0920-0822 Nisvs - Paper Cognitive Testing Instrument, Round 1

Attachment D:

NISVS Redesign Paper Instrument

NOTE: The paper survey will be sent to the respondent who is identified on the screener. The screener will include information on the sex of the participant. We will send a different survey depending on the sex of the respondent. If the screener mis-identifies the sex of the respondent, the survey will ask the respondent to stop and send back the survey so we can send them the correct version (see CF14 below).

The question numbers for the survey use the numbers from the web instrument. The numbers will be changed (made consecutive) once the content of the survey is finalized.

The survey is not currently formatted for a paper instrument. This will be done once the content of the survey is finalized.

You have been randomly chosen to participate in an important study. The Centers for Disease Control and Prevention (CDC) is doing a telephone study of up to {fill: (# OF INTERVIEWS)} people. Men and women age 18 and older will be asked questions about their health and injuries they may have experienced. The data we are collecting are very important and will be used to inform prevention efforts.

The survey will take approximately 10 (?) minutes, on average. Since some of the questions are personal, we suggest that you be in a private setting during the survey.

There are minimal benefits or risks to being in this voluntary study. The answers you give us will be combined with the answers from other people who are in the survey. No information that could personally identify you will be given to the CDC or anyone else. You can skip any question or stop the survey at any time.

INSERT INCENTIVE INFORMATION

If you have questions or concerns about participating in the study, you may call the Survey Manager, {NAME}, at ###-###-####. If you have any questions about your rights as a research participant, please contact {CONTRACTOR} Office of Research Protection toll-free at ###-###-####.

CF14 Would you currently describe yourself as..

1 Male (Go to RCMO/RCYR)

2 Female (Go to RCMO/RCYR)

3 Transgender (Go to CF15)

NOTE: The skip will depend on the ‘sex’ of the questionnaire. For a ‘female’ questionnaire, if the respondent identifies as male, the respondent will skip to an instruction to send back the questionnaire. The same will be done for a ‘male’ questionnaire and the respondent identifies as female.

CF15 Would you prefer to be referred to as male or female?

1 Male

2 Female

NOTE: If the sex of the questionnaire is not the same as the answer to CF15, ask the respondent to send back the questionnaire to get the appropriate one.

Age How old are you?

1 Less than 18 (Go to End)

2 18-54

3. 65 and over

RCMO/RCYR What month and year were you born?

__/____ (MM/YYYY)

RC2 What is the highest level of education you have completed?

1 No schooling

2 1^st to 8^th Grade

3. Some High School

4. High school graduate or GED

5 Some College

6 Associates degree (2-year)

7 Bachelor’s degree (4-year)

8 Post Graduate Degree (Master’s Degree, Doctorate Degree, MD, JD)

9 Technical or Vocational School (Attended or Graduated)

RC5 Are you currently ….

1 Married

2 Divorced

3 Separated

4 Widowed

5 Not married but living with a partner

6 Never married

7 Something else (specify) ___________________________

RC6 Do you think of yourself as…

1 Lesbian or gay

2 Straight, that is, not lesbian or gay

3 Bisexual

RC3 Are you Hispanic or (Latina/Latino)?

1 Yes

2 No

RC4 What is your race? You may identify with more than one category (Mark all that apply)

1 White

2 Black or African American

3 Asian

4 Native Hawaiian or Pacific Islander

5 American Indian or Alaska Native (Go to RC8)

6 Other (specify) _________________________

RC7 Were you born in the United States, including U.S. territories and U.S. Military bases?

1 Yes (Go to RC8)

2 No

RC7a How many years have you lived in the United States?

_____ years

RC8. What was the total income from ALL household members during (YEAR), before taxes. Include income from all sources, such as work, investments, child support, and public assistance.

1 Less than $10,000

2 $10,000 to $14,999

3 $15,000 to $19,999

4 $20,000 to $24,999

5 $25,000 to $34,999

6. $35,000 to $49,999

7 $50,000 to $74,999

8 $75,000 or more

Health Conditions

The following questions are about health conditions you may have.

Do you have….

Yes No

HC01 Frequent Headaches 1 2

HC02 Chronic Pain 1 2

HC03 Difficulty sleeping 1 2

HC04 Asthma 1 2

HC05 Irritable Bowel Syndrome or IBS 1 2

HC07 Any type of depression 1 2

HC06 Have you ever, even once, taken any prescription pain medicine differently than how a doctor told you to use it?

1 Yes

2 No

HC08 Have you ever attempted suicide?

1 Yes

2 No

Victimization Introduction and Stalking

The next set of questions asks about experiences that can directly impact your health or may have resulted in injury.  These experiences may or may not have happened to you. There will be some questions about physical injuries, harassing behaviors, and unwanted sexual activity.

Remember, you don’t have to answer any question that you don’t want to. We suggest that you be in a private setting during the survey. If, at any time, you do not feel physically or emotionally safe, please stop taking the survey. If you think you are able to do it in a private setting or are emotionally safe, please return to complete it at a later time.

The first set of questions are about times in your life when someone may have ever given you unwanted attention by repeatedly contacting you, following you, or harassing you. When answering, please think about anyone who may have done these things to you, including strangers, a romantic or sexual partner,

a family member, a friend, teacher, co-worker or supervisor, or someone you have known briefly.  

Please DO NOT include bill collectors, telephone solicitors, other sales people, or others following or contacting you as part of their job

Has anyone ever ….

Yes No

ST01 followed you around, watched, or spied on you when you 1 2

did not want them to?

ST02 approached you or showed up in places, such as your home 1 2

work, or school when you did not want them to?

ST03 used technology, such as hidden cameras, computer software 1 2

apps, or GPS to monitor or track you location without your

permission? This includes GPS used in a phone or in social media,

such as Facebook.

This refers to times when you knew or you thought someone was

using GPS technology to monitor you.

GPS is Global Positioning Tracking.

ST04 sneaked onto your property, such as your home or car, and did 1 2

things to scare you by letting you know they had been there?

ST05 made unwanted phone calls, sent emails, voice, or text messages? 1 2

ST06 sent you unwanted messages through social media, such as 1 2

Facebook, Instagram, and chat rooms?

ST07 sent you cards, letters, flowers, or presents when they knew you 1 2

didn’t want them to?

ST07a Questions ST01 through ST07 asked if someone had ever followed, contacted or harassed you. Did you mark “yes” to any of these questions (questions ST01 to ST07)?

1 Yes (Go to ST08)

2 No (Go to next section)

ST08 Thinking about when you were contacted, followed or harassed, did the same person ever do this on more than one occasion?

1 Yes (Go to ST09/10)

2 No (Go to next section)

ST09/10 Think about the times when the same person repeatedly contacted, followed or harassed you on more than one occasion. At any of these times….

- were you ever fearful or feel threatened or concerned for your safety or the safety

of others?

- did any of the people make threats to physically harm you?

Please include ALL the people who made threats to physically harm you EVEN if you did

not take the threat seriously or did not feel fearful, threatened, or concerned for your safety or the safety of others.

1 Yes

2 No (Go to next section SC01)

For the following four questions, think about the times when someone repeatedly contacted, followed or harassed you ­and you felt threatened or there were threats to physically harm you.

ST12 How old were you when this first happened?

_____ years old

ST16 Did this happen within the last 12 months?

1 Yes

2 No

ST11 Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No (Go to next section)

ST11 How old were you when this first happened with a romantic or sexual partner?

______ years old

ST18 Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No

Verbal Harassment and Unwanted Touching

The next questions are about when you may have experienced unwanted sexual situations with anyone, including strangers or someone you knew such as a romantic or sexual partner, a family member, a friend, teacher, co-worker or supervisor, or someone you have known for only a short time.

These questions are detailed and the language is explicit, which some people may find upsetting. It is important to ask the questions this way so that you understand what we mean. Your answers will help us to learn how often these things happen. You can skip questions you don’t want to answer and you can stop at any time.

First, are some questions about unwanted sexual situations, including verbal harassment and unwanted sexual touching.

In your lifetime, has anyone ….

Yes No

SC01 ..in your workplace made unwanted sexual remarks, 1 2

sexual jokes, or offensive comments about your body or

appearance? Please include people you have worked with or come

Into contact with through your job.

SC03 .. in a public place verbally harassed you in a sexual way that made 1 2

you feel uncomfortable?

SC05 …kissed you in a sexual way when you did not want it to happen? 1 2

SC06 ..fondled, groped, grabbed or touched you in a sexual way when 1 2

you did not want it to happen?

SC06a Questions SC05 and SC06 asked if you had ever experienced unwanted sexual touching. Did you mark “yes” to either of these questions (questions SC06 or SC06?

1 Yes (Go to SC09)

2 No (Go to next section SC15)

For the following question, think about the when you experienced unwanted sexual contact.

SC08 How old were you when this first happened?

_____ years old

ST16 Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

SC09 Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

SC11 How old were you when this first happened with a romantic or sexual partner?

______ years old

SC12 Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

Coerced Sex

Sometimes unwanted sex happens after a person is pressured into it, such as through verbal and emotional pressure and other nonphysical kinds of pressure. The following questions are about times in your life when someone may have ever used verbal or other nonphysical pressure to make you have sex when you didn’t want to. This could be anyone, including strangers or someone you knew such as a romantic or sexual partner, a family member, a friend, teacher, co-worker or supervisor, or someone you have known for only a short time.

In your lifetime, have you had vaginal, oral, or anal sex after the person pressured you by doing any of the following?

Yes No

SC15 Telling lies, making promises about the future they know were 1 2

untrue, threatening to end your relationship, or threatening to

spread rumors about you?

SC16 Wearing you down by repeatedly asking for sex, or showing they 1 2

were unhappy?

SC17 Using their influence or authority over you, for example, your boss 1 2

or your teacher?

SC17a Questions SC15, SC16 and SC17 asked if you had ever been pressured to have vaginal, oral or anal sex. Did you mark “yes” to either of these questions (questions SC15, SC16, SC17)?

1 Yes (Go to SC20)

2 No (Go to next section)

For the following question, think about the when you experienced unwanted sexual contact.

SC19 How old were you when this first happened?

_____ years old

SC25 Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

SC20 Did it ever happen with a romantic or sexual partner. This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

SC22 How old were you when this first happened with a romantic or sexual partner?

______ years old

SC26a Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

Alcohol/Drug-Facilitated Rape and Made to Penetrate

These next questions are about situations in your life in which you experienced unwanted sex or sexual contact. By this, I mean sexual contact that you did not consent to and that you did not want to happen.

Sometimes unwanted sex or sexual contact happens when a person is unable to consent to it or stop it from happening because they are too drunk, high, drugged, or passed out from alcohol, drugs, or medications.  This can include times when they voluntarily consumed alcohol or drugs or times when they were given alcohol or drugs without their knowledge or consent.  Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault.

Did someone do any of the following when you did not want it to happen when you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?

Yes No

IF FEMALE RESPONDENT:

AD01 Put their mouth on your vagina? 1 2

AD02 Put their finger or an object in your vagina or anus? 1 2

AD03 Put their penis in your vagina? 1 2

AD04 Put their penis in your mouth or anus? 1 2

IF MALE RESPONDENT

AD05 Put their fingers or an object in your anus? 1 2

AD06 Put their mouth on your penis? 1 2

AD08a Questions (AD01, AD02, AD03 and AD04/AD05, AD06) asked if you have had unwanted sex or sexual contact when you were unable to consent or stop what was happening because you were too drunk, high, drugged or passed out.

Did you mark “yes” to any of these questions ((AD01, AD02, AD03 and AD04/AD05, AD06)?

1 Yes (Go to AD12)

2 No (Go to next section)

For the following question, think about when you had unwanted sex or sexual contact under these circumstances.

AD12 How old were you when this first happened?

_____ years old

AD16 Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

AD13 Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No (Go to next section)

AD15 How old were you when this first happened with a romantic or sexual partner?

______ years old

AD17a Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

IF FEMALE GO TO NEXT SECTION

IF MALE CONTINUE

Here are a few questions asking if someone made you penetrate them or penetrated you.

AD07 Did a FEMALE ever make you put your penis in their vagina when you did not want it to happen when you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drug?

1 Yes

2 No

AD08 Did a MALE ever put their penis in your mouth or anus when you did not want it to happen when you were unable to consent or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drug?

1 yes

2 no

AD08a Did you mark “yes” to either AD07 or AD08?

1 Yes (Go to AD13a)

2 No (Go to next section)

For the following question, think about when someone made you penetrate them or to penetrate you under these circumstances.

AD12a How old were you when this first happened?

_____ years old

AD16a Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

AD13a Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

AD15a How old were you when this first happened with a romantic or sexual partner?

______ years old

AD17a Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

Unwanted Sex Due to Threats or Harm/Physical Force

Some people are threatened with harm or physically forced to have sex or sexual contact when they don’t want to. Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no. To be clear, we are now asking only about times in your life when sex was unwanted and you did not give consent.

Did anyone ever use physical force or threats of physical harm to:

FEMALE RESPONDENT:

Yes No

FC01 Put their mouth on your vagina? 1 2

FC02 Put their finger or an object in your vagina or anus? 1 2

FC03 Put their penis in your vagina? 1 2

FC04 Put their penis in your mouth or anus? 1 2

MALE RESPONDENT

FC05 Put their fingers or an object in your anus? 1 2

FC06 Put their mouth on your penis? 1 2

FC08a Questions (FC01, FC02, FC03 and FC04/FC05, FC06) asked if you have had unwanted sex or sexual contact when someone used physical force or threats of physical force.

Did you mark “yes” to any of these questions (FC01, FC02, FC03 and FC04/FC05, FC06)?

1 Yes (Go to FC09)

2 No (Go to next section)

For the following question, think about when you had unwanted sex or sexual contact under these circumstances.

FC10 How old were you when this first happened?

_____ years old

FC14 Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

FC09 Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

FC13 How old were you when this first happened with a romantic or sexual partner?

______ years old

FC15a Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

IF FEMALE GO TO NEXT SECTION

IF MALE CONTINUE

Here are a few questions when someone made you penetrate them or penetrated you using physical force or threats of physical force.

FC07 Did a FEMALE ever make you put your penis in their vagina when you did not want it to happen when you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drug?

1 Yes

2 No

FC08 Did a MALE ever put their penis in your mouth or anus when you did not want it to happen when you were unable to consent or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drug?

1 yes

2 no

FC08a Did you mark “yes” to either FC07 or FC08?

1 Yes (Go to FC09aa)

2 No (Go to next section)

For the following question, think about when someone made you penetrate them or penetrated you under these circumstances.

FC10aa How old were you when this first happened?

_____ years old

FC14aa Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

FC09aa Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

FC13aa How old were you when this first happened with a romantic or sexual partner?

______ years old

FC15aa Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

Attempted Physically Forced Sex

The next set of questions are about times in your life when someone ever ATTEMPTED to have sex or sexual contact with you by using physical force or threats of harm but sex did NOT happen. Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no. To be clear, we are now asking only about times when sex was unwanted and you did not give consent, and sex did not happen.

Did anyone ever use physical force or threats of physical harm to:

Yes No

IF FEMALE RESPONDENT:

FA01 Has a male ever used physical force or threats of physical harm 1 2

to try to put their penis in your vagina, mouth, or anus, but it did

not happen?

IF MALE RESPONDENT

FA02 Has anyone ever used physical force or threats of physical harm 1 2

to try to put their mouth on your penis, but it did not happen?

FA02a Questions (FA01/FA02) asked if someone attempted to have unwanted sex or sexual contact using physical force or threats of physical force, but it did not happen.

Did you mark “yes” to any of these questions ((FA01/FA02)?

1 Yes (Go to FA05)

2 No (Go to next section)

For the following question, think about when someone attempted to have unwanted sex or sexual contact physical force or threats of physical force, but it did not happen.

FA06 How old were you when this first happened?

_____ years old

FA10 Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

FA05 Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

FA09 How old were you when this first happened with a romantic or sexual partner?

______ years old

FA11a Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

IF FEMALE GO TO NEXT SECTION

IF MALE CONTINUE

Here are a few questions when someone attempted to make you penetrate them or attempted to penetrated you using physical force or threats of physical force, but it did not happen.

Yes No

FA03 Has a female ever used physical force or threats of physical harm 1 2

to try to make you put your penis in their vagina but it did not

happen?

FA04 Has a male ever used physical force or threats of physical harm 1 2

to try to put their penis in your mouth or anus, but

it did not happen?

FA08a Did you mark “yes” to either FA03 or FA04?

1 Yes (Go to FA05aa)

2 No (Go to next section)

For the following question, think about when someone made you penetrate them or penetrate you under these circumstances.

FA06aa How old were you when this first happened?

_____ years old

FA10aa Did this happen within the last 12 months?

1 Yes

2 No (Go to next section)

FA05aa Did it ever happen with a romantic or sexual partner? This could be:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

1 Yes

2 No

FA09aa How old were you when this first happened with a romantic or sexual partner?

______ years old

FA11aa Did this happen with a romantic or sexual partner in the last 12 months?

1 Yes

2 No (Go to next section)

Psychological Aggression

The next questions ask about experiences you may have had in your life with your romantic or sexual partners. When asking about your romantic or sexual partners, think about people like:

- a spouse or ex-spouse

- a romantic partner, significant other or fiancé

- an ex-romantic partner, ex-significant other or ex-fiancé

- a boyfriend/girlfriend or dating partner

- an ex-boyfriend/girlfriend or ex-dating partner

- someone I was having sex with

- my child’s other parent

How many of your current or ex partners have ever….

Yes No

PA01 insulted or humiliated you in front of others? 1 2

PA02 kept you from having your own money? 1 2

PA03 tried to keep you from seeing or talking to your family or friends? 1 2

PA04 kept track of you by demanding to know where you were and what 1 2

you were doing?

PA05 made threats to physically harm you? 1 2

PA06 threatened to hurt themselves or commit suicide because they were

upset with you? 1 2

PA07 made decisions that should have been yours to make? 1 2

PA08 destroyed something that was important to you? 1 2

FOR FEMALES

PA12 tried to get you pregnant when you did not want to become 1 2

pregnant or tied to stop you from using birth control?

FOR MALES:

PA13 tried to get pregnant when you didn’t want them to get pregnant 1 2

or tried to stop you from using birth control?

MALES AND FEMALES

PA15 refused to use a condom when you wanted them to use one? 1 2

The next few questions are related to physical acts you may have experienced with your current or ex-romantic sexual partners.

Yes No

PV01 slapped, pushed, or shoved you? 1 2

PV04 hit you with a fist or something hard? 1 2

PV06 hurt you by pulling your hair? 1 2

PV07 slammed you against something? 1 2

PV08 tried to hurt you by choking or suffocating you? 1 2

PV09 used a knife on you? 1 2

PV10 used a gun on you? 1 2