2.3: TDV Screener 3

Instrument 2.3

TDV Screener 3

Instrument 3

Staff Member Name:

Case ID:

Participant Grade:

Date:

This protocol is a guide for giving youth some very basic information about healthy and unhealthy or abusive relationships, offering them an opportunity to talk about their own experiences with or concerns about relationship abuse, and supporting them in accessing other resources to increase their safety and making safe decisions about healthy relationship program participation.

You should meet with participants one on one, where no one will be within earshot to hear your conversation (like a room with the door closed), and ensure that you maintain utmost privacy, within the law. Do not include any identifying information about participants or other people when entering data into the Voxco system while conducting the interview.

1. Introductory Statement

IF YOU HAVE NOT YET HAD ANY OTHER INTERACTION WITH PARTICIPANT: Hi, my name is [NAME], and I work for [HEALTHY RELATIONSHIP PROGRAM]. Chat briefly with youth about weather, school, or other non-sensitive topics to establish some initial rapport and comfort.

IF INSTRUMENT 3 IS RANDOMIZED TO BE ADMINISTERED 1^st: Thank you again for being willing to participate.  We’ll have an initial conversation today, which will take about 15 minutes, and then I’ll reach out to you with two more sets of questions sometime in the next two months.  As we discussed, we will do our best to keep everything you say private.

IF INSTRUMENT 3 IS RANDOMIZED TO BE ADMINISTERED 2^nd: As part of the research study you are participating in with [PROGRAM NAME] and RTI, we’d like to have a 15 minute conversation with you today about your romantic relationships, including any experiences with unhealthy relationship behaviors and violence. You do not have to be in a relationship to have this conversation, participation is voluntary, and we will do our best to keep everything you say private.  If you choose to have this conversation with me today, you will receive a $10 gift card as a token of appreciation.

IF INSTRUMENT 3 IS RANDOMIZED TO BE ADMINISTERED 3^rd: As part of the research study you are participating in with [PROGRAM NAME] and RTI, we’d like to have one final, 15 minute conversation with you about your romantic relationships, including any experiences with unhealthy relationship behaviors and violence. You do not have to be in a relationship to have this conversation, participation is voluntary, and we will do our best to keep everything you say private.  If you choose to have this conversation with me today, you will receive a $10 gift card as a token of appreciation.

I wanted to talk to you a little bit about relationships, since that’s the focus of this program. When I say “relationships,” I mean any type of relationship when people are romantic or intimate with one another, like texting, seeing each other, hanging out, hooking up, dating, or being someone’s boyfriend or girlfriend–no matter whether it’s a public relationship that others know about, or a more private, side relationship. All types of relationships and intimate connections matter. We’re going to be talking a lot about healthy relationships, but we also know that sometimes relationships can be complicated.

2. Privacy Statement

The first thing I want to be sure you know is our privacy policy. In general, what you talk to me about is private. That means that I will not repeat what you say to others, including your teachers, counselors, parents, or other students, unless you specifically give me permission to share something you have told me in order to support you in getting help.

FOR MANDATED REPORTERS ONLY [If the staff member who will administer this guide is a mandated reporter, please tailor the following text based on your state’s mandated reporting law]: But, there are some kinds of information that I can’t keep private no matter what. If you tell me that a minor has been abused or assaulted, I am required by law to report that to the (name of child abuse reporting agency) or the local police department. If you tell me something that I need to report, I will also ask you to help me make the report if you want to.

Do you have any questions about your privacy?

Provided information about privacy policy

Participant had no questions about privacy policy

Answered questions about privacy policy

3. Statement about Healthy Relationship Experiences

This program will involve thinking and talking a lot about relationships. Relationships can be complex, and we have started talking to all our students about how you deserve to be treated by the people you are dating, hanging out with, or hooking up with.

Are you dating, hanging out, or hooking up with anyone?

Show safety card and read the text.

Anyone you’re involved with (whether talking, hanging out, hooking up, or dating, and whether it’s a public relationship that others know about or not) should:

• Make you feel safe and comfortable,

• Treat you respectfully,

• Not pressure you,

• Respect what you feel comfortable doing physically,

• Not try to get you drunk or high because they want to have sex with you,

• Give you space to hang out with your friends and family, in person and online, and

• Let you wear what you want to wear

These kinds of things are an important part of having a healthy relationship.

Allow the participant to react to what was read on the card. If the participant is silent, open up with a question like, What do you think about the information on this card? or Does this sound like someone you are involved with?

Provided general information about healthy and unhealthy relationships

Youth disclosed being in a dating relationship of any kind

Youth did not disclose being in a dating relationship of any kind (SKIP TO PART 5)

4. Opportunity to Disclose Teen Dating Violence

Relationships can get complicated.

Show safety card and read the text.

Sometimes, people experience disrespect in relationships or things that make them uncomfortable for different reasons, such as when a partner:

• Makes you feel stupid or “less than”; OR

• Pressures you to go to do things, like have sex, when you’re not ready; OR

• Tries to control where you go or what you do on social media OR

• Makes you afraid; OR

• Refuses to talk about or use birth control or condoms; OR

• Hurts or threatens you, or forces you to have sex.

If the person or people you are involved with do any of these things, participating in a healthy relationship education class in the same room as him or her could be risky. For example, that person could react negatively to the information presented by the instructor, or use information you share against you later. Whether you participate or not is completely your choice.

Allow the participant to react to what was read on the card. If the participant is silent, open up with a question like, What do you think about the information on this card? or Does this sound like someone you are involved with? Do you have any worries about participating in the healthy relationships class that you want to talk over?

Provided more information about healthy and unhealthy relationships

Participant disclosed being a victim of physical violence, emotional abuse, or controlling behavior by someone s/he is dating or seeing

Participant indicated that s/he felt that his/her relationship was healthy

Participant disclosed worries or concerns about teen dating violence or unhealthy relationships

5. Responding and Providing Resources and Referrals

Thank you so much for talking with me about all of this.

IF YOUTH HAS DISCLOSED ANY TDV EXPERIENCES OR CONCERNS RELATED TO TDV: There’s an organization you might be interested in called [LOCAL DOMESTIC VIOLENCE PROGRAM PARTNER] that supports teens and adults in addressing problems that come up in relationships and supporting them in staying safe. Would you like me to set up a time to talk with someone? [Provide additional information to decrease participant’s anxiety, e.g., the services are free, private, and the participant can talk to someone over-the-phone, if that is preferable to them.]

IF YES: Ask about schedule considerations and help the participant to make a plan to meet with the local domestic violence program staff.

IF NO: Okay. I know you know what is best for you and your situation. I want you to know that if you are ever worried about your relationship or your safety, you can come here for help. If participant declines your help in connecting them with resources, make sure to go over the remainder of the card (see below).

I am giving you a card with a hotline number on it. You can call the number anytime. The hotline staff really get how complicated it can be when you love someone and sometimes it feels unhealthy or scary. They have contact with lots of teens who have experienced this or know about it in a personal way.

I also want to mention again that participating in a healthy relationship education class in the same classroom as the person or people you are involved with could be risky. Is the person you are dating going to be in your healthy relationship class?

IF PARTICIPANT’S PARTNER IS ALSO IN THE SAME CLASS: Do you still want to participate in the class?

IF YES OR UNSURE: Okay. I’d like to talk with you more about how we can make sure that you can participate safely. Talk through each program activity with participant and any potential risks to safety that it could present. For activities in which s/he wishes to participate, offer and agree on any accommodations that s/he feels would support safer participation. For any activities s/he wishes to opt out of, offer and agree on strategies to protect his/her safety and privacy regarding the decision to opt out. (If s/he decides s/he does not wish to participate in any of these activities, proceed to “IF NO,” below).

IF NO: Okay. I’d like to talk with you more about how we can ensure your safety as you leave this program. Offer and agree on strategies to protect participant’s safety and privacy as s/he exits the program, including participant’s wishes regarding whether and how this information may be shared with his/her partner and school personnel.

I’d also like to follow up with you again to check in about this and see how things are going. Is that okay with you?

IF YES: Make a plan with participant for when you will follow up.

IF NO: Okay. I know you know what is best for you and your situation. I want you to know that I am available to talk and the hotline is also available 24/7.

IF PARTICIPANT DID NOT DISCLOSE ANY TDV CONCERNS: I’m glad to hear nothing like this is going on for you right now. We are giving this card to all of the students in this class so that they will know how to help a friend or a family member having problems with someone they are seeing, or know how to get help themselves if they ever need it. It has information about some resources that people have found helpful for staying safe in relationships, and it includes information for [LOCAL DOMESTIC VIOLENCE PROGRAM PARTNER] in case you or a friend ever want to get in touch with them. Also, I am here to talk about these issues.

IF PARTICIPANT SHARED TDV CONCERNS BUT DOES NOT DISCLOSE TDV EXPERIENCES: You mentioned things are sometimes complicated with the person you are seeing. I want you to know that if you are ever in trouble or concerned for your safety, you can come here for help.

I am giving you a card with a hotline number on it. You can call the number 24/7. The hotline staff really get how complicated it can be when you love someone and sometimes it feels unhealthy or scary. They have contact with lots of teens who have experienced this or know about it in a personal way. Also, if you or a friend ever feel that you want someone to talk to in person and who is local, please let me know because I can help connect you to someone from [LOCAL DOMESTIC VIOLENCE PROGRAM PARTNER]. I’m available to talk about these issues more, too.

Do you have any questions for me, or anything you’d like to talk more about? Address any questions.

I really enjoyed talking with you today. Thank you again.

Gave safety card
Referred youth to domestic violence program partner
	Appointment made with:
	Planned transportation:
	Participant declined services
	Planned follow-up with youth:
	Participant declined follow-up
Did not refer participant to domestic violence program partner
	Participant did not disclose any TDV experiences or concerns related to TDV
	Referral was not made for some other reason:

The Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 15 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: XXX ATTN: XXX (xxxx--xxxx). Do not return the completed form to this address.

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