ABS Paper Survey

The National Intimate Partner and Sexual Violence Survey (NISVS)

AttE.3_Paper Survey_12.17.19

Phase 2 - ABS Paper Survey

OMB: 0920-0822

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0822 can be found here:

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Attachment E.3

National Intimate Partner and Sexual Violence Survey (NISVS) 4.0

Paper (Mail-In) Survey

12.17.2019

General Population

Form Approved
OMB No: 0920-0822
Exp. Date: xx/xx/xxxx

Shape1

Public Reporting burden of this collection of information is estimated to average 25 minutes per person, 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 (0920-0822).

Shape3 Shape2 Section A

1. Are you age 18 or older?

Yes, age 18 or older
No, less than 18 years old: STOP

Please give this survey to the member of this household age 18 or older that was indicated in the letter that came with this survey.

2. In what month and year were you born?

|__|__| / |__|__|__|__|

3a. What sex were you assigned at birth, on your original birth certificate?

Male
Female

3b. How do you describe your gender identity?

Male
Female

Male-to-female transgender
Female-to-male transgender
Other gender identity, please specify:

|____________________________|

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

Lesbian or gay
Straight, that is, not lesbian or gay
Bisexual
Something else
I don’t know the answer

5. What is the highest level of education you have completed?

No schooling
1^st to 8^th grade
Some High School
High school graduate or GED
Technical or Vocational School
Some College
Associates degree (2-year)
Bachelor’s degree (4-year)
Postgraduate Degree (MASTERS’S DEGREE, DOCTORATE DEGREE, MD, JD)

6. Are you of Hispanic or Latino origin?

7. What is your race? You may mark more than one category?

Mark all that apply

White
Black or African American
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaska Native → GO TO 9
Other, please specify:

|____________________________|

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

Yes→ GO TO 10, NEXT PAGE
No

9. How many years have you lived in the United States?

If less than 1 year, write 0.

|__|__| years

10. Are you now…

Married
Divorced
Separated
Widowed
Not married, but living with a partner
Never married

11. Do you or any member of this household have access to the Internet using a…

a. cellular data plan for a smartphone
or other mobile device? Y N

b. broadband (high speed) Internet
service such as cable, fiber optic, or Y N
DSL service installed in this household?

c. satellite Internet service installed in this
household Y N

d. dial-up Internet service installed in this
household Y N

e. some other Internet service? Y N

12. Is this house, apartment, or mobile home…

Owned by you or someone in this household with a mortgage or loan?
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

13. What was the total income from all household members during 2018, before taxes?

Include income from all sources, such as work, investments, child support, and public assistance.

If you are a student, you should NOT include your parent’s income.

Less than $10,000
$10,000 to Less than $15,000
$15,000 to Less than $20,000
$20,000 to Less than $25,000
$25,000 to Less than $35,000
$35,000 to Less than $50,000
$50,000 to Less than $75,000
$75,000 or more

Section B

► Please answer “yes” or “no” to the following questions about health conditions that you may have.

14. Do you have…

a. frequent Headaches Y N

b. chronic Pain Y N

c. difficulty sleeping Y N

15. Have you ever been told by a doctor, nurse, or other health professional that you had…

a. asthma Y N

b. irritable Bowel Syndrome (IBS) Y N

16. Have you ever, even once, taken any prescription pain medicine without a prescription or differently than how a doctor told you to use it (for example, OxyContin, Vicodin, Lortab, or Percocet)?

17. Have you ever been told by a doctor, nurse, or other health professional that you had any type of depression?

► The following questions are about thoughts of suicide. Please remember that your answers are confidential.

18a. Have you ever seriously thought about trying to kill yourself?

Yes
No → GO TO THE NEXT PAGE

18b. Have you ever tried to kill yourself?

Health & Injury Experiences

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.
Some questions are about physical injuries, harassing behaviors, and unwanted sexual activity.
If at any point, the questions are making you upset and you would like to speak with a trained professional, please refer to the resources <add location later>.

Remember, you don’t have to answer any question that you don’t want to.

We suggest that you be in a private setting while completing this survey.

Section C

These next 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, a teacher, a supervisor or a co-worker, a neighbor, 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.

19. Has anyone ever…

followed you around, watched, or spied on you when you did not want them to?

approached you or showed up in places, such as your home, work, or school when you did not want them to?

used technology, such as hidden cameras, computer software, apps, or GPS to monitor or track your location without your permission?

GPS is Global Positioning System.

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.

sneaked onto your property, such as your home or car, and did things to scare you by letting you know they had been there?

made unwanted phone calls to you, sent you emails, voice, or text messages?

Do not include bill collectors or telephone solicitors.

sent you unwanted messages through social media, such as Facebook, Instagram, and chat rooms?

sent you cards, letters, flowers, or presents when they knew you didn’t want them to?

20. Did you mark “yes” to any of the questions 19a through 19g?

Yes
No → GO TO SECTION D, NEXT PAGE

21a (If Yes) Thinking about when you were followed, contacted, or harassed (questions 19a-19g), has the same person done any of these things to you on more than one occasion?

Yes
No → GO TO SECTION D, NEXT PAGE

21b. How many people did any of these things to you on more than one occasion?

|__|__| number of people

22. Think about times when you were followed, contacted, or harassed on more than one occasion. At any of these times…

a. How many of those people made you feel fearful or feel threatened or concerned for your safety or the safety of others?

Mark if none

|__|__| number of people

b. How many of the people made threats to physically harm you?

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.

Mark if none

|__|__| number of people

Did you write at least 1 or more persons in either of the questions 22a or 22b?

Yes
No → GO TO SECTION D, NEXT PAGE

► For the next five questions, think about the times when you were followed, contacted, or harassed on more than one occasion and

you felt fearful, threatened, concerned for your safety or the safety of others, or
there were threats to physically harm you.

24. How old were you the very first time this happened?

|__|__| years old

25. Did any of the times happen in the past 12 months?

26. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION D, NEXT PAGE

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

|__|__| years old

28. Did this happen with a romantic or sexual partner in the past 12 months?

Shape23 Shape22 Section D

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

29. In your lifetime, how many people from your workplace made unwanted sexual remarks or sexual jokes in your presence, or sexually offensive comments about your body or appearance? This may have happened at work, or elsewhere with people connected to your workplace.

Include people you have worked with or come into contact with through your job. If 10 or more people, write in 10.

Mark if none (this never happened)
GO TO 31

|__|__| number of people

30. Has anyone in your workplace made unwanted sexual remarks, sexual jokes, or sexually offensive comments about your body or appearance in the past 12 months?

31. While you were in a public place, how many people have ever verbally harassed you in a sexual way that made you feel uncomfortable?

If 10 or more people, write in 10.

Mark if none (this never happened)
GO TO SECTION E, NEXT PAGE

|__|__| number of people

32. Has anyone in a public place verbally harassed you in a sexual way that made you feel uncomfortable in the past 12 months?

► CONTINUE WITH SECTION E ON THE NEXT PAGE.

Shape27 Shape26 Section E

The next questions ask about times in your life when you may have experienced unwanted sexual contact 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 what we mean is clear.
Your answers will help us to learn how often these things happen.

33. How many people have ever…

kissed you in a sexual way when you did not want it to happen?

If 10 or more people, write in 10.

Mark if none (this never happened)

|__|__| number of people

fondled, groped, grabbed, or touched you in a sexual way when you did not want it to happen?

If 10 or more people, write in 10.

Mark if none (this never happened)

|__|__| number of people

34. Did you write at least 1 or more persons in either of the questions 33a or 33b?

Yes
No → GO TO SECTION F, NEXT PAGE

► For the next five questions, think about the times when you experienced unwanted sexual contact or touching.

35. How old were you the very first time you ever experienced unwanted sexual contact or touching?

|__|__| years old

36. Did any of the unwanted sexual contact or touching happen in the past 12 months?

37. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION F, NEXT PAGE

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

|__|__| years old

39. Did this happen with a romantic or sexual partner in the past 12 months?

Section F

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 well, or someone you have known for only a short time.

40. How many people have you had vaginal, oral, or anal sex with after the person pressured you by doing any of the following:

Telling you lies, making promises about the future they knew were untrue, threatening to end your relationship, or threatening to spread rumors about you?

Mark if none (this never happened)

|__|__| number of people

Wearing you down by repeatedly asking for sex, or showing they were unhappy?

Mark if none (this never happened)

|__|__| number of people

Using their influence or authority over you, for example, your boss or your teacher?

Do not include parents or other family members.

Mark if none (this never happened)

|__|__| number of people

41. Did you write at least 1 or more persons in any of the questions 40a, 40b, or 40c?

Yes
No → GO TO SECTION G.1, NEXT PAGE

► For the next five questions, think about the times when you were pressured to have vaginal, oral, or anal sex.

42. How old were you the very first time you were pressured to have vaginal, oral, or anal sex?

|__|__| years old

43. Did any of the times you were pressured to have vaginal, oral, or anal sex happen in the past 12 months?

44. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION G.1, NEXT PAGE

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

|__|__| years old

46. Did this happen with a romantic or sexual partner in the past 12 months?

Section G.1

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

These questions are different for men and women and ask about unwanted actions to private parts of your body. The question below will help determine what questions you should answer.

47. What is your sex?

Male → SKIP TO SECTION G.2, PAGE 13
Female → CONTINUE BELOW

Shape34 FEMALES

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. You might or might not have ever been in this type of situation.

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.
These questions use detailed and explicit language so that everyone is clear about what the questions are asking.

48. 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, how many people ever did the following when you did not want them to?

If this has never happened or you have never been drunk or drugged, mark none or not applicable.

Put their mouth on your vagina?

Mark if none or not applicable

|__|__| number of people

Put their fingers or an object in your vagina or anus?

Mark if none or not applicable

|__|__| number of people

Put their penis in your vagina?

Mark if none or not applicable

|__|__| number of people

Put their penis in your mouth or anus?

Mark if none or not applicable

|__|__| number of people

49. Did you write at least 1 or more persons in any of the questions 48a through 48d?

Yes
No → GO TO SECTION H.1, PAGE 11

► For the next five questions, think about when someone had unwanted sex or sexual contact with you under these circumstances.

50. How old were you the very first time someone had unwanted sex or sexual contact with you under these circumstances?

|__|__| years old

51. Did someone have unwanted sex or sexual contact under these circumstances in the past 12 months?

52. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION H.1, NEXT PAGE

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

|__|__| years old

54. Did this happen with a romantic or sexual partner in the past 12 months?

► CONTINUE WITH SECTION H.1 ON THE NEXT PAGE.

Section H.1 (Females)

► MALES, SKIP TO SECTION G.2, PAGE 13.

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, the next questions are now asking only about times in your life when sex was unwanted and you did not give consent.

55. How many people have ever used physical force or threats of physical harm to…

Put their mouth on your vagina?

Mark if none (this never happened)

|__|__| number of people

Put their fingers or an object in your vagina or anus?

Mark if none (this never happened)

|__|__| number of people

56. How many males have ever used physical force or threats of physical harm to…

Put their penis in your vagina?

Mark if none (this never happened)

|__|__| number of people

Put their penis in your mouth or anus?

Mark if none (this never happened)

|__|__| number of people

57. Did you write at least 1 or more persons in any of the questions 55a through 56b?

Yes
No → GO TO SECTION I.I. NEXT PAGE

► For the next five questions, think about when someone had unwanted sex or sexual contact with you by using physical force or threats of physical harm.

58. How old were you the very first time someone had unwanted sex or sexual contact with you by using physical force or threats of physical harm?

|__|__| years old

59. Did someone have unwanted sex or sexual contact with you under these circumstances in the past 12 months?

60. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION I.I. NEXT PAGE

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

|__|__| years old

62. Did this happen with a romantic or sexual partner in the past 12 months?

Section I.1 (Females)

► MALES, SKIP TO SECTION G.2, PAGE 13.

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, the next questions are now asking only about times when sex was unwanted and you did not give consent, and sex did not happen.

63. How many males have ever used physical force or threats of physical harm to try to put their penis in your vagina, mouth, or anus, but it did not happen?

Mark if none (this never happened)
GO TO SECTION J, PAGE 19

|__|__| number of people

64. How old were you the very first time this happened?

|__|__| years old

65. Did this happen in the past 12 months?

66. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION J, PAGE 19

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

|__|__| years old

68. Did this happen with a romantic or sexual partner in the past 12 months?

► GO TO SECTION J, PAGE 19

Section G.2 (Males)

These questions are for those who reported their sex as male.

► If you reported your sex as female, please go to Section J on page 18 otherwise, males continue below.

MALES

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.
These questions use detailed and explicit language so that everyone is clear about what the questions are asking.

69. 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, how many people ever did any of the following when you did not want them to?

If this has never happened or you have never been drunk or drugged, mark none or not applicable.

Put their fingers or an object in your anus?

Mark if none or not applicable

|__|__| number of people

Put their penis in your mouth or anus?

Mark if none or not applicable

|__|__| number of people

70. Did you write at least 1 or more persons in either of the questions 69a or 69b?

Yes
No → GO TO 76, NEXT PAGE

► For the next five questions, think about when someone had unwanted sex or sexual contact with you under these circumstances.

71. How old were you the very first time someone had unwanted sex or sexual contact with you under these circumstances?

|__|__| years old

72. Did someone have unwanted sex or sexual contact with you under these circumstances in the past 12 months?

73. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO 76, NEXT PAGE

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

|__|__| years old

75. Did this happen with a romantic or sexual partner in the past 12 months?

76. These next questions ask if someone made you penetrate them when you were unable to consent to it.

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, how many people ever put their mouth on your penis when you did not want it to happen?

Mark if none or not applicable

|__|__| number of people

77. 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, how many females ever made you put your penis in their vagina when you did not want them to?

Mark if none or not applicable

|__|__| number of people

78. Did you write at least 1 or more persons in either of the questions 76 or 77?

Yes
No → GO TO SECTION H.2, NEXT PAGE

► For the next five questions, think about times someone made you penetrate them under these circumstances.

79. How old were you the very first time someone made you penetrate them?

|__|__| years old

80. Did someone make you penetrate them in the past 12 months?

81. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION H.2, NEXT PAGE

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

|__|__| years old

83. Did this happen with a romantic or sexual partner in the past 12 months?

Section H.2 (Males)

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, the next questions are now asking only about times in your life when sex was unwanted and you did not give consent.

84. How many people have ever used physical force or threats of physical harm to…

Put their fingers or an object in your anus?

Mark if none (this never happened)

|__|__| number of people

Put their penis in your mouth or anus?

Mark if none (this never happened)

|__|__| number of people

85. Did you write at least 1 or more person in either of the questions 84a or 84b?

Yes
No → GO TO 91, NEXT PAGE

► For the next five questions, think about when someone had unwanted sex or sexual contact with you by using physical force or threats of physical harm.

86. How old were you the very first time someone had unwanted sex or sexual contact with you by using physical force or threats of physical harm?

|__|__| years old

87. Did someone have unwanted sex or sexual contact with you under these circumstances in the past 12 months?

88. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO 91, NEXT PAGE

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

|__|__| years old

90. Did this happen with a romantic or sexual partner in the past 12 months?

91. These next questions ask if someone made you penetrate them using physical force or threats of physical harm.

How many people ever used physical force or threats of physical harm to put their mouth on your penis, or make you put your penis in their mouth?

Mark if none (this never happened)

|__|__| number of people

92. How many females ever used physical force or threats of physical harm to make you put your penis in their vagina?

Mark if none (this never happened)

|__|__| number of people

93. Did you write at least 1 or more persons in either of the questions 91 or 92?

Yes
No → GO TO SECTION I.2, NEXT PAGE

► For the next five questions, think about when someone made you penetrate them by using physical force or threats of physical harm.

94. How old were you the very first time someone made you penetrate them by using physical force or threats of physical harm?

|__|__| years old

95. Did someone make you penetrate them under these circumstances in the past 12 months?

96. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION I.2, NEXT PAGE

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

|__|__| years old

98. Did this happen with a romantic or sexual partner in the past 12 months?

Section I.2 (Males)

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, the next questions are now asking only about times when sex was unwanted and you did not give consent, and sex did not happen.

99. How many males have ever used physical force or threats of physical harm to try to put their penis in your mouth or anus, but it did not happen?

Mark if none (this never happened)
GO TO 105, NEXT PAGE

|__|__| number of people

100. How old were you the very first time this happened?

|__|__| years old

101. Did this happen in the past 12 months?

102. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO 105, NEXT PAGE

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

|__|__| years old

104. Did this happen with a romantic or sexual partner in the past 12 months?

105. These next questions ask if someone attempted to make you penetrate them by using physical force or threats of physical harm.

How many people ever used physical force or threats of physical harm to try to put their mouth on your penis, or to try to make you put your penis in their mouth but it did not happen?

Mark if none (this never happened)

|__|__| number of people

106. How many females ever used physical force or threats of physical harm to try to make you put your penis in their vagina, but it did not happen?

Mark if none (this never happened)

|__|__| number of people

107. Did you write at least 1 or more persons in either of the questions 105 or 106?

Yes
No → GO TO SECTION J, NEXT PAGE

► For the next five questions, think about when someone attempted to make you penetrate them by using physical force or threats of physical harm.

108. How old were you the very first time someone attempted to make you penetrate them by using physical force or threats of physical harm?

|__|__| years old

109. Did someone attempt to make you penetrate them under these circumstances in the past 12 months?

110. Did this 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 you were having sex with
your child’s other parent

Do not include 1^st dates or one-time hook-up situations.

Yes
No → GO TO SECTION J, NEXT PAGE

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

|__|__| years old

112. Did this happen with a romantic or sexual partner in the past 12 months?

► CONTINUE WITH SECTION J ON THE NEXT PAGE

Section J

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

a spouse or ex-spouse
a boyfriend/girlfriend or ex-boyfriend/girlfriend
a dating partner or people you have dated
people you were seeing
someone you were having sex with

Do not include 1^st dates or one-time hook-up situations.

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

Kept you from having your own money?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Tried to keep you from seeing or talking to your family or friends?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Kept track of you by demanding to know where you were and what you were doing?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Made threats to physically harm you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Made decisions that should have been yours to make?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Destroyed something on purpose that was important to you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Insulted or humiliated you in front of others?

Mark if none (this never happened)

|__|__| number of current/ex-partners

114. Did you write at least 1 or more persons in any of the questions 113a through 113h?

Yes
No → GO TO 116, NEXT PAGE

115. Did a current or ex-partner do any of these things in the past 12 months?

116. How many of your current or ex-partners have ever tried to get you or themselves pregnant when you did not want a pregnancy or tried to stop you from using birth control?

Mark if none (this never happened)

|__|__| number of current/ex-partners

117. How many of your current or ex-partners have ever refused to use a condom when you wanted them to use one?

Mark if none (this never happened)

|__|__| number of current/ex-partners

118. Did you write a least 1 or more persons in either of the questions 116 or 117?

Yes
No → GO TO SECTION K, NEXT PAGE

119. Did any of these things happen in the past 12 months?

► CONTINUE WITH SECTION K ON THE NEXT PAGE

Section K

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

120. How many of your current or ex-partners have ever done any of the following…

Slapped, pushed, or shoved you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Hit you with a fist or something hard?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Kicked you or stomped on you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Hurt you by pulling your hair?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Slammed you against something?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Tried to hurt you by choking or suffocating you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Used a knife on you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

Used a gun on you?

Mark if none (this never happened)

|__|__| number of current/ex-partners

121. Did you write at least 1 or more persons in any of the questions 120a through 120h?

Yes
No → GO TO SECTION L, NEXT PAGE

122. Did any of these times when a current or ex-partner physically harmed or used a weapon on you happen in the past 12 months?

► CONTINUE WITH SECTION L ON THE NEXT PAGESection L

The next questions ask about the consequences of the different experiences that you may have shared involving a current or ex-romantic or sexual partner. This includes people like:

a spouse or ex-spouse
a boyfriend/girlfriend or ex-boyfriend/girlfriend
a dating partner or people you have dated
people you were seeing
someone you were having sex with

Do not include 1^st dates or one-time hookup situations.

123a. In the previous sections of this survey, did you answer “yes,” that any of the situations described below ever happened to you by a current or ex-romantic or sexual partner?

Question numbers are provided for your reference.

Section C: Repeatedly followed, contacted, or harassed you and made you feel fearful, threatened, or have safety concerns , or physically threatened you (#26)
Section E: Unwanted sexual touching or sexual contact (#37)
Section F: Unwanted sex due to verbal or emotional pressure (#44)
Section G: Unwanted sex that you did not consent to, but could not stop, because you were too drunk, high, drugged or passed out from alcohol or drugs (#52, #73, or #81)
Section H: Unwanted sex by using physical force or threats of physical harm (#60, #88, or #96)
Section I: Attempted, unwanted sex by using physical force or threats of physical harm (#66, #102, or #110)
Section K: Physically harmed you or used a weapon on you (#121)

Yes
No → GO TO SECTION M, PAGE 24

123b. When any of those things happened, were you ever concerned for you safety?

124. When any of those things happened, were you ever fearful for yourself or someone close to you?

125. Thinking back to the physical acts, unwanted sexual situations, or repeated unwanted attempts to contact, follow, or harass you by a current or ex-romantic or sexual partner…

did you ever have nightmares?

did you ever try hard not to think about or go out of your way to avoid being reminded of the things that were done to you?

did you ever feel like you were constantly on guard, watchful, or easily startled?

did you ever feel numb or detached from others, your activities, or your surroundings?

126. Here is a list of possible injuries. Please indicate which of these you have experienced because of the physical acts, unwanted sexual situations, or repeated unwanted attempts to contact, follow, or harass you by a current or ex-partner.

Did you experience…

a. minor bruises or scratches? Y N

b. cuts, major bruises, or black eyes? Y N

c. injury to any ligaments, muscles

or tendons? Y N

d. broken bones or teeth? Y N

e. back or neck injury? Y N

f. being knocked out after getting

hit, slammed against something Y N

or choked?

127. A concussion is when a blow to the head caused you to have one or more symptoms, such as blurred or double vision, sensitivity to light or noise, headaches, dizziness or balance problems, nausea, being dazed or confused, difficulty remembering, difficulty concentrating, or bring knocked out.

Did you ever experience a concussion because of what a current or ex-partner did to you?

Do not include situations where you were hurt accidentally.

128. Did you ever experience mental or emotional harm (for example, anxiety or depression) because of what a current or ex-partner did to you?

129. Did you ever need medical care because of what a current or ex-partner did to you?

130. Below is a list of services and assistance you might have needed because of what a current or ex-romantic or sexual partner did to you.

Have you ever talked to a crisis hotline operator?

Did you ever need housing services?

Did you ever need victim’s advocate services?

Did you ever need legal services or the advice of an attorney?

131. Did you ever file a police report because of the things that a current or ex-partner did to you?

132. About how many days of work or school did you ever have to miss when a current or ex-partner did these things to you?

|__|__|__| days of work missed

|__|__|__| days of school missed

Shape81 Shape82 Section M

133. The following questions are about your reactions to this survey. Please indicate how strongly you agree or disagree with each statement

You experienced intense emotions while completing the survey.

Strongly disagree
Disagree
Neutral
Agree
Strongly agree

The survey made you think about things you didn’t want to think about.

Strongly disagree
Disagree
Neutral
Agree
Strongly agree

You believe you have been able to help others by participating in this study.

Strongly disagree
Disagree
Neutral
Agree
Strongly agree

Now that you know what the survey is about, you would have made the same choice to participate.

Strongly disagree
Disagree
Neutral
Agree
Strongly agree

134. Was anyone else in the room while you were completing the survey?

135. Did anyone who lives here see your responses to any of these questions?

136. Do you think anyone in your household knows what this survey is about?

Yes
No
Not sure

137. Overall, how burdensome was this survey to you?

Very burdensome
Somewhat burdensome
A little burdensome
Not at all burdensome

138. Do you feel that the length of this survey was…

Too long,
Too short, or
About right

139 How would you rate your understanding of the questions asked in this survey?

Excellent
Very good
Good
Fair
Poor

140. How sure are you that you’ve reported all things that happened to you?

Very sure
Somewhat sure
Somewhat unsure
Very unsure

Thank you!

Thank you for taking the time to complete this important survey. Please return the survey in the postage paid envelope provided or mail to:

Health and Injury Survey

Westat

1600 Research Blvd RC-B16

Rockville, MD 20850

Once we receive your completed survey, we will mail you a check for {AMOUNT} as a token of appreciation.

For more information about this survey, or if this survey has brought up any concerns or feelings, please see the next page for more information.

Questions or Concerns

If you have any questions or concerns about participating in this survey, please feel free to call the Survey Helpdesk, at (1-###-###-####}. You will hear an option to speak with a project staff member.

Help and Assistance

Thank you for participating in CDC’s Study of Health and Injuries. We realize that some of the topics covered are quite personal and can be difficult to think about. We appreciate your time and willingness to be a part of this study and want you to know that we recognize the important contribution you have made.

Sometimes when people have participated in a study like this, they realize that they are interested in following up on some of the issues that they have been asked about in the study with someone who is professionally trained to deal with these kinds of issues. Provided below are toll-free numbers of resources that you can use now or in the future if you want to speak further with someone.

The National Domestic Violence Hotline at 1-800-799-SAFE (7233).
The National Sexual Assault Hotline at 1-800-656-HOPE (4673).
The National Child Abuse Hotline at 1-800-4-A-Child (1-800-422-4453).
The National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Douglas Williams
File Modified	0000-00-00
File Created	2021-05-27