0920-22HW DVACS Youth Participant Questionnaire

CORE VIOLENCE AGAINST CHILDREN SURVEY - DVACS
CONDUCTED BY INTERVIEWER
DEMOGRAPHICS
Q1_tb

HEAD OF HOUSEHOLD QUESTIONNAIRE COMPLETED FOR YES
THIS HOUSEHOLD
NO

Q1

RECORD THE TIME THE INTERVIEW BEGAN (00:00):

Q2

I would like to start by asking you questions about yourself:

Q3

Are you Hispanic or Latino?

Q4

1
2

YEARS OLD:
YES, HISPANIC OR LATINO

What is your race?

1

NO, NOT HISPANIC OR LATINO

2

DON’T KNOW

98

DECLINED

99

AMERICAN INDIAN OR ALASKAN NATIVE

1

ASIAN

2

BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
WHITE

3

DON’T KNOW

98

DECLINED

99

4
5

CONDUCTED IN ACASI
As previously mentioned, now it is time for you to complete some of the survey questions on the tablet by yourself. To make sure that you feel
prepared to use the tablet, we have included examples of the types of questions you will see. If you have any questions about how to use the tablet, it
is a good time to ask your interviewer.
ODK Tutorial
Here is an example of a question where you can only select one answer option:
T1

What is your favorite color?

RED

1

BLUE

2

YELLOW

3

ORANGE

4

PURPLE

5

GREEN

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Here is an example of a question where you can select more than one response option:

99

T2

CHICKEN

A

BEEF

B

PORK

C

FRUIT

D

What food(s) do you enjoy eating?
Please select all responses that apply.

VEGETABLES

E

DON’T KNOW THE ANSWER

Y

DECLINED TO ANSWER

Z

Here is an example of a question where you will enter a response into an open field:
T3

How old were you when you lost your first “baby tooth”? Please answer
YEARS OLD:
in years.
DON’T KNOW THE ANSWER
(The open field will accept any number from 0-24.)
DECLINED TO ANSWER

[Video of screen recording will play here to show the following actions:]
Here is how you turn the audio off if you want to.

-1-

98
99

Here is how you go backwards and forwards if you need to.
Q5

Q6

Q7

Which of the following best represents how you think of yourself?
Lesbian or gay? Straight, that is, not lesbian or gay? Bisexual? Or
something else?

GAY (LESBIAN OR GAY)
STRAIGHT, THAT IS, NOT GAY (OR
LESBIAN OR GAY)
BISEXUAL
I DON’T KNOW WHAT THIS QUESTION IS
ASKING

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

What words to you use to describe your gender identity? Male, female,
non-binary, or do you use another term?

1
2
3
4

I DON’T KNOW HOW TO ANSWER THIS
QUESTION/ I’M STILL FIGURING IT OUT

5

SOMETHING ELSE

97

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE
I AM TRANSGENDER AND IDENTIFY AS A
BOY OR MAN
I AM TRANSGENDER AND IDENTIFY AS A
GIRL OR WOMAN
I AM TRANSGENDER AND IDENTIFY IN
SOME OTHER WAY
I DON’T KNOW WHAT THIS QUESTION IS
ASKING

2
3
4
5
6

I DON’T KNOW HOW TO ANSWER THIS
QUESTION/ I’M STILL FIGURING IT OUT

7

NONE OF THESE

8

DECLINED TO ANSWER

99

CONDUCTED BY INTERVIEWER
Q9

Q10

Q11

Q12

Q13

Are you deaf or do you have serious difficulty hearing?

YES

Are you blind or do you have serious difficulty seeing, even when
wearing glasses?

Because of a physical, mental, or emotional condition, do you have
serious difficulty concentrating, remembering, or making decisions?

Do you have serious difficulty walking or climbing stairs?

Do you have difficulty dressing or bathing?

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

IF Q2>=15 YEARS OLD CONTINUE TO Q14, ELSE CONTINUE TO Q15
Q14

Because of a physical, mental, or emotional condition, do you have
difficulty doing errands alone such as visiting a doctor’s office or

-2-

difficulty doing errands alone such as visiting a doctor’s office or
shopping?

Q15

Q16

Q17

Q18

Are you currently in school?

What is the highest grade or year of school you completed?

What is your current grade or level of school?

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

ELEMENTARY (GRADES 1-8)

1

SOME HIGH SCHOOL (GRADES 9-11)
HIGH SCHOOL GRADUATE (GRADE 12 OR
GED)

2

SOME COLLEGE OR TECHNICAL SCHOOL

4

3

COLLEGE GRADUATE (COLLEGE 4 YEARS
OR MORE)
DON’T KNOW

98

DECLINED

99

6TH GRADE OR LOWER

1

7TH GRADE

2

8TH GRADE

3

9TH GRADE

4

10TH GRADE

5

11TH GRADE

6

12TH GRADE

7

SOME COLLEGE OR TECHNICAL SCHOOL

8

98

DECLINED

99

6-10 DAYS

9

1
2
3

10 OR MORE DAYS

4

DON’T KNOW

98
99

Q19

DECLINED
During this school year, were you taught any of the the following in school:

Q19A

How to manage anger?

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

-3-

Q20

5

COLLEGE GRADUATE (COLLEGE 4 YEARS
OR MORE)
DON’T KNOW
When you were in [FILL RESPONSE FROM Q17], how many times did 0 DAYS
you skip a full day of school (count only non-excused absences)?
1-5 DAYS

Q17

Q20

Q19B

Q19C

Q19D

How to avoid physical fights and violence?

How to avoid bullying?

How to avoid dating violence and sexual assault?

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

CONDUCTED BY INTERVIEWER
WORK, FRIENDS, FAMILY
Q20

WORK:

YES

In the past 12 months, were you ever employed or working any job for
which you were paid?
Q21

1

NO

2

DON’T KNOW

98

DECLINED

99

FRIENDSHIPS:
For each of the following statements please tell me if this is true for you or not:

Q21A

Q21B

Q21C

Q21D

Q22

My friends really try to help me

YES

I can count on my friends when things go wrong.

I have friends with whom I can share my good times and bad times.

I can talk about problems with my friends.

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

COMMUNITY CONNECTEDNESS
For each of the following statements please tell me if this is true for you or not:

Q22A

Q22B

Q22C

Outside of my home and school, there is an adult who really cares about YES
me.
NO

Outside of my home and school, there is an adult whom I trust who
notices when I am upset about something.

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED
Outside of my home and school, there is an adult who tells me when I do YES
a good job.
NO
DON’T KNOW

-4-

1

99
1
2
98

Q22D

Outside of my home and school, there is an adult who always wants me
to do my best.

DECLINED

99

YES

1

NO

2

DON’T KNOW

98
99

Q23

DECLINED
For each of the following statements, please tell me if this is true for you or not:

Q23A

I am part of a club.

1

Q23B

Q23C

Q23D

YES

I am part of a sports team.

I am part of a church, temple, or mosque.

I am part of some other group.

-5-

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

Q24

FAMILY:
(For 13-17yo):
What grown-ups live in your house?
(For 18-24yo):
Before you turned 18, what adults lived in your house?
(Choose all responses that apply)

MOTHER

A

FATHER

B

STEPMOTHER/FATHERS GIRLFRIEND

C

STEPFATHER/MOTHERS BOYFRIEND

D

FOSTER MOTHER/FEMALE GUARDIAN

E

FOSTER FATHER/MALE GUARDIAN

F

GRANDMOTHER

G

GRANDFATHER

H

AUNT

I

UNCLE

J

OTHER RELATIVES OR FRIENDS

K

YOUR BOYFRIEND/GIRLFRIEND
FAMILY OF YOUR
BOYFRIEND/GIRLFRIEND
DON’T KNOW

L
M

DECLINED

Z

CONDUCTED BY INTERVIEWER
MARRIAGE/PARTNERSHIP, GENDER ATTITUDES

-6-

Y

Q43

MARRIAGE AND PARTNERSHIP
The next questions ask about marriage and dating partners. Dating
partners are people you have been involved with romantically or
sexually, which might include husbands, wives, boyfriends, girlfriends,
people you have dated, people you were seeing, or people you hooked
up with.

Q44

Q45

Q45A

Q46

Q46A

Q47

Q48

Have you ever had a dating partner?
Have you ever lived with a dating partner or been married?

How old were you when you first started living with any dating partner
or got married?

Would you say that you were: 10-17 years old, or 18 or older?

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES, EVER LIVED WITH A PARTNER

1

YES, EVER MARRIED
NO, NEVER MARRIED OR LIVED WITH A
PARTNER
DON’T KNOW

2

98

DECLINED

99

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

What is your marital status now? Are you living with a dating partner,
married, widowed, divorced, separated, single (not dating), single
(dating someone)?

3

YEARS OLD:
98

DECLINED

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW

98

DECLINED

99
Q47
98

DECLINED

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW

98

DECLINED

99

LIVING WITH A DATING PARTNER

1

MARRIED

2

WIDOWED

3

DIVORCED

4

SEPARATED

5

SINGLE (NOT DATING)

6

SINGLE (DATING SOMEONE)

7

DON’T KNOW

98

DECLINED

99

GENDER ATTITUDES:
How strongly do you agree or disagree with the following statements:

Q48A

Q48B

Guys take responsibility for their actions

Girls take responsibility for their actions

-7-

Q47

Q46

DON’T KNOW

How old was this dating partner when you first started living together or
YEARS OLD:
got married? Please give us your best guess.
DON’T KNOW

Q48

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

Q48C

Q48D

Q48E

Q48F

Q48G

Q48H

Q48I

Guys need to hit other guys to get respect

Girls wearing revealing clothing deserve to have comments made about
them

It bothers me when guys act like girls

It bothers me when girls act like guys

Guys should sleep with as many girls as possible

If guys tell people their worries, they will look weak

In a good dating relationship, guys get their way most of the time

-8-

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

Q48J

Q48K

Q48L

Q48M

Q48N

Q48O

Q48P

In a good dating relationship, girls get their way most of the time

Guys should only have sex with girls

Girls should only have sex with guys

I respect guys who back down from a fight

I respect girls who back down from a fight

Guys should share in household chores

Often when girls are raped it is because they did not say “no” clearly
enough

-9-

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

STRONGLY AGREE

1

AGREE SOMEWHAT

2

NEUTRAL

3

DISAGREE SOMEWHAT

4

Q49

ATTITUDES ABOUT CORPORAL PUNISHMENT:
Do you believe that in order to bring up a child properly, a parent or
caregiver needs to physically punish the child, for example by spanking
or hitting the child?

STRONGLY DISAGREE

5

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

IF Q2=13-17, CONTINUE TO Q50 (DISCIPLINE)
IF Q2=18-24, SKIP TO Q51 (SAFETY)
Q50

DISCIPLINE:
In the past 12 months, has a parent or adult caregiver punished or corrected you by:

Q50A

Q50B

Q50C

Q51

Q52

Shouting, yelling, or screaming at you; calling you offensive names,
such as ‘dumb’ or ‘lazy’; taking away food; or ignoring you for several
hours?

YES

1

NO

2

DON’T KNOW

98

DECLINED
Shaking, hitting, spanking, or slapping you anywhere on your body with YES
a bare hand or a hard object?
NO

2
98

DECLINED

99
1
2
98

DECLINED

99

YES

1

NO

2

During the past 12 months, were there times you did not go to school or
did not leave home because you felt it would be unsafe for any reason? DON’T KNOW
DECLINED
SURVIVORSHIP:
YES
At any time in your life was anyone you felt close to murdered?

1

DON’T KNOW
Taking away privileges, forbidding something you liked or wanted to do; YES
explaining why the behavior is wrong; or giving you a reminder or
NO
warning not to do it again?
DON’T KNOW
SAFETY:

99

98
99
1

NO

2

DON’T KNOW

98

DECLINED

99

CONDUCTED IN ACASI
CARRYING WEAPONS
Q53

CARRYING WEAPONS:

YES

1

NO

2

DON’T KNOW THE ANSWER

98

Have you ever carried a weapon such as a gun, knife, or club?

DECLINED THE ANSWER

99

What type of weapon have you carried?

GUN

A

KNIFE

B

Now I am going to ask questions about weapons. For these questions,
please do not include times you carried a gun or knife only for hunting
or for a sport, such as target shooting.
Remember you can skip questions if you don’t want to answer.

Q54

(Choose all responses that apply)

Q55

During the past 12 months, how often did you carry a weapon such as a
gun, knife, or club?

- 10 -

CLUB

C

OTHER WEAPON

X

DON’T KNOW THE ANSWER

Y

DECLINED THE ANSWER

Z

NEVER

1

RARELY

2

SOMETIMES

3

MOST OF THE TIME

4

Q63

Q63

Q56

What is the main reason that you carried a weapon such as a gun, knife,
or club, during the past 12 months?

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER
FOR PROTECTION AGAINST ATTACKS BY
OTHER PEOPLE

99

BECAUSE MY FRIENDS CARRY WEAPONS

2

BECAUSE IT MAKES ME FEEL
IMPORTANT
TO “SHOW OFF” AND IMPRESS MY
FRIENDS

Q57

Q58

During the past 12 months, did you use a weapon to threaten or injure
another person?

During the past 12 months, how many times did you use a weapon to
threaten or injure another person?

1

3
4

BECAUSE I WANTED TO HURT SOMEONE

5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

1 TIME

1

2 – 4 TIMES

2

5 OR MORE TIMES

3

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

NEVER

1

IF Q54=A (GUN) CONTINUE WITH Q59, ELSE SKIP TO Q63
Q59

GUNS:

RARELY
Now I would like to specifically ask you about guns. For these questions,
SOMETIMES
do not count any times when you may have carried a gun only for
hunting or for a sport, such as target shooting.
MOST OF THE TIME

Q60

2
3
4

During the past 12 months, how often did you carry a gun onto school
property?

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

During the past 12 months, how often did you carry a gun in your
neighborhood?

NEVER

1

RARELY

2

SOMETIMES

3

MOST OF THE TIME

4

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

PARENT OR OTHER FAMILY MEMBER’S
GUN TAKEN FROM HOME

A

IF Q59=1 AND Q60=1, SKIP TO Q62, ELSE CONTINUE WITH Q61
Q61

Where did you get the gun(s) that you carried during the past 12 months?
(Choose all responses that apply)

I PURCHASED FROM A STORE THAT
SELLS GUNS
ADULT PURCHASED FOR ME

Q62

(For 13-17 yo):
How long would it take you to get and be ready to fire a loaded gun
without a parent’s or adult’s permission? This gun could be yours or

- 11 -

B
C

PURCHASED “ON THE STREET
BORROWED FROM A FRIEND OR
SOMEONE I KNOW
STOLEN

D

PURCHASED FROM A GUN SHOW

G

DON’T KNOW THE ANSWER

Y

DECLINED THE ANSWER

Z

I COULD NOT GET A LOADED GUN

1

LESS THAN 10 MINUTES

2

E
F

Q59

without a parent’s or adult’s permission? This gun could be yours or
someone else’s and it could be located anywhere.
(For 18-24 yo):
How long would it take you to get and be ready to fire a loaded gun?
This gun could be yours or someone else’s and it could be located
anywhere.

10 OR MORE MINUTES, BUT LESS THAN 1
HOUR
1 OR MORE HOURS, BUT LESS THAN 4
HOURS
4 HOURS OR MORE, BUT LESS THAN 24
HOURS
24 HOURS OR MORE

6

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

3
4
5

IF Q15>1 (PARTICIPANT IS NOT CURRENTLY ATTENDING TO SCHOOL) SKIP TO Q64
Q63

Now I have a few questions about gangs.
Is there gang activity in your school?

Q64

Is there gang activity in your neighborhood?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

IF Q63=2,98,99 AND Q64=2,98,99 SKIP TO Q67 (JUVENILE AND PEER DELINQUENCY)
Q65

Q66

During the past 12 months, how many times did you feel threatened as a 0 TIMES
result of gang activity?
1 TIME

During the past 12 months, have you ever been a member of a gang?

0
1

2 – 4 TIMES

2

5 OR MORE TIMES

3

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

CONDUCTED BY INTERVIEWER
JUVENILE AND PEER DELINQUENCY
Q67

JUVENILE AND PEER DELINQUENCY
(For 13-17)
The next questions are about events that may have happened during your life. Did you ever:
(For 18-24)
The next questions are about events that may have happened in your childhood, before you turned 18. Thinking back before you were 18 years
old, did you ever:

Q67A

Q67B

Q67C

Q67D

Stay out later than your parents said you could?

YES

Lie to your parents about something important?

Take something from a store without paying?

Intentionally damage school property ?

- 12 -

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

Q67E

Q67F

Q68

Have your parent or guardian brought in to school because you broke a
school rule?

Skip school without permission?

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED
(For 13-17)
The next questions are about your friends. Please think of your closest friends. Did your closest friends ever:

99

(For 18-24)
The next questions are about your friends growing up before you turned 18. Now, thinking back before you were 18 years old. Did your closest
friends ever:
Q68A

Stay out later than their parents said they could?
IF PARTICIPANT SAYS THEY DID NOT HAVE ANY FRIENDS
THEN SELECT OPTION 0 NO FRIENDS

Q68B

Q68C

Q68D

Q68E

Q68F

Q68G

Q68H

Hurt someone badly enough to need a doctor?

Lie to their parents about something important?

Take something from a store without paying?

Intentionally damage school property ?

Have to have a parent or guardian brought in to school because they
broke a school rule?

Skip school without permission?

Get drunk or use drugs?

PARTICIPANT HAS NO FRIENDS

0

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

CONDUCTED IN ACASI
WITNESSING PHYSICAL VIOLENCE

- 13 -

Q69

Q69

WITNESSING PHYSICAL VIOLENCE:
NEVER

1

Q71

The following questions are about witnessing physical violence by
strangers or people you know well in your home or neighborhood.
ONCE
For participants 13-17:
How many times in your life have you seen or heard your parent or
guardian being hit, punched, kicked, or beaten by her or his husband,
wife, or dating partner? Would you say: never, once, or more than once? MORE THAN ONE TIME
For participants 18-24:
Before the age of 18. How many times did you see or hear your parent or DON’T KNOW THE ANSWER
guardian being hit, punched, kicked, or beaten by her or his husband,
wife, or dating partner? Would you say: never, once, or more than once?

2

3

98
Q71

DECLINED THE ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

NEVER

1

For participants 13-17 ONLY:
Q70

Q71

Did this happen in the past 12 months?

How many times did you see or hear a parent or guardian or their
husband, wife, or dating partner punch, kick, or beat your brothers or
sisters? Never, once, more than once, or I have no brothers or sisters?

ONCE

2

MORE THAN ONE TIME

3

I HAVE NO BROTHERS OR SISTERS

4

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

YES

1

For participants 13-17 ONLY:
Q72

Did this happen in the past 12 months?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

Q73

Outside of your home, in real life, how many times did you see anyone:

Q73A

physically attacked or beaten? Would you say never, once, or more than NEVER
once?
ONCE

Q73B

Q73C

stabbed with a knife or sharp weapon? Would you say never, once, or
more than once?

shot with gun, BB gun or air rifle? Would you say never, once, or more
than once?

1
2

MORE THAN ONE TIME

3

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

NEVER

1

ONCE

2

MORE THAN ONE TIME

3

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

NEVER

1

ONCE

2

MORE THAN ONE TIME

3

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

IF ALL RESPONSES IN Q73A, Q73B AND Q73C = 1 (NEVER) OR 98/99 (DON'T KNOW/DECLINED) THEN SKIP TO Q25 (ACES),
OTHERWISE IF THERE IS AT LEAST 1 RESPONSE = 2 OR 3 (ONCE/MORE THAN ONCE) THEN CONTINUE TO Q74
For participants 13-17 ONLY:
Q74

Did this happen in the past 12 months?

- 14 -

YES

1

NO

2

Q73

Q73

DON’T KNOW THE ANSWER

98

DECLINED THE ANSWER

99

CONDUCTED IN ACASI
ACES
Q25

ACES:
YES
For participants 13-17:
The next questions are about events that may have happened during your
life.
NO
(use present tense in the below questions)

Q26

Q27

Q28

Q29

Q30

Q31

Q32

1

2

For participants 18-24:
The next questions are about events that may have happened in your
childhood, before you turned 18. Before you were 18 years old:
(use past tense in the below questions)

DON’T KNOW THE ANSWER

98

Did your mother, father, or guardian die?

DECLINED TO ANSWER

99

Did one or both of your parents ever live in a different place than you for YES
more than half a year?
NO

Have you ever been in foster care?

How often does/did your family cut the size of meals or skip meals
because there was not enough money for food?

How often is/was there an adult living with you who tries/tried hard to
make sure your basic needs are/were met, such as looking after your
safety and making sure you have/had clean clothes and enough to eat?

How often is/was there an adult living with you who makes/made you
feel safe and protected?

Have you ever lived/did you live with someone who was having a
problem with alcohol or drug use?

Have you ever lived/did you live with someone who was depressed,
mentally ill, or suicidal?

- 15 -

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

NEVER

1

RARELY

2

SOMETIMES

3

MOST OF THE TIME

4

ALWAYS

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

NEVER

1

RARELY

2

SOMETIMES

3

MOST OF THE TIME

4

ALWAYS

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

NEVER

1

RARELY

2

SOMETIMES

3

MOST OF THE TIME

4

ALWAYS

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

Q33

Q34

Q35

Q36

Q37

Q38

Q39

Have you ever been/were you ever separated from a parent or guardian
because they went to jail, prison, or a detention center?

If your birth parents were married to each other at one point, did they
ever separate or divorce?

How often have you felt/ did you feel that you were treated badly or
unfairly because of your race or ethnicity?

How often have you felt/ did you feel that you were treated badly or
unfairly because of your sexual orientation?

How often have you felt/ did you feel that you were treated unfairly by
the police?

For 13-17 year olds dependents: use present tense
For 18-24 year olds/13-17 year old non-dependents and if parents are
deceased: use past tense

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO
PARENTS NEVER MARRIED TO EACH
OTHER
DON’T KNOW THE ANSWER

2

98

DECLINED TO ANSWER

99

NEVER

1

RARELY

2

3

SOMETIMES

3

MOST OF THE TIME

4

ALWAYS

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

NEVER

1

RARELY

2

SOMETIMES

3

MOST OF THE TIME

4

ALWAYS

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

NEVER HAD CONTACT WITH THE POLICE

1

NEVER TREATED UNFAIRLY BY THE
POLICE
RARELY TREATED UNFAIRLY BY THE
POLICE
SOMETIMES TREATED UNFAIRLY BY THE
POLICE
MOST OF THE TIME TREATED UNFAIRLY
BY THE POLICE
ALWAYS TREATED UNFAIRLY BY THE
POLICE
DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

VERY EASY

1

EASY

2

2
3
4
5
6

DIFFICULT

3

Thinking of the parent or guardian with whom you have the closest
relationship, how easy or difficult is/wa s it to talk to that person about
things that really bother you? Would you say very easy, easy, difficult,
very difficult, or do not have/never had a relationship with your
parents/guardians?

VERY DIFFICULT

4

NO RELATIONSHIP

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

For 13-17 year olds dependents: use present tense
For 18-24 year olds/13-17 year old non-dependents and if parents are
deceased: use past tense

VERY CLOSE

1

CLOSE

2

NOT CLOSE
Thinking of the parent or guardian with whom you have the closest
relationship, how close do/did you feel to that person? Would you say NO RELATIONSHIP
very close, close, not close, or do not have/never had a relationship with DON’T KNOW THE ANSWER
your parents/guardians?

- 16 -

3
4
98

Q41

your parents/guardians?
DECLINED TO ANSWER
Q40

99

For 13-17 year old dependents: use present tense
For 18-24 year olds/13-17 year old non-dependents: use past tense
Thinking of the parent or guardian with whom you have the closest relationship, how much does/did this person really know about the following
things:

Q40A

Who your friends are/were ? Do/did they know a lot, a little, or nothing? A LOT
A LITTLE

Q40B

Q40C

Q40D

Q40E

Q40F

Q41

How you spend/spent your money? Do/did they know a lot, a little, or
nothing?

Where you go/went after school? Do/did they know a lot, a little, or
nothing?

Where you go/went at night? Do/did they know a lot, a little, or
nothing?

Q42

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

A LOT

1

A LITTLE

2

NOTHING

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

A LOT

1

A LITTLE

2

NOTHING

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

A LOT

1

A LITTLE

2

NOTHING

3

DON’T KNOW THE ANSWER

98
1
2
3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

A LOT

1

A LITTLE

2

NOTHING

3

DON’T KNOW THE ANSWER

98
99
1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

For 13-17 year old dependents: use present tense
YES
For 18-24 year olds and 13-17 year old non-dependents: use past tense
NO
Including your parents or guardians and any other adult family members,
would you say that you have/had an adult family member who is/was
DON’T KNOW THE ANSWER
willing to help you make decisions?
DECLINED TO ANSWER
CONDUCTED IN ACASI
PHYSICAL VIOLENCE

- 17 -

99

NOTHING

DECLINED TO ANSWER
For 13-17 year old dependents: use present tense
YES
For 18-24 year olds and 13-17 year old non-dependents: use past tense
Including your parents or guardians and any other family members,
would you say that you have/had an adult family member who
cares/cared about you?

2

NOTHING

DECLINED TO ANSWER
What you do/did with your free time? Do/did they know a lot, a little, or A LOT
nothing?
A LITTLE

What you do/did on the internet? Do/did they know a lot, a little, or
nothing?

1

1
2
98
99

FOR GARRETT COUNTY: SKIP TO Q112 (PEERS)
IF Q43=2/98/99 (NEVER PARTNER), GO TO Q112 (PEERS)
IF Q43=1 (EVER PARTNER), CONTINUE WITH Q100
Q100

PV: PHYSICAL VIOLENCE
PV1: INTIMATE PARTNER VIOLENCE
The next questions ask about experiences you may have had in your life with your dating or sexual partners. When we ask about your dating or
sexual partners, please think about people you have been involved with romantically or sexually, which might include boyfriends, girlfriends,
people you have dated, people you were seeing, people you hooked up with, or your husband or wife.
Remember, you can skip any question you do not want to answer.
Has your current or ex-partner ever:

- 18 -

Q100A

Q100B

Q100C

Q100D

slapped, pushed, shoved, shook, or intentionally threw something at you YES
to hurt you?
NO

punched, kicked, whipped, or beat you with an object?

choked, smothered, tried to drown you, or burned you intentionally?

used or threatened you with a knife, gun, or other weapon?

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q100A =1 OR Q100B=1 OR Q100C=1 OR Q100D=1, GO TO Q101
IF Q100A=2/98/99 AND Q100B=2/98/99 AND Q100C=2/98/99 AND Q100D=2/98/99, SKIP TO Q112 (PEERS)
Q101

Q102

PV1:
ONCE
Now think back about any of these incidents when a current or ex dating
MORE THAN ONCE
or sexual partner was violent to you. Did this happen once or more than
DON’T KNOW THE ANSWER
once?
DECLINED TO ANSWER
PV1: MOST RECENT TIME

YES

Did this happen in the past 12 months?

Q103

Q103A

Q104

Q105

Q105A

How old were you the last time this happened?

1
2
98
99

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

How old was this current or ex-partner? Please give your best guess.

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Q104

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Was this current or ex-partner someone you were married to, living with, YES, MARRIED
or someone you were not married to or living with at the time?
YES, LIVING WITH

99
1
2

NOT MARRIED OR LIVING WITH

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Q106

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

SKIP TO Q107
Q106

PV1: FIRST TIME

- 19 -

Q106

1

YEARS OLD:

Would you say that you were: 10-17 years old, 18 or older?

Q106

Did this happen in the past 12 months?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q101=1, CONTINUE WITH Q107 AS WRITTEN
IF Q101=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED” FOR Q107
Q107

Q107A

Q108

Q109

Q109A

How old were you the first time this happened?

YEARS OLD:

Would you say that you were: 10-17 years old, 18 or older?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Was this current or ex-partner someone you were married to, living with, YES, MARRIED
or someone you were not married to or living with at the time?
YES, LIVING WITH

How old was your partner at that time? Please give your best guess.

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Q108

99
1
2

NO MARRIED OR LIVING WITH

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Q110

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98
99

Q110

DECLINED TO ANSWER
Has a current or ex-partner ever hurt you so that you were injured in any of the following ways:

Q110A

bruises, cuts, scrapes, or scratches?

1

Q110B

Q110C

Q110D

Q110E

Q110F

YES

black eyes or other eye injuries?

gashes, deep wounds such as from a knife, gun or other object?

broken bones or teeth?

burns such as from a cigarette, hot liquid, open flame?

other injuries?

- 20 -

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q110A=1 OR Q110B=1 OR Q110C=1 OR Q110D=1 OR Q110E=1 OR Q110F =1, CONTINUE WITH Q111
IF Q110A=2/98/99 AND Q108B=2/98/99 AND Q110C=2/98/99 AND Q110D=2/98/99 AND Q110E=2/98/99 AND Q110F=2/98/99, GO TO Q112
Q110G

Q111

Q111A

Q112

Did you ever need medical care because of any of these injuries?

How old were you the first time a current or ex-partner injured you in
any of these ways?

Would you say that you were: 10-17 years old, 18 or older?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Q112

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PV2: PEER VIOLENCE
The next questions are about people about your own age not including a current or ex-partner or siblings. These may include people who you
may or may not know such as schoolmates, neighbors, or strangers.
Remember, you can skip any question you do not want to answer.
Has a person about your own age ever:

- 21 -

Q112A

Q112B

Q112C

Q112D

slapped, pushed, shoved, shook, or intentionally threw something at you YES
to hurt you?
NO

punched, kicked, whipped, or beat you with an object?

choked, smothered, tried to drown you, or burned you intentionally?

used or threatened you with a knife, gun, or other weapon?

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q112A =1 OR Q112B=1 OR Q112C=1 OR Q112D=1, GO TO Q113
IF Q112A=2/98/99 AND Q112B=2/98/99 AND Q112C=2/98/99 AND Q112D=2/98/99, GO TO Q124 (PARENTS, ADULT CARETAKERS, ADULT
RELATIVES)
Q113

Q114

PV2:
Now think back about any of these incidents when someone your own
age was violent to you. Did this happen once or more than once?

PV2: MOST RECENT TIME
Did this happen in the past 12 months?

Q115

Q115A

How old were you the last time this happened?

ONCE

1

MORE THAN ONCE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
98

DECLINED TO ANSWER

99

12-17 YEARS OLD

Q116

Q117

Was this person male or female?

- 22 -

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Of the people who hurt you the last time this happened, think of the
FRIEND
person who hurt you the most for the following questions. What was this CLASSMATE/SCHOOLMATE
person’s relationship to you?
NEIGHBOR
OTHER PERSON THAT YOU KNOW ABOUT
YOUR AGE
STRANGER

Q118

Q116

DON’T KNOW THE ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q118

1
2
3
4
5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q119
Q118

PV2: FIRST TIME
Did this happen in the past 12 months?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q113=1, CONTINUE WITH Q119 AS WRITTEN
IF Q113=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED” FOR Q119
Q119

How old were you the first time this happened?

YEARS OLD:
DON’T KNOW THE ANSWER

Q119A

Q120

Q121

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

What was this person’s relationship to you?

Was this person male or female?

Q120
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

FRIEND

1

CLASSMATE/SCHOOLMATE

2

NEIGHBOR
OTHER PERSON THAT YOU KNOW ABOUT
YOUR AGE
STRANGER

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

4
5

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Has anyone about your own age ever hurt you so that you were injured in any of the following ways:

99

Q122
Q122A

bruises, cuts, scrapes, or scratches?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

Q122B

Q122C

Q122D

Q122E

Q122F

black eyes or other eye injuries?

gashes, deep wounds such as from a knife, gun or other object?

broken bones or teeth?

burns such as from a cigarette, hot liquid, open flame?

other injuries?

- 23 -

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q122A=1 OR Q122B=1 OR Q122C=1 OR Q122D=1 OR Q122E=1 OR 122F=1, CONTINUE WITH Q123
IF Q122A=2/98/99 AND Q122B=2/98/99 AND Q122C=2/98/99 AND Q122D=2/98/99 AND Q122E=2/98/99 AND Q122F=2/98/99, GO TO Q124
Q123

How old were you the first time someone about your own age injured
you in any of these ways?

YEARS OLD:
DON’T KNOW THE ANSWER

Q123A

Q124

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q124
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PV3: PARENTS, ADULT CAREGIVERS AND OTHER ADULT RELATIVES
The next set of questions are about parents, adult caregivers, or other adult relatives. This means only adults related to you, responsible for your
care or that you have lived with. We will ask about other adults in the next section, so please do not include them here. Remember, you can skip
any question you do not want to answer.
Has a parent, adult caregiver, or other adult relative ever:

Q124A

Q124B

Q124C

Q124D

slapped, pushed, shoved, shook, or intentionally threw something at you YES
to hurt you?
NO

punched, kicked, whipped, or beat you with an object?

choked, smothered, tried to drown you, or burned you intentionally?

used or threatened you with a knife, gun, or other weapon?

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q124A =1 OR Q124B=1 OR Q124C=1 OR Q124D=1, CONTINUE TO Q125
IF Q125A=2/98/99 AND Q125B=2/98/99 AND Q125C=2/98/99 AND Q125D=2/98/99, MOVE TO Q137 (ADULTS IN THE COMMUNITY)
Q125

Q126

PV3:
Now think back about any of these incidents when a parent, adult
caregiver or adult relative was violent to you. Did this happen once or
more than once?
PV3: MOST RECENT TIME
Did this happen in the past 12 months?

Q127

How old were you the last time this happened?

ONCE
MORE THAN ONCE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

- 24 -

1

Q129

Q129

Q127B

Q127A

Q127B

Q127C

Q128

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

What was this person’s relationship to you?

Was this person male or female?

1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PARENT

1

STEPPARENT

2

OTHER ADULT RELATIVE OR CAREGIVER

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
When this last happened, was this adult living in the same house as you? YES

99
1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q130
Q129

PV3: FIRST TIME
Did this happen in the past 12 months?

IF Q125=1, CONTINUE WITH Q130 AS WRITTEN
IF Q125=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED” FOR Q130
Q130
How old were you the first time this happened?
YEARS OLD:

Q130A

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

Q131

Q132

What was this person’s relationship to you?

Was this person male or female?

Q131

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PARENT

1

STEPPARENT

2

OTHER ADULT RELATIVE OR CAREGIVER

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q125=1, CONTINUE WITH Q134 AS WRITTEN
IF Q125=2/98/99, READ “WHEN THIS HAPPENED, WAS THIS ADULT LIVING IN THE SAME HOME AS YOU?” FOR Q134
Q134
When this first happened, was this adult living in the same home as you? YES
1

- 25 -

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Has a parent, adult caregiver, or adult relative ever hurt you so that you were injured in any of the following ways:

99

Q135
Q135A

bruises, cuts, scrapes, or scratches?

1

Q135B

Q135C

Q135D

Q135E

Q135F

YES

black eyes or other eye injuries?

gashes, deep wounds such as from a knife, gun or other object?

broken bones or teeth?

burns such as from a cigarette, hot liquid, open flame?

other injuries?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q135A=1 OR Q135B=1 OR Q135C=1 OR Q135D=1 OR Q135E=1 ORQ135F=1, CONTINUE WITH Q136
IF Q135A=2/98/99 AND Q135B=2/98/99 AND Q135C=2/98/99 AND Q135D=2/98/99 AND Q135E=2/98/99 AND Q135F=2/98/99, MOVE TO Q137
Q136

Q136A

Q137

How old were you the first time a parent, adult caregiver or adult relative
YEARS OLD:
injured you in any of these ways?
DON’T KNOW THE ANSWER
DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q137
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PV4: ADULTS IN THE COMMUNITY/NEIGHBORHOOD
The next set of questions are about adults in your community who are not related to you or responsible for your care and who does not live with
you. This includes adults such as teachers, police, employers, religious or community leaders, neighbors, or even adults you don’t know
personally. Remember, you can skip any question that you do not want to answer.
Has one of these people ever:

Q137A

slapped, pushed, shoved, shook, or intentionally threw something at you YES
to hurt you?
NO
DON’T KNOW THE ANSWER

- 26 -

1
2
98

Q137B

Q137C

Q137D

punched, kicked, whipped, or beat you with an object?

choked, smothered, tried to drown you, or burned you intentionally?

used or threatened you with a knife, gun, or other weapon?

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q137A =1 OR Q137B=1 OR Q137C=1 OR Q137D=1, GO TO Q138
IF Q137A=2/98/99 AND Q137B=2/98/99 AND Q137C=2/98/99 AND Q137D=2/98/99: CHECK THE FOLLOWING:
IF Q100A/B/C/D=1 OR Q112A/B/C/D =1 OR Q124A/B/C/D =1, GO TO Q149 (PV SERVICES)
IF Q100A/B/C/D =2/98/99 AND Q112A/B/C/D =2/98/99 AND Q124A/B/C/D =2/98/99, GO TO Q200 (PV PERPETRATION)
Q138

Q139

PV4:
ONCE
Now think back about any of these incidents when an adult in your
MORE THAN ONCE
community was violent to you. Did this happen once or more than once?
DON’T KNOW THE ANSWER
PV4: MOST RECENT TIME
Did this happen in the past 12 months?

Q140

How old were you the last time this happened?

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

Q141

Q142

98
99
1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TEACHER

1

POLICE OFFICER

2

What was this person’s primary relationship to you?

COACH

3

NEIGHBOR

4

EMPLOYER

5

OTHER ADULT

6

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

SKIP TO Q144
Q143

PV4: FIRST TIME
Did this happen in the past 12 months?

- 27 -

Q143

Q141

Of these people who hurt you the last time this happened, think of the
person who hurt you the most for the following questions.

Was this person male or female?

Q143

2
98

DECLINED TO ANSWER

DON’T KNOW THE ANSWER
Q140A

1

DECLINED TO ANSWER

99

IF Q138=1, CONTINUE WITH Q144 AS WRITTEN
IF Q138=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q144
Q144
How old were you the first time this happened?
YEARS OLD:

Q144A

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

Q145

Q146

What was this person’s primary relationship to you?

Was this person male or female?

Q145

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TEACHER

1

POLICE OFFICER

2

COACH

3

NEIGHBOR

4

EMPLOYER

5

OTHER ADULT

6

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

Q147

DECLINED TO ANSWER
99
Has an adult in your neighborhoor or community who is not related to you or responsible for your care and who does not live with you ever hurt
you so that you were injured in any of the following ways?

Q147A

bruises, cuts, scrapes, or scratches?

Q147B

Q147C

Q147D

Q147E

Q147F

black eyes or other eye injuries?

gashes, deep wounds such as from a knife, gun or other object?

broken bones or teeth?

burns such as from a cigarette, hot liquid, open flame?

other injuries?

- 28 -

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q147A=1 OR Q147B=1 OR Q147C=1 OR Q147D=1 OR Q147E=1 OR Q147F=1, CONTINUE WITH Q148
IF Q147A=2/98/99 AND Q147B=2/98/99 AND Q147C=2/98/99 AND Q147D=2/98/99 AND Q147E=2/98/99 AND 147F=1, GO TO Q149
Q148

Q148A

How old were you the first time an adult in your neighborhoor or
community who is not related to you or responsible for your care and
who does not live with you injured you in any of these ways?

YEARS OLD:
DON’T KNOW THE ANSWER

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q149
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CONDUCTED IN ACASI
PHYSICAL VIOLENCE SERVICES
Q149

Q150

Q151

Q152

PV SERVICES

YES

1

Did you ever have to miss school because you had been hurt by anyone
we just asked about, including parents, other adults, dating partners,
people about your own age, or others in the community?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

Did you know of a place to go for help when you had been hurt by
anyone we just asked about, including parents, other adults, dating
partners, people about your own age, or others in the community?

Did you try to seek professional help or services because you had been
physically hurt by anyone we just asked about, including parents, other
adults, dating partners, people about your own age, or others in the
community?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
99
There are many reasons why people do not seek professional help or services when they have been hurt. Do you agree or disagree with each of
the following as reasons you did not seek help?
I did not seek help because:

Q152A

Q152B

Q152C

Q152D

Q152E

Q153

Services were too far away?

Services were too expensive?

I was afraid of getting in trouble?

I was afraid of getting kicked out or not having someone to take care of
me?

I was embarrassed?

- 29 -

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q152F

Q152G

Q152H

Q152I

Q152J

Q152K

Q152L

Q152M

Q152N

I did not want to embarrass my family?

Someone told me not to seek help?

I am not a snitch?

I did not want the person who hurt me to get in trouble?

What happened to me was not a problem?

I did not want or need help?

It would not actually help?

I was afraid the person would hurt me again?

Other?

- 30 -

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q154B
Q153

Q153A

Q154A

Q154B

Q155

Did you receive professional help or services?

From whom did you receive professional help or services?

Besides the professional people or service providers you just selected,
did you tell anyone else about any of these experiences?

Did you tell anyone about any of these experiences?

Whom did you tell?
(Choose all responses that apply)

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

HEALTHCARE PROFESSIONAL

1

POLICE

2

LAWYER OR LEGAL PROFESSIONAL
SOCIAL WORKER, COUNSELOR OR CHILD
PROTECTIVE SERVICES
911

3

Q154A

4
5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CURRENT OR EX DATING PARTNER

A

RELATIVE

B

FRIEND OR NEIGHBOR
SERVICE PROVIDER (LIKE A DOCTOR OR
COUNSELOR)
AUTHORITY FIGURE (LIKE A TEACHER
OR POLICE OFFICER)
OTHER

C

X

DON’T KNOW THE ANSWER

Y

DECLINED TO ANSWER

Z

Q155
Q156

Q156

D
E

SKIP TO Q200
Q156

There are many reasons why people do not tell anyone when they have been hurt. Do you agree or disagree with each of the following as reasons
you did not tell anyone?
I did not tell anyone because:

Q156A

Q156B

Q156C

Q156D

I was afraid of getting in trouble?

I was afraid of getting kicked out or not having someone to take care of
me?

I was embarrassed?

I did not want to embarrass my family?

- 31 -

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

Q156E

Q156F

Q156G

Q156H

Q156I

Q156J

Q156K

Q156L

Someone told me not to seek help?

I am not a snitch?

I did not want the person who hurt me to get in trouble?

What happened to me was not a problem?

I did not want or need help?

It would not actually help?

I was afraid the person would hurt me again?

Other?

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q43=2/98/99 (NEVER HAD A PARTNER), GO TO Q203
IF Q43=1 (EVER PARTNER), CONTINUE WITH Q200
CONDUCTED IN ACASI
PHYSICAL VIOLENCE PERPETRATION
Q200

PV PERPETRATION
Have you ever done any of the following to a current or ex-partner:

Q200A

Q200B

Q200C

slapped, pushed, shoved, shook, or intentionally thrown something to
hurt them?

punched, kicked, whipped, or beat them with an object?

choked, smothered, tried to drown them, or burned them intentionally?

- 32 -

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

Q200D

used or threatened them with a knife, gun, or other weapon?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q200A=1 OR Q200B=1 OR Q200C=1 OR Q200D=1, CONTINUE TO Q201
IF Q200A=2/98/99 AND Q200B=2/98/99, AND Q200C=2/98/99 AND Q200D=2/98/99, SKIP TO Q203
Q201

Q202

Q202A

Q203
Q203A

Q203B

Q203C

Q203D

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

How old were you the first time this happened?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say that you were: 10-17 years old, or 18 or older?

Q203

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Have you ever done any of the following to someone who is not a current or ex-partner:

99

slapped, pushed, shoved, shook, or intentionally thrown something at
them?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

punched, kicked, whipped, or beat them with an object?

choked, smothered, tried to drown them, or burned them intentionally?

used or threatened them with a knife, gun, or other weapon?

IF Q203A=1 OR Q203B=1 OR Q203C=1 OR Q203D=1, CONTINUE TO Q204
IF Q203A=2/98/99 AND Q203B=2/98/99, AND Q203C=2/98/99 AND Q203D=2/98/99, SKIP TO Q206
Q204

Q205

Did you do any of these things to anyone who was not a dating partner in YES
the past 12 months?
NO

How old were you the first time this happened?

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
DON’T KNOW THE ANSWER

Q205A

1

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, or 18 or older?
6-11 YEARS OLD

- 33 -

Q206
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

Q206

PHYSICAL FIGHTING:
During the past 12 months, were you in a physical fight with anyone?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
CONDUCTED IN ACASI
EMOTIONAL VIOLENCE
Q300

99

EMOTIONAL VIOLENCE
EV1: PARENT, ADULT CAREGIVER, OR OTHER ADULT RELATIVE
The next questions ask about what a parent, adult caregiver, or other adult relative may have said to you.
Has a parent, adult caregiver, or other adult relative ever:

Q300A

Q300B

Q300C

told you that you were not loved, or did not deserve to be loved?

said they wished you had never been born or were dead?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
ridiculed you or put you down, for example, said that you were stupid or YES
useless?
NO

IF Q300A=1 OR Q300B=1 OR Q300C=1, CONTINUE WITH Q301
IF Q300A=2/98/99 AND Q300B=2/98/99 AND Q300C=2/98/99, GO TO Q310

- 34 -

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q301

Q302

Has a parent, adult caregiver, or other adult relative ever said these
things to you more than once?

EV1: MOST RECENT TIME
Did this happen in the past 12 months?

Q303

How old were you the last time this happened?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
DON’T KNOW THE ANSWER

Q303A

Q304

Q305

Q306

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, or 18 or older?
6-11 YEARS OLD

What was this person’s relationship to you?

Was this person male or female?

Q304
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PARENT

1

STEPPARENT

2

OTHER ADULT RELATIVE OR CAREGIVER

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
When this last happened, was this adult living in the same home as you? YES

Q307

99
1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

SKIP TO Q308
Q307

EV1: FIRST TIME
Did this happen in the past 12 months?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q301=1, CONTINUE WITH 308 AS WRITTEN
IF Q301=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?”
Q308

Q308A

Q309

How old were you the first time this happened?

YEARS OLD:
DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, or 18 or older?
6-11 YEARS OLD

What was this person’s relationship to you?

- 35 -

Q309

1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

PARENT

1

STEPPARENT

2

Q310

Was this person male or female?

OTHER ADULT RELATIVE OR CAREGIVER

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q301=1, CONTINUE WITH 311 AS WRITTEN
IF Q301=2/98/99, READ “WHEN THIS HAPPENED, WAS THE ADULT LIVING IN THE SAME HOME AS YOU?”
Q311

When this first happened, was this adult living in the same home as you? YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

FOR GARRETT COUNTY: SKIP TO Q319 (PEER EV)
IF Q44=3/98/99 (NEVER MARRIED/NEVER LIVED W/ SOMEONE AS MARRIED/DK/DTA) AND Q43=2/98/99 (NEVER PARTNER), GO TO
Q319 (PEER EV)
IF Q44=1/2 (EVER MARRIED OR LIVED WITH SOMEONE AS MARRIED) OR Q43=1 (EVER PARTNER), CONTINUE WITH Q312
(INTIMATE PARTNER EV)
Q312
EV2: INTIMATE PARTNER
The next questions ask about experiences you may have had in your life with your dating or sexual partners. When we ask about your dating or
sexual partners, please think about people you have been involved with romantically or sexually, which might include boyfriends, girlfriends,
people you have dated, people you were seeing, people you hooked up with, or your husband or wife.
Has a current or ex-partner ever done any of these things to you:
Q312A

Q312B

Q312C

Q312D

insulted, humiliated, or made fun of you in front of others?

YES

kept you from having your own money?

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

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

- 36 -

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q312E

Q312F

made threats to physically harm you?

shared a sexually-explicit image or video of you without your consent?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q312A=1 OR Q312B=1 OR Q312C=1 OR Q312D=1 OR Q312E=1 OR 312F=1, CONTINUE WITH Q313
IF Q312A=2/98/99 AND Q312B=2/98/99 AND Q312C=2/98/99 AND Q312D=2/98/99 AND Q312E=2/98/99 AND 312F=2/98/99, GO TO Q319
Q313

Q314

Now think back about any of these incidents when a current or past
partner said or did these things to you. Did this happen once or more
than once?

EV2: MOST RECENT TIME
Did this happen in the past 12 months?

Q315

Q315A

How old were you the last time this happened?

1

MORE THAN ONCE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say that you were: 10-17 years old, or 18 or older?

SKIP TO Q317
Q316
EV2: FIRST TIME
Did this happen in the past 12 months?

Q317

ONCE

Was this current or ex-partner someone you were married to or living
with at the time?

Q316

Q316

Q317

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES, MARRIED

1

YES, LIVING WITH

2

NO

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q313=1, CONTINUE WITH Q318 AS WRITTEN
IF Q313=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q318
Q318

Q318A

How old were you the first time this happened?

YEARS OLD:

Would you say that you were: 10-17 years old, or 18 or older?

- 37 -

Q319

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q319

EV3: PEER EMOTIONAL VIOLENCE
The next questions are about people your own age not including a current or ex-partner. This could be a schoolmate, a neighbor, or a stranger. It
could have happened in person or virtually through things like text messages, instant/direct messages, calls, videos, emails, social media, apps,
online gaming etc.
Has someone your own age done any of these things to you:

Q319A

Q319B

Q319C

made you get scared or feel really bad because they were calling you
names, saying mean things to you, or saying they didn’t want you
around?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

told lies or spread rumors about you, or tried to make others dislike you? YES

kept you out of things on purpose, excluded you from their group of
friends, or completely ignored you?

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

ONCE

1

IF Q319A=1 OR Q319B=1 OR Q319C=1, CONTINUE WITH Q320
IF Q319A=2/98/99 AND Q319B=2/98/99 AND Q319C=2/98/99, GO TO Q400
Q320

Q321

Now think back about any of these incidents when a person your own
age said or did these things to you. Did this happen once or more than
once?

EV3: MOST RECENT TIME
Did this happen in the past 12 months?

Q322

How old were you the last time this happened?

MORE THAN ONCE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
DON’T KNOW THE ANSWER

Q322A

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, or 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

Q323

Q324

98
99
1
2
3
4

DON’T KNOW THE ANSWER

98

DON’T KNOW THE ANSWER
DECLINED TO ANSWER
Did this happen in person or virtually through things like text messages, IN PERSON
instant/direct messages, calls, videos, emails, social media, apps, etc.?
VIRTUALLY

99
1
2
98
99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q326
Q325

EV3: FIRST TIME
Did this happen in the past 12 months?

- 38 -

Q325

Q323

18 YEARS OR OLDER
DECLINED TO ANSWER
The last time this happened, did one person or more than one person do 1 PERSON
this to you?
MORE THAN ONE PERSON

Q325

IF Q320=1, CONTINUE WITH Q326 AS WRITTEN
IF Q320=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q326
Q326

Q326A

How old were you the first time this happened?

YEARS OLD:

Q327

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, or 18 or older?
6-11 YEARS OLD

1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q320=1, CONTINUE WITH Q327 AS WRITTEN
IF Q320=2/98/99, READ “WHEN THIS HAPPENED, DID ONE PERSON OR MORE THAN ONE PERSON DO THIS TO YOU?” FOR Q327
Q327

Q328

The first time this happened, did one person or more than one person do 1 PERSON
this to you?
MORE THAN ONE PERSON

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Did this happen in person or virtually through things like text messages, IN PERSON
instant/direct messages, calls, videos, emails, social media, apps, etc.?
VIRTUALLY

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CONDUCTED IN ACASI
SEXUAL BEHAVIOR
Q400

SEXUAL BEHAVIOR:
The next questions are about sexual activity. By sex we mean vaginal,
oral, or anal sex or the insertion of hands, fingers, or other objects into
your vagina or anus by someone else.
Have you ever had sex?

Q401

During your life, with whom have you had sexual contact, males,
females, or both?

- 39 -

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALES

1

FEMALES

2

BOTH MALES AND FEMALES

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q600

Q402

Q402A

How old were you when you had sex for the very first time?

YEARS OLD:

Q403

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, or 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

FOR GARRETT COUNTY: SKIP TO Q405
IF Q402 HAS AN ASWER (NOT EQUAL TO 98 OR 99) THEN SKIP TO Q405
Q403

Q404

Q405

Q406

Q406A

Q406B

The first time you had sex, would you say that you wanted to have sex, WANTED TO
you did not want to have sex but it happened anyway, or were you forced DID NOT WANT TO BUT IT HAPPENED
to have sex?
ANYWAY
FORCED TO

The first time you had sex, were you verbally persuaded, pressured
(through harassment or threats), too drunk or drugged to say no, or
physically forced?

What was the person’s relationship to you the first time you had sex?

Was this person male or female?

How old was this person? Please give your best guess.

1
2
3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

VERBALLY PERSUADED

1

PRESSURED/THREATENED

2

TOO DRUNK TO SAY NO

3

PHYSICALLY FORCED

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CURRENT OR EX-DATING PARTNER

1

RELATIVE

2

FRIEND/CLASSMATE/SCHOOLMATE

3

ADULT IN MY COMMUNITY (TEACHER,
POLICE/ SECURITY PERSON, NEIGHBOR,
EMPLOYER, COMMUNITY/ RELIGIOUS
LEADER)

4

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Q407

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF PARTICIPANT IS A MALE PLEASE SKIP TO Q409 SEX HISTORY AND RISK TAKING, ELSE IF PARTICIPANT IS A FEMALE
CONTINUE WITH Q407
Q407

PREGNANCY:

YES

- 40 -

Q405

1

The next questions are about pregnancy.
Have you ever been pregnant?
Q408

Q408A

Q409

How old were you the first time that you got pregnant?

Q411

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q409

YEARS OLD:

Would you say that you were: 10-17 years old, or 18 or older?

SEX HISTORY AND RISK TAKING:

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

NUMBER OF PERSONS:

In your life, how many people have you ever had sex with?

Q410

NO

Have you had sex within the past 12 months?

How many people have you had sex within the past 12 months?

TOO MANY TO RECALL

66

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q500

NUMBER OF PERSONS:

- 41 -

TOO MANY TO RECALL

66

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q500

Q412

The last time you had sex, what method did you or your partner use to
prevent pregnancy?
(Choose all responses that apply)

Q413

Q414

Q415

The last time you had sex, did you or your partner use a condom?

Has a current or ex-partner ever refused to use a condom when you
wanted them to?

If participant is Female:
Has a current or ex-partner ever tried to get you pregnant
when you did not want to become pregnant, or tried to stop you from
using birth control?

AN IUD (SUCH AS MIRENA OR
PARAGARD) OR IMPLANT (SUCH AS
IMPLANON OR NEXPLANON)

A

A SHOT (SUCH AS DEPO-PROERA), PATCH
(SUCH AS ORTHO EVRA), OR A BIRTH
CONTROL RING (SUCH AS NUVARING)

B

BIRTH CONTROL PILLS

C

CONDOM

D

WITHDRAWAL OR PULL-OUT

E

NO METHOD

F

OTHER

X

DON’T KNOW THE ANSWER

Y

DECLINED TO ANSWER

Z

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

If participant is Male:
DON’T KNOW THE ANSWER
Has a current or ex-partner ever tried to get pregnant when you did not
want them to get pregnant, or tried to stop you from using birth control?
DECLINED TO ANSWER

98
99

FOR GARRETT COUNTY: SKIP TO Q600
Q500

TRANSACTIONAL SEX

Q501

NO
Have you ever started a relationship with someone mainly in order to get
DON’T KNOW THE ANSWER
things that you need such as money, gifts, favors, or housing, etc.?
DECLINED TO ANSWER
Did this happen in the past 12 months?
YES

YES

- 42 -

1
2
98
99
1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q600

Q502

Including all your experiences having sex with someone because they
gave you things that you need, what did they give you?

MONEY

A

FOOD

B

(Choose all responses that apply)

GIFTS/FAVORS

C

HOUSING

D

OTHERS

X

DON’T KNOW THE ANSWER

Y

DECLINED TO ANSWER

Z

CONDUCTED IN ACASI
SEXUAL VIOLENCE
Q600N

SEXUAL VIOLENCE:
Young people may experience unwanted sexual contact by people they know well, such as a current or ex-partner, family member or friend, or by
strangers. Your answers are confidential and you can skip any questions that you don’t feel comfortable answering.

Q600

Q601

Has anyone ever touched you in a sexual way against your will, but did YES
not try and force you to have sex? This could include fondling, pinching, NO
or grabbing in a sexual way. It could also include touching you on or
DON’T KNOW THE ANSWER
around your sexual body parts.
DECLINED TO ANSWER
SV1: TOUCHING WITHOUT PERMISSION- LIFETIME
Has this happened to you more than once?

Q602

SV1A: TOUCHING – MOST RECENT
Was the last time this happened within the past 12 months?

Q603

Q603A

Q604

How old were you the last time this happened?

1
2
98
99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

This last time, how many people touched you in a sexual way without
your permission?

IF Q604=2, PROVIDE TEXT BELOW
IF Q604=1/98/99, SKIP TO Q605

- 43 -

Q610

Q604

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q700

1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

1 PERSON

1

MORE THAN 1 PERSON

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q605_N
Q605

Q606

Q607

Q607A

Of these people who touched you in a sexual way against your will the last time, think of the person who hurt you the most for the following
questions:
What was this person’s relationship to you?
CURRENT OR EX DATING PARTNER
1

Was this person male or female?

How old was this person at the time? Please give your best guess.

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE A TEACHER
OF POLICE OFFICER)
FRIEND

3
4
5

STRANGER

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

- 44 -

Q608

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q608

Q609

Where were you when this happened to you?

About what time of day did this happen?

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q611
Q610

SV1B: TOUCHING – FIRST TIME
Did this happen to you within the past 12 months?

IF Q601=1, CONTINUE WITH Q611 AS WRITTEN
IF Q601=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q611
Q611

Q611A

How old were you the first time anyone touched you in a sexual way
against your will but did not try to force you to have sex?

YEARS OLD:

Q612

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q601=1, CONTINUE WITH Q612 AS WRITTEN
IF Q601=2/98/99, READ “WHEN THIS HAPPENED, DID ONE PERSON OR MORE THAN ONE PERSON DO THIS TO YOU?” FOR Q612
Q612

The first time this happened, did one person or more than one person do 1 PERSON
this to you?
MORE THAN 1 PERSON

IF Q612=2, PROVIDE TEXT BELOW
IF Q612=1/98/99, GO TO Q613

- 45 -

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q613_N

Of these people who touched you in a sexual way against your will the first time, think of the person who hurt you most for the following
questions:

Q613

What was this person’s relationship to you?

Q614

Q615

Q615A

Was this person male or female?

How old was this person at the time? Please give your best guess.

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3

STRANGER

6

4
5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

- 46 -

Q616

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q616

Q617

Q700

Where were you when this happened to you?

About what time of day did this happen?

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
99
These next questions ask you about sex, by sex I mean vaginal, oral, or anal sex or the insertion of hands, fingers, or other objects into your
vagina or anus by someone else.

IF Q43=1 (EVER PARTNERED), THEN ASK Q700A, Q700B, Q800A, Q800B, Q900A, Q900B, Q1000A AND Q1000B. AND PROGRAM
“ELSE” FOR Q700B, Q800B, Q900B, AND Q1000B.
IF Q43=2/98/99 (NEVER PARTNERED/DK/DTA), THEN SKIP Q700A, Q800A, Q900A, Q1000A.
Information contained in [ ] brackets is meant for participants who have had an intimate partner.
Q700A

Q700B

ATTEMPTED FORCED SEX
YES
For the next few questions when we ask about dating or sexual partners,
think about people you have been involved with romantically or
sexually, which might include boyfriends, girlfriends, people you have
NO
dated, people you were seeing, people you hooked up with, or your
husband or wife.

1

Has a current or ex-dating or sexual partner ever tried to make you have DON’T KNOW THE ANSWER
sex against your will but the sex did not happen? They might have tried
to physically force you to have sex or they might have tried to pressure
you to have sex through harassment or threats.
DECLINED TO ANSWER

98

Has anyone [else] ever tried to make you have sex against your will but
the sex did not happen? If the individual did not have an intimate
partner: They might have tried to physically force you to have sex or
they might have tried to make you have sex through harassment or
threats.

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

2

99

IF Q700A=1 OR 700B=1, CONTINUE TO Q701
IF Q700A=2/98/99 AND 700B=2/98/99, SKIP TO Q800
Q701

Q702

SV2: ATTEMPTED SEX- LIFETIME

NO
Has anyone tried to physically force you to have sex or tried to pressure
DON’T KNOW THE ANSWER
you to have sex through harassment or threats, but the sex did not
happen, more than once?
DECLINED TO ANSWER

98

SV2A: ATTEMPTED SEX – MOST RECENT

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Was the last time this happened within the past 12 months?

Q703

How old were you the last time this happened?

2

99

YEARS OLD:

- 47 -

Q710

Q704

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q703A

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

Q704

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
The last time this happened, did one person or more than one person try 1 PERSON
to make you have sex against your will?
MORE THAN ONE PERSON

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q704=2, PROVIDE TEXT BELOW
IF Q704=1/98/99, GO TO Q705
Q705_N
Q705

Q706

Q707

Q707A

Q708

Q709

Of these people who tried to have sex with you against your will this last time, think of the person who hurt you the most for the following
questions:
What was this person’s relationship to you?
CURRENT OR EX DATING PARTNER
1

Was this person male or female?

How old was this person at the time? Please give your best guess.

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3

STRANGER

6

4
5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Where were you when this happened to you?

About what time of day did this happen?

- 48 -

Q708

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q711
Q710

SV2B: ATTEMPTED SEX - FIRST TIME
Did this happen to you within the past 12 months?

IF Q701=1, CONTINUE WITH Q711 AS WRITTEN
IF Q701=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q711
Q711

How old were you the first time anyone tried to make you have sex
against your will but it did not happen?

YEARS OLD:
DON’T KNOW THE ANSWER

Q711A

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q712
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q701=1, CONTINUE WITH Q712 AS WRITTEN
IF Q701=2/98/99, READ “WHEN THIS HAPPENED, DID ONE PERSON OR MORE THAN ONE PERSON TRY TO MAKE YOU HAVE SEX
AGAINST YOUR WILL?” FOR Q712
Q712

The first time this happened, did one person or more than one person try 1 PERSON
to make you have sex against your will?
MORE THAN ONE PERSON

IF Q712=2, PROVIDE TEXT BELOW
IF Q712=1/98/99, GO TO Q713

- 49 -

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q713_N

Of these people who attempted to have sex with you against your will this first time, think of the person who hurt you the most for the following
questions:

Q713

What was this person’s relationship to you?

Q714

Q715

Q715A

Q716

Q717

Was this person male or female?

How old was this person at the time? Please give your best guess.

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3
4
5

STRANGER

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Where were you when this happened to you?

About what time of day did this happen?

Q716

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q43=1 (EVER PARTNERED), THEN ASK Q800A AND Q800B. AND PROGRAM “ELSE” FOR Q800B.
IF Q43=2/98/99 (NEVER PARTNERED/DK/DTA), THEN SKIP Q800A.
Information contained in [ ] brackets is meant for participants who have had an intimate partner.
Q800A

PHYSICALLY FORCED SEX

YES

Has a current or ex-partner ever physically forced you to have sex
against your will?
Q800B

Has anyone [else] ever physically forced you to have sex against your
will?

- 50 -

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO
DON’T KNOW THE ANSWER

2
98

DECLINED TO ANSWER

99

IF Q404=4 AND Q800A OR Q800B =2/98/99, THEN: “WE KNOW IT MAY BE HARD TO REMEMBER OR SHARE CERTAIN THINGS
THAT HAVE HAPPENED TO YOU. BECAUSE YOUR EXPERIENCES ARE IMPORTANT, WE WANT TO MAKE SURE WE HAVE
ACCURATELY CAPTURED THEM. THEN REASK THE QUESTION(S) FOR WHICH WE HAVE INCONSISTENT DATA.”
IF Q800A=1 OR Q800B=2/98/99, CONTINUE TO Q801
IF Q800A=2/98/99 AND Q800B=2/98/99, SKIP TO Q900
Q801

SV3: PHYSICALLY FORCED SEX- LIFETIME
Have you been physically forced to have sex more than once?

Q802

SV3A: PHYSICALLY FORCED SEX – MOST RECENT
Was the last time this happened within the past 12 months?

Q803

How old were you the last time this happened?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
DON’T KNOW THE ANSWER

Q803A

DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

Q804

The last time this happened, did one person or more than one person
physically force you to have sex?

IF Q804=2, PROVIDE TEXT BELOW
IF Q804=1/98/99, GO TO Q805

- 51 -

Q811

Q804
98
99
1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

1 PERSON

1

MORE THAN 1 PERSON

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q805_N

Of the people who physically forced you to have sex the last time, think of the person who hurt you the most for the following questions:

Q805

What was this person’s relationship to you?

Q806

Q807

Q807A

Q808

Q809

Q810

Was this person male or female?

How old was this person at the time? Please give your best guess.

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3
4
5

STRANGER

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Did the person who did this to you this last time use a weapon such as a YES
gun or knife?
NO

Where were you when this happened to you?

About what time of day did this happen?

Q808

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q811
Q811

SV3B: PHYSICALLY FORCED SEX – FIRST TIME
Did this happen to you within the past 12 months?

IF Q801=1, CONTINUE WITH Q812 AS WRITTEN
IF Q801=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q812

- 52 -

Q812

Q812A

How old were you the first time anyone physically forced you to have
sex?

YEARS OLD:

Q813

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q801=1, CONTINUE WITH Q813 AS WRITTEN
IF Q801=2/98/99, READ “WHEN THIS HAPPENED, DID ONE PERSON OR MORE THAN ONE PERSON PHYSICALLY FORCE YOU TO
HAVE SEX?” FOR Q813
Q813

The first time this happened, did one person or more than one person
physically force you to have sex?

IF Q813=2, PROVIDE TEXT BELOW
IF Q813=1/98/99, GO TO Q814

- 53 -

1 PERSON

1

MORE THAN ONE PERSON

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q814_N

Of the people who physically forced you to have sex the first time, think of the person who hurt you the most for the following questions:

Q814

What was this person’s relationship to you?

Q815

Q816

Q816A

Q817

Q818

Q819

Was this person male or female?

How old was this person at the time? Please give your best guess.

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3

STRANGER

6

4
5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Did the person who did this to you the first time use a weapon such as a YES
gun or knife?
NO

Where were you when this happened to you?

About what time of day did this happen?

Q817

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q43=1 (EVER PARTNERED), THEN ASK Q900A AND Q900B. AND PROGRAM “ELSE” FOR Q900B.
IF Q43=2/98/99 (NEVER PARTNERED/DK/DTA), THEN SKIP Q900A.
Information contained in [ ] brackets is meant for participants who have had an intimate partner.
Q900A

PRESSURED SEX
Has a current or ex-partner ever pressured you to have sex, through

- 54 -

YES

1

NO

2

Has a current or ex-partner ever pressured you to have sex, through
harassment or threats?
Q900B

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Has anyone [else] ever pressured you to have sex, through harassment or YES
threats?
NO

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q404=2 AND Q900A=2 OR Q900B=2/98/99, THEN: “WE KNOW IT MAY BE HARD TO REMEMBER OR SHARE CERTAIN THINGS
THAT HAVE HAPPENED TO YOU. BECAUSE YOUR EXPERIENCES ARE IMPORTANT, WE WANT TO MAKE SURE WE HAVE
ACCURATELY CAPTURED THEM. THEN REASK THE QUESTION(S) FOR WHICH WE HAVE INCONSISTENT DATA.”
IF Q900A=1 OR Q900B=2/98/99, CONTINUE TO Q901
IF Q900A=2/98/99 AND Q900B=2/98/99, SKIP TO Q1000
Q901

SV4: PRESSURED SEX- LIFETIME
Have you been pressured to have sex against your will through
harassment or threats more than once?

Q902

SV4A: PRESSURED INTO SEX – MOST RECENT
Was the last time this happened within the past 12 months?

Q903

Q903A

Q904

How old were you the last time this happened?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
98

DECLINED TO ANSWER

99

- 55 -

1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

The last time this happened, did one person or more than one person do 1 PERSON
this to you?
MORE THAN ONE PERSON

IF Q904=2 PROVIDE TEXT BELOW
IF Q904=1/98/99, GO TO Q905

Q904

DON’T KNOW THE ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q909

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q905_N

Of the people who pressured you to have to have sex against your will the last time, think of the person who hurt you the most for the following
questions:

Q905

What was this person’s relationship to you?

Q905A

Q906

Q906A

Q907

Q908

Was this person male or female?

How old was this person at the time? Please give your best guess.

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3

STRANGER

6

4
5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Where were you when this happened to you?

About what time of day did this happen?

Q907

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q910
Q909

SV4B: PRESSURED INTO SEX – FIRST TIME
Did this happen to you within the past 12 months?

IF Q901=1, CONTINUE WITH Q910 AS WRITTEN
IF Q901=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q910
Q910

How old were you the first time anyone pressured you to have sex
against your will?

YEARS OLD:

- 56 -

Q911

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q910A

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD
12-17 YEARS OLD

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q901=1, CONTINUE WITH Q911 AS WRITTEN
IF Q901=2/98/99, READ “WHEN THIS HAPPENED, DID ONE PERSON OR MORE THAN ONE PERSON PRESSURE YOU TO HAVE SEX
AGAINST YOUR WILL?” FOR Q911
Q911
The first time this happened, did one person or more than one person
1 PERSON
1
pressure you to have sex against your will?
MORE THAN ONE PERSON
2

IF Q911=2 PROVIDE TEXT BELOW
IF Q911=1/98/99 GO TO Q912

- 57 -

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q912_N

Of the people who pressured you to have sex against your will the first time, think of the person who hurt you the most for the following
questions:

Q912

What was this person’s relationship to you?

Q913

Q914

Q914A

Q915

Q916

Was this person male or female?

How old was this person at the time? Please give your best guess.

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3
4
5

STRANGER

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Where were you when this happened to you?

About what time of day did this happen?

Q915

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q43=1 (EVER PARTNERED), THEN ASK Q1000A AND Q1000B. AND PROGRAM “ELSE” Q1000B.
IF Q43=2/98/99 (NEVER PARTNERED/DK/DTA), THEN SKIP Q1000A.
Information contained in [ ] brackets is meant for participants who have had an intimate partner.
Q1000A

Q1000B

ALCOHOL-FACILITATED FORCED SEX

YES

1

NO

2

Has a current or ex-partner ever had sex with you when you were unable
DON’T KNOW THE ANSWER
to consent to it or stop it from happening because you were too drunk,
high or drugged to say no?
DECLINED TO ANSWER
Has anyone [else] ever had sex with you when you were unable to
YES
consent to it or stop it from happening because you were too drunk,
NO
high, or drugged to say no?

- 58 -

98
99
1
2

high, or drugged to say no?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q1000A=1 OR Q1000B=2/98/99, CONTINUE TO Q1001
IF Q1000A=2/98/99 AND Q1000B=2/98/99, CHECK THE FOLLOWING:
IF PARTICIPANT IS A FEMALE AND Q407=1 (EVER PREGNANT), MOVE TO Q1100 (PREGNANCY OUTCOMES)
IF Q407=2/98/99, SKIP TO Q1200 IF APPLY.
IF PARTICIPANT IS A MALE SKIP TO Q1200 IF APPLY.
Q1001

Q1002

SV5: LIFETIME ALCOHOL FACILITATED FORCED SEX

YES

1

You indicated that someone had sex with you when you were unable to
consent to it or stop it from happening because you were too drunk,
high, or drugged. Has this happened more than once?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

SV5A: ALCOHOL FACILITATED SEX – MOST RECENT
Was the last time this happened within the past 12 months?

Q1003

Q1003A

Q1004

How old were you the last time this happened?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Q1004

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

This last time this happened, did one person or more than one person
1 PERSON
have sex with you when you were unable to consent to it or stop it from MORE THAN ONE PERSON
happening because you were too drunk, high, or drugged?
DON’T KNOW THE ANSWER
DECLINED TO ANSWER

Q1010

1
2
98
99

IF Q911=2 PROVIDE TEXT BELOW
IF Q911=1/98/99 GO TO Q912
Q1005_N Of the people who you had sex with when you were unable to consent this last time, think of the person who hurt you the most for the following
questions:
Q1005

Q1006

Q1007

What was this person’s relationship to you?

CURRENT OR EX DATING PARTNER

Was this person male or female?

How old was this person at the time? Please give your best guess.

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

3

STRANGER

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

4
5

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

- 59 -

Q1007

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

Q1007A

Q1008

Q1009

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Where were you when this happened to you?

About what time of day did this happen?

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SKIP TO Q1011
Q1010

SV5B: ALCOHOL FACILITATED FORCED SEX – FIRST TIME
Did this happen to you within the past 12 months?

IF Q1001=1, CONTINUE WITH Q1011 AS WRITTEN
IF Q1001=2/98/99, READ “HOW OLD WERE YOU WHEN THIS HAPPENED?” FOR Q1011
Q1011

Q1011A

How old were you the first time anyone had sex with you when you were
YEARS OLD:
unable to consent to it or stop it from happening because you were too
drunk, high, or drugged?
DON’T KNOW THE ANSWER
DECLINED TO ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q1012
98
99
1
2

12-17 YEARS OLD

3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q1001=1, CONTINUE WITH Q1012 AS WRITTEN
IF Q1001=2/98/99, READ “WHEN THIS HAPPENED, DID ONE PERSON OR MORE THAN ONE PERSON HAVE SEX WITH YOU WHEN
YOU WERE UNABLE TO CONSENT TO IT OR STOP IT FROM HAPPENING BECAUSE YOU WERE TOO DRUNK, HIGH, OR
DRUGGED?” FOR Q1012
Q1012

This first time this happened, did one person or more than one person
1 PERSON
have sex with you when you were unable to consent to it or stop it from MORE THAN ONE PERSON
happening because you were too drunk, high, or drugged?
DON’T KNOW THE ANSWER
DECLINED TO ANSWER

1
2
98
99

IF Q1012=2 PROVIDE TEXT BELOW
IF Q1012=1/98/99 GO TO Q1013
Q1013_N Of the people who you had sex with when you were unable to consent the first time, think of the person who hurt you the most for the following
questions:
Q1013

What was this person’s relationship to you?

- 60 -

CURRENT OR EX DATING PARTNER

1

RELATIVE

2

CLASSMATE/SCHOOLMATE
AUTHORITY FIGURE (LIKE TEACHER OR
POLICE OFFICER)
FRIEND

Q1014

Q1015

Q1015A

Q1016

Q1017

Was this person male or female?

How old was this person at the time? Please give your best guess.

3
4
5

STRANGER

6

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MALE

1

FEMALE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say this person was:
Younger than you,
About the same age as you,
More than 5 years older than you,
More than 10 years older than you?

Where were you when this happened to you?

About what time of day did this happen?

Q1016

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YOUNGER

1

ABOUT THE SAME AGE

2

MORE THAN 5 YEARS OLDER

3

MORE THAN 10 YEARS OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

SOMEONE’S HOME

1

AN OUTSIDE LOCATION

2

SCHOOL

3

INSIDE A CAR/BUS

4

BAR, CLUB OR RESTAURANT

8

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORNING (SUNRISE TO NOON)

1

AFTERNOON (NOON TO SUNSET)

2

EVENING (SUNSET TO MIDNIGHT)

3

LATE AT NIGHT (MIDNIGHT TO SUNRISE)

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF PARTICIPANT IS A MALE PLEASE SKIP TO SV SERVICES IF NEEDED, ELSE IF PARTICIPANT IS A FEMALE CONTINUE WITH
Q1100
Q1100

PREGNANCY OUTCOMES:

YES

NO
Did you ever get pregnant as a result of being physically forced or
pressured to have sex, or when you were unable to consent to it or stop it
DON’T KNOW THE ANSWER
from happening because you were too drunk or high?
DECLINED TO ANSWER

1
2
98

Q1200

99

IF Q1100=1 AND Q407=2, THEN: “IT MAY BE HARD TO REMEMBER OR SHARE CERTAIN THINGS THAT HAVE HAPPENED TO YOU.
YOUR EXPERIENCES ARE IMPORTANT TO ACCURATELY CAPTURE.” THEN QUESTION(S) FOR WHICH WE HAVE INCONSISTENT
DATA WILL BE RE-ASKED.
IF Q600 OR Q700A/B OR Q800A/B OR Q900A/B OR Q1000A/B =1 MOVE TO Q1200
IF Q600 AND Q700A/B AND Q800A/B AND Q900A/B AND Q1000A/B SKIP TO Q1300
CONDUCTED IN ACASI
SEXUAL VIOLENCE SERVICES
Q1200

SV SERVICES

YES

- 61 -

1

Did you ever have to miss school because anyone we just asked about
had sex with you when you were unable to consent to it or stop it from
happening because you were too drunk, high, or drugged?

Q1201

Q1202

Q1203

Did you know of a place to go for help because anyone we just asked
about had sex with you when you were unable to consent to it or stop it
from happening because you were too drunk, high, or drugged?

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Did you try to seek professional help or services because anyone we just YES
asked about had sex with you when you were unable to consent to it or NO
stop it from happening because you were too drunk, high, or drugged?
DON’T KNOW THE ANSWER

99
1
2
98

DECLINED TO ANSWER
99
There are many reasons why people do not seek professional help or services when they have been hurt. Do you agree or disagree with each of
the following as reasons you did not seek help?
I did not seek help because:

Q1203A

Q1203B

Q1203C

Q1203D

Q1203E

Q1203F

Q1203G

Q1203H

Q1203I

Q1204

Services were too far away?

TRUE

Services were too expensive?

I was afraid of getting in trouble?

I was afraid of getting kicked out or not having someone to take care of
me?

I was embarrassed?

I did not want to embarrass my family?

Someone told me not to seek help?

I am not a snitch?

I did not want the person who hurt me to get in trouble?

- 62 -

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

Q1203J

Q1203K

Q1203L

What happened to me was not a problem?

I did not want or need help?

It would not actually help?

Q1203M I was afraid the person would hurt me again?

Q1203N

Other?

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

HEALTHCARE PROFESSIONAL

1

POLICE

2

LAWYER OR LEGAL PROFESSIONAL
SOCIAL WORKER, COUNSELOR OR CHILD
PROTECTIVE SERVICES
911

3

SKIP TO Q1206B
Q1204

Q1205

Q1206A

Q1206B

Q1207

Did you receive professional help or services?

From whom did you receive professional help or services?

Besides the professional people or service providers you just selected,
did you tell anyone else about any of these experiences?

Did you tell anyone about any of these experiences?

Whom did you tell?
(Choose all responses that apply)

- 63 -

Q1206A

4
5

OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CURRENT OR EX DATING PARTNER

A

RELATIVE

B

FRIEND OR NEIGHBOR
SERVICE PROVIDER (LIKE A DOCTOR OR
COUNSELOR)
AUTHORITY FIGURE (LIKE A TEACHER
OR POLICE OFFICER)
OTHER

C
D
E
X

Q1207
Q1208

DON’T KNOW THE ANSWER

Y

DECLINED TO ANSWER

Z

SKIP TO Q1300
Q1208

There are many reasons why people do not tell anyone when they have been hurt. Do you agree or disagree with each of the following as reasons
you did not tell anyone?
I did not tell anyone because:

Q1208A

Q1208B

Q1208C

Q1208D

Q1208E

Q1208F

Q1208G

Q1208H

Q1208I

Q1208J

Q1208K

I was afraid of getting in trouble?

TRUE

I was afraid of getting kicked out or not having someone to take care of
me?

I was embarrassed?

I did not want to embarrass my family?

Someone told me not to seek help?

I am not a snitch?

I did not want the person who hurt me to get in trouble?

What happened to me was not a problem?

I did not want or need help?

It would not actually help?

I was afraid the person would hurt me again?

- 64 -

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

Q1208L

Other?

DECLINED TO ANSWER

99

TRUE

1

FALSE

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

IF Q43=2/98/99 (NEVER PARTNER) SKIP TO Q1303
IF Q43=1 (EVER PARTNER) CONTINUE WITH Q1300
Q1300

SV PERPETRATION

Q1301

NO
Have you ever forced a current or ex-partner to have sex with you when
DON’T KNOW THE ANSWER
they did not want to?
DECLINED TO ANSWER
Did this happen in the past 12 months?
YES

Q1302

Q1302A

Q1303

Q1304

Q1305

Q1305A

How old were you the first time this happened?

2
98
99
1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:

Would you say that you were: 10-17 years old, 18 or older?

Did this happen in the past 12 months?

How old were you the first time this happened?

Q1303

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

10-17 YEARS OLD

1

18 YEARS OR OLDER

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Have you ever forced someone who was not your current or ex-partner to YES
have sex with you when they did not want to?
NO

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YEARS OLD:
98

DECLINED TO ANSWER

99

12-17 YEARS OLD

Q1400

Q1400

DON’T KNOW THE ANSWER
Would you say that you were: 0-5 years old, 6-11 years old, 12-17 years 0-5 YEARS OLD
old, 18 or older?
6-11 YEARS OLD

Q1303

1
2
3

18 YEARS OR OLDER

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CONDUCTED IN ACASI
UNWANTED SEXUAL EXPERIENCES ONLINE
Q1400

UNWANTED SEXUAL EXPERIENCES ONLINE:
The next questions are about sexual things that might have taken place on the internet, on social media apps, through email, or through text
messaging.
In the past 12 months did you have access to:

Q1400A

The Internet?

- 65 -

YES

1

NO

2

DON’T KNOW THE ANSWER

98

Q1400B

Q1400C

Q1400D

Social media apps?

Email?

Text messaging?

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

IF Q1400A=1 OR Q1400B=1 OR 1400C=1 OR 1400D=1, CONTINUE TO 1401
IF Q1400A=2/98/99 AND Q1400B=2/98/99 AND Q1400C=2/98/99 AND Q1400D=2/98/99, SKIP TO Q1500
Q1401

Q1402

Q1403

Q1404

Q1405

Q1406

Q1407

Q1408

In the past 12 months did you talk about sexual acts with someone on the YES
internet, on social media, through email or through text messaging
NO
because you were pressured to do so against your will?
DON’T KNOW THE ANSWER
What was this person’s relationship to you?

In the past 12 months did you send a photo or video showing your
private parts on the internet, on social media, through email or through
text messaging because you were pressured to do so against your will?

What was this person’s relationship to you?

In the past 12 months, did you do anything else sexual on the internet,
on social media, through email or through text messaging because you
were pressured to do so against your will?

What was this person’s relationship to you?

In the past 12 months did you pressure a partner or ex-partner against
their will to talk about sexual acts on the internet, on social media,
through email or through text message?

2
98

DECLINED TO ANSWER

99

CURRENT OR EX DATING PARTNER

1

FRIEND OR CLASSMATE

2

STRANGER

3

SOMEONE ELSE

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CURRENT OR EX DATING PARTNER

1

FRIEND OR CLASSMATE

2

STRANGER

3

SOMEONE ELSE

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CURRENT OR EX DATING PARTNER

1

FRIEND OR CLASSMATE

2

STRANGER

3

SOMEONE ELSE

4

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
In the past 12 months did you pressure anyone [else] against their will to YES
talk about sexual acts on the internet, on social media, through email or NO
through text message?

- 66 -

1

99
1
2

Q1403

Q1405

Q1407

through text message?

Q1409

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

In the past 12 months did you pressure a partner or ex-partner against
YES
their will to send you a photo or video showing their private parts on the NO
internet, on social media, through email or through text message?
DON’T KNOW THE ANSWER
DECLINED TO ANSWER

Q1410

Q1411

Q1412

Q1413

Q1414

In the past 12 months did you pressure anyone [else] against their will to YES
send you a photo or video showing their private parts on the internet, on NO
social media, through email or through text message?
DON’T KNOW THE ANSWER
In the past 12 months did you pressure a partner or ex-partner against
their will to do anything else sexual on the internet, on social media,
through email or through text message?

Whom did you tell?
(Choose all responses that apply)

2
98
99
1
2
98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

In the past 12 months did you pressure anyone [else] against their will to YES
do anything else sexual on the internet, on social media, through email NO
or through text message?
DON’T KNOW THE ANSWER
Did you tell anyone about any of these unwanted sexual experiences
online?

1

1
2
98

DECLINED TO ANSWER

99

YES

1

NO, I DIDN’T NEED HELP

2

NO, I DIDN’T KNOW HOW TO GET HELP

3

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CURRENT OR EX DATING PARTNER

A

RELATIVE

B

FRIEND OR NEIGHBOR
SERVICE PROVIDER (LIKE A DOCTOR OR
COUNSELOR)
AUTHORITY FIGURE (LIKE A TEACHER
OR POLICE OFFICER)
OTHER

C

X

DON’T KNOW THE ANSWER

Y

DECLINED TO ANSWER

Z

D
E

CONDUCTED IN ACASI
SUBSTANCE ABUSE
Q1500

SUBSTANCE ABUSE
During the past 30 days, on how many days did you have at least one
drink of alcohol?

Q1500A

Q1501

During the past 30 days, did you have at least one drink of alcohol on
more than 10 days or less than 10 days?

I DID NOT DRINK ALCOHOL IN PAST 30
DAYS
1-2 DAYS

3

6-9 DAYS

4

10-19 DAYS

5

20-29 DAYS

6

ALL 30 DAYS

7

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MORE THAN 10 DAYS

1

LESS THAN 10 DAYS

2

DON’T KNOW THE ANSWER

98

- 67 -

DON’T KNOW THE ANSWER

Q1502

2

3-5 DAYS

DECLINED TO ANSWER
In the past 30 days, on how many days did you have 4 or more drinks of
NUMBER OF DAYS:
alcohol in a row, that is within a couple of hours?
[Note for females it is 4 or more drinks and for males it is 5 or more

1

99

98

Q1501

drinks]
Q1502

Q1503

This question is about smoking cigarettes (ones that have to be lit and
burned). In the past 30 days, have you smoked a cigarette, even one or
two puffs?

In the past 30 days have you used any of the following drugs:

Q1504A

Marijuana or cannabis (also called weed or pot)?

Q1504C

Q1504D

Q1504E

Q1504F

Q1504G

Q1504H

Q1505

Q1506

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

This question is about electronic cigarettes or e-cigarettes, such as
YES
JUUL, Vuse, blu, and Logic. E-cigarettes are battery powered devices
that usually contain a nicotine-based liquid that is vaporized and inhaled. NO
You may also know them as e-cigs, vape-pens, e-hookas, vapes, or
DON’T KNOW THE ANSWER
mods. In the past 30 days, have you used an e-cigarette?

Q1504

Q1504B

DECLINED TO ANSWER

Synthetic Marijuana (also called spice, fake weed or K2)?

Cocaine (including powder, crack, freebase, coke, or blow)?

Sniffed glue/breathed the contents of aerosol spray cans, or inhaled any
paints or sprays to get high?

Heroin (also called smack, junk, H, Black Tar, or China White)?

Fentanyl

- 68 -

98
99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

In the past 30 days have you taken prescription pain medicine without a YES
doctor’s prescription or different than how a doctor told you to use it?
NO

In the last 30 days, would you say that in general your health has been
excellent, very good, good, fair, or poor?

2

DECLINED TO ANSWER

Methamphetamines (also called speed, crystal meth, crank, ice, glass, or YES
meth)?
NO

Ecstasy (also called MDMA, Molly, ETC, E, or X)?

1

1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

EXCELLENT

1

VERY GOOD

2

Q1507

GOOD

3

FAIR

4

POOR

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

MENTAL HEALTH:
During the past 30 days, how often did you feel the following ways: all the time, most of the time, some of the time, a little of the time, or none of
the time?

Q1507A

Q1507B

Q1507C

Q1507D

Q1507E

Q1507F

Nervous?

ALL THE TIME

Hopeless?

Restless?

So sad that nothing could cheer you up?

That everything was an effort?

Worthless?

- 69 -

1

MOST OF THE TIME

2

SOME OF THE TIME

3

A LITTLE OF THE TIME

4

NONE OF THE TIME

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

ALL THE TIME

1

MOST OF THE TIME

2

SOME OF THE TIME

3

A LITTLE OF THE TIME

4

NONE OF THE TIME

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

ALL THE TIME

1

MOST OF THE TIME

2

SOME OF THE TIME

3

A LITTLE OF THE TIME

4

NONE OF THE TIME

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

ALL THE TIME

1

MOST OF THE TIME

2

SOME OF THE TIME

3

A LITTLE OF THE TIME

4

NONE OF THE TIME

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

ALL THE TIME

1

MOST OF THE TIME

2

SOME OF THE TIME

3

A LITTLE OF THE TIME

4

NONE OF THE TIME

5

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

ALL THE TIME

1

MOST OF THE TIME

2

SOME OF THE TIME

3

A LITTLE OF THE TIME

4

NONE OF THE TIME

5

DON’T KNOW THE ANSWER

98

Q1508

Have you ever hurt yourself on purpose in any way?

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DECLINED TO ANSWER

99

YES
NO
DON’T KNOW THE ANSWER

1
2
98

DECLINED TO ANSWER

99

Q1509

Q1510

During the past 12 months, did you ever seriously consider attempting
suicide?

During the past 12 months did you actually attempt suicide?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CONDUCTED IN ACASI
STI
Q1511

STD/STI:
Have you ever tested positive for:

Q1511A

Q1511B

Q1511C

Q1511D

Q1511E

Q1511F

Q1511G

Q1512
Q1512A

Q1512B

HIV?

Syphilis?

Gonorrhea?

Chlamydia?

Herpes?

Mycoplasma genetalium?

Any other sexually transmitted disease or infection?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Have you ever had any of the following when you thought you might have a sexually transmitted disease or infection:

99

For Female participants:
Unusual discharge or oozing from your vagina?

YES

1

NO

2

For Male participants:
Unusual discharge or oozing from your penis?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

For Female participants:
Unexplained sores or bumps on your vagina?

YES

1

NO

2

For Male participants:
Unexplained sores or bumps on your penis?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

- 71 -

Q1511

Q1512C

Q1512D

Pain when you urinated?

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER
Other pain that you thought might be from a sexually transmitted disease YES
or infection?
NO

99
1
2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

CONDUCTED IN ACASI
RESPONSES TO SENSITIVE QUESTIONS
Q1600

RESPONSES TO SENSITIVE QUESTIONS:

YES, WORTHWHILE

Thank you for taking the time to answer these questions. We would like
NO, NOT WORTHWHILE
to ask you about your opinion of this survey and the questions that you
were asked.
DON’T KNOW THE ANSWER

1
2
98

Do you feel that participating in this survey was a good use of your time?
DECLINED TO ANSWER
Q1601

Q1602

Q1603

Q1604

At any point during the interview, were you afraid that someone might YES
see your answers and hurt or embarrass you in any way because of what NO
they saw?
DON’T KNOW THE ANSWER
Did any of the questions make you feel upset because of a past
experience?

Did you find it upsetting or stressful to answer any of these questions?

Do you think surveys like this should ask questions about violence?

99
1
2
98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

HARD TO ANSWER QUESTIONS ABOUT
DIFFICULT EXPERIENCES IN MY LIFE

1

I FELT UNCOMFORTABLE ANSWERING
SUCH PERSONAL QUESTIONS

2

IF Q1602=1 OR Q1603=1, CONTINUE WITH Q1605
IF Q1602=2/98/99 AND Q1603=2/98/99, GO TO Q1606
Q1605

Q1606

Why did you find it upsetting or stressful to answer these questions?

QUESTIONS ABOUT SEX MAKE ME
UNCOMFORTABLE
OTHER

88

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

3

You were asked some difficult things. How has sharing these things
MUCH BETTER
made you feel? Do you feel better, about the same, or worse than you did SOMEWHAT BETTER
before you started answering these questions?
ABOUT THE SAME

2

SOMEWHAT WORSE

4

- 72 -

1
3

MUCH WORSE

5

DON’T KNOW THE ANSWER

98

Q1607

Q1608

Q1_TE

DECLINED TO ANSWER

99

The questionnaire is almost finished. Please answer just a few more
questions about your experiences.

YES

1

NO

2

Thinking of all of these experiences we have asked about today, do you
feel like you are in immediate danger?
Thinking about all of these experiences we have asked about today, do
you feel unsafe in your current living situation?

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

YES

1

RECORD THE TIME THE INTERVIEW ENDED:

NO

2

DON’T KNOW THE ANSWER

98

DECLINED TO ANSWER

99

TIME: (00:00)

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