REFUSED


  1. How old was this person?


BEST GUESS AGE ________ [IF CANNOT GET EXACT AGE THEN USE THE FOLLOWING RESPONSES]


    1. < 12 years old

    2. 13 to17 years old

    3. 18 to 29 years old

    4. 30 to 44 years old

    5. 45 to 59 years old

    6. 60 to 64 years old

    7. > 65 years old

    8. DON’T KNOW

    9. REFUSED


  1. Was this person a [Latino/Latina] or of Hispanic origin?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. What was the race of this person?


(GIVE GREEN SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. American Indian / Alaska Native

    2. Asian

    3. Black or African American

    4. Native Hawaiian / Pacific Islander

    5. White or Caucasian

    6. Other (specify): ________________________

    7. DON’T KNOW

    8. REFUSED


  1. When you [FIRST] had unwanted [sex / attempted sex], what was your relationship to this person?


(GIVE YELLOW SHOW CARD TO R, THEN CODE RESPONSE)


    1. Current boyfriend / girlfriend / romantic partner / significant other

    2. Former boyfriend / girlfriend / romantic partner / significant other

    3. Current legal spouse (including common law)

    4. Former legal spouse (including common law)

    5. Someone you were dating but who you would not label as a boyfriend/girlfriend

    6. Someone you were going on a first date with

    7. Family member (specify): ___________________________________

    8. Friend

    9. Acquaintance

    10. Someone in a position of power or trust, such as an employer, teacher, clergy, or police officer (specify): ___________________________________

    11. Someone you knew for 24 hours or less

    12. Someone else you knew (specify): ___________________________________

    13. Complete stranger (Skip to NOTE 3)

    14. DON’T KNOW

    15. REFUSED


  1. At the time you [FIRST] had unwanted [sex / attempted sex], how long had you known this person?














Years


Months


Weeks


Days


Hours


  1. Were you living with this person at the time you [FIRST] had unwanted [sex / attempted sex]?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED



IF RELATIONSHIP TO PERSON WAS FORMER OR CURRENT BOYFRIEND/ GIRLFRIEND, ROMANTIC PARTNER OR SPOUSE (q5.11 = A-e) ASK Q5.14 and PROBES; OTHERWISE, SKIP TO Note 3.


  1. How long had you been involved with this person at the time you [FIRST] had unwanted [sex / attempted sex]?














Years


Months


Weeks


Days


Hours


NOTE 3

IF MORE THAN ONE PERSON WAS INVOLVED IN THE INCIDENT, REPEAT 5.6 TO 5.14A FOR EACH PERPETRATOR. USE SUPPLEMENTAL FORM FOR MULTIPLE PERPETRATORS; ELSE CONTINUE.


STEM 5.1: At the time of your [FIRST] experience of unwanted [sex / attempted sex], were you…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. recovering from surgery or pregnancy, or were you recovering from something else that made you go to a doctor or stay in a hospital?

  2. limited in any way because of a physical impairment or other health problem? This could include difficulties seeing, hearing, or moving about freely.



The next set of questions looks at things that may have happened prior to your [FIRST] experience with unwanted [sex / attempted sex].


  1. During your [FIRST] experience, do you think you were given a drug to make you pass out prior to the incident and without your knowledge? Examples of these drugs might be GHB, Rohypnol, ecstasy or Ketamine.

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. To your knowledge, did the [person/people] who did this to you drink alcohol prior to your [FIRST] experience of unwanted [sex / attempted sex]?

    1. Yes

    2. No (Skip to Q5.20)

    3. Some did and some didn’t (only if Q5.4 = ‘Yes’)

    4. DON’T KNOW (Skip to Q5.20)

    5. REFUSED (Skip to Q5.20)


  1. How drunk did the [person/people] who did this to you seem?

    1. Not at all (fine / normal)

    2. Slightly drunk (slightly buzzed)

    3. Moderately drunk (on the way to being drunk)

    4. Very drunk

    5. DON’T KNOW

    6. REFUSED


  1. To your knowledge, did the [person/people] who did this to you use some other recreational drug (such as marijuana, crack, ecstasy, meth, or oxycontin) prior to your [FIRST] experience of unwanted [sex / attempted sex]?

a) Yes (specify):________________________________________________________

b) No

c) DON’T KNOW

d) REFUSED



The next set of questions asks about your alcohol and drug use prior to your [FIRST] experience of unwanted [sex / attempted sex]. Remember, even if someone uses alcohol or drugs, every person has a right not to be sexually assaulted.


  1. Were you voluntarily drinking alcohol prior to your [FIRST] experience of unwanted [sex / attempted sex]?

    1. Yes

    2. No (Skip to Q5.23)

    3. DON’T KNOW (Skip to Q5.23)

    4. REFUSED (Skip to Q5.23)


  1. How intoxicated were you after you as a result of drinking prior to your [FIRST] experience of unwanted [sex / attempted sex]?

    1. Not at all (fine / normal)

    2. Slightly intoxicated (slightly buzzed)

    3. Moderately intoxicated (on the way to being drunk)

    4. Very intoxicated (drunk)

    5. DON’T KNOW

    6. REFUSED


  1. Were you voluntarily misusing prescribed medication or using some illegal street drug (such as marijuana, cocaine, inhalants, meth, ecstasy, or oxycontin) prior to your [FIRST] experience of unwanted [sex / attempted sex]?

    1. Yes (Specify:___________________________________________________)

    2. No

    3. DON’T KNOW

    4. REFUSED



IF R REPORTS ONLY ONE EXPERIENCE OF UNWANTED SEX, ASK Q5.24 TO Q5.26 AND THEN SKIP TO INTRO AFTER Q5.32



The next set of questions, asks about the kinds of things the [person/people] did during your [FIRST] experience to get you to have unwanted [sex / attempted sex] with [him/her/them].


  1. Did the [person/people] who did this to you use physical force or threats of force to get you to do what [he/she/they] wanted? Remember, this could include such things as holding you down with [his/her/their] body[ies] or pinning your arms. It could also include using a weapon, or threatening to hurt you or someone close to you.

    1. Yes

    2. No (Skip to STEM 5.2)

    3. DON’T KNOW (Skip to STEM 5.2)

    4. REFUSED (Skip to STEM 5.2)


  1. Did the [person/people] who did this to you use a weapon to get you to do what [he/she/they] wanted?

    1. Yes

    2. No (Skip to STEM 5.2)

    3. DON’T KNOW (Skip to STEM 5.2)

    4. REFUSED (Skip to STEM 5.2)


  1. What weapons were used during your [FIRST] experience of unwanted [sex / attempted sex]? (MARK ALL THAT APPLY)

    1. Gun

    2. Knife

    3. Other weapon (Specify:_________________________________________________)

    4. DON’T KNOW

    5. REFUSED


STEM 5.2: During your [FIRST] experience of unwanted [sex / attempted sex], did the [person / people] who did this to you…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. give you alcohol or drugs to get you to do what [he/she/they] wanted?

  2. do things like tell you lies, make promises about the future they knew were untrue, threaten to end your relationship, or threaten to spread rumors about you?

  3. wear you down by repeatedly asking for sex, or showing you they were unhappy?

  4. use their influence or authority over you, for example, your boss or your teacher?


  1. During your [FIRST] experience of unwanted [sex / attempted sex], did the [person / people] do this to you when you were unable to consent, such as when you were passed out, asleep, drunk, or high. To be clear, I’m talking about times other than when someone gave you alcohol or drugs to get you to have sex with [him/her/them].

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. During your [FIRST] experience of unwanted [sex / attempted sex] did the person do anything else to get you to do what [he/she/they] wanted? This is besides what we’ve talked about already.

    1. Yes (Specify:___________________________________________________)

    2. No

    3. DON’T KNOW

    4. REFUSED



Now, I would like to ask you some questions about other things that might have happened after or as a result of your [FIRST] experience with unwanted [sex / attempted sex]. We are also interested in whether any of these things happened to you because of your [FIRST] experience of unwanted [sex / attempted sex].


STEM 5.3: As a result of your [FIRST] experience of unwanted [sex / attempted sex], has a doctor, nurse, or other health professional told you that you have…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. HIV, the virus that causes AIDS?

  2. a sexually transmitted disease (other than HIV)?


IF VAGINAL SEX OCCURRED (SEE SECTION 5 INTRO QUESTION & Q5.1), CONTINUE; ELSE SKIP TO Q5.37.


  1. Did you get pregnant due to your [FIRST] experience of unwanted vaginal sex?

    1. Yes

    2. No (Skip to Q5.37)

    3. DON’T KNOW (Skip to Q5.37)

    4. REFUSED (Skip to Q5.37)


  1. What happened to the pregnancy?

    1. Birthed the baby and kept him or her

    2. Birthed the baby and placed him or her up for adoption

    3. Miscarriage

    4. Had an abortion

    5. DON’T KNOW

    6. REFUSED


  1. Did you lose an existing pregnancy due to your [FIRST] experience of unwanted [sex / attempted sex]?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. Were you physically injured due to your [FIRST] experience of unwanted [sex / attempted sex]? For example, did you have bruises, vaginal or anal tears, or other internal or external injuries?

  1. Yes

  2. No (Skip to Q5.44)

  3. DON’T KNOW (Skip to Q5.44)

  4. REFUSED (Skip to Q5.44)


STEM 5.4: Did your injuries include…

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED



  1. minor bruises or scratches?

  2. cuts, major bruises, or black eyes?

  3. broken bones or teeth?

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

  5. other injuries? (Specify: ______________________________________________)


  1. As a result of your [FIRST] experience of unwanted [sex / attempted sex], did you need medical care from a doctor or nurse or other health care professional?

    1. Yes

    2. No (Skip to Q5.47)

    3. DON’T KNOW (Skip to Q5.47)

    4. REFUSED (Skip to Q5.47)


  1. Were you able to get the medical care you needed?

    1. Yes (Skip to Q5.47)

    2. No

    3. DON’T KNOW (Skip to Q5.47)

    4. REFUSED (Skip to Q5.47)


  1. Why were you not able to get the medical care that you needed?


__________________________________________________________________________________________________________________________________________________________________________


  1. As a result of your [FIRST] experience of unwanted [sex / attempted sex], did you have to stay at a hospital or get some other inpatient medical care?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. As a result of your [FIRST] experience of unwanted [sex / attempted sex], did a doctor or nurse take any physical evidence from you (for example, samples of bodily fluid for a “rape kit”)?

    1. Yes

    2. No, Wasn’t offered

    3. No, Did not want

    4. Don’t Know

    5. Refused


  1. As a result of your [FIRST] experience of unwanted [sex / attempted sex], did you need mental health services from a therapist, counselor, or other mental health care provider?

    1. Yes

    2. No (Skip to STEM 5.5)

    3. DON’T KNOW (Skip to STEM 5.5)

    4. REFUSED (Skip to STEM 5.5)


  1. Were you able to get the mental health services you needed?

    1. Yes (Skip to STEM 5.5)

    2. No

    3. DON’T KNOW (Skip to STEM 5.5)

    4. REFUSED (Skip to STEM 5.5)


  1. Why were you not able to get the mental health services that you needed?


________________________________________________________________________________________________________________________________________________________


STEM 5.5: As a result of your [FIRST] experience of unwanted [sex / attempted sex] did you:

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. feel unsafe in the neighborhood where you lived?

  2. miss work?

  3. was forced to stay with other family members or friends?

  4. was forced to relocate from the area where I lived?


  1. Did you talk about the incident with any of these people after your [FIRST] experience of unwanted [sex / attempted sex]?


(GIVE BLUE SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. No one [Skip to Q5.58]

    2. Friends

    3. Parents

    4. Siblings

    5. Husband / romantic or sexual partner

    6. Other family members

    7. Teachers

    8. Social service delivery person (e.g., counselor at a shelter, rape crisis center, rape hotline)

    9. The police

    10. Religious professionals

    11. Traditional healer

    12. Elders in the community

    13. Other (Specify:___________________________________________________)

    14. DON’T KNOW

    15. REFUSED


  1. Did you find talking with [RESPONSE TO Q5.56] …

    1. Very helpful (Skip to Q5.59)

    2. Somewhat helpful (Skip to Q5.59)

    3. Neither helpful nor hurtful (Skip to Q5.59)

    4. Somewhat hurtful (Skip to Q5.59)

    5. Very hurtful (Skip to Q5.59)

    6. DON’T KNOW (Skip to Q5.59)

    7. REFUSED (Skip to Q5.59)


  1. What was your reason or reasons for not talking about the incident with anyone?


(GIVE SALMON SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. Afraid

    2. Embarrassed or ashamed

    3. Thought I would be treated unfairly because of my race

    4. Just didn’t want to tell anyone

    5. Didn’t think it would do any good

    6. Could be harmful to me

    7. Didn’t want to get the person (people) who did this to me in trouble

    8. Other (Specify:___________________________________________________)

    9. DON’T KNOW

      1. REFUSED


  1. Were the authorities (e.g., the police) contacted, regardless of who contacted them, about your [FIRST] experience of unwanted [sex / attempted sex]?

  1. Yes (Skip to STEM 5.6)

  2. No

  3. DON’T KNOW (Skip to STEM 5.6)

  4. REFUSED (Skip to STEM 5.6)


  1. Why were the authorities not contacted?


________________________________________________________________________________________________________________________________________________________


SKIP TO STEM 5.6



  1. When the authorities were contacted because of your [FIRST] experience of unwanted [sex / attempted sex], did any of the following happen? (MARK ALL THAT APPLY)

    1. Charges were brought against the [person/persons]

    2. The [person was / persons were] tried in court

    3. The [person/persons] who did this [was/were] convicted

    4. Other legal outcome (Specify): _____________________________

    5. Were able to receive services (e.g., legal, medical, mental health) tied to reporting the crime

    6. DON’T KNOW

    7. REFUSED


STEM 5.6: Did you ever need any of the following services as a result of your [FIRST] experience of unwanted [sex / attempted sex]?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. Housing services?

  2. Community services?

  3. Victim’s advocate services (e.g., rape crisis center or other sexual assault services provider)?

  4. Legal services?

  5. Other services? (Specify: _________________________________________________)


  1. Were you able to get the service(s) that you needed as a result of your [FIRST] experience of unwanted [sex / attempted sex]?

    1. Yes (Skip to NOTE)

    2. No

    3. DON’T KNOW (Skip to NOTE)

    4. REFUSED (Skip to NOTE)


  1. Why were you not able to get the assistance that you needed?


________________________________________________________________________________________________________________________________________________________



NOTE: IF RESPONDENT WAS LESS THAN 18 YEARS OLD WHEN FIRST EXPERIENCE OCCURRED (SEE Q5.2), ASK Q5.69; ELSE SKIP TO Q5.70.


  1. Was child protective services contacted, regardless of who contacted them, about your [FIRST] experience of unwanted [sex / attempted sex]?

  1. Yes (Go to Section 6)

  2. No (Go to Section 6)

  3. DON’T KNOW (Go to Section 6)

  4. REFUSED (Go to Section 6)


  1. Was adult protective services contacted, regardless of who contacted them, about your [FIRST] experience of unwanted [sex / attempted sex]?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


Section 6: Severe Detail Questions – MOST RECENT EXPERIENCE


IF R REPORTED ONLY ONE UNWANTED SEXUAL EXPERIENCE [REPORTED IN SECTION 4], SKIP TO SECTION 7:


Now I’d like to ask you some detailed questions about your MOST RECENT experience of unwanted vaginal, oral, or anal sex. Again, it is important that I ask these questions this way so that you are clear about what I mean. Remember, your information will be kept private.


Please think about your MOST RECENT unwanted sexual experience. Did sex of any kind occur?

    1. Yes (In Section 6, FILL = “SEX” – Skip to Q6.1)

    2. No


During your MOST RECENT experience of unwanted sex, did someone TRY to have sex of any kind with you, but sex did NOT occur?

    1. Yes (In Section 5, FILL = “ATTEMPTED SEX” -- Skip to Q6.1)

    2. No


Please tell me what happened during your MOST RECENT experience of unwanted sex?


________________________________________________________________________________________________________________________________________________________


{INTERVIEWER TO PROBE WHY R INDICATED UNWANTED SEX IN SECTION 4, BUT IS NOT REPORTING IT HERE}


  1. Which of the following happened to you the MOST RECENT time you experienced unwanted [sex / attempted sex]? (MARK ALL THAT APPLY)

    1. Vaginal sex

    2. Oral sex

    3. Anal sex


  1. How old were you when you MOST RECENT experienced unwanted [sex / attempted sex]?


BEST GUESS AGE ________ [IF CANNOT GET EXACT AGE THEN USE THE FOLLOWING RESPONSES]


    1. < 12 years old

    2. 13 to17 years old

    3. 18 to 29 years old

    4. 30 to 44 years old

    5. 45 to 59 years old

    6. 60 to 64 years old

    7. > 65 years old

    8. DON’T KNOW

    9. REFUSED


  1. Where did your MOST RECENT experience of unwanted [sex / attempted sex] take place?

(GIVE WHITE SHOW CARD TO R, THEN CODE RESPONSE)


    1. In your home

    2. In the home of the [person/people] who did this to you

    3. In a home you share(d) with the [person/people] who did this to you

    4. In a friend or relative’s home where you were staying at the time

    5. In a group living institution

    6. At your workplace

    7. At the workplace of the [person/people] who did this to you

    8. In a public place, for example, the grocery store, a dress store, a shopping mall or the library

    9. In a car

    10. In a parking lot or garage

    11. Outdoors (specify)______________________________________________

    12. Other (specify)_________________________________________________

    13. DON’T KNOW

    14. REFUSED


  1. Did your MOST RECENT experience of unwanted [sex / attempted sex] happen ON or NEAR a reservation an Alaska Native village?

    1. On

    2. Near

    3. Neither

    4. DON’T KNOW

    5. REFUSED


  1. Was more than one person involved in unwanted [sex / attempted sex] with you during your MOST RECENT experience?

    1. Yes

    2. No (SKIP TO NOTE 6.1)

    3. DON’T KNOW (SKIP TO NOTE 6.1)

    4. REFUSED (SKIP TO NOTE 6.1)


  1. How many people had unwanted [sex / attempted sex] with you during this time?


BEST GUESS # ________ [Skip to Note 6.2]


NOTE 6.1

IF Q6.6=1, SAY:

Next, I want to ask you some specific information about the person who did this to you. [Skip to Q6.7]


NOTE 6.2

IF Q6.6 IS MORE THAN 1, SAY:

Next, I want to ask you some specific information about the people who did this to you. I will ask the next set of questions about the first person. Then, I will ask the questions again for each additional person who was involved. That is, the next set of questions will ask about the FIRST person who engaged in unwanted [sex / attempted sex] during your MOST RECENT experience. Then, I’ll ask you about the SECOND person and so on. Let’s start with the first person who did this to you.


FOR SECOND/THIRD … PERPERTRATOR SAY:

Now, I want to ask you about the [second, third…] person involved in your MOST RECENT experience with unwanted [sex / attempted sex].



  1. Was this person male or female?

    1. Male

    2. Female

    3. DON’T KNOW

    4. REFUSED


  1. How old was this person?


BEST GUESS AGE ________ [IF CANNOT GET EXACT AGE THEN USE THE FOLLOWING RESPONSES]


    1. < 12 years old

    2. 13 to17 years old

    3. 18 to 29 years old

    4. 30 to 44 years old

    5. 45 to 59 years old

    6. 60 to 64 years old

    7. > 65 years old

    8. DON’T KNOW

      1. REFUSED


  1. Was this person a [Latino/Latina] or of Hispanic origin?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. What was the race of this person?


(GIVE GREEN SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. American Indian / Alaska Native

    2. Asian

    3. Black or African American

    4. Native Hawaiian / Pacific Islander

    5. White or Caucasian

    6. Other (specify): ________________________

    7. DON’T KNOW

    8. REFUSED


  1. What was your relationship to this person at the time of your MOST RECENT experience of unwanted [sex / attempted sex]?


(GIVE YELLOW SHOW CARD TO R, THEN CODE RESPONSE)


    1. Current boyfriend / girlfriend / romantic partner / significant other

    2. Former boyfriend / girlfriend / romantic partner / significant other

    3. Current legal spouse (including common law)

    4. Former legal spouse (including common law)

    5. Someone you were dating but who you would not label as a boyfriend/girlfriend

    6. Someone you were going on a first date with

    7. Family member (specify): ___________________________________

    8. Friend

    9. Acquaintance

    10. Someone in a position of power or trust, such as an employer, teacher, clergy, or police officer (specify): ___________________________________

    11. Someone you knew for 24 hours or less

    12. Someone else you knew (specify): ___________________________________

    13. Complete stranger (Skip to 5.15)

    14. DON’T KNOW

      1. REFUSED



  1. At the time of your MOST RECENT experience of unwanted [sex / attempted sex], how long had you known this person?














Years


Months


Weeks


Days


Hours


  1. Were you living with this person at the time of your MOST RECENT experience of unwanted [sex / attempted sex]?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


IF RELATIONSHIP TO PERSON WAS FORMER OR CURRENT BOYFRIEND/ GIRLFRIEND, LOVER OR SPOUSE (q6.11 = A-e) ASK Q6.14 AND PROBES; ELSE SKIP TO Q6.15.


  1. How long had you been involved with this person at the time of your MOST RECENT experience of unwanted [sex / attempted sex]?














Years


Months


Weeks


Days


Hours



IF MORE THAN ONE PERSON WAS INVOLVED IN THE INCIDENT, REPEAT 6.6 TO 6.14 FOR EACH PERPETRATOR. USE SUPPLEMENTAL FORM FOR MULTIPLE PERPETRATORS.


STEM 6.1: At the time of your MOST RECENT experience of unwanted [sex / attempted sex], were you…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. recovering from surgery or pregnancy, or were you recovering from something else that made you go to a doctor or stay in a hospital?

  2. limited in any way because of a physical impairment or other health problem? This could include difficulties seeing, hearing, or moving about freely.



The next set of questions looks at things that may have happened prior to your MOST RECENT experience with unwanted [sex / attempted sex].


  1. During your MOST RECENT experience of unwanted [sex / attempted sex], do you think you were given a drug to make you pass out prior to the incident and without your knowledge? Examples of these drugs might be GHB, Rohypnol, ecstasy or Ketamine.

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED



  1. To your knowledge, did the [person/people] who did this to you drink alcohol prior to your MOST RECENT experience of unwanted [sex / attempted sex]?

    1. Yes

    2. No (Skip to Q6.20)

    3. Some did and some didn’t (only if Q6.4 = ‘Yes’)

    4. DON’T KNOW (Skip to Q6.20)

    5. REFUSED (Skip to Q6.20)


  1. How intoxicated did the [person/people] who did this to you seem?

    1. Not at all (fine / normal)

    2. Slightly intoxicated (slightly buzzed)

    3. Moderately intoxicated (on the way to being drunk)

    4. Very intoxicated (drunk)

    5. DON’T KNOW

    6. REFUSED


  1. To your knowledge, did the [person/people] who did this to you use some other recreational drug (such as marijuana, crack, ecstasy, meth, or oxycontin) prior to your MOST RECENT experience of unwanted [sex / attempted sex]?

a) Yes (specify):________________________________________________________

b) No

c) DON’T KNOW

d) REFUSED



The next set of questions asks about your alcohol and drug use prior to your MOST RECENT experience of unwanted [sex / attempted sex]. Remember, even if someone uses alcohol or drugs, every person has a right not to be sexually assaulted.


  1. Were you voluntarily drinking alcohol prior to your MOST RECENT experience of unwanted [sex / attempted sex]?

    1. Yes

    2. No (Skip to Q6.24)

    3. DON’T KNOW (Skip to Q6.24)

    4. REFUSED (Skip to Q6.24)


  1. How intoxicated were you after you drank prior to your MOST RECENT experience of unwanted [sex / attempted sex]?

    1. Not at all (fine / normal)

    2. Slightly intoxicated (slightly buzzed)

    3. Moderately intoxicated (on the way to being drunk)

    4. Very intoxicated (drunk)

    5. DON’T KNOW

    6. REFUSED


  1. Were you voluntarily misusing prescribed medication or using some illegal street drug (such as marijuana, cocaine, inhalants, meth, ecstasy, or oxycontin) prior to your MOST RECENT experience of unwanted [sex / attempted sex]?

      1. Yes (Specify:___________________________________________________)

      2. No

      3. DON’T KNOW

      4. REFUSED


The next set of questions, asks about the kinds of things the [person/people] did during your MOST RECENT experience to get you to have unwanted [sex / attempted sex] with [him/her/them].


  1. Did the [person/people] who did this to you use physical force or threats of force to get you to do what [he/she/they] wanted? Remember, this could include such things as holding you down with [his/her/their] body[ies] or pinning your arms. It could also include using a weapon, or threatening to hurt you or someone close to you.

    1. Yes

    2. No (Ask PROBE then Skip to STEM 6.2)

    3. DON’T KNOW (Ask PROBE then Skip to STEM 6.2)

    4. REFUSED (Ask PROBE then Skip to STEM 6.2)


  1. Did the [person/people] who did this to you use a weapon to get you to do what [he/she/they] wanted?

    1. Yes

    2. No (Skip to STEM 6.2)

    3. DON’T KNOW (Skip to STEM 6.2)

    4. REFUSED (Skip to STEM 6.2)


  1. What weapons were used during your MOST RECENT experience of unwanted [sex / attempted sex]? (MARK ALL THAT APPLY)

    1. Gun

    2. Knife

    3. Other weapon (Specify:_________________________________________________)

    4. DON’T KNOW

    5. REFUSED


STEM 6.2: During your MOST RECENT experience of unwanted [sex / attempted sex], did the [person / people] who did this to you…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. give you alcohol or drugs to get you to do what [he/she/they] wanted?

  2. do things like tell you lies, make promises about the future they knew were untrue, threaten to end your relationship, or threaten to spread rumors about you?

  3. wear you down by repeatedly asking for sex, or showing you they were unhappy?

  4. use their influence or authority over you, for example, your boss or your teacher?


  1. During your MOST RECENT experience of unwanted [sex / attempted sex], did the [person / people] do this to you when you were unable to consent, such as when you were passed out, asleep, drunk, or high. To be clear, I’m talking about times other than when someone gave you alcohol or drugs to get you to have sex with [him/her/them].

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. During your MOST RECENT experience of unwanted [sex / attempted sex] did the person do anything else to get you to do what [he/she/they] wanted? This is besides what we’ve talked about already.

    1. Yes (Specify:___________________________________________________)

    2. No

    3. DON’T KNOW

    4. REFUSED



Now, I would like to ask you some questions about other things that might have happened after or as a result of your MOST RECENT experience with unwanted [sex / attempted sex]. We are also interested in whether any of these things happened to you because of your MOST RECENT experience of unwanted [sex / attempted sex].


STEM 6.3: As a result of your MOST RECENT experience of unwanted [sex / attempted sex], has a doctor, nurse, or other health professional told you that you have…

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. HIV, the virus that causes AIDS?

  2. a sexually transmitted disease (other than HIV)?


IF VAGINAL SEX OCCURRED (SEE SECTION 6 INTRO QUESTION & Q6.1), CONTINUE; ELSE SKIP TO Q6.36.


  1. Did you get pregnant due to your MOST RECENT experience of unwanted vaginal sex?

  1. Yes

  2. No (Skip to Q6.36)

  3. DON’T KNOW (Skip to Q6.36)

  4. REFUSED (Skip to Q6.36)


  1. What happened to the pregnancy?

    1. Birthed the baby and kept him or her

    2. Birthed the baby and placed him or her up for adoption

    3. Miscarriage

    4. Had an abortion

    5. DON’T KNOW

    6. REFUSED


  1. Did you lose an existing pregnancy due to your MOST RECENT experience of unwanted [sex / attempted sex]?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. Were you physically injured due to your MOST RECENT experience of unwanted [sex / attempted sex]? For example, did you have bruises, vaginal or anal tears, or other internal or external injuries?

    1. Yes

    2. No (Skip to Q6.43)

    3. DON’T KNOW (Skip to Q6.43)

    4. REFUSED (Skip to Q6.43)



STEM 6.4: Did your injuries include…

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED



  1. minor bruises or scratches?

  2. cuts, major bruises, or black eyes?

  3. broken bones or teeth?

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

  5. other injuries? (Specify: ______________________________________________)


  1. As a result of your first experience of unwanted [sex / attempted sex], did you need medical care from a doctor or nurse or other health care professional?

    1. Yes

    2. No (Skip to Q.46)

    3. DON’T KNOW (Skip to Q.46)

    4. REFUSED (Skip to Q.46)


  1. Were you able to get the medical care you needed?

    1. Yes (Skip to Q.46)

    2. No

    3. DON’T KNOW (Skip to Q.46)

    4. REFUSED (Skip to Q.46)


  1. Why were you not able to get the medical care that you needed?


________________________________________________________________________________________________________________________________________________________


  1. As a result of your MOST RECENT experience of unwanted [sex / attempted sex], did you have to stay at a hospital or get some other inpatient medical care?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. As a result of your MOST RECENT experience of unwanted [sex / attempted sex], did a doctor or nurse take any physical evidence from you (for example, samples of bodily fluid for a “rape kit”)?

    1. Yes

    2. No, Wasn’t offered

    3. No, Did not want

    4. Don’t Know

    5. Refused


  1. As a result of your MOST RECENT experience of unwanted [sex / attempted sex], did you need mental health services from a therapist, counselor, or other mental health care provider?

    1. Yes

    2. No (Skip to STEM 6.5)

    3. DON’T KNOW (Skip to STEM 6.5)

    4. REFUSED (Skip to STEM 6.5)


  1. Were you able to get the mental health services you needed?

    1. Yes (Skip to STEM 6.5)

    2. No

    3. DON’T KNOW (Skip to STEM 6.5)

    4. REFUSED (Skip to STEM 6.5)


  1. Why were you not able to get the mental health services that you needed?


________________________________________________________________________________________________________________________________________________________


STEM 6.5: As a result of your MOST RECENT experience of unwanted [sex / attempted sex] did you:

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. feel unsafe in the neighborhood where you lived?

  2. miss work?

    1. was forced to stay with other family members or friends?

    2. was forced to relocate from the area where I lived?


  1. Did you talk about the incident with any of these people after your MOST RECENT experience of unwanted [sex / attempted sex]?


(GIVE BLUE SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. No one [Skip to Q6.58]

    2. Friends

    3. Parents

    4. Siblings

    5. Husband / romantic or sexual partner

    6. Other family members

    7. Teachers

    8. Social service delivery person (e.g., counselor at a shelter, rape crisis center, rape hotline)

    9. The police

    10. Religious professionals

    11. Traditional healer

    12. Elders in the community

    13. Other (Specify:___________________________________________________)

    14. DON’T KNOW

    15. REFUSED


  1. Did you find talking with [RESPONSE TO Q6.56] …

    1. Very helpful

    2. Somewhat helpful

    3. Neither helpful nor hurtful

    4. Somewhat hurtful

    5. Very hurtful

    6. DON’T KNOW

    7. REFUSED


SKIP TO Q6.59


  1. What was your reason or reasons for not talking about the incident with anyone?


(GIVE SALMON SHOW CARD TO R. ALLOW R TO CHOOSE ALL THAT APPLY.)


    1. Afraid

    2. Embarrassed or ashamed7

    3. Thought I would be treated unfairly because of my race

    4. Just didn’t want to tell anyone

    5. Didn’t think it would do any good

    6. Could be harmful to me

    7. Didn’t want to get the person (people) who did this to me in trouble

    8. Other (Specify:___________________________________________________)

    9. DON’T KNOW

      1. REFUSED


  1. Were the authorities (e.g., the police) contacted, regardless of who contacted them, about your MOST RECENT experience of unwanted [sex / attempted sex]?

  1. Yes (Skip to STEM 6.6)

  2. No

  3. DON’T KNOW (Skip to STEM 6.6)

  4. REFUSED (Skip to STEM 6.6)


  1. Why were the authorities not contacted?


________________________________________________________________________________________________________________________________________________________


  1. When the authorities were contacted because of your MOST RECENT experience of unwanted [sex / attempted sex], did any of the following happen? (MARK ALL THAT APPLY)

    1. Charges were brought against the [person/persons]

    2. The [person was / persons were] tried in court

    3. The [person/persons] who did this [was/were] convicted

    4. Other legal outcome (Specify): _____________________________

    5. Were able to receive services (e.g., legal, medical, mental health) tied to reporting the crime

    6. DON’T KNOW

    7. REFUSED


STEM 6.6: Did you ever need any of the following services as a result of your MOST RECENT experience of unwanted [sex / attempted sex]?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED


  1. Housing services?

  2. Community services?

  3. Victim’s advocate services (e.g., rape crisis center or other sexual assault services provider)?

  4. Legal services?

  5. Other services? (Specify: _________________________________________________)


  1. Were you able to get the service(s) that you needed as a result of your MOST RECENT experience of unwanted [sex / attempted sex]?

    1. Yes (Skip to Q6.68)

    2. No

    3. DON’T KNOW (Skip to Q6.68)

    4. REFUSED (Skip to Q6.68)


  1. Why were you not able to get the assistance that you needed?


________________________________________________________________________________________________________________________________________________________


NOTE: IF RESPONDENT WAS LESS THAN 18 YEARS OLD WHEN FIRST EXPERIENCE OCCURRED (SEE Q6.2), ASK Q6.68; ELSE SKIP TO Q6.70.


  1. Was child protective services contacted, regardless of who contacted them, about your MOST RECENT experience of unwanted [sex / attempted sex]?

      1. Yes (Go to Section 7)

      2. No (Go to Section 7)

      3. DON’T KNOW (Go to Section 7)

      4. REFUSED (Go to Section 7)


  1. Was adult protective services contacted, regardless of who contacted them, about your MOST RECENT experience of unwanted [sex / attempted sex]?

  1. Yes

  2. No

  3. DON’T KNOW

  4. REFUSED





Section 7: Mental Health Information


The next set of questions asks about your mental health. There are many factors that can affect a person’s health, including worry and stress.


STEM 7.1: In the past 12 months, how often would you say you were worried or stressed about having enough money to…

  1. Always

  2. Usually

  3. Sometimes

  4. Rarely

  5. Never


  1. pay your rent or mortgage?

  2. buy nutritious meals?


  1. Have you ever felt sad, down, or hopeless almost every day for two weeks or more in a row?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. Have you ever had little interest or pleasure in doing things almost every day for two weeks or more in a row? (IF QUESTIONED, SAY “DAILY ACTIVITIES”)

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


STEM 7.2: Have you ever had any experience that was so frightening, horrible, or upsetting that, for at least 1 month, you…

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. had nightmares about it or thought about it when you did not want to for at least 1 month?

  2. tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

  3. were constantly on guard, watchful, or easily startled?

  4. felt numb or distant from others, activities, or your surroundings?




  1. Have you ever seriously considered attempting suicide?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. During your lifetime, have you ever actually attempted suicide?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. Did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor, nurse, or other medical health professional?

    1. Yes

    2. No

    3. DON’T KNOW

    4. REFUSED


  1. During the last 12 months, about how often did you drink FOUR OR MORE drinks on one occasion?

    1. Never

    2. Less than monthly

    3. Monthly

    4. Weekly

    5. Daily or almost daily


  1. During the last 12 months, about how often did you misuse prescribed drugs or use illegal street drugs such as marijuana, cocaine, inhalants, meth, ecstasy, or oxycontin?

    1. Never

    2. Less than monthly

    3. Monthly

    4. Weekly

    5. Daily or almost daily





Section 8: Concluding Section


Thank you very much for completing this interview with me. Your answers have been very helpful as we begin to understand more about sexual violence in minority communities. I know that many questions may have been very emotional for you, causing you distress.



    1. Would you like to talk about any issues, concerns, or things bothering you about the interview questions at this time?

    1. Yes (Can you tell me about them?)

    2. No

    3. DON’T KNOW

    4. REFUSED


____________________________________________________________________________________________________________________________________________________________


    1. Can you remember whether there were specific questions that bothered you the most?

  1. Yes (Can you tell me which ones?) Why?

  2. No

  3. None that I can remember

  4. DON’T KNOW

  5. REFUSED


____________________________________________________________________________________________________________________________________________________________


    1. Did any of the questions make you feel defensive or feel like you were being judged in any way?

  1. Yes (Can you tell me which ones?) Why?

  2. No

  3. None that I can remember

  4. DON’T KNOW

  5. REFUSED


____________________________________________________________________________________________________________________________________________________________






    1. How are you feeling now that the interview is finished? [OPEN ENDED]


____________________________________________________________________________________________________________________________________________________________


    1. Is there anything I can do to be of assistance to you?

  1. Yes (How can I help you?)

  2. No

  3. DON’T KNOW

  4. REFUSED


____________________________________________________________________________________________________________________________________________________________


    1. What is the best way to reach you to conduct surveys?

    1. Land line

    2. Cell phone

    3. Face-to-face interview

    4. Mail survey

    5. Electronic (online) survey

    6. Some other method (SPECIFY: __________________________________________)



Thank you for helping us with this important study. We are pleased you agreed to talk with us. Your information will provide important details that will help shape our understanding of sexual violence. We urge you to be careful who you tell about the specific topics in this interview. If someone asks you about the interview and you feel unsafe talking about some of the topics, remember you can always talk about the general health questions that were asked at the beginning of the interview. If you have concerns or are distressed in any way, here is a referral sheet with some professionals who are ready to talk to you.



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File TitleSV Questions
AuthorMerle Hamburger
Last Modified Byuzh6
File Modified2010-03-03
File Created2010-02-19
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