Survey

Understanding Relationship Dynamics and Conflict Survey--Formative Study

Attachment E - Survey Instrument

Survey - Incarcerated Respondents

OMB: 0920-1206

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Attachment E

Survey


Form Approved

OMB No.: 0920-xxxx

Expiration Date: XX/XX/XXXX


Public Reporting burden of this collection of information is estimated at 1 hour per response for mechanical turk survey respondents and 1 hour and 25 minutes for incarcerated responders, 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-XXXX).


We would like to start by asking you a few questions about yourself.


Demographics

  1. What is your age?

­­­_____ years

  1. What sex were you assigned at birth, on your original birth certificate?

0Male

1Female

  1. How do you describe your gender identity?

0Male

1Female

2Male-to-female transgender (MTF)

3Female-to-male transgender (FTM)

4Other gender identity

(specify)_______

  1. Which of the following best represents how you think of yourself?

0 Gay (lesbian or gay)

1 Straight, that is, not gay (lesbian or gay)

2 Bisexual

3 Something else

4 I don’t know the answer

  1. What is the highest grade or level of school that you have completed?

0 8th grade or less

1 Some high school, but did not graduate

2 High school graduate or GED

3 Some college or 2-year degree

4 4-year college graduate

5 More than 4-year college degree

  1. What best describes your employment status?

0 Employed full-time (work 35 or more hours a week at one or more places of employment)

1 Employed part-time (work less than 35 hours a week at one or more places of employment)

2 Voluntarily unemployed

3 A full-time student

4 Retired

5 Unable to work for health reasons

6 Unemployed

8 Other



[Program: If Age < 25 years, skip to Longest you have held job), # jobs = none, skip to income questions]

  1. Since turning 25 years old, how many jobs have you had? Consider a job to be a full or part-time, paid position.

0None  If None, go to #9

11 or 2

23 to 5

36 to 9

410 to 19

520 or more

  1. What is the longest you have held a job? Round to the nearest year.

0Less than 6 months

16 to 11 months

21-2 years

33-5 years

46-10 years

510 or more years


[Program: If incarcerated population, skip income and go to ‘Have you ever served in a combat zone’]

  1. What was your total household income during the past 12 months?

0 Less than $10,000

1 $10,000 to $14,999

2 $15,000 to $24,999

3 $25,000 to $34,999    

4 $35,000 to $49,999    

5 $50,000 to $74,999    

6 $75,000 to $99,999    

7 $100,000 to $149,999

8 $150,000 to $199,999

9 $200,000 or more

  1. Have you ever served in a combat zone or other especially dangerous area that is subject to hostile fire or mine explosions?

0 No

1 Yes

  1. Are you Hispanic or Latino?

0 No

1 Yes

  1. What is your race? Mark one or more.

0 White

1 Black or African American

2 Native Hawaiian or Other Pacific Islander

3 Asian

4 American Indian or Alaska Native



Stress and Emotional Regulation Skills


  1. The following questions ask you about your feelings and thoughts. In each case, please indicate, in general, how often you felt or thought a certain way.


    Never (0)

    Rarely

    (1)

    Sometimes

    (2)

    Often

    (3)

    Very Often

    (4)

    1. In general, how often have you felt that you were unable to control the important things in your life?






    1. In general, how often have you felt confident about your ability to handle your personal problems?






    1. In general, how often have you felt that things were going your way?






    1. In general, how often have you felt difficulties were piling up so high that you could not overcome them?






  2. Please indicate how strongly you agree or disagree with the following.


    Strongly Disagree (0)

    Disagree

    (1)

    Neither agree nor disagree

    (2)

    Agree

    (3)

    Strongly

    Agree

    (4)

    1. I can calm myself down when I am upset.






    1. I can usually tell when I am about to lose my temper.






    1. Before I let myself get really angry, I think about what will happen if I lose my temper.






    1. When I feel myself getting angry, I try to tell myself to calm down.






    1. I experience my emotions as overwhelming and out of control.






    1. When I’m upset, I feel out of control.






    1. When I’m upset, I have difficulty controlling my behaviors.






    1. When I’m upset, I know that I can find a way to eventually feel better.






    1. When I’m upset, it takes me a long time to feel better.






    1. When I’m upset, my emotions feel overwhelming.






    1. I often have tender, concerned feelings for people less fortunate than me.






    1. Sometimes I don't feel very sorry for other people when they are having problems.






    1. When I see someone being taken advantage of, I feel kind of protective towards them.






    1. Other people's misfortunes do not usually disturb me a great deal.






    1. I am often quite touched by things that I see happen.






    1. I would describe myself as a pretty soft-hearted person.






  3. How strongly do you agree or disagree with the following statements?


Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly

Agree

(4)

  1. I’m more tough-minded than other people.






  1. Most people are wimps.






  1. It tortures me to see an injured animal.






  1. I like to see fist-fights.






  1. My friends would say that I am a warm person.






  1. I avoid horror movies.






  1. I feel so sorry when I see a homeless person.






  1. I don’t bother to keep in touch with my family any more.






  1. I never cry at movies.






  1. People sometimes say that I’m cold-hearted.






  1. I love violent sports.






  1. People are too sensitive when I tell them the truth about themselves.






  1. People cry way too much at funerals.






  1. I never feel guilty over hurting others.






  1. I sometimes get rid of friends that I don’t need any more.












General Aggression & Typologies

  1. How strongly do you agree or disagree with the following statements?


Strongly Disagree

(0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly

Agree

(4)

  1. Sometimes I can't control the urge to hit another person.






  1. If somebody hits me, I hit back.






  1. I get into physical fights a little more than the average person.






  1. There are people who pushed me so far that we came to blows.






  1. I cannot think of a good reason to ever hit a person.






  1. I have threatened people I know.






  1. I have become so mad that I have broken things.






  1. When people annoy me, I may tell them what I think of them.






  1. I can't help getting into arguments when people disagree with me.






  1. When frustrated, I let my irritation show.






  1. I sometimes feel like I’m about to explode.






  1. I have trouble controlling my temper.






  1. I am sometimes consumed with jealousy.






  1. I wonder why sometimes I feel so bitter about things.






  1. I am suspicious of overly friendly strangers.






  1. When people are especially nice, I wonder what they want.







  1. There are times when most of us feel angry, or have done things we should not have done. Please indicate how often you have done the following things.



Never (0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. Yelled at others when they have annoyed you






  1. Hurt others to win a game






  1. Used physical force to get others to do what you want






  1. Gotten angry or mad when you lost a game






  1. Used force to obtain money or things from others






  1. Felt better after hitting someone






  1. Felt better after yelling at someone






  1. Threatened someone






  1. Bullied someone






  1. Hit others to defend yourself






  1. Carried a weapon to use in a fight






  1. Yelled at others so they would do things for you







  1. The next several questions ask about your actions against others. Do not include times when you acted out of self-defense.

  1. In your lifetime, how many times have you been in a physical fight with another person?

0Never

11-2 times

23-4 times

35-6 times

47-8 times

58 or more times

  1. In your lifetime, how many times have you attacked and injured someone?

0Never

11-2 times

23-4 times

35-6 times

47-8 times

58 or more times



  1. In your lifetime, how many times have you forced or attempted to force someone to have sex when they didn’t want to or could not say if they wanted to?

0Never

11-2 times

23-4 times

35-6 times

47-8 times

58 or more times

  1. In your lifetime, how many times did you pressure or try to pressure someone to have sex when they didn’t want to?

0Never

11-2 times

23-4 times

35-6 times

47-8 times

58 or more times



  1. In your lifetime, how many times have you hurt someone so that they needed bandages or medical care?

0Never

11-2 times

23-4 times

35-6 times

47-8 times

58 or more times





  1. How many times did you use a weapon in any of these situations?

0Never

11-2 times

23-4 times

35-6 times

47-8 times

58 or more times




The following questions ask about your arrest history.

  1. How many times have you been arrested?

00 times  If 0 times, go to #23

11 or 2 times

23 to 5 times

36 to 9 times

410 to 19 times

520 to 29 times

630 to 39 times

740+ times

  1. How many times have you been arrested for sexual assault or a sex-related offense?

00 times

11 or 2 times

23 to 5 times

36 to 9 times

410 to 19 times

520 to 29 times

630 to 39 times

740+ times

  1. How many times have you been arrested for a violent offense with or without a weapon? Do not include sexual assault or a sex-related offense.

00 times

11 or 2 times

23 to 5 times

36 to 9 times

410 to 19 times

520 to 29 times

630 to 39 times

740+ times



  1. How many times have you been arrested for violence against a dating partner or spouse? Include violence with or without a weapon.

00 times

11 or 2 times

23 to 5 times

36 to 9 times

410 to 19 times

520 to 29 times

630 to 39 times

740+ times


Adverse Childhood Experience

  1. While you were growing up, during your first 18 years of life…

Never (0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. How often did a parent or other adult in the household swear at you, insult you, put you down, or humiliate you?






  1. How often did a parent or other adult in the household act in a way that made you afraid that you might be physically hurt?






  1. How often did a parent or other adult in the household push, slap, or throw something at you?






  1. How often did a parent or other adult in the household ever hit you so hard that you had marks (bruises or cuts) or were injured?






  1. As a child, how often did anyone ever force you to have sex or to do something sexual that you did not want to do?






  1. As a child, how often did you hear or see one of your parents or guardians being physically hurt (e.g., hit, slapped, punched, kicked, etc.) by their partner?






  1. How often did you feel that no one in your family loved you or thought you were important or special?






  1. How often did you feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?






  1. How often did you feel that your parents or guardians were too drunk or high to take care of you or take you to the doctor if you needed it?








While you were growing up, during your first 18 years of life…

  1. Did you live with anyone who was a problem drinker or alcoholic or who regularly used drugs to get high?

0No

1Yes

2Not Sure

  1. Did you live with anyone who was depressed or mentally ill?

0No

1Yes

2Not Sure

  1. Did you live with anyone who attempted suicide?

0No

1Yes

2Not Sure

  1. Did you live with anyone who ever went to prison?

0No

1Yes

2Not Sure


Community Violence

  1. While you were growing up, during your first 18 years of life, …

Never (0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. How often did you see anyone shot or stabbed?






  1. How often did you see anyone beaten up or hurt really badly by someone else?






  1. How often were you afraid to go outside because of gangs or drugs in your neighborhood?






  1. How often did you have to hide someplace because of gun violence in your neighborhood?






Acceptance of Violence

  1. Please indicate how strongly you agree or disagree with the following statements.

    Strongly Disagree (0)

    Disagree

    (1)

    Neither agree nor disagree

    (2)

    Agree

    (3)

    Strongly

    Agree

    (4)

    1. Punishing a child physically when he/she deserves it will make him/her a responsible and mature adult.






    1. Giving misbehaving children a quick slap is the best way to quickly end trouble.






    1. A parent hitting a child when he/she does something bad on purpose teaches the child a good lesson.






    1. Young children who refuse to obey should be spanked.






    1. A teacher hitting a child when he/she does something bad on purpose teaches the child a good lesson.






  2. Please indicate how strongly you agree or disagree with the following statements.


    Strongly Disagree (0)

    Disagree

    (1)

    Neither agree nor disagree

    (2)

    Agree

    (3)

    Strongly

    Agree

    (4)

    1. It is normal for arguments to get physical sometimes in a relationship






    1. Women sometimes deserve to be hit by their partners.






    1. Men sometimes deserve to be hit by their partners.






  3. How strongly do you agree or disagree that it would be okay for a person to use physical force against their ex-partner in the following circumstances?

Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly

Agree

(4)

  1. If they refuse to return to the relationship






  1. In order to get access to their children






  1. If their ex-partner tries to turn the children against them






  1. If they are being unreasonable about property settlement and financial issues






  1. If they start a new relationship







Stalking

  1. An intimate partner could be anyone you are hooking up with, casually dating, in a relationship with, living together with, or engaged or married to. How many intimate partners or ex-intimate partners have you ever…



None

(0)

1-2 partners

(1)

3-4

partners

(2)

5-6

partners

(3)

7 or more partners

(4)

  1. Watched or followed from a distance, or spied on with a listening device, camera, or GPS [global positioning system]?






  1. Approached or showed up in places, such as their home, workplace, or school when they didn’t want you to be there?






  1. Left strange or potentially threatening items for them to find?






  1. Snuck into their home or car and did things to scare them by letting them know you had been there?






  1. Left unwanted messages? This includes text or voice messages.






  1. Made unwanted phone calls to them? This includes hang-up calls.






  1. Sent unwanted emails, instant messages, or sent messages through websites like Myspace or Facebook?






  1. Left cards, letters, flowers, or presents when you knew they didn’t want you to?









Relationship Context

We would like you to think about your current or most recent intimate partner when answering the next set of questions. An intimate partner could be anyone you are hooking up with, casually dating, in a relationship with, living together with, or engaged or married to.

  1. Are you currently intimately involved with anyone?

0No If No, go to #38

1Yes

  1. How many people are you currently intimately involved with?

______ people

  1. What is your current intimate partner’s gender identity?

0Male

1Female

2Male-to-female transgender (MTF)

3Female-to-male transgender (FTM)

4Other gender identity

(specify)_______

  1. Approximately, how long have you been with your current intimate partner?

_____ years ____ months

  1. Are you hooking up, casually dating, in a relationship, living together, engaged, or married to your current intimate partner? Mark all that apply.

0Hooking up

1Casually dating

2In a relationship

3Living together

4Engaged

5Marri

  1. Have you been intimately involved with anyone previously?

0No If No, go to #79

1Yes

  1. What is your most recent intimate partner’s gender identity?

0Male

1Female

2Male-to-female transgender (MTF)

3Female-to-male transgender (FTM)

4Other gender identity

(specify)_______

  1. Approximately, how long ago did you and your most recent intimate partner break up?

_____ years ____ months

  1. Approximately, how long were you and your most recent intimate partner together?

_____ years ____ months

  1. Were you hooking up, casually dating, in a relationship, living together, engaged, or married to your most recent intimate partner?

0Hooking up

1Casually dating

2In a relationship

3Living together

4Engaged

5Married

  1. Were your previous partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

3I do not have any previous partners



Relationship Discord/Satisfaction

  1. Please answer the following questions thinking about how often the following occurred with your {current or most recent} partner.

Never

(0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. Little arguments escalate(d) into ugly fights with accusations, criticisms, name-calling, or bringing up past hurts.






  1. I criticize(d) or belittle(d) my partner’s opinions, feelings, or desires.






  1. When we have(had) a problem to solve, it is(was) like we are(were) on opposite teams.






  1. I hold(held) back from telling my partner what I really think(thought) and feel(felt).






  1. I think(thought) seriously about what it would be like to date or marry someone else.






  1. I feel(felt) lonely in this(that) relationship.






  1. When we argue(d), one of us withdraws(withdrew), that is, doesn't(didn’t) want to talk about it anymore; or leaves(left) the scene.










  1. In general, how satisfied are you with your relationship?

0Not at all satisfied

1Slightly satisfied

2Moderately satisfied

3Very satisfied

4Extremely satisfied

  1. In general, how often do you feel satisfied with your relationship?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. How often do you wish you had not gotten into this relationship?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. In general, how often do you argue in your relationship?

0Never

1Rarely

2Sometimes

3Often

4Very Often



Communication and Conflict Management

  1. Think about how you handle conflict with your {current or most recent} partner. Specifically, think about a significant conflict issue that you and your partner have disagreed about. Please indicate how strongly you agree or disagree with the following statements.




Not

Applicable

(0)

Strongly Disagree (1)

Disagree

(2)

Neither agree nor disagree

(3)

Agree

(4)

Strongly agree

(5)

  1. We try(tried) to find solutions that are(were) acceptable to both of us.







  1. We often resolve(d) conflict by talking about the problem.







  1. Our conflicts usually end(ed) when we reach(ed) a compromise.







  1. When my partner and I disagree(d), we consider(ed) both sides of the argument.







  1. In order to resolve conflicts, we try(tried) to reach a compromise.







  1. My partner and I negotiate(d) to resolve our disagreements.







  1. I try(tried) to meet my partner halfway to resolve a disagreement.







  1. My partner and I collaborate(d) to find a common ground to solve problems between us.







  1. We try(tried) to collaborate so that we can(could) reach a joint solution to a conflict.







  1. When we argue(d) or fight(fought), I try(tried) to win.







  1. I try(tried) to take control when we argue(d).







  1. I rarely let my partner win an argument.







  1. When we disagree(d), my goal is(was) to convince to my partner that I am(was) right.







  1. When we argue(d), I let my partner know I am(was) in charge.







  1. When we have(had) conflict, I try(tried) to push my partner into choosing the solution that I think(thought) is(was) best.







  1. When my partner and I disagree(d), we argue(d) loudly.







  1. Our conflicts usually last(ed) quite a while.







  1. My partner and I have(had) frequent conflicts.







  1. I suffer(ed) a lot from conflict with my partner.







  1. I become verbally abusive to my partner when we have(had) conflict.







  1. My partner and I often argue(d) because I do(did) not trust them.










Power and Control


  1. Please indicate how often the following occurred with your {current or most recent} partner.

Not Applicable

(0)

Never

(1)

Rarely

(2)

Sometimes

(3)

Often

(4)

Very Often

(5)

  1. I try(tried) to keep my partner from spending time with other people.







  1. I check(ed) where my partner is(was) and who they are(were) hanging out with.







  1. I do(did) not let my partner do things with other people.







  1. I show(ed) up at my partner’s home, school or work even when my partner doesn’t(didn’t) want me to.







  1. I use(d) cell phone, text messaging, or e-mail to check up on my partner and to see where they are(were).







  1. I need(ed) to approve the kinds of things my partner does(did) with friends







  1. My partner just goes(went) along with decisions about everyday kinds of things







  1. I keep(kept) my partner from using the car without my permission







  1. I keep(kept) track of my partner’s phone calls







  1. I read my partner’s emails







  1. My partner doesn’t(didn’t) have that much say about how the money is(was) spent







  1. I threaten(ed) to leave sometimes to get my partner to listen to me








Intimate Partner Violence Perpetration (and Victimization)

  1. Sometimes conflict between you and your partner may lead to physical contact or physical aggression. Here is a list of physical behaviors that people have reported doing to their partners or former partners. Please indicate how often you have used these behaviors at any time with your {current or most recent} partner.

    Never

    (0)

    Rarely

    (1)

    Sometimes

    (2)

    Often

    (3)

    Very Often

    (4)

    1. I threatened to hurt them physically






    1. I pushed, grabbed, or shoved them






    1. I slapped, hit, kicked, or punched them






    1. I threatened them with a knife, gun, or other weapon






    1. I choked or strangled them






    1. I beat them up






    1. I used a knife, gun, or other weapon against them






  2. When you did those things to your partner, how often were you under the influence of alcohol?

0Never

1Rarely

2Sometimes

3Often

4Very Often



  1. When you did those things to your partner, how often were you under the influence of drugs?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. Thinking about the physical behaviors you just reported, please indicate how often you did those things toward your {current or most recent} partner for each of the reasons listed.


Never

(0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. Self-defense or to get away from your partner






  1. To get back at or get revenge against your partner






  1. To show anger or other feelings that you couldn’t explain in words






  1. Because you were jealous






  1. Because you were angry at someone else but took it out on your partner






  1. Because your partner pushed you over the edge






  1. Because your partner cheated on you






  1. Because your partner was going to walk away or leave






  1. To feel more powerful






  1. To get control over your partner (not including in self-defense)






  1. To hurt your partner’s feelings






  1. To make your partner agree with you






  1. To make your partner scared or afraid






  1. Because you were afraid your partner was going to leave you






  1. To punish your partner (not including in self-defense)






  1. Because you didn’t believe your partner cared about you






  1. To get your partner’s attention






  1. Because it was sexually arousing






  1. Because you wanted to have sex and your partner didn’t






  1. Because you were fighting over money






  1. Because they were mistreating the kids







  1. Now I’m going to ask about your partner’s potential injuries. How often has your partner…


Never (0)


Rarely

(1)

Sometimes

(2)


Often

(3)

Very Often

(4)

  1. Had a sprain, bruise, or small cut because of a fight with you?






  1. Needed to go to a doctor, nurse, or healthcare professional because of a fight with you






  1. Had a broken bone from a fight with you






  1. Still felt physical pain the next day because of a fight you had






  1. Been hospitalized because of an injury you caused







  1. Which of these behaviors have you done to any other past partners? Mark all that apply


    Yes

    (1)

    1. I threatened to hurt them physically


    1. I pushed, grabbed, or shoved them


    1. I slapped, hit, kicked, or punched them


    1. I threatened them with a knife, gun, or other weapon


    1. I choked or strangled them


    1. I beat them up


    1. I used a knife, gun, or other weapon against them


  2. Were these past partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

  1. Have any of your partners died from injuries you caused?

0No

1Yes



  1. How often has your {current/most recent} partner done any of these physical behaviors to you?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. Which of these physical behaviors has any other partners done to you? Mark all that apply


    Yes

    (1)

    1. They threatened to hurt me physically


    1. They pushed, grabbed, or shoved me


    1. They slapped, hit, kicked, or punched me


    1. They threatened me with a knife, gun, or other weapon


    1. They choked or strangled me


    1. They beat me up


    1. They used a knife, gun, or other weapon against me


  2. Were these past partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

  1. Here is a list of sexual behaviors that people have reported doing to their partners or former partners. Please indicate how often you have used these behaviors at any time with your {current/most recent} partner.

Never

(0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. I insisted on sex when my partner did not want to or in a way that my partner didn’t like






  1. I made my partner have sex without a condom






  1. I physically forced my partner to have sex






  1. I intentionally got my partner drunk or high to have sex






  1. I had sex with them when they were unconscious






  1. I used threats to make them have sex with me






  1. I used force (like hitting, holding down, or using a weapon) to make my partner have vaginal, oral or anal sex.






  1. I attempted to make my partner have vaginal, oral, or anal sex against their will but intercourse or penetration did not occur






  1. I put my fingers or objects in my partner’s vagina or anus against my partner’s will or by using force or threats






  1. I used threats or manipulation to get my partner to have sex play (such as fondling or kissing, but not intercourse) when my partner didn’t want to






  1. I treated my partner like a sex object






  1. I touched my partner’s genitals when I knew my partner did not want me to







  1. When you did those things to your partner, how often were you under the influence of alcohol?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. When you did those things to your partner, how often were you under the influence of drugs?

0Never

1Rarely

2Sometimes

3Often

4Very Often


  1. Thinking about the sexual behaviors you just reported, please indicate how often you did those things toward your {current or most recent} partner for each of the reasons listed.




Never

(0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. To get back at, retaliate, or get revenge against your partner






  1. To show anger or other feelings that you couldn’t explain in words






  1. Because of stress






  1. Because you were jealous






  1. Because your partner provoked you or pushed you over the edge






  1. Because your partner cheated on you






  1. To feel more powerful






  1. To get control over your partner






  1. To hurt your partner’s feelings






  1. To make your partner scared or afraid






  1. Because you were afraid your partner was going to leave you






  1. To punish your partner






  1. To get your partner’s attention






  1. Because it was sexually arousing






  1. Because you wanted to have sex and your partner didn’t






  1. Because we were playing around






  1. Which of these sexual behaviors have you done to any other past partners? Mark all that apply .

Yes

(1)

  1. I insisted on sex when my partner did not want to or in a way that my partner didn’t like


  1. I made my partner have sex without a condom


  1. I physically forced my partner to have sex


  1. I intentionally got my partner drunk or high to have sex


  1. I had sex with them when they were unconscious


  1. I used threats to make them have sex with me


  1. I used force (like hitting, holding down, or using a weapon) to make my partner have vaginal, oral or anal sex.


  1. I attempted to make my partner have vaginal, oral, or anal sex against their will but intercourse or penetration did not occur


  1. I put my fingers or objects in my partner’s vagina or anus against my partner’s will or by using force or threats


  1. I used threats or manipulation to get my partner to have sex play (such as fondling or kissing, but not intercourse) when my partner didn’t want to


  1. I treated my partner like a sex object


  1. I touched my partner’s genitals when I knew my partner did not want me to


  1. Were these past partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

  1. How often has your {current/most recent} partner done any of these sexual behaviors to you?

0Never

1Rarely

2Sometimes

3Often

4Very Often



  1. Which of these sexual behaviors has any other partner done you? Mark all that apply


Yes

(1)

  1. They insisted on sex when I did not want to or in a way that I didn’t like


  1. They made me have sex without a condom


  1. They physically forced me to have sex


  1. They intentionally got me drunk or high to have sex


  1. They had sex with me when I was unconscious


  1. They used threats to make me have sex with them


  1. They used force (like hitting, holding down, or using a weapon) to make me have vaginal, oral or anal sex.


  1. They attempted to make me have vaginal, oral, or anal sex against my will but intercourse or penetration did not occur


  1. They put their fingers or objects in my vagina or anus against my will or by using force or threats


  1. They used threats or manipulation to get me to have sex play (such as fondling or kissing, but not intercourse) when I didn’t want to


  1. They treated me like a sex object


  1. They touched my genitals when they knew I did not want them to


  1. Were these past partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

  1. Here is a list of verbal and other behaviors that people have reported doing to their partners or former partners. Please indicate how often you have used these behaviors at any time with your {current/most recent} partner.

Never

(0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. I called my partner names.






  1. I swore at my partner.






  1. I yelled and screamed at my partner.






  1. I used our money or made important financial decisions without talking to my partner about it.






  1. I accused my partner of having an affair with another person.






  1. I tried to keep my partner from doing things to help {himself or herself}.






  1. I restricted my partner’s use of the telephone.






  1. I tried to make my partner feel crazy.







  1. When you did those things to your partner, how often were you under the influence of alcohol?

0Never

1Rarely

2Sometimes

3Often

4Very Often



  1. When you did those things to your partner, how often were you under the influence of drugs?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. Which of these verbal or other behaviors have you done to any other past partners? Mark all that apply


Yes

(1)

  1. I called my partner names.


  1. I swore at my partner.


  1. I yelled and screamed at my partner.


  1. I used our money or made important financial decisions without talking to my partner about it.


  1. I accused my partner of having an affair with another person.


  1. I tried to keep my partner from doing things to help {himself or herself}.


  1. I restricted my partner’s use of the telephone.


  1. I tried to make my partner feel crazy.


  1. Were these past partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

  1. How often has your {current/most recent} partner done any of these verbal or other behaviors to you?

0Never

1Rarely

2Sometimes

3Often

4Very Often

  1. Which of these verbal or other behaviors has any other partners done to you? Mark all that apply


Yes

(1)

  1. I called my partner names.


  1. I swore at my partner.


  1. I yelled and screamed at my partner.


  1. I used our money or made important financial decisions without talking to my partner about it.


  1. I accused my partner of having an affair with another person.


  1. I tried to keep my partner from doing things to help {himself or herself}.


  1. I restricted my partner’s use of the telephone.


  1. I tried to make my partner feel crazy.






  1. Were these past partners only men, only women, or both men and women?

0Only men

1Only women

2Both men and women

Psychological Conditions


  1. Has a doctor, therapist or other health professional ever told you that you have any of the following conditions?

No

(0)

Yes

(1)

Not Sure

(2)

  1. Post-traumatic stress disorder (PTSD)




  1. An anxiety disorder (other than PTSD)




  1. Anti-social personality disorder (ASPD)




  1. Oppositional/defiant disorder or conduct disorder (ODD or CD)




  1. Depression




  1. Borderline personality disorder (BPD)




  1. Insecure or anxious attachment or attachment disorder




  1. Deviant sexual arousal




  1. Traumatic brain injury




  1. A concussion can occur when someone has even a minor head injury. Symptoms are usually temporary but can include headaches and problems with sensitivity to light and/or sound, concentration, memory, balance and coordination. How many concussions have you had in your lifetime?

_____ concussions

  1. Have you ever had 2 or more concussions within a single month?

0No

1Yes

Substance Use/Disorder

  1. In your lifetime, have you used any of the following substances?


No

(0)

Yes

(1)

  1. Alcohol



  1. Prescription pain killers?



  1. Cannabis products (marijuana, pot, weed, grass, hash, etc.) ?



  1. Inhalants (nitrous, glue, petrol, paint thinner, etc.) ?



  1. Opioids (heroin, morphine, methadone, codeine, etc.)?



  1. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)



  1. Amphetamine type stimulants (crystal meth, speed, ecstasy, etc.)



  1. Sedatives (Benzos, Barbituates, Valium, Serepax, Rohypnol, etc.)



  1. Cocaine (coke, crack, etc.)







  1. In a typical month, how often do you…

Never

(0)

Rarely

(1)

Sometimes

(2)

Often

(3)

Very Often

(4)

  1. Drink alcohol until intoxicated (i.e., get drunk)?






  1. Use prescription pain killers?






  1. Use cannabis products (marijuana, pot, weed, grass, hash, etc.) ?






  1. Use inhalants (nitrous, glue, petrol, paint thinner, etc.) ?






  1. Use opioids (heroin, morphine, methadone, codeine, etc.)?






  1. Use hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)






  1. Use Amphetamine type stimulants (crystal meth, speed, ecstasy, etc.)






  1. Use sedatives (Benzos, Barbituates, Valium, Serepax, Rohypnol, etc.)






  1. Use cocaine (coke, crack, etc.)








Sexual Preference and Attraction

The following questions ask about the types of people you are attracted to.

  1. My sexual fantasies are about…

1Only the opposite sex

2Mainly the opposite sex, rarely about the same sex

3Mainly the opposite sex, sometimes about the same sex

4Both the same and the opposite sex

5Mainly the same sex, rarely about the opposite sex

6Only the same sex

  1. The idea of having sexual intercourse with someone of the opposite sex is:

0Desirable

1Alluring

2Interesting

3Tolerable

4Negative

5Disgusting

  1. The idea of having sexual intercourse with someone of the same sex is:

0Desirable

1Alluring

2Interesting

3Tolerable

4Negative

5Disgusting



Gender Roles


  1. Please say how strongly you agree or disagree with the following statements:

Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly

Agree

(4)

  1. Many women are actually seeking special favors, such as hiring policies that favor them over men, under the guise of asking for "equality."






  1. Most women interpret innocent remarks or acts as being sexist.






  1. Women are too easily offended.






  1. Feminists are not seeking for women to have more power than men.






  1. Most women fail to appreciate fully all that men do for them.






  1. Women seek to gain power by getting control over men.






  1. Women exaggerate problems they have at work.






  1. Once a woman gets a man to commit to her, she usually tries to put him on a tight leash.






  1. When women lose to men in a fair competition, they typically complain about being discriminated against.






  1. Few women enjoy teasing men by seeming sexually available and then refusing male advances.






  1. Feminists are making entirely reasonable demands of men








  1. Please rate the following situations according to how stressful each situation would be if it happened to you.

Not stressful (0)

Slightly Stressful

(1)

Somewhat Stressful

(2)

Moderately Stressful

(3)

Extremely Stressful

(4)

  1. Being outperformed at work by a woman






  1. Letting a woman control the situation






  1. Being perceived by someone as “gay”






  1. Being married to someone who makes more money than you






  1. Losing in a sports competition






  1. Admitting that you are afraid of something






  1. Being with a woman who is more successful than you






  1. Being perceived as having feminine traits






  1. Having your children see you cry






  1. Being outperformed in a game by a woman






  1. Having people say that you are indecisive






  1. Appearing less athletic than a friend






  1. Having others say that you are too emotional






  1. Being compared unfavorably to other men






  1. Getting passed over for a promotion








  1. Please indicate how strongly you agree or disagree with the following statements.

Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly

Agree

(4)

  1. I am less masculine than the average guy.






  1. Compared to my guy friends, I am not very masculine.






  1. I wish I was more “manly.”






  1. Most women I know would say that I am not as masculine as my friends.






  1. I wish I was interested in things that other guys find interesting.






  1. Most women would consider me to be less masculine than the typical guy.






  1. I worry that people judge me because I am not like the typical man.






  1. Most guys would think I am not very masculine compared to them.






  1. Sometimes I worry about my masculinity.






  1. I worry that women find me less attractive because I’m not as macho as other guys.






  1. It doesn’t bother me that I am not as masculine as other guys.









  1. Please indicate how strongly you agree or disagree with the following statements.

Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly

Agree

(4)

  1. I am less feminine than the average woman.






  1. Compared to my girlfriends, I am not very feminine.






  1. I wish I was more “girly.”






  1. Most guys I know would say that I am not as feminine as my friends.






  1. I wish I was interested in things that other women find interesting.






  1. Most men would consider me to be less feminine than the typical woman.






  1. I worry that people judge me because I am not like the typical woman.






  1. Most women would think I am not very feminine compared to them.






  1. Sometimes I worry about my femininity.






  1. I worry that men find me less attractive because I’m not as girly as other women.






  1. It doesn’t bother me that I am not as feminine as other women.









Self-Esteem and Self-Efficacy

  1. Below is a list of statements dealing with your general feelings about yourself. Indicate how strongly you agree or disagree with the statement.


Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly Agree

(4)

  1. On the whole, I am satisfied with myself.






  1. At times, I think I am no good at all.






  1. I feel that I have a number of good qualities.






  1. I am able to do things as well as most other people.






  1. I feel I do not have much to be proud of.






  1. I certainly feel useless at times.






  1. I feel that I’m a person of worth, at least on an equal plane with others.






  1. I wish I could have more respect for myself.






  1. All in all, I am inclined to feel that I am a failure.






  1. I take a positive attitude toward myself.



















  1. Please indicate how strongly you agree or disagree with the following statements about yourself .


Strongly Disagree (0)

Disagree

(1)

Neither agree nor disagree

(2)

Agree

(3)

Strongly Agree

(4)

  1. I can always manage to solve difficult problems if I try hard enough.






  1. If someone opposes me, I can find ways to get what I want.






  1. It is easy for me to stick to my aims and accomplish my goals.






  1. I am confident that I can deal with unexpected events.






  1. I have the resources to handle most situations.






  1. With the right amount of effort, I can solve most problems if I invest the necessary effort.






  1. I am able to remain calm and cope with difficulties.






  1. When I am confronted with a problem, I can usually find several solutions.






  1. If I am in trouble, I can usually think of a solution






  1. I can usually handle whatever comes my way.










File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAIR Report
SubjectAIR Report
AuthorAmerican Institutes for Research
File Modified0000-00-00
File Created2021-01-21
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