1.2: IPV Screener 2

Instrument 1.2

IPV Screener 2

Instrument 2

Staff Member Name: ____________________________

Case ID: ____________________________

Date: _____________________________

Is this the client’s…

1^st time completing a tool?

2^nd time completing a tool?

3^rd time completing a tool?

IF INSTRUMENT 2 IS RANDOMIZED TO BE ADMINISTERED 1^st: Thank you again for being willing to participate. I’ll be asking you an initial set of questions today, which will take about 10 minutes, and then two more sets of questions sometime in the next two months. As we discussed, we will do our best to keep all of the answers to these questions private.

IF INSTRUMENT 2 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 ask you the next set of questions about your romantic relationships, including any experiences with unhealthy relationship behaviors and violence. The questions will take about 10 minutes. You do not have to be in a relationship to answer them, participation is voluntary, and we will do our best to keep all of the answers to these questions private. If you choose to answer them today, you will receive a $5 gift card as a token of appreciation.

IF INSTRUMENT 2 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 ask you one final set of questions about your romantic relationships, including any experiences with unhealthy relationship behaviors and violence. The questions will take about 10 minutes. You do not have to be in a relationship to answer them, participation is voluntary, and we will do our best to keep all of the answers to these questions private. If you choose to answer them today, you will receive a $5 gift card as a token of appreciation plus an extra $5 for completing all three sets of questions.

I will read each item and ask you if it describes how your partner usually treats you. If you do not now have a partner, think about your last one. Choose a number from 1 to 5, where one (1) indicates that you do not agree at all and a five (5) indicates that you strongly agree. Your answers are private and will not be shared with your partner.

	I do not agree at all			I strongly agree		Prefer not to answer
1. My partner never admits when she or he is wrong.	1	2	3	4	5	□
2. My partner is unwilling to adapt to my needs and expectations	1	2	3	4	5	□
3. My partner is more insensitive than caring.	1	2	3	4	5	□
4. I am often forced to sacrifice my own needs to meet my partner’s needs.	1	2	3	4	5	□
5. My partner refuses to talk about problems that make him or her look bad.	1	2	3	4	5	□
6. My partner withholds affection unless it would benefit her or him.	1	2	3	4	5	□
7. It is hard to disagree with my partner because she or he gets angry.	1	2	3	4	5	□
8. My partner resents being questioned about the way he or she treats me.	1	2	3	4	5	□
9. My partner builds himself or herself up by putting me down.	1	2	3	4	5	□
10. My partner retaliates when I disagree with him or her.	1	2	3	4	5	□
11. My partner is always trying to change me.	1	2	3	4	5	□
12. My partner believes he or she has the right to force me to do things.	1	2	3	4	5	□
13. My partner is too possessive or jealous.	1	2	3	4	5	□
14. My partner tries to isolate me from family and friends.	1	2	3	4	5	□
15. Sometimes my partner physically hurts me.	1	2	3	4	5	□

The Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 10 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: RTI International, 3040 E Cornwallis Rd, Durham NC, 27709 ATTN: Tasseli McKay (919-485-5747). Do not return the completed form to this address.