Nisvs

The National Intimate Partner and Sexual Violence Survey (NISVS)

Attachment G- 2013 NISVS Survey_OMB - 2-27-2013

National Intimate Partner and Sexual Violence Survey

OMB: 0920-0822

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0822 can be found here:

Document [doc]

Download: doc | pdf

2013 National Intimate Partner and Sexual Violence Survey Proposed Revised Study Questionnaire

February 27, 2013

Table of Contents

Section	Subject	Question Numbers	Page
CF	Control Form
RC	Respondent Characteristics
H	Health
PA	Psychological Aggression
PV	Physical Violence
S	Stalking
SFU	Stalking Follow-Up
SV	Sexual Violence
SVFU	Sexual Violence Follow Up
R	Relationships
FU	General Follow Up Questions
IP	Intimate Partner Information
M	Minors Module
W	Wrap-Up

Conventions used in this document are as follows:

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

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

“[ ]”).

Text for interviewers to read is in bold font.

Section CF: Control Form

Form Approved

OMB No. 0920-0822

Exp. Date: 11/30/2013

Public Reporting burden of this collection of information is estimated at 25 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 Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0822).

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 {if nonresponse sample:, and if someone in your household is selected to participate we will send that person a check for $40 for completing the survey}. 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. IF SOMEONE OVER 18 COMES TO THE PHONE, RE-READ PARAGRAPH ABOVE. IF CAN’T GET SOMEONE OLDER THAN 18, BREAKOFF]

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}

6 REFUSED {go to BREAKOFF}

9 MORE CODES {go to NC}

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 CF2_1}

2 NO {go to CF3}

98 (VOL) DK {go to BREAKOFF}

99 (VOL) RF {go to BREAKOFF}

(cell phone path = CF2_1 – CF7_1A) (landline path = CF3 – CF11)

CF2_1

Are you driving a vehicle at this moment?

1 YES {go to CF2_2}

2 NO {go to CF2_3A}

CF2_2

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]

CF2_3A

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

[RECORD NUMBER OF CELL PHONES] {go to CF2_4A}

[RANGE 1-9]

98 (VOL) DK

99 (VOL) RF

CF2_4A

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 MOSTLY_C}

[RANGE 0-5]

98 (VOL) DK

99 (VOL) RF

MOSTLY_C

Of all the telephone calls that you or your family receives, are….

All or most all calls received on cell phones
Some received on cell phones and some on regular phones
Very few or none on cell phones

CF2_5

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 CF7_1A}

CF7_1A

{IF NECESSARY: Please tell me your gender.}

1 MALE

2 FEMALE

3 TRANSGENDERED1

98 (VOL) DK

99 (VOL) RF

{go to CF11}

{end of cell phone path, beginning landline path}

CF3

Is this a private residence?

1 YES {go to CFTEL1}

2 NO {go to CF3_1}

98 (VOL) DK {go to CF3_1}

99 (VOL) RF {go to CF3_1}

CF3_1

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

[TERMINATE INTERVIEW]

CFTEL1

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]

[RANGE 1-5]

98 (VOL) DK

99 (VOL) RF

CFTEL2

How many working cell phones do you have?

[RECORD NUMBER OF CELL PHONES] {if 0, go to CFTEL3; else go to MOSTLY_L}

[RANGE 0 - 9]

98 (VOL) DK

99 (VOL) RF

CFTEL3

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

1 YES {go to MOSTLY_L}

2 NO {go to NUM_ADULTS}

98 (VOL) DK {go to NUM_ADULTS}

99 (VOL) RF {go to NUM_ADULTS}

MOSTLY_L

Of all the telephone calls that you or your family receives, are….

All or most all calls received on cell phones
Some received on cell phones and some on regular phones
Very few or none on cell phones

NUM_ADULTS

We need to randomly select one adult who lives in your household to be interviewed. Including yourself, how many adults age 18 or older currently live in your household?

[RECORD NUMBER OF ADULTS] {if NUM_ADULTS =0, go to CF11_1; if NUM_ADULTS =1, go to CF7; if NUM_ADULTS=2, go to CF8_1; if NUM_ADULTS > 2, go to CF8_MEN}

[RANGE 1 – 10]

98 (VOL) DK

99 (VOL) RF

CF11_1

Did you include yourself when you said that no one is 18 years old?

1 YES {go to CF6_1}

2 NO {go to NUM_ADULTS}

CF6_1

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

[TERMINATE INTERVIEW – CODE AS INELIGIBLE AGE]

CF7

Are you the adult?

1 YES {go to CF7_1}

2 NO {go to CF13A}

98 (VOL) DK

99 (VOL) RF

CF7_1

Are you male or female?

Please tell me your gender.

1 MALE (go to CF11}

2 FEMALE {go to CF11}

98 (VOL) DK

99 (VOL) RF

CF8_1

Is the other person male or female?

MALE
FEMALE

98 (VOL) DK

99 (VOL) RF

CF8_2

Are you male or female?

MALE
FEMALE

98 (VOL) DK

99 (VOL) RF

{go to CF9_1}

CF8_MEN

How many of these adults are men?

[RECORD NUMBER OF MEN]

98 (VOL) DK

99 (VOL) RF

CF8_WOMEN

How many of these adults are women?

[RECORD NUMBER OF WOMEN]

98 (VOL) DK

99 (VOL) RF

{go to CF9}

CF9_1

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

The other adult is the person that I need to interview. {go to CF13_FIRST}

You are the person that I need to interview. {go to CF11}

CF9

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.

[ENTER 1 TO CONTINUE]

CF10

Are you that person?

1 YES {go to CF11}

2 NO {go to CF13_FIRST}

CF11

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] {go to CF_INTRO1A}

[IF RESPONDENT REFUSES, ASK FOR A FIRST INITIAL OR SOME OTHER IDENTIFIER. IF RESPONDENT STILL REFUSES, LEAVE BLANK AND CONTINUE.]

CF_INTRO1A

You have been randomly chosen to participate in an important study. This call may be monitored or recorded for quality assurance purposes. The Centers for Disease Control and Prevention (CDC) is doing a telephone study of up to 12,500 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 inform prevention efforts.

The survey will take approximately 25 minutes, on average. 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.

{ENTER 1 TO CONTINUE}

CF_INTRO1B

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 {if not nonresponse: $10; if nonresponse: $40} 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.

{ENTER 1 TO CONTINUE}

CF_INTRO1C

If you choose to receive the {if not nonresponse: $10; if nonresponse: $40}, 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, Jessica Williams, at 1-877-287-3782. If you have any questions about your rights as a research participant, please contact RTI’s Office of Research Protection toll-free at 1-866-214-2043.

May we begin?

YES {go to RC_1}
NO {go to CF12}

98 (VOL) DK {go to CF12}

99 (VOL) RF {go to CF12}

CF12

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

CF13A

Is this person male or female?

MALE
FEMALE

98 (VOL) DK

99 (VOL) RF

CF13_FIRST

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 OR SOME OTHER IDENTIFIER. IF RESPONDENT STILL REFUSES, LEAVE BLANK AND CONTINUE.]

CF14

May I speak with {fill: name from CF13_FIRST OR him/her}?

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_INTRO3A

CF_INTRO3B

CF_INTRO3C

May we begin?

YES {go to RC_INTRO}
NO {go to CF17}

98 (VOL) DK {go to CF17}

99 (VOL) RF {go to CF17}

CF17

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

CONFIRMSEX

INTERVIEWER: SELECTED GENDER FOR THIS CASE IS {FILL: MALE/FEMALE}

IF GENDER OF RESPONDENT IS DIFFERENT, CLOSE THIS CASE, SET NEW APPOINTMENT, AND NOTIFY SUPERVISOR

IF GENDER IS CORRECT, PRESS “1” TO START INTERVIEW.

RC1

In what month and year were you born?

[ELIGIBLE YEARS OF BIRTHS ARE: - CURRENT MONTH, 1995 ]

[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

9 ASSOCIATES DEGREE

10 NURSING SCHOOL DEGREE

98 (VOL) DK

99 (VOL) RF

RC3

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

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

RC4

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

[CODE ALL THAT APPLY]

1 White

2 Black or African American

3 Asian

4 Native Hawaiian or other Pacific Islander, or

5 American Indian or Alaskan Native?

6 OTHER, SPECIFY {max 25 characters}

98 (VOL) DK

99 (VOL) RF

RC4A

Do you think of yourself as…

Lesbian or gay {GO TO RC5}
Straight, that is, not gay {GO TO RC5}
Bisexual {GO TO RC5}
Something else {GO TO RC4AO}

98 (VOL) DK {GO TO RC4D}

99 (VOL) RF {GO TO RC5}

RC4AO By something else, do you mean that…

You are not straight, but identify with another label such as queer, trisexual, omnisexual or pan-sexual {GO TO RC5}
You are transgender or transexual {GO TO RC5}
You have not or are in the process of figuring out your sexuality {GO TO RC5}
You do not think of yourself as having a sexuality {GO TO RC5}
You personally reject all labels of yourself {GO TO RC5}
You made a mistake and did not mean to pick this answer {GO TO RC5}
You mean something else {GO TO RC4AOO}

98 (VOL) DK {GO TO RC4D}

99 (VOL) RF {GO TO RC5}

RC4AOO What do you mean by something else?

{max 100 chars} {GO TO

RC4AD
By Don’t Know, do you mean that…

You don’t understand the words {GO TO RC5}
You understand the words, but you have not or are in the process of figuring out your sexuality {GO TO RC5}
You mean something else {GO TO RC4ADO}

98 (VOL) DK {GO TO RC5}

99 (VOL) RF {GO TO RC5}

RC4ADO

What do you mean by something else?

{max 100 chars}

RC5

Were you born in the United States, including U.S. territories and U.S. military bases?

1 YES {go to RC7_1}

2 NO {go to RC5a}

98 (VOL) DK

99 (VOL) RF

RC5a

In what country were you born?

[RECORD NAME OF COUNTRY USING COUNTRY CODE LIST] {max 25 characters} {go to RC5b}

RC5b

How many years have you lived in the United States?

[RECORD NUMBER OF YEARS, or record 0 if LESS THAN ONE YEAR]

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…

[TI NOTE: STUDENTS SHOULD NOT INCLUDE THEIR PARENT’S INCOME.]

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

RC10

What is your zip code?

[RECORD ZIP CODE] {go to RC11}

98 (VOL) DK {go to RC13}

99 (VOL) RF {go to RC13}

RC11

Is this in {prefill state using file}?

1 YES {go to RC12}

2 NO {go to RC11a}

[IF YES, PRE-FILLED STATE IS SAVED IN RC11a]

RC11a

What state do you live in?

[USE LOOK UP FILE]

RC12

Do you live in {prefill county using file} county?

1 YES {go to H1}

2 NO {go to RC12a}

[IF YES, PRE-FILLED COUNTY IS SAVED IN RC12a]

RC12a

What county do you live in?

[USE LOOK UP FILE]

{go to H1}

{add soft check when county name does not match selected zip code}

[INTERVIEWER NOTE:

-IN LOUISIANA A COUNTY MAY BE REFERRED TO AS A PARISH. IN ALASKA A COUNTY MAY BE REFERRED TO AS A BOROUGH OR CENSUS TRACT.

-IF RESPONDENT SAYS THEY LIVE IN DADE COUNTY, FLORIDA CODE AS MIAMI-DADE.

-IF RESPONDENT REPORTS A COUNTY THAT IS NOT LISTED SAY: “LET ME VERIFY THAT YOU SAID ________ COUNTY.” IF THE RESPONDENT SAYS TO THE UNLISTED COUNTY, RECORD COUNTY NAME.

RC13 [IF NO ZIP CODE IS PROVIDED} I understand that people sometimes do not know their ZIP code, but for statistical purposes we need to know in what area you live.

What state do you live in?

[USE LOOK UP FILE]

RC13a

What county do you live in?[USE LOOK UP FILE]

[INTERVIEWER NOTE: IN LOUISIANA A COUNTY MAY BE REFERRED TO AS A PARISH. IN ALASKA A COUNTY MAY BE REFERRED TO AS A BOROUGH OR CENSUS TRACT.]

Section H: Health Questions

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

H1_A Asthma?

H1_IBS Irritable bowel syndrome or IBS?

H1_D Diabetes?

H1_HBP High blood pressure?

Do you have…

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H2_FH Frequent headaches?

H2_CP Chronic pain?

H2_DS Difficulty sleeping?

H3_2013

Are you do you have serious difficulty hearing?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H4_2013

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H5_2013

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H6_2013

Do you have serious difficulty walking or climbing stairs?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H7_2013

Do you have difficulty dressing or bathing?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

H8_2013

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

1 YES

2 NO

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 1-877-287-3782.

Do you have any questions?

VIC_INTROa

Shall we continue?

1 YES

2 NO {BREAKOFF}

98 (VOL) DK

99 (VOL) RF

VIC_INTROb

The next questions ask about experiences you may have had with your romantic or sexual partners. When I ask about your romantic or sexual partners, I want you to think about anybody you have been involved with romantically or sexually, which might include spouses, boyfriends, girlfriends, people you have dated, people you were seeing, or people you hooked up with.

Psychological Aggression (PA)

How many of your current or ex romantic or sexual partners have ever…?

[RECORD NUMBER OF PARTNERS FOR EACH ITEM]

[RANGE 0 – 15 PARTNERS]

PA1 insulted, humiliated, or made fun of you in front of others?

[TI NOTE: IF R ASKS IF THEY SHOULD INCLUDE, OR IF THEY INDICATE INCLUDING PHYSICAL VIOLENCE, PHYSICAL VIOLENCE SHOULD NOT COUNT HERE.]

PA2_2013 (CCE10) kept you from having your own money?

PA3_2013 (CCE1) tried to keep you from seeing or talking to your family or friends?

PA4_2013 (CCE3) kept track of you by demanding to know where you were and what

you were doing?

PA5_2013 (PV1) made threats to physically harm you?

NOTE: NO FOLLOW-UP QUESTIONS FOR PA ENDORSED BEHAVIORS.

Physical VIOLENCE (PV)

PV_INTRO How many of your current or ex romantic or sexual partners have ever…?

[RECORD NUMBER OF PARTNERS FOR EACH ITEM]

[RANGE 0 – 15 PARTNERS]

PV2 slapped you?

PV3 pushed or shoved you?

PV4 hit you with a fist or something hard?

PV5 kicked you?

PV6 hurt you by pulling your hair?

How many of your current or ex romantic or sexual partners have ever…?

PV7 slammed you against something?

PV9 tried to hurt you by choking or suffocating you?

PV10 beaten you?

PV11 burned you on purpose?

PV12 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 ANY initials, read: I’d like for you to tell me some way that we can refer to {fill: if any PV1 – 12 =1, this person; if any PV1 – 12 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any PV1 – 12 =1, this person; if any PV1 – 12 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any PV1 – 12 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR IP]

{if any PV1 – 12 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

{once ANY initials have been recorded, then only display: Please tell me the initials of the {fill: if any PV1 – 12 > 1, first} person who {fill: behavior}?}

PV1a

[if collecting new initials]

Is {fill: initials} male or female?

MALE
FEMALE

PVb

{for each set of initials, fill initials 1, initials 2, etc. up to 15}

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

1 One time,

2 Two times,

3 Three to five times,

4 Six to ten times,

5 Eleven to twenty times, or

6 More than twenty times?

98 (VOL) DK

99 (VOL) RF

PVf

{Fill: Has this person / Did 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 {go to next PV item}

98 (VOL) DK {go to next PV item}

99 (VOL) RF {go to next PV item}

PVg

{if multiple perps}

Which people did this in the past twelve months?

[RECORD INITIALS OF PARTNERS]

PVh

{for all sets of initials endorsed at PVg, fill initials 1, initials 2, etc. up to 15}

{only display answer options LT or EQUAL to PVb (reported # of times ever)]

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

1 One time,

2 Two times,

3 Three to five times,

4 Six to ten times,

5 Eleven to twenty times, or

6 More than twenty times?

98 (VOL) DK

99 (VOL) RF

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

PVj

[ask for each set of initials, fill initials 1, initials 2, etc.]

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

[INTERVIEWER: IF R ASKS FOR A LIST OF BEHAVIORS ENDORSED READ:

{FILL: LIST OF ENDORSED PV BEHAVIORS} ]

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

Section S: Stalking

S_INTRO

I’m going to ask you some detailed questions about times when you may have been contacted, followed or harassed. When answering, please think about anyone who may have done these things to you, including strangers or someone you knew, including a romantic or sexual partner; a friend, teacher or co-worker, or superior; or a family member. Please do not include bill collectors, telephone solicitors, or other sales people.

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

How many people have ever…?

[RECORD NUMBER OF PEOPLE FOR EACH ITEM]

[RANGE 0 – 15 PEOPLE]

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 you didn’t want 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 scare you by letting you know they had been there?

How many people have ever…?

S8 left you unwanted messages? This includes text or voice messages.

S1 made unwanted phone calls to you? This includes hang-up calls.

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

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

{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}

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

{if 1^st time collecting ANY 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}

{once ANY initials have been recorded, then only display: Please tell me the initials of the {fill: if any S1 – 7 > 1, first} person who {fill: behavior}?}

S1a

[if collecting new initials]

Is {fill: initials} male or female?

MALE
FEMALE

{for each set of initials, fill initials 1, initials 2, etc. up to 15}

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

1 One time,

2 Two times,

3 Three to five times,

4 Six to ten times,

5 Eleven to twenty times, or

6 More than twenty times?

98 (VOL) DK

99 (VOL) RF

{Fill: Has this person / Did 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 {go to next S item}

98 (VOL) DK {go to next S item}

99 (VOL) RF {go to next S item}

{if multiple perps}

Which people did this in the past twelve months?

[RECORD INITIALS OF PARTNERS]

{for all sets of initials endorsed at Sg, fill initials 1, initials 2, etc. up to 15}

{only display answer options LT or EQUAL to Sb (reported # of times ever)]

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

1 One time,

2 Two times,

3 Three to five times,

4 Six to ten times,

5 Eleven to twenty times, or

6 More than twenty times?

98 (VOL) DK

99 (VOL) RF

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

STALKING FOLLOW-UP QUESTIONS

(NOTE: one behavior, one time gets no follow-up questions – for stalking either has to be more than one behavior at least one time, or one behavior more than one time)

SFU_INTRO

{establish loop for each perp initials collected, and cycle through SFU_INTRO2 – SFU6 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

How old were you the first time {fill: initials} did {fill: this / these things}?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SFU1a

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

SFU2a

Think about the time period between the first time {fill: initials} did {fill: this/these things} and the last time it happened. About how many years, months, weeks, or days did {fill: initials} do {fill: this/these things}?

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

SFU3

Were you ever fearful for yourself when {fill: initials} did {fill: this / these things}?

1 YES {go to SFU3a}

2 NO {go to SFU4}

98 (VOL) DK

99 (VOL) RF

SFU3a

Thinking about when you were the most fearful, how fearful were you about the things {fill: initials} did? Were you…

1 Very fearful,

2 Somewhat fearful, or

3 A little fearful

98 (VOL) DK

99 (VOL) RF

SFU4

[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

SFU5

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

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SFU6

Did you ever believe you or someone close to you would be seriously harmed or killed when {fill: initials} did {fill: this / these things}?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

{loop back to SFU_INTRO2 and continue with 2^nd set of initials, 3^rd set of initials, etc. until all perps have received follow-up questions SFU1 – SFU6}

Section SV: Sexual Violence

SV_INTRO

I’m going to ask you some detailed questions about times when you may have experienced unwanted sexual situations with a stranger or someone you knew, including a romantic or sexual partner; a friend, teacher, coworker, or supervisor; or a family member. These questions are detailed and the language is explicit, which some people may find upsetting. It is important that I ask the questions this way so that you are clear about what I mean. Your answers will help us to learn how often these things happen.

I’m going to ask you about unwanted sexual situation that did NOT involve touching and situations that DID involve touching. I will also ask you about situation in which you were unable to provide consent to sex because of alcohol or drugs, AND about your experiences with unwatned sex that happened when someone used physical force or verbal pressure. Shall we continue?

Shall we continue?

1 CONTINUE

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]

{only ask SV1-SV1_SV4_Rel when minors module being administered}

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 when you didn’t want it to happen?

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

SV4 verbally harassed you while you were in a public place in a way that made you feel unsafe?

SV1_SV4_Age

How old were you the first time this or any of these things {fill: SV1-SV4 behaviors} happened to you?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SV1_SV4_Rel

What was your relationship the first time this or any of these things (SV1-SV4) happened to you?

[INTERVIEWER: REMINDER – THE NEXT SCREEN ASKS WHETHER THE INTIMATE PARTNER (IP) WAS A CURRENT OR EX IP. DO NOT USE “OTHER” TO RECORD CURRENT OR EX IP, RATHER GO TO NEXT SCREEN AND CODE ACCORDINGLY.]

[IP CATEGORIES:

1 HUSBAND / WIFE

2 LIVE-IN PARTNER

3 FIANCE

4 BOY / GIRL FRIEND

5 DATING PARTNER

6 SOMEONE YOU WERE SEEING

SOMEONE YOU WERE HAVING SEX WITH]

[NON-IP CATEGORIES:

FAMILY MEMBER {go to SV1_4_REL _2}
ACQUAINTANCE {go to SV1_4_REL _3}

12 PERSON OF AUTHORITY {go to SV1_4_REL _4}

13 PERSON KNOWN FOR A SHORT TIME {go to SV1_4_REL _5}

10 STRANGER

11 OTHER, SPECIFY {max 25 characters}} {go to SV1_4_REL sp}]

SV1_4_REL_2

{FAMILY MEMBER SUB-CATEGORIES}

1 FATHER / MOTHER

2 STEP-FATHER / MOTHER

3 FOSTER PARENT (MALE / FEMALE)

16 FATHER/MOTHER-IN_LAW

4 BROTHER / STEP-BROTHER

5 SISTER / STEP – SISTER

17 FOSTER BROTHER/FOSTER SISTER

6 BROTHER / SISTER IN-LAW

7 UNCLE / AUNT

8 COUSIN

9 GRANDFATHER / MOTHER

10 SON/STEP-SON

11 DAUGHTER/STEP-DAUGHTER

18 FOSTER SON/FOSTER DAUGHTER

19 SON/DAUGHTER-IN-LAW

12 GRANDSON/STEP-GRANDSON

13 GRANDDAUGHTER/STEP-GRANDDAUGHTER

20 NIECE/NEPHEW

14 OTHER MALE RELATIVE (SPECIFY) {go to SV1_4_REL _2sp}

15 OTHER FEMALE RELATIVE (SPECIFY) {go to SV1_4_REL _2sp}

SV1_4_REL_ 3

{ACQUAINTANCE SUB-CATEGORIES}

1 FIRST DATE

3 FRIEND

4 FAMILY FRIEND

5 NEIGHBOR

13 CLASSMATE

14 FRIEND OF A FRIEND

7CO-WORKER / CUSTOMER / CLIENT

12 OTHER ACQUAINTANCE (SPECIFY) {go to SV1_4_REL _3sp}

SV1_4_REL _4

{PERSON OF AUTHORITY SUB-CATEGORIES}

BOSS / SUPERVISOR / SUPERIOR IN COMMAND
TEACHER / PROFESSOR / TEACHING ASSISTANT, COACH
CLERGY MEMBER
DOCTOR / NURSE / THERAPIST
CAREGIVER
OTHER PERSON OF AUTHORITY (SPECIFY) {go to SV1_4_REL_4sp}

SV1_4_REL _5

{PERSON KNOWN FOR A SHORT TIME SUB-CATEGORIES}

SOMEONE KNOWN FOR LESS THAN 24 HOURS
SOMEONE KNOWN BY SIGHT ONLY
SOMEONE YOU JUST MET
OTHER PERSON KNOWN FOR A SHORT TIME (SPECIFY) {go to SV1_4_REL_5sp}

{if SV1_SV4_REL = DK/RF, go to SV5

SV1_4_REL _1

{IP relationships}

[INTERVIEWER: IF R VOLUNTEERED CURRENT OR EX ON PRIOR QUESTION, RECORD RESPONSE HERE AND DO NOT ASK THIS QUESTION.

IF R DID NOT VOLUNTEER RESPONSE, ASK: Was this person your current or ex{fill response from R1} the first time {fill: this / any of these things} happened?

[1 CURRENT

2 EX]

How many people have ever…

SV5 kissed you in a sexual way when you didn’t want it to happen?

SV6 fondled, groped, grabbed, or touched you in a way that made you feel unsafe?

[only ask SV5_SV6_Age & SV5_SV6_Rel when minors module being administered}

SV5_SV6_Age

How old were you the first time this or any of these things {fill: SV5-SV6 behaviors} happened to you?

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SV5_SV6_Rel

What was your relationship the first time this or any of these things (SV5-SV6) happened to you?

[IP CATEGORIES:

1 HUSBAND / WIFE

2 LIVE-IN PARTNER

3 FIANCE

4 BOY / GIRL FRIEND

5 DATING PARTNER

6 SOMEONE YOU WERE SEEING

SOMEONE YOU WERE HAVING SEX WITH]

[NON-IP CATEGORIES:

FAMILY MEMBER {go to SV5_6_REL _2}
ACQUAINTANCE {go to SV5_6_REL _3}

12 PERSON OF AUTHORITY {go to SV5_6_REL _4}

13 PERSON KNOWN FOR A SHORT TIME {go to SV5_6_REL _5}

10 STRANGER

11 OTHER, SPECIFY {max 25 characters}} {go to SV5_6_REL sp}]

SV5_6_REL_2

{FAMILY MEMBER SUB-CATEGORIES}

1 FATHER / MOTHER

2 STEP-FATHER / MOTHER

3 FOSTER PARENT (MALE / FEMALE)

16 FATHER/MOTHER-IN_LAW

4 BROTHER / STEP-BROTHER

5 SISTER / STEP – SISTER

17 FOSTER BROTHER/FOSTER SISTER

6 BROTHER / SISTER IN-LAW

7 UNCLE / AUNT

8 COUSIN

9 GRANDFATHER / MOTHER

10 SON/STEP-SON

11 DAUGHTER/STEP-DAUGHTER

18 FOSTER SON/FOSTER DAUGHTER

19 SON/DAUGHTER-IN-LAW

12 GRANDSON/STEP-GRANDSON

13 GRANDDAUGHTER/STEP-GRANDDAUGHTER

20 NIECE/NEPHEW

14 OTHER MALE RELATIVE (SPECIFY) {go to SV5_6_REL _2sp}

15 OTHER FEMALE RELATIVE (SPECIFY) {go to SV5_6_REL _2sp}

SV5_6_REL_ 3

{ACQUAINTANCE SUB-CATEGORIES}

1 FIRST DATE

3 FRIEND

4 FAMILY FRIEND

5 NEIGHBOR

13 CLASSMATE

14 FRIEND OF A FRIEND

7CO-WORKER / CUSTOMER / CLIENT

12 OTHER ACQUAINTANCE (SPECIFY) {go to SV5_6_REL _3sp}

SV5_6_REL _4

{PERSON OF AUTHORITY SUB-CATEGORIES}

BOSS / SUPERVISOR / SUPERIOR IN COMMAND
TEACHER / PROFESSOR / TEACHING ASSISTANT, COACH
CLERGY MEMBER
DOCTOR / NURSE / THERAPIST
CAREGIVER
OTHER PERSON OF AUTHORITY (SPECIFY) {go to SV5_6_REL_4sp}

SV5_6_REL _5

{PERSON KNOWN FOR A SHORT TIME SUB-CATEGORIES}

SOMEONE KNOWN FOR LESS THAN 24 HOURS
SOMEONE KNOWN BY SIGHT ONLY
SOMEONE YOU JUST MET
OTHER PERSON KNOWN FOR A SHORT TIME (SPECIFY) {go to SV5_6_REL_5sp}

{if SV5_SV6_REL = DK/RF, go to SV7

SV5_6_REL _1

{IP relationships}

[INTERVIEWER: IF R VOLUNTEERED CURRENT OR EX ON PRIOR QUESTION, RECORD RESPONSE HERE AND DO NOT ASK THIS QUESTION.

IF R DID NOT VOLUNTEER RESPONSE, ASK: Was this person your current or ex{fill response from R1} the first time {fill: this / any of these things} happened?

[1 CURRENT

2 EX]

Sometimes unwanted sex happens when a person is unable to consent to it or stop it from happening because they were too 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. Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault.

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

SV7 made you have vaginal sex? By vaginal sex, we mean that {if female: a man or boy put his penis in your vagina} {if male: a woman or girl made you put your penis in her vagina}.

SV8 {if male} made you perform anal sex, meaning they made you put your penis into their anus.

SV9 made you receive anal sex, meaning they put their penis into your anus?

SV10a put their mouth on your {if male, fill: penis; if female, fill: vagina}?

SV10b put their mouth on your anus?

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

SV11a made you put your mouth on their vagina or anus?

SV11b made you put your mouth on their penis?

SV11c put their fingers or an object in your {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 the use of violence.

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

SV12 have vaginal sex?

SV13 {if male} perform anal sex?

SV14 receive anal sex?

SV15a put their mouth on your {if male, fill: penis; if female, fill: vagina}?

SV15b put their mouth on your anus?

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

SV16a make you put your mouth on their vagina or anus?

SV16b make you put your mouth on their penis?

SV17 put their fingers or an object in your {if female, fill: vagina or} anus?

SV18a {if male} TRY to make you have vaginal sex with them, but sex did not happen?

SV18b TRY to have {if female, fill: vaginal,} oral, or anal sex with you, but sex did not happen?

The following questions are asking about other experiences with unwanted sex beyond what you have already told me.

Sometimes unwanted sex happens after a person is pressured in a nonphysical way.

How many people have you had vaginal, oral, or anal sex with after they pressured you by …

SV19 Doing 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?

SV20 Wearing you down by repeatedly asking for sex, or showing they were unhappy?

SV21 Using their influence or authority over you, for example, your boss or your teacher?

{if R endorses any SV7 – SV11, and then endorses any SV12 – SV18b and gives identical initials, ask:

SV22

Previously you told me that {fill: initials} {fill: behavior from SV7 – SV11} and you just reported that {fill: initials} {fill: behavior from SV12 – SV18b}. Did these things happen on the same occasion?

1 YES {count follow-up questions already answered for SV7 – SV11, do not ask follow-ups for behavior endorsed from SV12 – SV18b}

2 NO {continue to ask all follow-ups for behavior endorsed from SV12 – SV18b}

98 (VOL) DK

99 (VOL) RF

{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 ANY initials, read: I’d like for you to tell me some way that we can refer to {fill: if any SV1 – 21 =1, this person; if any SV1 – 21 > 1, these people}, such as their initials or a nickname, so that if I ask you other questions about {fill: if any SV1 – 21 =1, this person; if any SV1 – 21 > 1, these people} you’ll know who I’m talking about.} Please tell me the initials of the {fill: if any SV1 – 21 > 1, first} person who {fill: behavior}?

[RECORD INITIALS FOR PERP]

{if any SV1 – 21 > 1, ask Please tell me the initials of the next person who {fill: behavior}?, until # of sets of initials = number of reported partners}

{once ANY initials have been recorded, then only display: Please tell me the initials of the {fill: if any SV1 – 21 > 1, first} person who {fill: behavior}?}

SV1a

[if collecting new initials]

Is {fill: initials} male or female?

MALE
FEMALE

SVb

{for each set of initials, fill initials 1, initials 2, etc. up to 15}

{if SV7 – SV18b (rape or made to penetrate behaviors), ask}

How many times did {fill: initials} ever {fill: behavior}?

[RECORD NUMBER OF TIMES] [RANGE = 1 – 100, 100 = 100+]

{for all other endorsed behaviors (non-rape behaviors), ask}

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

1 One time,

2 Two times,

3 Three to five times,

4 Six to ten times,

5 Eleven to twenty times, or

6 More than twenty times?

98 (VOL) DK

99 (VOL) RF

SVf

{Fill: Has this person / Did 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 next SV item}

98 (VOL) DK

99 (VOL) RF

SVg

{if multiple perps}

Which people did this in the past twelve months?

[RECORD INITIALS OF PARTNERS]

SVh

{for all sets of initials endorsed at SVg, fill initials 1, initials 2, etc. up to 15}

{if SV7 – SV18b, ask}How many times did {fill: initials} {fill: behavior} in the past 12 months?

[RECORD NUMBER OF TIMES] [RANGE = 1 – 100, 100 = 100+]

{only display answer options LT or EQUAL to SVb (reported # of times ever)]

{for all other endorsed behaviors, ask}

1 One time,

2 Two times,

3 Three to five times,

4 Six to ten times,

5 Eleven to twenty times, or

6 More than twenty 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

{For SV7 – SV11c, skip SVk and go to SVl}

Were you using alcohol, drugs or both the first time {fill: initials} {fill: behavior}? {if this is the 1^st time these questions are being asked, display: Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault. After displaying one time, do not display again.}

1 ALCOHOL

2 DRUGS

3 BOTH ALCOHOL AND DRUGS

4 NEITHER ALCOHOL OR DRUGS

98 (VOL) DK

99 (VOL) RF

SV?

{only ask if any SV7 – SV11c is endorsed}

When {fill: initials} {fill: if SV7 ≥ 1, made you have vaginal sex with you; if SV10a ≥ 1, put their mouth on your {if male, fill: penis; if female, fill: vagina}; if SV10b ≥ 1, put their mouth on your anus; if SV11a ≥ 1, made you put your mouth on their vagina or anus; if SV11b ≥ 1, made you put your mouth on their penis; if SV8 or SV9 ≥ 1, had anal sex with you; if SV11c ≥ 1, put their fingers or an object in you} and you were unable to consent because you were too drunk, high, drugged or passed out:

SVl: Do you think you were given alcohol without your knowledge?

(VOL) DK
(VOL) RF

SVM: Do you think you were given drugs without your knowledge?

(VOL) DK
(VOL) RF

SVN: Had you voluntarily used drugs or alcohol (Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault)?

(VOL) DK
(VOL) RF

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

CHK2

{If R endorses 1 or more behaviors in the SV section}

I’d like to check in with you to make sure you’re feeling alright and would like to continue the interview. Shall we continue?

YES {go to SVFU_INTRO}

2 NO {BREAKOFF AND CODE AS DISTRESS}

SEXUAL VIOLENCE FOLLOW-UP QUESTIONS

SVFU_INTRO

{only ask SVFU questions for those who endorse any of SV7 – SV18b, else skip to R_INTRO}

{establish loop for each perp initials collected, and cycle through SVFU_INTRO2 – SFU7 for each perp}

Let’s talk some more about your experiences with {fill: all initials identified in SV7 – SV18b}.

SVFU_INTRO2You said that {fill: first set of initials} {fill: endorsed behaviors from SV7 – SV18b only}.

SVFU1

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

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

{If only SV18 a or SV18b are endorsed, then do not ask SVFU2}

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

{If only SV18 a or SV18b are endorsed, then do not ask SVFU3}

SVFU3 {if female only, else skip to SVFU4}

Did you ever get pregnant when {fill: initials} did {fill: this / any of these things}?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

SVFU4

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

SVFU5

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

SVFU6a

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

98 (VOL) DK

99 (VOL) RF

SECTION R: RELATIONSHIPS

R_INTRO

Now I’m going to ask you some questions about how you knew some of the people that you told me about. I will want you to tell me if they were someone you knew, or were a stranger. If you knew the person, I’ll ask how you knew them. I’d like you to tell me if they were a current or ex romantic or sexual partner, a family member, someone in a position of authority over you like a boss, coach, or teacher, or were someone you knew some other way, such as a neighbor, friend, someone you knew by sight only, or someone you knew for less than 24 hours.

R1_INTRO [TI NOTE: PLEASE READ THIS SCREEN IN A RESPECTFUL MANNER.]

You told me previously that {fill: initials 1} {fill: all endorsed behaviors from all sections}.

How did you know or what was your relationship to {fill: initials 1} the first time {fill: this / any of these things} happened?

[IP CATEGORIES:

1 HUSBAND / WIFE

2 LIVE-IN PARTNER

3 FIANCE

4 BOY / GIRL FRIEND

5 DATING PARTNER

6 SOMEONE YOU WERE SEEING

SOMEONE YOU WERE HAVING SEX WITH]

[NON-IP CATEGORIES:

FAMILY MEMBER {go to R1_2}
ACQUAINTANCE {go to R1_3}

12 PERSON OF AUTHORITY {go to R1_4}

13 PERSON KNOWN FOR A SHORT TIME {go to R1_5}

10 STRANGER

11 OTHER, SPECIFY {max 25 characters}} {go to R1sp}]

R1_2

{FAMILY MEMBER SUB-CATEGORIES}

1 FATHER / MOTHER

2 STEP-FATHER / MOTHER

3 FOSTER PARENT (MALE / FEMALE)

16 FATHER/MOTHER-IN_LAW

4 BROTHER / STEP-BROTHER

5 SISTER / STEP – SISTER

17 FOSTER BROTHER/FOSTER SISTER

6 BROTHER / SISTER IN-LAW

7 UNCLE / AUNT

8 COUSIN

9 GRANDFATHER / MOTHER

10 SON/STEP-SON

11 DAUGHTER/STEP-DAUGHTER

18 FOSTER SON/FOSTER DAUGHTER

19 SON/DAUGHTER-IN-LAW

12 GRANDSON/STEP-GRANDSON

13 GRANDDAUGHTER/STEP-GRANDDAUGHTER

20 NIECE/NEPHEW

14 OTHER MALE RELATIVE (SPECIFY) {go to R1_2sp}

15 OTHER FEMALE RELATIVE (SPECIFY) {go to R1_2sp}

R1_3

{ACQUAINTANCE SUB-CATEGORIES}

1 FIRST DATE

3 FRIEND

4 FAMILY FRIEND

5 NEIGHBOR

13 CLASSMATE

14 FRIEND OF A FRIEND

7 CO-WORKER / CUSTOMER / CLIENT

12 OTHER ACQUAINTANCE (SPECIFY) {go to R1_3sp}

R1_4

{PERSON OF AUTHORITY SUB-CATEGORIES}

BOSS / SUPERVISOR / SUPERIOR IN COMMAND
TEACHER / PROFESSOR / TEACHING ASSISTANT, COACH
CLERGY MEMBER
DOCTOR / NURSE / THERAPIST
CAREGIVER
OTHER PERSON OF AUTHORITY (SPECIFY) {go to R1_4sp}

R1_5

{PERSON KNOWN FOR A SHORT TIME SUB-CATEGORIES}

SOMEONE KNOWN FOR LESS THAN 24 HOURS
SOMEONE KNOWN BY SIGHT ONLY
SOMEONE YOU JUST MET
OTHER PERSON KNOWN FOR A SHORT TIME (SPECIFY) {go to R2_5sp}

{if R1 = DK/RF, go to R4

Note: R1a is not asked here, since it is asked earlier question will automatically be filled. Variable will remain in the data set for analysis.

R1_1

{IP relationships}

[INTERVIEWER: IF R VOLUNTEERED CURRENT OR EX ON PRIOR QUESTION, RECORD RESPONSE HERE AND DO NOT ASK THIS QUESTION.

IF R DID NOT VOLUNTEER RESPONSE, ASK: Was this person your current or ex{fill response from R1} the first time {fill: this / any of these things} happened?

[1 CURRENT

2 EX]

{if R1_1 = DK/RF, go to R2}

{skip question if only one behavior was reported one time}

How did you know or what was your relationship to {fill: initials 1} the last time {fill: this

/ any of these things} happened?

[IP CATEGORIES:

1 HUSBAND / WIFE

2 LIVE-IN PARTNER

3 FIANCE

4 BOY / GIRL FRIEND

5 DATING PARTNER

SOMEONE YOU WERE SEEING

7 SOMEONE YOU WERE HAVING SEX WITH]

[NON-IP CATEGORIES:

8 FAMILY MEMBER {go to R2_2}

9 ACQUAINTANCE {go to R2_3}

12 PERSON OF AUTHORITY {go to R2_4]

13 PERSON KNOWN FOR A SHORT TIME {go to R2_5}

10 STRANGER

11 OTHER, SPECIFY{max 25 characters}}{go to R2sp}]

R2_2

{FAMILY MEMBER SUB-CATEGORIES}

1 FATHER / MOTHER

2 STEP-FATHER / MOTHER

3 FOSTER PARENT (MALE / FEMALE)

16 FATHER/MOTHER-IN-LAW

4 BROTHER / STEP-BROTHER

5 SISTER / STEP – SISTER

17 FOSTER BROTHER/FOSTER SISTER

6 BROTHER / SISTER IN-LAW

7 UNCLE / AUNT

8 COUSIN

9 GRANDFATHER / MOTHER

10 SON/STEP-SON

11 DAUGHTER/STEP-DAUGHTER

18 FOSTER SON/FOSTER DAUGHTER

19 SON/DAUGHTER-IN-LAW

12 GRANDSON/STEP-GRANDSON

13 GRANDDAUGHTER/STEP-GRANDDAUGHTER

20 NIECE/NEPHEW

14 OTHER MALE RELATIVE (SPECIFY) {go to R2_2sp}

15 OTHER FEMALE RELATIVE (SPECIFY) {go to R2_2sp}

R2_3

{ACQUAINTANCE SUB-CATEGORIES}

1 FIRST DATE

3 FRIEND

4 FAMILY FRIEND

5 NEIGHBOR

13 CLASSMATE

14 FRIEND OF A FRIEND

7 CO-WORKER / CUSTOMER / CLIENT

12 OTHER ACQUAINTANCE (SPECIFY) {go to R2_3sp}

R2_4

{PERSON OF AUTHORITY SUB-CATEGORIES]

BOSS / SUPERVISOR / SUPERIOR IN COMMAND
TEACHER / PROFESSOR / TEACHING ASSISTANT, COACH
CLERGY MEMBER
DOCTOR / NURSE / THERAPIST
CAREGIVER
OTHER PERSON OF AUTHORITY (SPECIFY) {go to R2_4sp}

R2_5

{PERSON KNOWN FOR A SHORT TIME SUB-CATEGORIES}

SOMEONE KNOWN FOR LESS THAN 24 HOURS
SOMEONE KNOWN BY SIGHT ONLY
SOMEONE YOU JUST MET
OTHER PERSON KNOWN FOR A SHORT TIME (SPECIFY) {go to R2_5sp}

{if R2 = DK/RF, go to R3}

R2_1

{IP relationships}

[INTERVIEWER: IF R VOLUNTEERED CURRENT OR EX ON PRIOR QUESTION, RECORD RESPONSE HERE AND DO NOT ASK THIS QUESTION.

IF R DID NOT VOLUNTEER RESPONSE, ASK: Was this person your current or ex {fill response from R2} the last time {fill: this / any of these things} happened?

[1 CURRENT

2 EX]

{if R2_1 = DK/RF, go to R3}

{If no stalking or SV7-SV18b endorsed, skip to R2a}

Note: If relationship bucket changes between R1 and R2, we would then follow up with those respondents for stalking and rape or made to penetrate.

Note: If relationship is “other” at R1 and/or R2, we would then follow up with those respondents for stalking and rape or made to penetrate.

For stalking and rape or made to penetrate (if reported for that specific perpetrator):

R2newa_1

[repeat question for each initials who meet criteria]

{If reported stalking behavior and:

R1=1-7 and R2=1-7, then skip to R2newb_1,

R1=8 and R2=8, then skip to R2newb_1,

R1=9 and R2=9 then skip to R2newb_1,

R1=12 and R2=12 then skip to R2newb_1,

R1=13 and R2=13 then skip to R2newb _1,

R1=10 and R2=10 then skip to R2newb_1,

else ask:

If R1=11 or R1_2=14 or 15, or R1_3=12, or R1_4=6 or R1_5=4 then ask:

{If stalking = yes}

You told me previously that [initials] did {fill: this / these things}: {fill: all endorsed stalking behaviors (S1-S8)}.

Was [initials] a {fill: R1} when {fill: she/he} did {fill: this / any of these things?

1 YES
2 NO

98 (VOL) DK

99 (VOL) RF

R2newa_2

Was [initials] a {fill: R2} when {fill: she/he} did {fill: this / any of these things}?

1 YES
2 NO

98 (VOL) DK

99 (VOL) RF

R2new b_1

[repeat question for each initials who meet criteria]

{If reported SV7-SV18b behavior and:

R1=1-7 and R2=1-7, then skip to R2a,

R1=8 and R2=8, then skip to R2a,

R1=9 and R2=9 then skip to R2a,

R1=12 and R2=12 then skip to R2a,

R1=13 and R2=13 then skip to R2a,

R1=10 and R2=10 then skip to R2a,

else ask:

If R1=11 or R1_2=14 or 15, or R1_3=12, or R1_4=6 or R1_5=4 then ask:

{If rape/made to penetrate = yes}

You told me previously that [initials] did {fill: this / these things}: {fill: endorsed rape/made to penetrate behaviors (SV7-SV18b)}.

Was [initials] a {fill: R1} when {fill: she/he} did {fill: this / any of these things}?

1 YES
2 NO

98 (VOL) DK

99 (VOL) RF

R2newb_2

Was [initials] a {fill: R2} when {fill: she/he} did {fill: this / any of these things}?

1 YES
2 NO

98 (VOL) DK

99 (VOL) RF

R2a

{if respondent indicates IP was current at R1, and EX at R2}

Were the things that {fill: initials} did more severe before your relationship ended, after your relationship ended, or during the time your relationship was ending?

BEFORE RELATIONSHIP ENDED
AFTER RELATIONSHIP ENDED
DURING RELATIONSHIP ENDING
NOT SEVERE AT ALL

98 (VOL) DK

99 (VOL) RF

{if R has only reported PV, S or SV7 – SV18b items, skip R4 – R6 and go to R7}

Thinking about all of the things you told me {fill: initials} did

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

[RECORD AGE]

98 (VOL) DK

99 (VOL) RF

R6a

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

{fill Latina/Latino from sex reported first time perp listed}

Is {fill: initials} Hispanic or {if female: Latina; if male: Latino; if perp sex unkown fill: Latina or Latino}?

1 YES {go to R7a}

2 NO {go to R8}

98 (VOL) DK

99 (VOL) RF

What is {fill: initials}’s race? You may identify more than one category. Would you say. . .

[CODE ALL THAT APPLY]

1 White

2 Black or African American

3 Asian

4 Native Hawaiian or other Pacific Islander, or

5 American Indian or Alaskan Native?

6 OTHER, SPECIFY {max 25 characters}

98 (VOL) DK

99 (VOL) RF

{CATI will keep count of the number of times this question is asked for each perpetrator. Once question has been asked 3 times, and all response categories have been read 3 times to R, program will change to show response options in ALL CAPS, indicating that response options do not have to be read aloud unless necessary}

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

Section FU: General follow-up Questions

{if R has reported onlyS perpetrators who did only 1 behavior (S) 1 time, skip section FU for that perpetrator}

{if R has reported only S1, S2, or S8 perpetrator, but then SFU3, SFU4, SFU5, and SFU6 all = 2, skip section FU for that perpetrator}

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: {initials} / any of these people}?

1 YES {go to FU1a}

2 NO {go to FU2}

98 (VOL) DK

99 (VOL) RF

FU1a

{skip if only one perp reported}

Which of these people made you feel concerned for your safety?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU2

{if respondent has only reported S items, skip to FU3_1}

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

1 YES {go to FU2a}

2 NO {go to FU3_1}

98 (VOL) DK

99 (VOL) RF

FU2a

{skip if only one perp reported}

Which of these people made you feel fearful?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU2b

Thinking about when you were the most fearful, how fearful were you about the things {fill: initials} did? Were you…

1 Very fearful,

2 Somewhat fearful, or

3 A little fearful

98 (VOL) DK

99 (VOL) RF

FU3_1

{for each set of initials reported at FU1a and/or FU2a loop through FU3_1 – FU3_4}

Did you ever have nightmares because of what {fill: initials} did to you?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

FU3_2

Did you ever try hard not to think about or go out of your way to avoid being reminded of what {fill: initials} did to you?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

FU3_3

Did you ever feel like you were constantly on guard, watchful, or easily startled because of what {fill: initials} did to you?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

FU3_4

Did you ever feel numb or detached from others, your activities, or your surroundings because of what {fill: initials} did to you?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

FU4

{ask if endorsed behaviors in PV, S, or SV only, else skip to FU5}

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

1 YES {go to FU4a}

2 NO {go to FU_end}

98 (VOL) DK

99 (VOL) RF

FU4a

{skip if only one perp reported}

Which of these people caused your injuries?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU4b

When{fill: 1^st set of initials from FU4a} injured you, did those injuries include:

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

FU4b_1 minor bruises or scratches?

FU4b_2 cuts, major bruises, or black eyes?

FU4b_2a injury to any ligments, muscles or tendons?

FU4b_3 broken bones or teeth?

FU4b_3a back or neck injury?

FU4b_4 being knocked out after getting hit, slammed against something, or choked?

FU4b_4a head injury?

FU4b_6 vaginal or anal injuries?

FU4b_7 mental or emotional harm?

FU4b_5 other injuries? [SPECIFY, MAX 75 CHARACTERS]

{repeat FU4b for all initials reported at FU4a: You also said that {fill: 2^nd set of intials, 3^rd set, etc.} injured you. Did those injuries include: …}

FU5_2

Have you ever talked to a medical doctor or nurse about what {fill: {initials} / any of these people} did?

1 YES {go to FU5_2_12}

2 NO {go to FU5_4}

98 (VOL) DK

99 (VOL) RF

FU5_2_12

In the last 12 months, have you talked to a medical doctor or nurse about what {Fill: {initials}/any of these people} did?

1 YES {go to FU5_4}

2 NO {go to FU5_4}

98 (VOL) DK

99 (VOL) RF

FU5_4

Have you ever talked to a crisis hotline operator about what {fill: {initials} / any of these people} did?

1 YES {go to FU5_4_12}

2 NO {go to FU6_1}

98 (VOL) DK

99 (VOL) RF

FU5_4_12

In the last 12 months, have you talked to a crisis hotline operator about what {fill: {initials} / any of these people} did?

1 YES {go to FU6_1}

2 NO {go to FU6_1}

98 (VOL) DK

99 (VOL) RF

FU6_1

Did you ever need medical care because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6a}

2 NO {go to FU6_2}

98 (VOL) DK

99 (VOL) RF

{NOTE: For each Yes in FU6 series, get asked FU6a (who) then asked 12 mo question (FU6_#_12). Then go to FU6b-c, and then ask about next service.}

FU6_1_12

In the last 12 months, did you ever need medical care because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6b}

2 NO {go to FU6b}

98 (VOL) DK

99 (VOL) RF

FU6_2

Did you ever need housing services because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6a}

2 NO {go to FU6_4}

98 (VOL) DK

99 (VOL) RF

FU6_2_12

In the past 12 months, did you need housing services because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6b}

2 NO {go to FU6b}

98 (VOL) DK

99 (VOL) RF

FU6_4

Did you ever need victim’s advocate services because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6a}

2 NO {go to FU6_4a}

98 (VOL) DK

99 (VOL) RF

FU6_4_12

In the last 12 months, did you ever need victim’s advocate services because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6b}

2 NO {go to FU6b}

98 (VOL) DK

99 (VOL) RF

FU6_4a

Did you ever need help from law enforcement because of what {fill;{initials}/ any of these people} did?

1 YES {go to FU6a12}

2 NO {go to FU6b}

98 (VOL) DK

99 (VOL) RF

FU6_4a_12

In the past 12 months, did you need help from law enforcement because of what {fill;{initials}/ any of these people} did?

1 YES {go to FU6b}

2 NO {go to FU6b}

98 (VOL) DK

99 (VOL) RF

FU6_5

Did you ever need legal services because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6b}

2 NO {go to FU7}

98 (VOL) DK

99 (VOL) RF

FU6_5_12

In the past 12 months, did you need legal services because of any of the things that {fill: {initials} / any of these people} did?

1 YES {go to FU6b}

2 NO {go to FU6b}

98 (VOL) DK

99 (VOL) RF

FU6a

{skip if only one perp reported}

Which people caused you to need {fill:{service}?

{TI: THIS QUESTION REFERS TO WHICH PEOPLE EVER CAUSED…}

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

{repeat FU6a for all servcies reported} {Then ask FU6_#_12 question for associated behavior before going to FU6b-c}

FU6b

Were you able to get the {fill: service} that you needed when {fill: initials} did {fill: this / these things}?

{TI: THIS QUESTION REFERS TO EVER ABLE TO GET SERVICE}

1 YES {go to Next Service in the List; if last service got to FU7}

2 NO {go to FU6c_a}

98 (VOL) DK

99 (VOL) RF

FU6c _a

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

[CHOOSE ALL THAT APPLY]

NOT HAVE ENOUGH MONEY
MADE TOO MUCH MONEY TO QUALIFY FOR SERVICES
SERVICES WERE UNAVAILABLE
TOO YOUNG TO RECEIVE SERVICES

DID NOT SEEK HELP

DID NOT KNOW ABOUT AVAILABLE SERVICES

DID NOT HAVE INSURANCE

OTHER, SPECIFY {go to FU6c}

FU6c

{TI: RECORD REASON R NOT ABLE TO GET THE ASSISTANCE NEEDED}

[RECORD VERBATIM RESPONSE]

[MAX 250 CHARACTERS]

{repeat FU6b through FU6c for all initials reported at FU6a} You also said that you needed services, because of what fill: 2nd set of initials from FU6a, 3^rd set of initials, etc.} did. Were you able to get those services that you needed?

FU7

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

1 YES {go to FU7a}

2 NO {go to FU7_sch}

98 (VOL) DK

99 (VOL) RF

FU7a

Which people caused you to miss work?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU7b

How many days of work did {fill: initials 1, initials 2, etc.} cause you to miss?

[RECORD NUMBER OF DAYS] [RANGE 1 – 365]

FU7_12 In the last 12 months, did you have to miss days of work when {fill: this / any of these things} happened with {fill: {initials} / any of these people}?

1 YES {go to FU7_sch}

2 NO {go to FU7_sch}

98 (VOL) DK

99 (VOL) RF

FU7_sch Did you ever have to miss days school when {fill: this / any of these things} happened with {fill: {initials} / any of these people}?

1 YES {go to FU7a_sch}

2 NO {go to IP1a}

98 (VOL) DK

99 (VOL) RF

FU7a_sch Which people caused you to miss school?

[OPTIONS TO INCLUDE ALL IDENTIFIED SETS OF INITIALS]

[IF NECESSARY, PROMPT BY READING AVAILABLE INITIALS]

FU7b_sch How many days of school did {fill: initials 1, initials 2, etc.} cause you to miss?

[RECORD NUMBER OF DAYS] [RANGE 1 – 365]

FU7_sch_12 In the last 12 months, did you have to miss days of school when {fill: this / any of these things} happened with {fill: {initials} / any of these people}?

1 YES {go to IP1a}

2 NO {go to IP1a}

98 (VOL) DK

99 (VOL) RF

Section IP: Intimate partner Questions

IP1a

The last few questions are general questions about your relationships.

IP1

During your lifetime, have you had sex with only men, only women, or both men and women?

1 ONLY MEN

2 ONLY WOMEN

3 BOTH MEN AND WOMEN

4 OTHER, SPECIFY {max 25 characters}

5 NEITHER

98 (VOL) DK

99 (VOL) RF

IP2

Are you currently married, divorced, separated, widowed, have you never been married, or not married but living with a partner? [PROBE: TI: IF RESPONDENT SAYS THEY ARE “SINGLE” OR “ENGAGED” PLEASE PROBE FURTHER TO FIND OUT WHICH OF THE LISTED CATEGORIES IS CORRECT]

1 MARRIED

2 DIVORCED

3 SEPARATED

4 WIDOWED

6 NOT MARRIED BUT LIVING WITH PARTNER: OF OPPOSITE SEX

7 NOT MARRIED BUT LIVIGN WITH PARTNER: OF SAME SEX

5 NEVER MARRIED

OTHER (specify __________)(max 25 characters)

98 (VOL) DK

99 (VOL) RF

SECTION M: Minors Module

I’d like to ask you some questions about events that happened in your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions.

At the end of the survey, I will give you a phone number for an organization that can provide information and referral for these issues.

Please keep in mind that you can ask me to skip any question you do not want to answer.

All questions refer to the time period before you were 18 years of age. Now looking back before you were 18 years of age---

M1 Did you live with anyone who was depressed, mentally ill or suicidal?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

M2. (Before you were 18 years of age…) Did you live with anyone who was a problem drinker or alcoholic?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

M3. (Before you were 18 years of age…) Did you live with anyone who used illegal street drugs or who abused prescription medications?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

M4. (Before you were 18 years of age…) Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facilitates?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

M5. Were your parents separated or divorced?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

M6. How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?

1 Never

2 Once

3 More than once

98 (VOL) DK

99 (VOL) RF

M7. How often did a parent or adult in your home ever hit, beat, kick or physically hurt you in any way? Do not include spanking.

1 Never

2 Once

3 More than once

98 (VOL) DK

99 (VOL) RF

M8. How often did a parent or adult in your home ever swear at you, insult you, or put you down?

1 Never

2 Once

3 More than once

98 (VOL) DK

99 (VOL) RF

M9. How often did anyone at least 5 years older than you or an adult, ever touch you sexually?

1 Never

2 Once

3 More than once

98 (VOL) DK

99 (VOL) RF

M10. How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually?

1 Never

2 Once

3 More than once

98 (VOL) DK

99 (VOL) RF

M11. How often did anyone at least 5 years older than you or an adult, force you to have sex?

1 Never

2 Once

3 More than once

98 (VOL) DK

99 (VOL) RF

M12. Before the age of 18, were you ever physically hurt because of something a brother or sister did to you on purpose?

1 YES

2 NO

3 ONLY CHILD / NO SIBLINGS {GO TO IP9}

98 (VOL) DK

99 (VOL) RF

M13. Before the age of 18, were you ever scared that your brother or sister would hurt you badly?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

M14. Did a brother or sister ever break or ruin any of your things on purpose or ever take something from you and never give it back?

1 YES

2 NO

98 (VOL) DK

99 (VOL) RF

IP9

TI: WAS THIS INTERVIEW COMPLETED IN ENGLISH OR SPANISH?

ENGLISH
SPANISH

Section W: Wrap-up

That’s my last question in this survey. To thank you for your participation, we will either mail you a check for {if not nonresponse: $10; if nonresponse: $40} or donate the {if not nonresponse: $10; if nonresponse: $40} to the United Way on your behalf. Which would you prefer?

RECEIVE INCENTIVE {go to W2}
DONATE INCENTIVE {go to W3}

In order to mail you your check for {if not nonresponse: $10; if nonresponse: $40}, 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] {go to W4}

Thank you for your donation.

If you have any questions or concerns about participating in the survey, please feel free to call the survey manager, Jessica Williams at 1-877-287-3782. You will hear an option to speak with a project staff member.

Thank you for participating in CDC’s study of health and injuries. We realize that some of the topics covered are quite personal and can be difficult to think and talk about. We appreciate your willingness to be a part of this study and want you to know that we recognize the important contribution you have made. Sometimes when people have participated in a study like this, they realize that they are interested in following up on some of the issues that they have been asked about in the study with someone who is professionally trained to deal with these kinds of issues. We are going to provide you the toll-free numbers of resources that you can use now or in the future if you want to speak further with someone.

CONTINUE

You can reach the National Domestic Violence Hotline at 1-800-799-SAFE (7233). You can reach the Rape, Abuse and Incest National Network at 1-800-656-HOPE (4673). You can reach the National Child Abuse Hotline at 1-800-4-A-Child (1-800-422-4453).

[PAUSE THEN SAY: Would you like me to repeat these numbers?]

That completes the interview. Thank you for your participation.

2013 NISVS Survey

File Type	application/msword
File Title	National Survey on Violence Against Women and Men
Author	brhodes
Last Modified By	CDC User
File Modified	2013-02-27
File Created	2013-02-27