National Survey of Hospital-based Victim Services

Attachment 1: NSHVS Screener Questions to be cognitively tested

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

Survey Instructions

Survey Purpose and Sponsors

The National Survey of Hospital-Based Victim Services (NSHVS) is designed to gather basic information about hospital services provided to victims of crime or abuse. This survey is sponsored by the U.S. Department of Justice’s Bureau of Justice Statistics (BJS) and conducted by the National Center for Health Statistics (NCHS). The survey should take 60 minutes on average to complete.

Who Should Complete the Survey?

The survey is best completed by one or more people in your hospital with knowledge of the different ways your hospital provides services to victims of crime or abuse. In some hospitals different services are offered for different types of victims and across different hospital programs, units or departments, so this survey might have to be completed by multiple people. The survey will ask for general information about programs, staff, and inter-agency collaborations operated by, co-located within, or supported by hospital resources.

Definitions

• VICTIM of crime or abuse - Any person who experienced reckless or intentional injury or harm. (Examples include victims of sexual assault, domestic violence, human trafficking, community violence, assault, child abuse and neglect, elderly abuse, etc.)

• VICTIM SERVICE - Any service that is provided to a patient or his/her family specifically because he/she is a victim of crime or abuse.

Services

This survey asks about three ways hospitals may be structured to provide services to victims of crime or abuse:

• Programs or entities operated by, co-located within, or supported by hospital resources, including any programs, centers, clinics, units, divisions, or institutes dedicated to providing services to victims of crime or abuse, whether run by hospital staff, contract staff, or volunteer or pro-bono staff. Examples include domestic violence programs or clinics, violence intervention programs, child advocacy centers, legal aid programs, human trafficking intervention programs, and victim houses, among others ; [see question 1]

• Staff teams or individual staff who either volunteer and/or are employed by the hospital or an outside agency to provide programming or services specifically for victims of crime or abuse. Examples include social workers or mental health professionals who provide services to victims, sexual assault nurse examiners (SANEs) or other forensic medical care professionals, in-house assessment teams, etc.; [see question 2]

• Inter-agency partnerships, taskforces, or other types of inter-agency collaborations that the hospital participates in to provide or enhance services to victims. Examples include partnerships with community-based victim service providers, other hospitals, police or corrections for the purpose of providing services or connecting victims to services; inter-agency domestic violence assessment teams; child abuse assessment teams; taskforces on human trafficking or other crime types; and other established collaborations focused on helping victims. [see question 3]

The survey aims to gather information about the unique ways your hospital provides services to different types of victims of crime or abuse. The person(s) completing this survey should select the best category(s) for describing the delivery of services to victims. For example, one hospital might consider themselves to have an onsite Sexual Assault Nurse Examiners (SANEs) program (in question 1) while another might categorize themselves as having onsite SANE staff (in question 2). Another hospital might offer SANE services through a partnership with a nearby hospital (and list this in question 3). Please do not list a program or entity, staff position or team, or inter-agency partnership more than once in this survey.

Before you begin, please complete the following information for your hospital:

Hospital Information

Please provide the following information for the point of contact who we may follow-up with regarding this survey.

Position Title:

Name:

Contact info:

How many staffed inpatient beds are currently in your hospital?

• less than 6 beds

• 6-49 beds

• 50-99 beds

• 100-199 beds

• 200-299 beds

• 300-499 beds

• 500-999 beds

• 1000 or more beds

Which of the following best describes your hospital?

• General Acute

• Children

• Psychiatric

• Other (Specify): __________________

Does your hospital have an emergency department?

• Yes → Proceed to the question below

• No

If yes, does it operate 24 hours a day?

• Yes

• No

Victim Services Survey

Programs or Entities Serving Victims

1. Are there any programs or entities operated by, co-located within, or supported by hospital resources that have a mission to provide programming or services to victims of crime or abuse? Include programs or entities run by hospital staff, contract staff, volunteer, and pro-bono staff. Examples include child abuse advocacy centers, domestic violence clinics, legal aid programs, violence intervention programs, family justice centers, etc.

• Yes → Proceed to item 1a.

• No → Skip to item 2

1a. In the grid below, please provide contact information for each program or entity:

	Contact information:	Crime types for which services are provided (check all that apply):
1)	Program/entity name: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________
	Contact information:	Crime types for which services are provided (check all that apply):
2)	Program/entity name: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: ____________________
	Contact information:	Crime types for which services are provided (check all that apply):
3)	Program/entity name: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________
	Contact information:	Crime types for which services are provided (check all that apply):
4)	Program/entity name: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________

Other Staff Serving Victims

2. Are there any additional staff (salary, contract, volunteer or pro-bono) in-house, co-located within, or supported by hospital resources that are dedicated to serving victims of crime or abuse? Do not include staff already accounted for in entities or programs described above. Examples include a sexual assault nurse examiner (SANE) or other forensic care providers, crisis intervention staff, social worker dedicated to providing services to victims, group counselor or mental health specialist, victim compensation specialists, etc. that are not part of the entities or programs listed above.

• Yes → Proceed to item 2a.

• No → Go to item 3

2a. If yes, please provide information about these staff:

	Contact information:	Crime types for which services are provided (check all that apply):
1)	Staff position title/staff team name: Email: Mailing address: Phone number:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________
2)	Staff position title/staff team name: Email: Mailing address: Phone number:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __Homicide (including support groups for surviving family) __Elder abuse __Other, specify: ___________ __________

Partnerships

If you listed programs, entities, or staff above, we recognize inter-agency collaborations are an important part of those roles. Next, we would like to know if your hospital provides programming or services to victims through any additional inter-agency partnerships, teams, or taskforces that are independent from the programs and staff listed above.

3. Does your hospital work with other agencies through partnerships, taskforces, or teams to provide programming or services to victims of crime or abuse? Please do not list partnerships that are part of the programs, entities, or staff responsibilities listed above. Examples include inter-agency violence intervention teams, human trafficking taskforces, and partnerships with police, other hospitals, or community-based agencies to connect victims to services, etc.

• Yes → Proceed to item 3a.

• No

3a. If yes, please provide the following information for each:

	Inter-agency partnership, taskforce, or team:	Crime types for which the partnership serves:
1)		__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __Homicide __Elder abuse __Other, specify: _____________________

	Inter-agency partnership, taskforce, or team:	Crime types for which the partnership serves:
2)		__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __Homicide __Elder abuse __Other, specify: _____________________

4. Does your hospital offer any other programming or services for victims of crime or abuse that were not described previously?

• Yes → Proceed to item 4a.

• No

4a. If yes, specify: _______________________________________________________________

Plans for new victim services

5. In the next year, is your hospital planning to create any new programs or entities, hire new staff, or participate in any new inter-agency partnerships, taskforces, or teams designated to serve victims of crime or abuse?

• Yes → Proceed to item 5a.

• No

• Do not know

5a. If yes, specify: _______________________________________________________________

Record Keeping

6. When providing victim services, does your hospital use any type of electronic system that maintains and/or tracks individual victim cases?

• Yes → Proceed to item 6a.

• No

6a. If yes, specify: _______________________________________________________________

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