24 Month Follow-up Interview

Form Approved

OMB No. 0990-0458

Exp. Date 08/31/2020

DVHF Evaluation

Domestic Violence Survivor Follow-Up Interviews (6, 12, and 18 month follow-up)

1. Participant ID#: ____________________

2. Enter the name or Nickname of the abuser from Interview 1.

Name/Nickname of abuser: _____________

3. Enter the name of the target child from Interview 1.

Name/Nickname of child:_____________

4. Name of organization serving this participant:

LifeWire	1
Lower Valley Crisis and Support Services	2
New Beginnings	3
YWCA of Yakima	4

5. Please indicate what month was six months ago. Month: _____________________

H1. [INTERVIEWER: INDICATE HERE WHETHER PARTICIPANT IS STAYING IN THE AGENCY’S RESIDENTIAL SHELTER OR TRANSITIONAL HOUSING:

Yes, staying at agency’s residential shelter	1
Yes, staying in transitional housing	2
Yes, staying in another agency’s residential shelter	3
No	0
Not Applicable	88

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Similar to your first interview, many of the questions in this interview will be asking about the last 6 months, close to when you did that interview. So 6 months ago would have been ________ (month). Was there anything else that was happening around that time like an important event or something significant or memorable – like a birthday, wedding, start of a new job – that I could refer to that will help you recall what has been going on for you since then?

Event: __________________________

SERVICES

I want to start out by asking you some questions about how things have gone with the help you were wanting from _____________(Organization’s name).

S1. What types of services have you received from ______________ (org name) over the last 6 months??

		Yes (1)	No (2)	N/A (88)	Ref (99)
a.	Counseling
b.	Support Group
c.	Shelter
d.	Transitional Housing
e.	Financial Help
f.	Advocacy
g.	Referrals
h.	Other (specify): _____________

S2. Can you tell me the name of the main person from ______________(org name) that you have been working with?

Advocate’s name: _________________

[if more than one, they can think about them together]

I want you to think about how things have gone since you first started working with ____________(advocate’s name). I’d like to remind you that anything you say will be held in the strictest of confidence. She will not know what you say to me today, and we really want to know your true feelings about ________________(advocate’s name) and _______________ (organization’s name).

S3. How long has it been since you and your advocate have been in touch (i.e., met in person, emailed, texted, or talked by phone)?

We were in touch today	1
Sometime this week	2
Last week	3
More than a week ago, but less than a month	4
More than a month ago	5
Not applicable	88
Refused to Answer	99

S4. Has your advocate driven you anywhere?

Yes	1
No	0
Not applicable	88
Refused to Answer	99

S5. Were you able to speak with your advocate(s) in the language you preferred?

Yes	1
No	0
Not applicable	88
Refused to Answer	99

[SOURCE: CAP FIDELITY MEASURES]

S6. On average, how many hours a week have you worked with ____________(A) in the last 6 months?

NUMBER OF HOURS: _______________

S7. Thinking back over all of your interactions with ____________(A) over the last six months, how have you generally communicated -- in person, texting, by phone? If you broke those into percentages, what percentage of the time have you:

Texted
Talked by phone
Met in person
Video chatted
Emailed
Other
TOTAL	100%

S8. Overall, how satisfied have you been with the amount of time ____________(A) has put in toward working on things with you? [INTERVIEWER: READ ALL RESPONSE OPTIONS.]

NOT ENOUGH TIME	0
SATISFIED	1
TOO MUCH TIME	2
Refused to Answer	99

S9. Overall, how satisfied are you with the amount of effort ____________(A) has put in toward working on things with you? [INTERVIEWER: READ ALL RESPONSE OPTIONS.]

VERY DISSATISFIED	0
SOMEWHAT DISSATISFIED	1
SOMEWHAT SATISFIED	2
VERY SATISFIED	3
Refused to Answer	99

S10. Now I would like to ask you some questions about your experience with the services you have received. Using this card (#15), for each statement I read please tell me which answer best reflects your experience. The options are: Not at all, A little, Somewhat, or Very Much.

0	NOT AT ALL
1	A LITTLE
2	SOMEWHAT
3	VERY MUCH
88	Not Applicable
99	Declined to answer

The advocate I worked with….

a.	…was knowledgeable about community resources.
b.	…knew how to connect me to community resources.
	…actively worked to connect me to community resources
c.	…provided me with regular support.
d.	…noticed my best qualities.
e.	…was interested in meeting my safety needs.
f.	…was interested in meeting my housing needs.
g.	…was interested in meeting my needs beyond safety & housing.
h.	…listened to me.
i.	…helped me learn new skills or practice existing skills.
j.	...valued my opinion.
k.	…was available when I needed her.
l.	…worked on meeting the needs of my whole family.
m.	…cared about my unique needs.
n.	…supported and encouraged me.
o.	…worked on meeting the needs of my children.
p.	…helped me define and meet the goals I thought were important.
q.	…was nonjudgmental toward me.

S11. Using the same card again, how connected did you feel to your advocate during the program? By connected I mean feeling like there was a bond between the two of you? So, how connected did you feel to ____________(A)?

NOT AT ALL	0
A LITTLE	1
SOMEWHAT	2
A LOT	3
DOES NOT APPLY TO ME	4

S11a. Did the two of you work together well? In what ways? [INTERVIEWER: Probe; Open-ended question.]

S11b. Did the two of you share the same vision? In what ways? [INTERVIEWER: Probe; Open-ended question.]

S12. What were the most important skills or characteristics your advocate possessed? [INTERVIEWER: Probe; Open-ended question.]

S13. Now using the same card again (#15) please answer the following questions.

0	NOT AT ALL
1	A LITTLE
2	SOMEWHAT
3	VERY MUCH
88	Not Applicable
99	Declined to answer

To what extent, if at all, would you say you feel the following because of the work your advocate did with you. So to what extent would you say you:

a.	are safer
b.	Are better able to get what you need for yourself
c.	Are better able to get what you need for your children
d.	Have more information that will help you
e.	Have more ways to keep yourself safer
f.	Have more ways to keep your children safe
g.	Understand more about the causes of domestic violence
h.	Understand more about how domestic violence affects you
i.	Understand more about how domestic violence affects your children
j.	Are able to deal/handle/cope with the impact of domestic violence
k.	Know more about the community resources you might need
l.	Feel more hopeful about the future

Thanks for answering all of those questions about ___________ (advocate name).

[SOURCE: ITEMS FROM TIPS (GOODMAN, ET AL, IN PRESS)]

S14. Now I would like to ask you some questions about how it feels to participate in this program with _______________ (org name). We are especially interested in the extent to which staff at this program (overall, not just your advocate) recognize your challenges and difficulties, as well as your strengths and coping strategies.

Please tell me how true the following statements are as you thing about your interactions with all of the staff overall at _______________ (org name) over the last 6 months on a scale for 0 to 3, using this card (#16). You may feel different ways about different staff members. Please respond with your overall impression of the staff.

0	NOT AT ALL TRUE
1	A LITTLE TRUE
2	SOMEWHAT TRUE
3	VERY TRUE
	I don’t know
99	Declined to answer

Agency Subscale (9 items)
a.	Staff respect my privacy.
b.	Staff are supportive when I’m feeling stressed out or overwhelmed
c.	I decide what I want to work on in this program.
d.	Staff treat me with dignity.
e.	Staff understand that I know what’s best for me.
f.	Staff respect the choices that I make.
g.	In this program, I can share things about my life on my own terms and at my own pace.
h.	Staff can handle difficult situations.
i.	I can trust staff.
Information Subscale. (5 items)
j.	I have the opportunity to learn how abuse and other difficulties affect responses in the body.
k.	I have the opportunity to learn how abuse and other difficulties affect peoples’ mental health.
l.	This program creates opportunities for me to learn how abuse and other hardships affect peoples’ relationships.
m.	This program gives me opportunities to learn how abuse, and other difficulties affect peoples’ ability to think clearly and remember things.
n.	I am learning more about how to handle unexpected reminders of the abuse and difficulties I have endured.

[TIPS SUBSCALE, CONTINUED]

0	NOT AT ALL TRUE
1	A LITTLE TRUE
2	SOMEWHAT TRUE
3	VERY TRUE
	I don’t know
99	Declined to answer

Strengths Subscale (3 items)
o.	Staff respect the strengths I have gained through my life experiences.
p.	Staff respect the strengths I get from my culture or family ties.
q.	The strengths I bring to my relationships with my children, my family, or others are recognized in this program.
Cultural Responsiveness and Inclusivity Subscale (8 items)
r.	Peoples’ cultural backgrounds are respected in this program.
s.	Peoples’ religious or spiritual beliefs are respected in this program.
t.	Staff respect peoples’ sexual orientations and gender expressions.
u.	Staff understand what it means to be in my financial situation.
v.	Staff understand the challenges faced by people who are immigrants.
w.	Staff understand how discrimination impacts peoples’ everyday experience.
x.	Staff recognize that some people or cultures have endured generations of violence, abuse, and other hardships.
y.	This program treats people who face physical or mental health challenges with compassion.

[SOURCE: CAP FIDELITY MEASURES]

S15. How satisfied have you been with ______ (org name) overall? Would you say [INTERVIEWER, READ THE RESPONSE OPTIONS]:

VERY DISSATISFIED	0
SOMEWHAT DISSATISFIED	1
SOMEWHAT SATISFIED	2
VERY SATISFIED	3

S15a. Can you tell me more about that? [INTERVIEWER: Probe, Open-ended question.]

S16. We’re also wondering about the services you may have been receiving from any other agencies in the last 6 months and how helpful they may or may not have been. In the last 6 months, have you received services from….

		Yes (1)	No (0)	If yes, how helpful were the services (using card #15)? Not at all (0) A Little (1) Somewhat (2) Very Much (3) Not Applicable (88)
a.	Another DV program
b.	A housing program
c.	Substance abuse program
d.	Program helping w immigration issues
e.	Program providing legal help
f.	Home visiting nurse
g.	Religious-based program
h.	Counseling/therapy/psychiatric
i.	Other (specify)

CURRENT & RECENT HOUSING

Now I would like to ask you some questions about your housing.

Source: From the Family Options Study]

H2. Where are you living now?

[INTERVIEWIER: NO NEED TO LIST ALL OF THE ITEMS, CHECK THE ITEM THAT BEST FITS THE SURVIVOR’S RESPONSE. MAKE SURE TO PROBE:

• IF THE SURVIVOR SAYS THEY ARE/WERE LIVING WITH A PARTNER TO DETERMINE IF IT IS/WAS WITH __________(A).

• IF THE SURVIVOR IS IF THE SURVIVOR IS/WAS STAYING WITH SOMEONE ELSE TO FIND OUT IF THEY CONTRIBUTED TO RENT.

• IF THE SURVIVOR WAS STAYING IN A HOTEL/MOTEL, FIND OUT IF THEY WERE PAYING FOR IT THEMSELVES OR IF THEY WERE USING VOUCHERS.

• IF THEY SAID THEY WERE HOMELESS TO DETERMINE IF THEY WERE LIVING OUT OF A CAR, IN AN ABANDONED BUILDING SOMEWHERE, OUTSIDE SOMEWHERE, ETC.]

	Yes (1)	No (0)	REF (77)	DK (99)
H2a. A house or apartment that you own or rent.
H2b. __________(A’s) place, and paying part of the rent.
H2c. __________(A’s) place, but not paying part of the rent.
H2d. At a boy/girlfriend’s/fiancé’s/significant other’s place who is not ______________(A), and paying part of the rent.
H2e. At a boy/girlfriend’s/fiancé’s/significant other’s place who is not ______________(A), but not paying part of the rent.
H2f. A friend or relative’s house or apartment, and paying part of the rent.
H2g. A friend or relative’s house or apartment but not paying part of the rent.
If H2a through H2g = YES SKIP to H3. Otherwise, continue down H3h through H3r until a yes response is reached.

	Yes (1)	No (0)	REF (77)	DK (99)
H2h. A permanent housing program with services to help you keep your housing (on site or coming to you). [IF YES: SKIP TO H3]
H2i. A transitional housing program. [IF YES: SKIP TO H3]
H2j. A voucher hotel or motel. [IF YES: SKIP TO H3]
H2k. A hotel or motel you paid for yourself. [IF YES: SKIP TO H3]
H2i. A residential drug or alcohol treatment program. [IF YES: SKIP TO H3]
H2l. Jail or prison. [IF YES: SKIP TO H3]
H2m. A domestic violence shelter. [IF YES: SKIP TO H3]
H2n. An emergency shelter other than a domestic violence shelter. [IF YES: SKIP TO H3]
H2o. A car or other vehicle. [IF YES: SKIP TO H3]
H2p. An abandoned building. [IF YES: SKIP TO 32]
H2q. Anywhere outside [PROBE: STREETS, PARKS, ETC.] [IF YES: SKIP TO H3]
H2r. OTHER -> SPECIFY: _____________ [IF YES: SKIP TO H3]

[SOURCE FOR H3 & H4: FAMILY OPTIONS STUDY]

H3. How many other adults, that is, people who are 18 years old or older, are living with you right now?

NUMBER OF ADULTS: ______

H4. How many children are living with you right now whether they are your own children or someone else’s? By children I mean people 17 years old or younger.

NUMBER OF CHILDREN: ______

[SOURCE: Housing Instability Index]

H5. Okay, so thinking about 6 months ago:

		Yes (1)	No (0)	n/a (88)	Ref (99)
a.	Have you had to live somewhere that you did not want to live?
b.	Have you had difficulty (or were unable to) pay for housing?
c.	Since ______, have you had trouble getting housing?
d.	Have you had to borrow money or ask friends/family or others for money to pay your rent/mortgage payment?
e.	[IF RENTING] Have you had trouble with a landlord in the last 6 months?
f.	[IF RENTING] Has your landlord threatened to evict you?
g.	[IF RENTING] Have you been served an eviction notice?

H6. In the last 6 months, have you been homeless or had to live with family or friends to avoid being homeless?

Yes	1
No	0
Declined to answer	99

H7. How many times have you moved in the last 6 months?

Number of times: _____________

[Source: Family Options Study]

H8. Can you tell me a little about those moves, where you went when you moved?

		Indicate the total number of times having moved in last 6 months
a.	A house or apartment that you owned or rented.
b.	______________ (A’s) place.
c.	A boy/girlfriend’s/fiancé, significant other’s (who is not A) place.
d.	A friend or relative’s house or apartment, and paying part of the rent.
e.	A friend or relative’s house or apartment but not paying part of the rent.
f.	A permanent housing program with services to help you keep your housing (on site or coming to you).
g.	A transitional housing program.
h.	A voucher hotel or motel.
i.	A hotel or motel you paid for yourself.
j.	A residential drug or alcohol treatment program.
k.	Jail or prison.
l.	A domestic violence shelter.
m.	An emergency shelter other than a domestic violence shelter.
n.	A car or other vehicle
o.	An abandoned building.
p.	Anywhere outside [PROBE: STREETS, PARKS, ETC.]
q.	Back to the home you were living in
r.	OTHER -> SPECIFY: _____________

FINANCES

Now I have some questions about work and money.

[Source for Questions 1-5: CAP]

F1. In the last 6 months, have you been employed?

GO TO F1a, F1b, & F1c 	Yes	1
SKIP TO F2 	No	0
	Declined to Answer	99

F1a. What’s your employment status right now? Would you say:

Employed, working 40 or more hours per week	1
Employed, working 30 - 40 hours per week	2
Employed, working less than 30 hours per week	3
Not employed, looking for work	4
Not employed, NOT looking for work	5
Retired	6
Disabled, not able to work	7
Not Applicable	88
Declined to answer	99

F1b. How many jobs do you currently work? Number of Jobs:_________

F1c. What is your current job (or current primary job if more than one job]:

Personal Care and Service	1
Food Preparation and Serving	2
Healthcare Support (health aide, nurse aide, etc.)	3
Healthcare Practitioner	4
Social Services	5
Housekeeping	6
Grounds and Maintenance	7
Farmworker	8
Fishing and Forestry	9
Office and Administrative Support	10
Production	11
Sales	12
Construction	13
Legal	14
Computer and Mathematical	15
Management	16
Education	17
Installation, Maintenance, and Repair	18
Architecture and Engineering	19
Business and Financial Operations	20
Transportation	21
Other (please specify): ___________	22
Not Applicable	88
Declined to answer	99

F2. Do any of your current jobs provide you with:

		Yes (1)	No (0)	No, but I have this (2)	n/a (88)
a.	Health insurance for yourself
b.	Health insurance for your children
c.	Paid sick days
d.	Paid vacation days

[SOURCE: CAP]

F3. [ASK EVERYONE, EVEN IF UNEMPLOYED]: Using this card #1, how do you feel about your current employment situation? Would you say:

Extremely happy	1
Happy	2
Mostly satisfied	3
Mixed (equally satisfied and unsatisfied)	4
Mostly dissatisfied	5
Unhappy	6
Terrible	7
Declined to answer	99

F4. How much are you currently earning or bringing in each month?

0$/month	0
1$ to $99/month	1
$100 to $500/month	2
$501 to $1,000/month	3
$1,000 to $1,500/month	4
$1,501 to $2,000/month	5
$2,001 to $2,500/month	6
$2,501 to 3,000/month	7
1,001 to $3,500/month	8
$3,501 to 4,000/month	9
$4,001 or more/month	10
Declined to answer	99

F4a. Of the following, how much does each of the following contribute to your monthly earnings?

Employment: $__________________

Family/Friends: $__________________

__________(abuser): $__________________

Child Support: $__________________

Social Services: $__________________

SSI/SSDI: $__________________

Other (please specify):

_________________: $__________________

_________________: $__________________

F5. Using Card #1 again, how do you feel about the amount of money you live on?

Extremely happy	1
Happy	2
Mostly satisfied	3
Mixed (equally satisfied and unsatisfied)	4
Mostly dissatisfied	5
Unhappy	6
Terrible	7
Declined to answer	99

F6. Are you attending school or working on a degree right now?

Yes	1
No	0
Declined to answer	99

F7. Did you join the military, including the National Guard, in the last 6 months?

I have not joined the military/National Guard.	0
I joined the military/National Guard in the last 6 months.	1
Declined to answer	99

[SOURCE: BARRERA ECONOMIC HARDSHIP SCALE; INABILITY TO MAKE ENDS MEET SUBSCALE]

F8. Think over the last 6 months. Generally, at the end of each month did you end up with . [INTERVIEWERS: PLEASE READ ALL RESPONSES]:

More than enough money left	5
Some money left	4
Just enough money left	3
Somewhat short of money	2
Very short of money	1
Declined to Answer	99

F9. Again, Think back over the last 6 months and tell us how much difficulty you have had with paying your bills. Using this card (#2), would you say you had:

A great deal of difficulty	4
Quite a bit of difficulty	3
Some difficulty	2
A little difficulty	2
No difficulty at all	0
Not Applicable	88
Declined to Answer	99

[SOURCE: REVISED ADEQUACY OF FINANCIAL SUPPORT, MOWBRAY (1999)]

F10. Using the same card (#2), please rate the degree of difficulty you have had paying for the following over the past 6 months.

		A great deal of difficulty (4)	Quite a bit of difficulty (3)	Some difficulty (2)	A little bit of difficulty (1)	No difficulty at all (0)	I did not have these bills (88)
a.	Food
b.	Rent/mortgage
c.	Utilities
d.	Medical expenses
e.	Transportation to get to places you needed to go
f.	Transportation to visit friends and family
g.	Social activities
h.	To pay debts
i.	Childcare
j.	Anything else?__

For the next few questions I want you to think about the next six months.

[SOURCE for F11 & F12: HOUSING INSTABILITY INDEX]

Now I have a couple of questions about your future housing.

[INTERVIEWER: MARK “N/A” FOR F10 AND F11 IF SURVIVOR IS CURRENTLY STAYING IN SHELTER.]

F11. How likely is it, do you think, that you will be able to pay for your housing (e.g. rent/mortgage) this month? Would you say, very unlikely, unlikely, likely, or very likely?

Very Unlikely	1
Unlikely	2
Likely	3
Very Likely	4
Don’t Know	77
Not Applicable	88
Declined to Answer	99

F12. Do you expect to stay in your current housing situation for the next 6 months?

Yes	1
No	0
Don’t Know	77
Not Applicable	88
Declined to Answer	99

[SOURCE for F13 & F14: BARRERA ECONOMIC HARDSHIP SCALE; FINANCIAL STRAIN SUBSCALE]

F13. Choosing from the options on this card [PROVIDE CARD #3], in the next 6 months, how often do you think that you and your family will experience bad times such as poor housing or not having enough food?

Almost never	1
Once in awhile	2
Sometimes	3
A lot of the time (frequently)	4
Almost always	5
Don’t Know	77
Declined to Answer	99

F14. Using card # 3 again, in the next 6 months how often do you expect that you will have to do without the basic things your family needs?

Almost never	1
Once in awhile	2
Sometimes	3
A lot of the time (frequently)	4
Almost always	5
Don’t Know	77
Declined to Answer	99

ABUSE

Okay, so now I have some questions about __________ (abuser’s name), similar to what we asked you in the last interview.

AB1. What is your current relationship with (A) now?

MARRIED………………..……….…………............	1
MARRIED, SEPARATED….………………………	2
DIVORCED..………………………………………..	3
GIRL/BOYFRIEND……...….………………………	4
EX-GIRLFRIEND/EX-BOYFRIEND………………	5
DATING, BUT NOT GIRL/BOYFRIEND…………	6
FRIENDS……………………………………………	7
OTHER_____________________________________	8
Declined to answer	99

AB1a. (ONLY ASK IF SURVIVOR INDICATED THEY ARE CURRENTLY IN A RELATIONSHIP) So to be clear, are you currently in a romantic or intimate relationship with (A)________?

Not in a relationship	1
In a relationship	2
Declined to answer	99

AB1b. (ONLY ASKED IF NO LONGER IN A RELATIONSHIP) How long ago did the relationship with (A) ____________ end?

NUMBER OF YEARS: _______________

NUMBER OF MONTHS: _______________

NUMBER OF DAYS: _______________

Not applicable (88): _______________

Declined to Answer (99): _______________

[SOURCE: SHARE STUDY]

AB2. [ASK IF THEY HAVE HAD A JOB IN THE LAST 6 MONTHS] In the past 6 months, did you have to take time off from work?

GO TO AB2a 	Yes	1
SKIP TO AB3 	No	0
	Not Applicable	88
	Declined to Answer	99

AB2a. How many of these missed work days were related to the abuse?

NONE	0
ONE DAY	1
2 – 4 DAYS	2
5-7 DAYS	3
MORE THAN 1 WEEK	4
MORE THAN 1 MONTH	5
Don’t Know	77
Not Applicable	88
Declined to Answer	99

AB3. In the past 6 months have you been enrolled in school?

GO TO AB3a 	Yes	1
SKIP TO AB4 	No	0
	Not Applicable	88
	Declined to Answer	99

ABa. [ASK IF THEY WERE IN SCHOOL IN THE LAST 6 MONTHS] In the past 6 months, did you have to take time off from school?

GO TO AB3b 	Yes	1
SKIP TO A4 	No	0
	Not Applicable	88
	Declined to Answer	99

AB3b. How many of these missed school days were related to the abuse?

NONE	0
ONE DAY	1
2 – 4 DAYS	2
5-7 DAYS	3
MORE THAN 1 WEEK	4
MORE THAN 1 MONTH	5
Don’t Know	77
Not Applicable	88
Declined to Answer	99

AB4. Has (A) joined the military, including the National Guard, in the last 6 months?

They did not join the military/National Guard in the last 6 months.	0
They joined the military/National Guard in the last 6 months.	1
Declined to answer	99

[SOURCE: COMMUNITY COMPOSITE SCALE]

AB5. Now I would like to know about some of (A)_______________’s behaviors toward you during the past 6 months. After I ask you each question, please tell me, to the best of your recollection, what statement on this card (Hand participant card #5.) gives the best summary of how frequently, if at all, each thing happened in the last 6 months (since event: _____________).

0	NEVER
1	ONCE
2	SEVERAL TIMES
3	ONCE A MONTH
4	ONCE A WEEK
5	DAILY
99	Declined to Answer

How often, if at all, did ___________ (abuser’s name)….

a.	Tell you that you weren’t good enough
b.	Keep you from receiving medical care
c.	Follow you
d.	Turn family/friends/children against you
e.	Lock you in the bedroom
f.	Slap you
g.	Force you to take part in unwanted sexual activity
h.	Tell you that you were ugly
i.	Try to keep you from seeing or talking to family
j.	Throw you
k.	Hang around outside your house
l.	Blame you for causing their violent behavior
m.	Harass you over the telephone or through text, tweet or similar?
n.	Shake you
o.	Harass you at work
p.	Push/grab/shove you
q.	Use a knife, gun, or other weapon
r.	Become upset if dinner or housework were not done
s.	Tell you that you were crazy
t.	Tell you that no one would ever want you
u.	Take your wallet and left you stranded
v.	Hit or try to hit you with something
w.	Not want you to socialize with female friends
x.	Refuse to let you work outside the home
y.	Kick you, bite you, or hit you with a fist
z.	Try to convince friends, family, or children that you were crazy
aa.	Tell you that you were stupid
bb.	Beat you up
cc.	Demanded sex whether you wanted to or not
dd.	Forced sexual activity

[SOURCE: REPRODUCTION COERCION SCALE (McCauley, et al., 2016)]

AB6. Using the same card (#5) for these next questions, in the past 6 months, how often has ___________ (A) done the following:

0	NEVER
1	ONCE
2	SEVERAL TIMES
3	ONCE A MONTH
4	ONCE A WEEK
5	DAILY
99	Declined to Answer

How often, if at all, did (A)_______________….

a.	Tell you not to use any birth control (like the pill, shot ring, etc.)?
b.	Take your birth control (like pills) way from you or kept you from going to the clinic to get birth control?
c.	Make you have sex without a condom so you would get pregnant?
d.	Take off the condom while you were having sex, so you would get pregnant?
e.	Put holes in the condom or break the condom on purpose so you would get pregnant?

[SOURCE: ITEMS TAKEN FROM THE SCALE OF ECONOMIC ABUSE (ADAMS, 2008)]

AB7. Now I am going to go through a list of things some people do to hurt their partner or ex-partner financially. Using this card (#6) could you tell me, to the best of your recollection, how frequently, (A)_______ has done any of the following things in the last 6 months?

0	NEVER
1	HARDLY EVER
2	SOMETIMES
3	OFTEN
4	QUITE OFTEN
8	Not Applicable
9	Declined to Answer

Economic Control Subscale
	Steal the car keys or take the car so you couldn’t go look for a job or go to a job interview………………………………………………………………………
	[ASK IF CURRENTLY EMPLOYED] Do things to keep you from going to your job………………………………
	[ASK IF NOT EMPLOYED] Do things to keep you from getting a job……….
	Beat you up if you said you needed to go to work……………………………
	Threaten you to make you leave work………………………………………...
	Demand that you quit your job…………………………………………………..
	Do things to keep you from having money of your own…………………………
	Take your paycheck, financial aid check, tax refund check, disability payment or other support payments from you……………………………………………
	Decide how you could spend money rather than letting you spend it how you saw fit…………………………………………………………………………………
	Demand to know how money was spent…………………………………………
	Demand that you give him receipts and/or change when you spent money…
	Keep you from having the money you needed to buy food, clothes or other necessities………………………………………………………
	Hid money so that you could not find it………………………………………
	Keep you from having access to your bank accounts…………………………
	Keep financial information from you……………………………………………
	Make important financial decisions without talking with you about it first……
	Make you ask him for money……………………………………………………
	Threaten you or beat you up for paying the bills or buying things that were needed…………………….

[Scale of Economic Abuse, continued]

AB7. [cont.] Continuing using this card (#6), how frequently, (A)_______ has done any of the following things in the last 6 months?

0	NEVER
1	HARDLY EVER
2	SOMETIMES
3	OFTEN
4	QUITE OFTEN
5	Not in the last 6 months, but it has happened in the past
8	Not Applicable
9	Declined to Answer

Economic Exploitation Subscale
	Take money from your purse, wallet or bank account without your permission and/or knowledge……………………………………………………
	Force you to give him money or let him use your checkbook, ATM card or credit card…………………………………………………………………………...
	Steal your property……………………………………………………………….
	Pay bills late or not pay bills that were in your name or in both of your names…..
	Build up debt under your name by doing things like use your credit card or run up the phone bill………………………………………………………….
	Refuse to get a job so you had to support your family alone………………
	Gamble with your money or your shared money…………………………......
	Have you ask your family or friends for money but not let you pay them back……..
	Convince you to lend him money but not pay it back…………………………...
	Pawn your property or your shared property…………………………………….
	Spend the money you needed for rent or other bills………………………..

SOCIAL SUPPORT

[SOURCE FOR 9-19: SOCIAL SUPPORT, MODIFIED (BOGAT ET AL, 1983; BEEBLE ET AL, 2009; SULLIVAN & BYBEE, 1999; THERAN ET AL, 2006)]

Thank you for answering all of those questions. Now I’d like to switch gears and ask you some questions about people who are a part of your life who provide you with help or support. I’ll have you use this card (#7) for the following questions.

SS1. The first questions are about companionship. In general, how do you feel about the amount of companionship that you have? By companionship I mean people you feel comfortable being around, people you enjoy spending time with. Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS2. In general, how do you feel about the quality of companionship that you have? Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS3. Now, how do you feel about the amount of advice and information you receive? Meaning, advice and information about personal matters (such as problems with your kids, friends, or partner, or dealing with a personal situation). Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS4. In general, how do you feel about the quality of advice and information you receive? Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

The next two questions have to do with another type of support called “practical assistance.” This would be people you can count on to help you get things or do things, or people you can count on to do a favor for you (for example, take you someplace you need to go, watch your kids, loan or give you money or something you need, etc.).

SS5. How do you feel about the amount of practical assistance that you receive? Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS6. In general, how do you feel about the quality of practical assistance that you receive? Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS7. The next two questions are about “emotional support” or people you can count on to listen to you when you want to talk about something personal, or people who make you feel cared about.

How do you feel about the amount of emotional support that you receive? Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS8. In general, how do you feel about the quality of emotional support that you receive? Do you feel:

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

SS9. Now, for the last question in this section, how do you feel overall about the amount and quality of support you receive from others?

1	Terrible
2	Unhappy
3	Mostly dissatisfied
4	Equally dissatisfied and satisfied
5	Mostly satisfied
6	Pleased
7	Extremely pleased

MENTAL HEALTH SYMPTOMOLOGY & SUBSTANCE ABUSE

[SOURCE: CAGE-AID]

Now I would like to ask some questions about alcohol and drug use. People use alcohol or drugs for a variety of reasons, and these questions help us to know how different people cope with different things in their lives. Remember that if you do not want to answer any of the questions in the interview, we can just move on, but I just want to remind you that everything you tell me is completely confidential – just between us.

MH1. Do you drink alcohol?

GO TO MH1a through MH1d 	Yes	1
SKIP TO MH2	No	0

MH1a. In the last 6 months, have you felt you ought to cut down on your drinking?

Yes	1
No	0

MH1b. In the last 6 months, have people annoyed you by criticizing your drinking?

Yes	1
No	0

MH1c. In the last 6 months, have you felt bad or guilty about your drinking?

Yes	1
No	0

MH1d. In the last 6 months, have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Yes	1
No	0

MH2. Do you use drugs, other than prescription medications and over the counter drugs OR have you used prescription drugs more than in the prescribed amount or frequency?

GO TO MH2a through MH2d 	Yes	1
SKIP TO MH3	No	0

MH2a. In the last 6 months, have you felt you ought to cut down on your drug use?

Yes	1
No	0

MH2b. In the last 6 months, have people annoyed you by criticizing your drug use?

Yes	1
No	0

MH2c. In the last 6 months, have you felt bad or guilty about your drug use?

Yes	1
No	0

MH2d. In the last 6 months, have you ever used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Yes	1
No	0

[SOURCE: GENERAL HEALTH (WARE, KOSINSKI, DEWEY, & GANDEK, 2001)]

MH3. In general, how would you rate your overall physical health? [INTERVIEWERS, READ THE RESPONSE OPTIONS ALOUD.] Would you say:

Poor	1
Fair	2
Good	3
Very Good	4
Excellent	5

[SOURCE for MH4 & MH5; PHQ-9 (KROENKE, SPITZER, & WILLIAMS, 2001)]

MH4. For these next questions, we would like to know how you have been feeling over the past two weeks. Using this card (#8), please tell me the number that best describes how often have you been bothered by any of the following problems.

0	NOT AT ALL
1	SEVERAL DAYS
2	MORE THAN HALF THE DAYS
3	NEARLY EVERYDAY

a.	Little interest or pleasure in doing things…………
b.	Feeling down, depressed, or hopeless………….
c.	Trouble falling asleep, staying asleep, or sleeping too much…….
d.	Feeling tired or having little energy…………
e.	Poor appetite or overeating………..
f.	Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down……………………
g.	Trouble concentrating on things such as reading the newspaper or watching television……………..
h.	Moving or speaking so slowly that other people have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual……..
i.	Thinking that you would be better off dead or that you want to hurt yourself in some way…………..

[INTERVIEWER: If participant answered 1 or higher to any question above; complete question 5. If participant did not answer 1 or higher to any question above; skip question MH5 and move on to MH6.]

MH5. And using this card (#9), how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all	0
Somewhat difficult	1
Very difficult	2
Extremely difficult	3

[SOURCE for MH6 & MH7; GAD-7 (SPITZER, KROENKE, WILLIAMS, & LOWE, 2006)]

MH6. And again thinking about how you have been feeling over the past two weeks, using this card (#10) please tell me how often you been bothered by any of the following problems.

0	NOT AT ALL
1	SEVERAL DAYS
2	MORE THAN HALF THE DAYS

a.	Feeling nervous, anxious, or on edge…
b.	Not being able to stop or control worrying……
c.	Worrying too much about different things…….
d.	Trouble relaxing…………
e.	Being so restless that it is hard to sit still.
f.	Becoming easily annoyed or irritable….
g.	Feeling afraid as if something awful might happen……………..

[INTERVIEWER: If participant answered 1 or higher to any question above; complete question 7. If participant did not answer 1 or higher to any question above; skip MH7 and move on to MH8.]

MH7. And using this card again (#9), how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all	0
Somewhat difficult	1
Very difficult	2
Extremely difficult	3

[SOURCE: PTSD & TRAUMA (BREWIN ET AL, 2002)]

MH8. Now I’m going to mention a few reactions that sometimes happen after a traumatic event and which might or might not be some of your personal reactions to the abuse you’ve experienced. I’d like to know whether you have experienced any of the following at least twice in the past week.

		YES (1)	NO (0)
a.	Upsetting thoughts or memories about the event that have come into your mind against your will
b.	Upsetting dreams about the event
c.	Acting or feeling as though the event were happening again
d.	Feeling upset by reminders of the event
e.	Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event
f.	Difficulty falling or staying asleep
g.	Irritability or outbursts of anger
h.	Difficulty concentrating
i.	Heightened awareness of potential dangers to yourself and others
j.	Being jumpy or being startled at something unexpected

CHILDREN & TARGET CHILD

Thanks for answering those questions. Now I’d like to talk a little about any children you may be responsible for.

CH1. How many children under the age of 18 are you parenting or currently responsible for?

NUMBER OF CHILDREN: __________

[INTERVIEWER: If no children, skip to SERVICES SECTION.]

CH2. What are the names and ages of the children under the age of 18 are you parenting or currently responsible for?

	b. What is their age?	c. Do they live with you at least 50% of the time or more? (Y/N)
CH2.1a. Child 1 Name: ___________	b. Age: ______
CH2.2a. Child 1 Name: ___________	b. Age: ______
CH2.3a. Child 1 Name: ___________	b. Age: ______
CH2.4a. Child 1 Name: ___________	b. Age: ______
CH2.5a. Child 1 Name: ___________	b. Age: ______

[SOURCE: LIFEWIRE]

CH3. Have any of your children had to change schools because of your moving in the last 6 months? I don’t mean natural moves from junior high to high school, for example, but moves related to you moving.

No, in the same school as before	0
Yes, moved to a new school	0

[SOURCE: SHARE STUDY]

CH4. In the last 6 months, has Child Welfare opened a case against you about one or more of your children?

Yes	1
No	0
Declined to Answer	99

4a. (IF YES) Have any of your children been removed from the home in the last 6 months?

Yes	1
No	0
Declined to Answer	99

CH5. In the last 6 months, have any of your children been returned to your care after having been removed from child welfare?

Yes	1
No	0
Declined to Answer	99

Like your first interview, now I have a few questions about _____________(child’s name) for the rest of the interview.

CH6. Is _____________(child’s name) enrolled in school? (INTERVIEWER: IF IT IS CURRENTLY SUMMER BREAK ask: Was your child enrolled in school in June?)

Yes, full-time	1
Yes, part-time	2
Child is home-schooled	3
No	0

CH7. In the last 6 months, about how many days of school has _____________(child’s name) missed?

NUMBER OF DAYS: _______________

7a. How many of the days missed from school were a result of domestic violence?

NUMBER OF DAYS: _______________

CH8. Since your last interview, has your child’s school performance [INTERVIEWER, PLEASE READ THE RESPONSES]:

Decreased	1
Stayed the Same	2
Improved	3
Don’t Know	77
Not Applicable	88
Refused to Answer	99

CH9. Has __________ (child’s name) had to repeat a grade in the last 6 months?

Yes	1
No	0
Not Applicable	88
Refused to Answer	99

CH10. Has ________ (child’s name) been in foster care in the last 6 months?

Yes	1
No	0
Not Applicable	88
Refused to Answer	99

[SOURCE: CHILD STRENGTHS AND DIFFICULTIES QUESTIONNAIRE (GOODMAN, 1997)]

CH11. I now want to talk about some of your child’s strengths and difficulties. Again, we are talking about _________(child’s name). For each item, use this card (#11) and tell me if each statement is Not True, Somewhat True, or Certainly True. Please think about your child’s behavior over the last six months.

0	Not True
1	Somewhat True
2	Certainly True

Your child is…

a.	Considerate of other people’s feelings
b.	Restless, overactive, cannot stay still for long
c.	Often complains of headaches, stomach-aches or sickness
d.	Share readily with other children (for example toys, treats, pencils)
e.	Often loses temper
f.	Rather solitary, prefers to play alone
g.	Generally well-behaved, usually does what adults request
h.	Many worries or often seems worried
i.	Helpful if someone is hurt, upset or feeling ill
j.	Constantly fidgeting or squirming
k.	Has at least one good friend
l.	Often fights with other children or bullies them
m.	Often unhappy depressed, or tearful
n.	Generally liked by other children
o.	Easily distracted, concentration wanders
p.	Nervous or clingy in new situations, easily loses confidence
q.	Kind to younger children
r.	Often lies or cheats
s.	Picked on or bullied by other children
t.	Often offers to help others (parents, teachers, other children)
u.	Thinks things out before acting
v.	Steals from home, school or elsewhere
w.	Gets along better with adults than with other children
x.	Many fears, easily scared
y.	Good attention span, sees things worked through to the end

WELL-BEING

[SOURCE: HERTH HOPE INDEX (HHI: HERTH, 1992; PEREYRA, 1996)]

WB1. Now I’d like to go back to talking about you and how you feel like you’re doing. Using this card (#12) I’d like to know how much you agree or disagree with the following statements.

1	STRONGLY DISAGREE
2	DISAGREE
3	NEUTRAL/MIXED
4	AGREE
5	STRONGLY AGREE

a.	I have a positive outlook toward life
b.	I have short and/or long-range goals
c.	I feel all alone
d.	I can see possibilities in the midst of difficulties
e.	I have a faith that gives me comfort
f.	I feel scared about my future
g.	I can recall happy/joyful times
h.	I have deep inner strength
i.	I am able to give and receive caring/love
j.	I have a sense of direction
k.	I believe that each day has potential
l.	I feel my life has value and worth

[SOURCE: MEASURE OF VICTIM EMPOWERMENT RELATED TO SAFETY (MOVERS), (GOODMAN ET AL, 2014)]

WB2. You may be facing a variety of different challenges to safety. When we use the word safety in the next set of statements, we mean safety from physical or emotional abuse by another person. Please choose from the following options (card #13) how true each of the statements are regarding how you think about your and your family’s safety right now. When you are responding to these statements, it is fine to think about your family’s safety along with your own if that is what you usually do.

Never true	0
Sometimes true	1
Half the time true	3
Mostly true	4
Always true	5
Refused to Answer	99

a.	I can cope with whatever challenges come at me as I work to keep safe.
b.	I have to give up too much to keep safe.
c.	I know what to do in response to threats to my safety.
d.	I have a good idea about what kinds of support for safety that I can get from people in my community (friends, family, neighbors, people in my faith community , etc.)
e.	I know what my next steps are on the path to keeping safe.
f.	Working to keep safe creates (or will create) new problems for me.
g.	When something doesn’t work to keep safe, I can try something else.
h.	I feel comfortable asking for help to keep safe.
i.	When I think about keeping safe, I have a clear sense of my goals for the next few years.
j.	Working to keep safe creates (or will create) new problems for people I care about.
k.	I feel confident in the decisions I make to keep safe.
l.	I have a good idea about what kinds of support for safety I can get from community programs and services.
m.	Community programs and services provide support I need to keep safe.

[Source: modified Differential Emotions Scale]

WB3. Please think back to how you have felt over the last two weeks. Using this card (#14), please indicate the greatest amount that you have experienced each of the following feelings.

0	Not at all
1	A little bit
2	Moderately
3	Quite a bit
4	Extremely
88	Not Applicable
99	Declined to Answer

a.	What is the most amused, fun-loving, or silly you felt?
b.	What is the most angry, irritated, or annoyed you felt?
c.	What is the most ashamed, humiliated, or disgraced you felt?
d.	What is the most awe, wonder, or amazement you felt?
e.	What is the most contemptuous, scornful, or disdainful you felt?
f.	What is the most disgust, distaste, or revulsion you felt?
g.	What is the most embarrassed, self-conscious, or blushing you felt?
i.	What is the most grateful, appreciative, or thankful you felt?
j.	What is the most guilty, repentant, or blameworthy you felt?
k.	What is the most hate, distrust, or suspicion you felt?
l.	What is the most hopeful, optimistic, or encouraged you felt?
m.	What is the most inspired, uplifted, or elevated you felt?
n.	What is the most interested, alert, or curious you felt?
o.	What is the most joyful, glad, or happy you felt?
p.	What is the most love, closeness, or trust you felt?
q.	What is the most proud, confident, or self-assured you felt?
r.	What is the most sad, downhearted, or unhappy you felt?
s.	What is the most scared, fearful, or afraid you felt?
t.	What is the most serene, content, or peaceful you felt?
u.	What is the most stressed, nervous, or overwhelmed you felt?

[SOURCE: QOL (SULLIVAN & BYBEE, 1999)]

WB4. Now I would like to ask you how you feel about various parts of your life. Using this card (#1), please tell me the feelings you have in general – taking into account what has happened in the last 6 months.

As I ask each question, please tell me how you feel about the part of your life, either[INTERVIEWERS, READ RESPONSES]:

Extremely Happy	7
Happy	6
Mostly Satisfied	5
Equally Dissatisfied and Satisfied	4
Mostly Dissatisfied	3
Unhappy	2
Terrible	1
Refused to Answer	99

a.	First a very general question. How do you feel about your life overall?
b.	In general, how do you feel about yourself?
c.	How do you feel about your personal safety?
d.	How do you feel about the amount of fun and enjoyment you have?
e.	How do you feel about the responsibilities you have for members of your family?
f.	How do you feel about the accomplishments in your life?
g.	How do you feel about your independence or freedom - that is, how free do you feel to live the kind of life you want?
h.	How do you feel about your emotional or psychological well-being?
i.	How do you feel about the way you spend your spare time?

FINAL SECTION

Thank you so much for answering all of those questions. We hope that what we learn from you and other people in similar situations will help us help communities provide more and better resources and responses. Just before we wrap up this interview, could you tell me a little about what you are hoping to get from ____________ (name of agency)?

FS1. For example, with regard to housing, are you:

Hoping to stay in your current home or return to your current home	1
Looking for a new home	2
Not sure	77
Declined to answer	99

FS2. Okay, and do you think that the kind of help you’re looking for from ____________ (name of agency) is….

Probably brief or short-term, you just need some fairly brief or immediate help.	1
More than brief help.	2
Not sure	77
Declined to answer	99

FS3. And would you say you’re looking for…

Financial help only	1
Support from staff to help you get what you need	2
Both	3
Not sure	77
Declined to answer	99

END OF INTERVIEW: Thank you again for taking the time to do this interview today – I know there was a lot to answer. Before we finish up, do you have any questions for me? [INTERVIEWER, PLEASE RECORD ALL QUESTIONS AND ANSWER THEM TO THE BEST OF YOUR KNOWLEDGE AND ABILITY WITHIN THE FRAMEWORK OF THIS STUDY. IF THERE IS SOMETHING YOU ARE NOT SURE ABOUT, PLEASE MAKE SURE TO REFER THE SURVIVOR BACK TO THE ORGANIZATION.]

We will be contacting you again in 3 months to just do a quick check in and make sure we have up-to-date information in order to contact you for your next interview six months from now.

[PLEASE PAY THE SURVIVOR AND HAVE THEM FILL OUT A RECEIPT.]

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