2.1: TDV Screener 1

Instrument 2.1

TDV Screener 1

Instrument 1

Case ID: ____________________________

Date: _____________________________

Is this your…

1^st session?

2^nd session?

3^rd session?

IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 1^st: Thank you again for being willing to participate. Here is the first set of questions, which will take about 10 minutes. There will be 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 1 IS RANDOMIZED TO BE ADMINISTERED 2^nd: We have some more questions for you as part of the research study you are taking part in with [PROGRAM NAME] and RTI. The questions are about romantic relationships, including unhealthy relationship behaviors and violence. They will take about 10 minutes. You do not have to be in a relationship to answer the questions. It is your choice whether to answer them. If you choose to, you will receive a $5 gift card as a token of appreciation. We will do our best to keep all of your answers private.

IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 3^rd: We have one last set of questions for you as part of the research study you are taking part in with [PROGRAM NAME] and RTI. The questions are about romantic relationships, including unhealthy relationship behaviors and violence. They will take about 10 minutes. You do not have to be in a relationship to answer the questions. It is your choice whether to answer them. If you choose to, you will receive a $5 gift card as a token of appreciation. We will do our best to keep all of your answers private.

These questions ask about things that may have happened between you and anyone you were dating or going out with in the past 12 months.

	I did not date or go out with anyone during the past 12 months	0 times	1 time	2 or 3 times	4 or 5 times	6 or more times	Prefer not to answer
1. During the past 12 months, how many times did someone you were dating or going out with try to keep you from seeing or talking with your friends or family?							
During the past 12 months, how many times did someone you were dating or going out with try to prevent you from going to work or school?							
During the past 12 months, how many times did someone you were dating or going out with force you to do sexual things that you did not want to do? (Count things like kissing, touching, or being physically forced to have sexual intercourse.)							
During the past 12 months, how many times did someone you were dating or going out with physically hurt you on purpose? (Count such things as being hit, slammed into something, or injured with an object or weapon.)							

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.

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