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pdfOMB No xxx‐xxxx Expires xx/xx/xxxx
Crime Survey
A Survey Sponsored by The
Bureau of Justice Statistics
Title 42, Section 3732, United States Code, authorizes the Bureau of Justice Statistics, Department of Justice, to collect
information using this survey and requires us to keep all information about you and your household strictly confidential.
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB number. The valid OMB control number for this information collection is xxxx-xxxx.
Comments regarding any other aspect of this data collection may be sent to, to the Bureau of Justice Statistics Director at
Bureau of Justice Statistics, 810 Seventh Street, NW Washington, DC 20531 or by calling survey support staff toll-free 1xxx-xxx-xxxx.
Start Here
Please use a black or blue pen to complete this
5.
form.
Become safer
Stayed the same
Become less safe
Don’t know
Mark to indicate your answer. If you want
1.
to change your answer, darken the box and
mark the correct answer.
On the whole, how much of the time is the
community where you live safe?
6.
Always safe
Mostly safe
Sometimes safe
Rarely safe
Never safe
Is there any place within a mile of your home
where you would be afraid to walk alone at
night?
7.
Yes
No
3.
While living at this address, have you ever
contacted the local police department for
assistance?
Yes GO TO 8
No GO TO 9
How often does fear of crime prevent you from
doing things you would like to do?
Very often
Somewhat often
Rarely
Never
8.
If yes, how satisfied were you with the police
response?
Very satisfied
Mostly satisfied
Somewhat satisfied
Not at all satisfied
4.
Overall, how much of the time is the place
where you work safe?
Always safe
Mostly safe
Sometimes safe
Rarely safe
Never safe
Does not apply; do not work
2.
In the last 3 years, do you believe your
community has:
When you leave your home, how often do you
think about it being broken into or vandalized
while you're away?
9.
Very often
Somewhat often
Rarely
Never
How would you rate the job the local police
department is doing in your community?
Excellent
Good
Fair
Poor
Don’t know
1
17. In what month and year did the most recent
break‐in occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Thefts and Break‐ins
10. In the last 12 months, did anyone break into
your home or get in without permission?
Yes GO TO 11
No GO TO 19
11. In the last 12 months, was you home broken
into or entered without permission more than
once?
month
year
18. Please describe the most recent break‐in:
what happened and where it happened.
Yes
No
12. Was someone at home any time in the last 12
months when someone broke in or entered your
home without permission?
Yes GO TO 13
No GO TO 14
19. In the last 12 months, did anyone try to break
into your home, but not succeed?
13. When someone was home, did they see the
offender?
Yes
No, no attempted break‐ins
Yes
No
20. In the last 12 months, was a car, truck, or other
motor vehicle belonging to anyone in your
household …
14. Was anything stolen when someone broke in or
entered your home without permission any time
in the last 12 months?
The vehicle was vandalized or broken into
Something was stolen from the vehicle
The vehicle itself was stolen
Yes GO TO 15
No GO TO 16
Yes No
15. What was stolen in the last 12 months?
21. Besides what you told us about earlier, was
anything else stolen from your home, yard or
vehicle in the last 12 months?
Yes GO TO 22
No GO TO 24
22. In what month and year did the most recent
theft occur?
If you are unsure, make your best guess—
including the month the incident occurred.
16. In the past 12 months, was any break‐in or entry
without permission reported to the police?
Yes
No
2
month
year
23. Please describe what was stolen during the most
recent theft.
29. How many children ages 0‐17 live in this
household? Please include small children and
infants.
Number of children ages 0‐17
24. Thinking about everything that may have been
stolen from your hone or from members of your
household in the past 12 months, what yould
you say was the total value of everything that
was taken?
30. Which category best fits the approximate total
income of all persons in your household over the
past 12 months?
Include money from jobs or other earnings,
pensions, interest, rent, Social Security payments,
and so on.
Nothing was taken
Less than $10
$10‐$49
$50‐$249
$250‐$999
$1,000 or more
$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to 50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,000 or more
25. In the past 12 months, were any of these thefts
reported to the police?
Yes
No
Does not apply, nothing stolen
Questions
about You (Adult 1)
Your Household
You are Adult 1. Please answer Questions 31 to 80
for yourself (Adult 1).
26. Do you own or rent the place where you’re
living?
Physical Attacks
Own
Rent
Other, describe below
31. In the last 12 months, has anyone physically
attacked you?
Yes GO TO 32
No GO TO 41
27. How long have you lived at this address?
32. In the last 12 months, were you physically
attacked more than once?
1 year or less
Less than 5 years, more than 1 year
5 years or more
Yes
No
28. Including yourself ‐‐How many people age 18
and older live in this household? Include
yourself, family members, roommates, and
boarders.
33. Did the person(s)who attacked you have a
weapon?
Yes GO TO 34
No GO TO 35
Don’t know GO TO 35
Number of people age 18 and older
3
34. What type of weapon(s) did they have?
Threats
41. In the last 12 months, has anyone threatened
you with physical violence?
Yes GO TO 42
No GO TO 50
35. In the last 12 months, were you injured during
an attack?
Yes
No
42. In the last 12 months, were you threatened on
more than one occassion?
Yes
No
36. In the last 12 months, was anything stolen from
you during an attack?
Yes
No
43. Did the person(s) who threatened you have a
weapon?
Yes GO TO 44
No GO TO 45
Don’t know GO TO 45
37. At the time, what was your relationship with the
person or persons who attacked you?
Please mark all that apply.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
44. What type of weapon(s) did they have?
45. In the last 12 months, was anything stolen when
you were threatened?
38. In the past 12 months, were any of these attacks
reported to the police?
Yes
No
Yes
No
46. At the time, what was your relationship with the
person or persons who threatened you with
physical violence?
Please mark all that apply.
39. In what month and year did the most recent
attack occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
year
40. Please describe the most recent attack: what
happened and where it happened.
47. In the past 12 months, were any of these threats
reported to the police?
Yes
No
4
55. At the time, what was your relationship with the
person or persons who forced you to have
unwanted sexual activity?
Please mark all that apply.
48. In what month and year did the most recent
threat occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
year
49. Please describe the most recent threat:
what happened and where it happened
56. In the past 12 months, was any of the forced
unwanted sexual activity reported to the police?
Yes
No
57. In what month and year did the most recent
forced unwanted sexual activity occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Unwanted Sexual Activity
50. In the last 12 months, did anyone force you to
have any type of unwanted sexual activity?
Yes GO TO 51
No GO TO 59
month
year
58. Please describe the most recent forced
unwanted sexual activity: what happened and
where it happened
51. Were you forced to have unwanted sexual
activity more than once?
Yes
No
52. Did the person(s) who forced you to have
unwanted sexual activity have a weapon?
Yes GO TO 53
No GO TO 54
Don’t know GO TO 54
Threats of Unwanted Sexual Activity
53. What type of weapon(s) did they have?
59. In the last 12 months, did anyone threaten you
with any type of forced unwanted sexual
activity? Include times when someone
threatened or tried to force you but did not
succeed.
54. In the last 12 months, were you injured during
forced unwanted sexual activity?
Yes GO TO 60
No GO TO 68
Yes
No
5
67. Please describe the most recent threat of
unwanted sexual activity: what happened and
where it happened
60. In the last 12 months, were you threatened with
unwanted sexual activity more than once?
Yes
No
61. Did the person(s) who threatened you with
forced unwanted sexual activity have a weapon?
Yes GO TO 62
No GO TO 63
Don’t know GO TO 63
62. What type of weapon(s) did they have?
Other Thefts Not Described Earlier
68. Besides what you may have told us about
earlier, did you have anything else stolen in the
last 12 months? (For example: cash, a wallet,
purse, watch, jewelry, cell phone, tablet, or
anything else that might have been stolen.)
63. Were you injured during the threat of forced
unwanted sexual activity?
Yes
No
Yes GO TO 69
No GO TO 71
64. At the time, what was your relationship with the
person or persons who threatened you with
forced unwanted sexual activity?
Please mark all that apply.
69. In what month and year did your most recent
theft occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
month
year
70. Please describe what was stolen in the most
recent theft:
65. In the past 12 months, were any of the threats
of forced unwanted sexual activity reported to
the police?
Yes
No
71. In the past 12 months, were any of the other
things stolen reported to the police?
66. In what month and year did the most recent
threat of forced unwanted sexual activity occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Yes
No
72. In the last 12 months, did you have a credit or
debit card stolen or used without your
permission?
year
Yes
No
6
Adult 2
73. In the last 12 months, did you have a bank
account used without your permission?
Please answer Questions 81 to 130 about Adult 2.
If you are the only adult in the household, please
mail the completed survey back in the postage‐paid
envelope.
Yes
No
Physical Attacks
74. In the last 12 months, did anyone steal your
private information or use it to get a credit card
or a loan?
81. In the last 12 months, has anyone physically
attacked Adult 2?
Yes
No
Yes GO TO 82
No GO TO 91
75. In the past 12 months, did you or anyone else
tell the police about any unauthorized use of
your financial accounts or personal information?
82. In the last 12 months, was Adult 2 physically
attacked more than once?
Yes
No
Yes
No
About You – Adult 1
83. Did the person(s) who attacked Adult 2 have a
weapon?
76. What is your gender?
Male
Female
77. What is your age?
Yes GO TO 84
No GO TO 85
Don’t know GO TO 85
84. What type of weapon(s) did they have?
78. Are you of Hispanic or Latino origin?
Yes, Hispanic or Latino
No, not Hispanic or Latino
85. In the last 12 months, was Adult 2 injured during
an attack?
79. What is your race?
Please mark all that apply.
Yes
No
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
86. In the last 12 months, was anything stolen from
Adult 2 during an attack?
Yes
No
80. What is the highest grade of school completed,
or the highest degree you have received?
Less than High School
High School diploma or GED
Some College or Technical School
Bachelor’s degree
Master’s degree or higher
7
87. At the time, what was Adult 2’s relationship
with the person or persons who attacked
him/her?
Please mark all that apply.
93. Did the person(s) who threatened Adult 2 have a
weapon?
Yes GO TO 94
No GO TO 95
Don’t know GO TO 95
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
94. What type of weapon(s) did they have?
95. In the last 12 months, was anything stolen when
Adult 2 was threatened?
88. In the past 12 months, were any of these attacks
on Adult 2 reported to the police?
Yes
No
Yes
No
96. At the time, what was Adult 2’s relationship
with the person or persons who threatened
Adult 2 with physical violence?
Please mark all that apply.
89. In what month and year did the most recent
attack on Adult 2 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
year
90. Please describe the most recent attack on Adult 2:
what happened and where it happened.
97. In the past 12 months, were any of these threats
on Adult 2 reported to the police?
Yes
No
98. In what month and year did the most recent
threat on Adult 2 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Threats
91. In the last 12 months, has anyone threatened
Adult 2 with physical violence?
Yes GO TO 92
No GO TO 100
92. In the last 12 months, was Adult 2 threatened
on more than one occassion?
Yes
No
8
month
year
105. At the time, what was Adult 2’s relationship
with the person or persons who forced Adult 2
to have unwanted sexual activity?
Please mark all that apply.
99. Please describe the most recent threat on Adult 2:
what happened and where it happened
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
106. In the past 12 months, was any of the forced
unwanted sexual activity on Adult 2 reported to
the police?
Unwanted Sexual Activity
100. In the last 12 months, did anyone force Adult 2
to have any type of unwanted sexual activity?
Yes
No
Yes GO TO 101
No GO TO 109
107. In what month and year did the most recent
forced unwanted sexual activity on Adult 2
occur?
If you are unsure, make your best guess—
including the month the incident occurred.
101. Was Adult 2 forced to have unwanted sexual
activity more than once?
Yes
No
102. Did the person(s) who forced Adult 2 to have
unwanted sexual activity have a weapon?
month
year
108. Please describe the most recent forced
unwanted sexual activity on Adult 2: what
happened and where it happened
Yes GO TO 103
No GO TO 104
Don’t know GO TO 104
103. What type of weapon(s) did they have?
104. In the last 12 months, was Adult 2 injured during
forced unwanted sexual activity?
Yes
No
Threats of Unwanted Sexual Activity
109. In the last 12 months, did anyone threaten Adult 2
with any type of forced unwanted sexual activity?
Include times when someone threatened or tried
to force Adult 2 but did not succeed.
Yes GO TO 110
No GO TO 118
9
110. In the last 12 months, was Adult 2 threatened
with unwanted sexual activity more than once?
117. Please describe the most recent threat of
unwanted sexual activity on Adult 2: what
happened and where it happened
Yes
No
111. Did the person(s) who threatened Adult 2 with
forced unwanted sexual activity have a weapon?
Yes GO TO 112
No GO TO 113
Don’t know GO TO 113
112. What type of weapon(s) did they have?
Other Thefts Not Described Above
118. Besides what you may have told us about
earlier, did Adult 2 have anything else stolen in
the last 12 months? (For example: cash, a wallet,
purse, watch, jewelry, cell phone, tablet, or
anything else that might have been stolen.)
113. Was Adult 2 injured during the threat of forced
unwanted sexual activity?
Yes
No
Yes GO TO 119
No GO TO 121
114. At the time, what was Adult 2’s relationship
with the person or persons who threatened
Adult 2 with forced unwanted sexual activity?
Please mark all that apply.
119. In what month and year did Adult 2’s most
recent theft occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
month
year
120. Please describe what was stolen from Adult 2 in
the most recent theft:
115. In the past 12 months, were any of the threats
of forced unwanted sexual activity on Adult 2
reported to the police?
Yes
No
121. In the past 12 months, were any of the other
things stolen from Adult 2 reported to the
police?
116. In what month and year did the most recent
threat of forced unwanted sexual activity on
Adult 2 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Yes
No
year
10
130. What is the highest grade of school completed,
or the highest degree Adult 2 has received?
122. In the last 12 months, did Adult 2 have a credit
or debit card stolen or used without his/her
permission?
Less than High School
High School diploma or GED
Some College or Technical School
Bachelor’s degree
Master’s degree or higher
Yes
No
123. In the last 12 months, did Adult 2 have a bank
account used without his/her permission?
Yes
No
124. In the last 12 months, did anyone steal Adult 2’s
private information or use it to get a credit card
or a loan?
Please answer Questions 131 to 180 about Adult 3.
If there are only 2 adults in the household, please
mail the completed survey back in the postage‐paid
envelope.
Adult 3
Yes
No
125. In the past 12 months, did Adult 2 or anyone
else tell the police about any unauthorized use
of Adult 2’s financial accounts or personal
information?
Physical Attacks
Yes
No
131. In the last 12 months, has anyone physically
attacked Adult 3?
About Adult 2
Yes GO TO 132
No GO TO 141
126. What gender is Adult 2?
Male
Female
132. In the last 12 months, was Adult 3 physically
attacked more than once?
127. How old is Adult 2?
Yes
No
133. Did the person(s) who attacked Adult 3 have a
weapon?
128. Is Adult 2 of Hispanic or Latino origin?
Yes, Hispanic or Latino
No, not Hispanic or Latino
Yes GO TO 134
No GO TO 135
Don’t know GO TO 135
129. What race is Adult 2 ?
Please mark all that apply.
134. What type of weapon(s) did they have?
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
135. In the last 12 months, was Adult 3 injured during
an attack?
Yes
No
11
142. In the last 12 months, was Adult 3 threatened
on more than one occassion?
136. In the last 12 months, was anything stolen from
Adult 3 during an attack?
Yes
No
Yes
No
137. At the time, what was Adult 3’s relationship
with the person or persons who attacked
him/her?
Please mark all that apply.
143. Did the person(s) who threatened Adult 3 have a
weapon?
Yes GO TO 144
No GO TO 145
Don’t know GO TO 145
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
144. What type of weapon(s) did they have?
145. In the last 12 months, was anything stolen when
Adult 3 was threatened?
138. In the past 12 months, were any of these attacks
on Adult 3 reported to the police?
Yes
No
Yes
No
146. At the time, what was Adult 3’s relationship
with the person or persons who threatened
Adult 3 with physical violence?
Please mark all that apply.
139. In what month and year did the most recent
attack on Adult 3 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
year
140. Please describe the most recent attack on Adult 3:
what happened and where it happened.
147. In the past 12 months, were any of these threats
on Adult 3 reported to the police?
Yes
No
148. In what month and year did the most recent
threat on Adult 3 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Threats
141. In the last 12 months, has anyone threatened
Adult 3 with physical violence?
Yes GO TO 142
No GO TO 150
12
month
year
155. At the time, what was Adult 3’s relationship
with the person or persons who forced Adult 3
to have unwanted sexual activity?
Please mark all that apply.
149. Please describe the most recent threat on Adult 3:
what happened and where it happened
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
Unwanted Sexual Activity
156. In the past 12 months, was any of the forced
unwanted sexual activity on Adult 3 reported to
the police?
150. In the last 12 months, did anyone force Adult 3
to have any type of unwanted sexual activity?
Yes
No
Yes GO TO 151
No GO TO 159
151. Was Adult 3 forced to have unwanted sexual
activity more than once?
157. In what month and year did the most recent
forced unwanted sexual activity on Adult 3
occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Yes
No
152. Did the person(s) who forced Adult 3 to have
unwanted sexual activity have a weapon?
Yes GO TO 150
No GO TO 151
Don’t know GO TO 151
month
year
158. Please describe the most recent forced
unwanted sexual activity on Adult 3: what
happened and where it happened
153. What type of weapon(s) did they have?
154. In the last 12 months, was Adult 3 injured during
forced unwanted sexual activity?
Yes
No
Threats of Unwanted Sexual Activity
159. In the last 12 months, did anyone threaten Adult
3 with any type of forced unwanted sexual
activity? Include times when someone
threatened or tried to force Adult 3 but did not
succeed.
Yes GO TO 160
No GO TO 168
13
160. In the last 12 months, was Adult 3 threatened
with unwanted sexual activity more than once?
167. Please describe the most recent threat of
unwanted sexual activity on Adult 3: what
happened and where it happened
Yes
No
161. Did the person(s) who threatened Adult 3 with
forced unwanted sexual activity have a weapon?
Yes GO TO 162
No GO TO 163
Don’t know GO TO 163
162. What type of weapon(s) did they have?
Other Thefts Not Described Above
168. Besides what you may have told us about
earlier, did Adult 3 have anything else stolen in
the last 12 months? (For example: cash, a wallet,
purse, watch, jewelry, cell phone, tablet, or
anything else that might have been stolen.)
163. Was Adult 3 injured during the threat of forced
unwanted sexual activity?
Yes
No
Yes GO TO 169
No GO TO 171
164. At the time, what was Adult 3’s relationship
with the person or persons who threatened
Adult 3 with forced unwanted sexual activity?
Please mark all that apply.
169. In what month and year did Adult 3’s most
recent theft occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
month
year
170. Please describe what was stolen from Adult 3 in
the most recent theft:
165. In the past 12 months, were any of the threats
of forced unwanted sexual activity on Adult 3
reported to the police?
Yes
No
171. In the past 12 months, were any of the other
things stolen from Adult 3 reported to the
police?
166. In what month and year did the most recent
threat of forced unwanted sexual activity on
Adult 3 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Yes
No
172. In the last 12 months, did Adult 3 have a credit
or debit card stolen or used without his/her
permission?
year
Yes
No
14
Adult 4
Please answer Questions 181 to 230 about Adult 4.
If there are only 3 adults in the household, please
mail the completed survey back in the postage‐paid
envelope.
174. In the last 12 months, did anyone steal Adult 3’s
private information or use it to get a credit card
or a loan?
Physical Attacks
173. In the last 12 months, did Adult 3 have a bank
account used without his/her permission?
Yes
No
181. In the last 12 months, has anyone physically
attacked Adult 4?
Yes
No
Yes GO TO 182
No GO TO 191
175. In the past 12 months, did Adult 3 or anyone
else tell the police about any unauthorized use
of Adult 3’s financial accounts or personal
information?
182. In the last 12 months, was Adult 4 physically
attacked more than once?
Yes
No
Yes
No
About Adult 3
183. Did the person(s) who attacked Adult 4 have a
weapon?
176. What gender is Adult 3?
Male
Female
177. How old is Adult 3?
Yes GO TO 184
No GO TO 185
Don’t know GO TO 185
184. What type of weapon(s) did they have?
178. Is Adult 3 of Hispanic or Latino origin?
Yes, Hispanic or Latino
No, not Hispanic or Latino
185. In the last 12 months, was Adult 4 injured during
an attack?
179. What race is Adult 3 ?
Please mark all that apply.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Yes
No
186. In the last 12 months, was anything stolen from
Adult 4 during an attack?
180. What is the highest grade of school completed,
or the highest degree Adult 3 has received?
Less than High School
High School diploma or GED
Some College or Technical School
Bachelor’s degree
Master’s degree or higher
15
Yes
No
193. Did the person(s) who threatened Adult 4 have a
weapon?
187. At the time, what was Adult 4’s relationship
with the person or persons who attacked
him/her?
Please mark all that apply.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
194. What type of weapon(s) did they have?
195. In the last 12 months, was anything stolen when
Adult 4 was threatened?
188. In the past 12 months, were any of these attacks
on Adult 4 reported to the police?
Yes
No
196. At the time, what was Adult 4’s relationship
with the person or persons who threatened
Adult 4 with physical violence?
Please mark all that apply.
189. In what month and year did the most recent
attack on Adult 4 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
year
190. Please describe the most recent attack on Adult 4:
what happened and where it happened.
197. In the past 12 months, were any of these threats
on Adult 4 reported to the police?
Yes
No
198. In what month and year did the most recent
threat on Adult 4 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Threats
191. In the last 12 months, has anyone threatened
Adult 4 with physical violence?
Yes GO TO 192
No GO TO 200
192. In the last 12 months, was Adult 4 threatened
on more than one occassion?
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
Yes
No
Yes GO TO 194
No GO TO 195
Don’t know GO TO 195
Yes
No
16
month
year
205. At the time, what was Adult 4’s relationship
with the person or persons who forced Adult 2
to have unwanted sexual activity?
Please mark all that apply.
199. Please describe the most recent threat on Adult 4:
what happened and where it happened
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
Unwanted Sexual Activity
206. In the past 12 months, was any of the forced
unwanted sexual activity on Adult 4 reported to
the police?
200. In the last 12 months, did anyone force Adult 4
to have any type of unwanted sexual activity?
Yes GO TO 201
No GO TO 209
Yes
No
201. Was Adult 4 forced to have unwanted sexual
activity more than once?
207. In what month and year did the most recent
forced unwanted sexual activity on Adult 4
occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Yes
No
202. Did the person(s) who forced Adult 4 to have
unwanted sexual activity have a weapon?
Yes GO TO 203
No GO TO 204
Don’t know GO TO 204
year
208. Please describe the most recent forced
unwanted sexual activity on Adult 4: what
happened and where it happened
203. What type of weapon(s) did they have?
204. In the last 12 months, was Adult 4 injured during
forced unwanted sexual activity?
month
Yes
No
Threats of Unwanted Sexual Activity
209. In the last 12 months, did anyone threaten Adult
4 with any type of forced unwanted sexual
activity? Include times when someone
threatened or tried to force Adult 4 but did not
succeed.
17
Yes GO TO 210
No GO TO 218
210. In the last 12 months, was Adult 4 threatened
with unwanted sexual activity more than once?
217. Please describe the most recent threat of
unwanted sexual activity on Adult 4: what
happened and where it happened
Yes
No
211. Did the person(s) who threatened Adult 4 with
forced unwanted sexual activity have a weapon?
Yes GO TO 212
No GO TO 213
Don’t know GO TO 213
212. What type of weapon(s) did they have?
Other Thefts Not Described Above
218. Besides what you may have told us about
earlier, did Adult 4 have anything else stolen in
the last 12 months? (For example: cash, a wallet,
purse, watch, jewelry, cell phone, tablet, or
anything else that might have been stolen.)
213. Was Adult 4 injured during the threat of forced
unwanted sexual activity?
Yes
No
Yes GO TO 219
No GO TO 222
214. At the time, what was Adult 4’s relationship
with the person or persons who threatened
Adult 4 with forced unwanted sexual activity?
Please mark all that apply.
219. In what month and year did Adult 4’s most
recent theft occur?
If you are unsure, make your best guess—
including the month the incident occurred.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or
girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
month
year
220. Please describe what was stolen from Adult 4 in
the most recent theft:
215. In the past 12 months, were any of the threats
of forced unwanted sexual activity on Adult 4
reported to the police?
Yes
No
221. In the past 12 months, were any of the other
things stolen from Adult 4 reported to the
police?
216. In what month and year did the most recent
threat of forced unwanted sexual activity on
Adult 4 occur?
If you are unsure, make your best guess—
including the month the incident occurred.
month
Yes
No
222. In the last 12 months, did Adult 4 have a credit
or debit card stolen or used without his/her
permission?
year
18
Yes
No
223. In the last 12 months, did Adult 4 have a bank
account used without his/her permission?
231. Are there more than 4 adults living at your
home?
Yes
No
224. In the last 12 months, did anyone steal Adult 4’s
private information or use it to get a credit card
or a loan?
Yes GO TO 232
No Survey is complete
232. Did any of the other adults in this home
experience a crime in the last 12 months?
Yes
No
Yes GO TO 233
No Survey is complete
225. In the past 12 months, did Adult 4 or anyone
else tell the police about any unauthorized use
of Adult 2’s financial accounts or personal
information?
233. Please describe the crime(s):
Yes
No
About Adult 4
226. What gender is Adult 4?
Male
Female
227. How old is Adult 4?
228. Is Adult 4 of Hispanic or Latino origin?
Yes, Hispanic or Latino
No, not Hispanic or Latino
229. What race is Adult 4?
Please mark all that apply.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Thank you.
Please return survey in the
envelope provided.
230. What is the highest grade of school completed,
or the highest degree Adult 4 has received?
Less than High School
High School diploma or GED
Some College or Technical School
Bachelor’s degree
Master’s degree or higher
19
| File Type | application/pdf |
| File Title | Microsoft Word - Appx A cover.docx |
| Author | giambo_p |
| File Modified | 2015-02-10 |
| File Created | 2015-01-21 |