0920-0222 NISVS Questionnaire

Attachment 1: Questions to be cognitively tested

Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026

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NISVS Traumatic Brain Injury Questions for Cognitive Testing

[DEMOGRAPHIC QUESTIONS: NO PROBES]

First, how old are you?

Age _________

Are you:

1. Female

2. Male

3. Transgender, non-binary or another gender identity

Are you Spanish, Hispanic, or Latino?

1. Yes

2. No

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

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

Are you now…?

1. Married

2. Divorced

3. Separated

4. Widowed

5. Not married but living with a partner

6. Never married

[INTIMATE PARTNER VIOLENCE - TRAUMATIC BRAIN INJURY SECTION]

The next set of questions ask about experiences that can directly impact your health or may have resulted in injury. You may find that some of the questions are sensitive. Remember you may choose not to answer any question for any reason. If you do not want to answer a question, say so, and we will move on to the next one. You may also stop the interview at any time.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Slapped, pushed, or shoved you?	Yes	No
Hit you with a fist or something hard?	Yes	No
Kicked or stomped on you?	Yes	No
Slammed you against something to hurt you?	Yes	No
Hit you in the head or made you hit your head on another object?	Yes	No

[IF YES TO ANY OF THE ABOVE, THEN CONTINUE

IF NO TO ALL, GO TO ANOXIC BRAIN INJURY]

6. In your lifetime, did you ever have an injury to your head or face because of the things your current or ex-partner did to you?

1. Yes

2. No [go to anoxic brain injury section]

[Head/Face Injury Section Intro] We are interested in learning about times in your lifetime when you experienced an injury to the head or face because of what a current or ex-partner did to you.

Please think about the most severe injury to your head or face because of what a current or ex-partner did to you.

7. Approximately when did this injury occur?

1. Within the last 12 months, since (date)

2. 1-3 years ago

3. 4-7 years ago

4. More than 8 years ago

[Signs/Symptoms Intro] Please continue thinking about the most severe injury to your head or face. In the next set of questions, I will ask about what you might have experienced soon after this injury. For each question, please indicate if it happened to you or not. We only want to know about things caused by the injury to your head or face or made worse by this injury. After this injury…

8. Were you dazed, confused or did you have trouble thinking straight?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you have difficulty remembering what happened just before or after the head injury?

   1. Yes

   2. No

   3. Not sure/Don’t remember

9. Were you knocked out or did you lose consciousness, even briefly?

   1. Yes

   2. No

   3. Not sure/Don’t remember

After this injury…

8. Did you feel sick to your stomach, or did you vomit?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you have a headache?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Was there ever a time when you were dizzy, clumsy, or had balance problems?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you have blurred or double vision, or other changes in your vision?

   1. Yes

   2. No

   3. Not sure/Don’t remember

After this injury…

8. Did you have trouble concentrating?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you have difficulty learning or remembering new things?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Were you more sensitive than usual to either light or noise?

   1. Yes

   2. No

   3. Not sure/Don’t remember

After this injury…

8. Did you experience a change in mood or temperament such as irritability, or feel more emotional than usual?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you have trouble sleeping or were you more tired than usual?

   1. Yes

   2. No

   3. Not sure/Don’t remember

[Follow-up / Contextual Questions (if they said yes to any of the symptoms)] Please think about the most severe injury to your head or face because of what a current or ex-partner did to you.

8. After this injury, were you examined by a doctor, nurse, paramedic, or other health professional?

1. Yes

2. No (go to #21)

3. Not sure/Don’t remember

8. Why not? (Check all that apply)

1. Didn’t think the injury was serious

2. Difficulty paying for it

3. Did not have transportation

4. Could not take time off work

5. Prevented from seeking care by current or ex-partner

6. Unable to seek care because of COVID-19 (?)

7. Some other reason

[INTIMATE PARTNER VIOLENCE ANOXIC BRAIN INJURY SECTION]

Now I will ask you about other experiences you might have had with a current or former intimate partner.

8. In your lifetime, has a current or ex-romantic or sexual partner ever put their hands around your neck, put something over your mouth, or done anything else that made you feel choked, strangled, suffocated, or like you couldn’t breathe?

   1. Yes (go to Q23)

   2. No (go to sexual violence section)

   3. Not sure/Don’t remember (go to sexual violence section)

Please think about the most severe time that this happened. That is, when a current or ex-romantic or sexual partner put their hands around your neck, put something over your mouth, or did anything else that made you feel choked, strangled, suffocated, or like you couldn’t breathe.

8. Approximately when did this incident occur?

1. Within the last 12 months, since (fill date)

2. 1-3 years ago

3. 4-7 years ago

4. More than 8 years ago

[Signs/Symptoms Intro] In the next set of questions, I will ask about what you might have experienced soon after this happened. For each question, please indicate if it happened to you or not. We only want to know about things caused by the incident or made worse by it. After this incident…

8. Did you lose consciousness or pass out, even briefly?

1. Yes

2. No

3. Not sure/Don’t remember

8. Were you dazed, confused or did you have trouble thinking straight?

1. Yes

2. No

3. Not sure/Don’t remember

8. Did you have difficulty remembering what happened just before or after the incident?

1. Yes

2. No

3. Not sure/Don’t remember

8. Did you experience a seizure, not explained by a pre-existing seizure disorder?

   1. Yes

   2. No

   3. Not sure/Don’t remember

After this incident…

8. Did you lose control of your bladder or bowels (accidentally pee or poop on yourself)?

1. Yes

2. No

3. Not sure/Don’t remember

8. Did you see stars or spots or have blurred, double or tunnel vision?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you have ringing in your ears or experience decreased ability to hear?

   1. Yes

   2. No

   3. Not sure/Don’t remember

8. Did you feel dizzy, clumsy or have balance problems?

1. Yes

2. No

3. Not sure/Don’t remember

[SEXUAL VIOLENCE SECTION: NO PROBES]

Next are some detailed questions about times in your life when you may have experienced unwanted sexual situations with anyone, including strangers or someone you knew such as a romantic or sexual partner, a family member, a friend, teacher, co-worker or supervisor, or someone you have known for only a short time. These questions are detailed, and the language is explicit, which some people may find upsetting. It is important that the questions are asked this way so that you understand what we mean. Remember you may choose not to answer any question for any reason. If you do not want to answer a question, say so, and we will move on to the next one. You may also stop the interview at any time.

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

Females only:

32. In your LIFETIME, has anyone ever penetrated you by putting their penis in your vagina, mouth, or anus when you did NOT consent to it, and it was not wanted, by using physical force or threats of physical harm? (Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no).

a. Yes

b. No

33. In your LIFETIME, has anyone EVER used physical force or threats of physical harm to TRY to put their penis in your vagina, mouth, or anus, but it did not happen? (Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no).

a. Yes

b. No

[IF YES TO 32 OR 33, THEN CONTINUE TO NEXT SECTION;

IF NO TO BOTH, END SURVEY]

Males only:

32. In your LIFETIME, has anyone ever penetrated you by putting their penis in your mouth or anus when you did NOT consent to it, and it was not wanted, by using physical force or threats of physical harm? (Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no).

a. Yes

b. No

33. In your LIFETIME, has anyone EVER used physical force or threats of physical harm to TRY to put their penis in your mouth or anus, but it did not happen? (Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no).

a. Yes

b. No

[IF YES TO 32 OR 33, THEN CONTINUE TO NEXT SECTION;

IF NO TO BOTH, END SURVEY]

[SEXUAL VIOLENCE TRAUMATIC BRAIN INJURY QUESTIONS]

34. You reported that someone used physical force or threats of harm to have, or try to have, (IF FEMALE: vaginal,) oral, or anal sex with you. Was your head or face ever injured during any of those incidents?

1. Yes [go to next question]

2. No [go to anoxic brain injury section]

[Head/Face Injury Section Introduction] Please think about the most significant injury to your head or face that happened because someone used physical force or threats of harm to have, or try to have (IF FEMALE: vaginal,) oral, or anal sex with you.

35. How did you know the person who did this to you? Was this person…

a. a current or former romantic or sexual partner

b. someone else

36. Approximately when did this injury occur?

1. Within the last 12 months, since (fill date)

2. 1-3 years ago

3. 4-7 years ago

4. More than 8 years ago

[Signs/Symptoms Intro] Please continue thinking about the most significant injury to your head or face. In the next set of questions, I will ask about what you might have experienced soon after this injury. For each question, please indicate if it happened to you or not. We only want to know about things caused by the injury to your head or face or made worse by this injury. After this injury…

37. Were you dazed, confused or did you have trouble thinking straight?

1. Yes

2. No

3. Not sure/Don’t remember

37. Did you have difficulty remembering what happened just before or after the head injury?

1. Yes

2. No

3. Not sure/Don’t remember

37. Were you knocked out or did you lose consciousness, even briefly?

1. Yes

2. No

3. Not sure/Don’t remember

After this injury…

37. Did you feel sick to your stomach, or did you vomit?

1. Yes

2. No

3. Not sure/Don’t remember

37. Did you have a headache?

1. Yes

2. No

3. Not sure/Don’t remember

37. Was there ever a time when you were dizzy, clumsy or had balance problems?

1. Yes

2. No

3. Not sure/Don’t remember

37. Did you have blurred or double vision, or other changes in your vision?

1. Yes

2. No

3. Not sure/Don’t remember

After this injury…

37. Did you have trouble concentrating?

1. Yes

2. No

3. Not sure/Don’t remember

37. Did you have difficulty learning or remembering new things?

1. Yes

2. No

3. Not sure/Don’t remember

37. Were you more sensitive than usual to either light or noise?

1. Yes

2. No

3. Not sure/Don’t remember

After this injury…

37. Did you experience a change in mood or temperament such as irritability, or feel more emotional than usual?

1. Yes

2. No

3. Not sure/Don’t remember

37. Did you have trouble sleeping or were you more tired than usual?

1. Yes

2. No

3. Not sure/Don’t remember

[Follow-up / Contextual Questions (if they said yes to any of the symptoms)] Please continue thinking about the most significant injury to your head or face that happened because someone used physical force or threats of harm to have, or try to have (IF FEMALE: vaginal,) oral, or anal sex with you.

37. After this injury, were you examined by a doctor, nurse, paramedic, or other health professional?

1. Yes

2. No (go to #50)

3. Not sure/Don’t remember

37. Why not? (Check all that apply)

1. Didn’t think the injury was serious

2. Difficulty paying for it

3. Did not have transportation

4. Could not take time off work

5. Prevented from seeking care by current or ex-partner

6. Unable to seek care because of COVID-19 (?)

7. Some other reason

[SEXUAL VIOLENCE ANOXIC BRAIN INJURY]

You reported that someone used physical force or threats of physical harm to have, or try to have (IF FEMALE: vaginal,) oral, or anal sex with you. Now I will ask you about other experiences you might have had when this happened. This might be a different experience from what you reported earlier.

51. In your lifetime, did someone ever put their hands around your neck, put something over your mouth, or do anything else that made you feel choked, strangled, suffocated, or like you couldn’t breathe during unwanted (IF FEMALE: vaginal,) oral, or anal sex?

1. Yes [go to next question]

2. No [End survey]

3. Not sure/don’t remember [End survey]

Please think about the most significant time that this happened.

52. How did you know the person who did this to you? Was this person…

a. A current or former romantic or sexual partner

b. Someone else

52. Approximately when did this incident occur?

1. Within the last 12 months, since (date)

2. 1-3 years ago

3. 4-7 years ago

4. More than 8 years ago

[Signs/Symptoms Intro] In the next set of questions, I will be asking you about what you might have experienced soon after this incident. For each question, please indicate if it happened to you or not. We only want to know about things caused by the incident or made worse by it. After this incident…

52. Did you lose consciousness or pass out, even briefly?

1. Yes

2. No

3. Not sure/Don’t remember

52. Were you dazed, confused or did you have trouble thinking straight?

1. Yes

2. No

3. Not sure/Don’t remember

52. Did you have difficulty remembering what happened just before or after the incident?

1. Yes

2. No

3. Not sure/Don’t remember

52. Did you experience a seizure, not explained by a pre-existing seizure disorder?

1. Yes

2. No

3. Not sure/Don’t remember

After this incident…

52. Did you lose control of your bladder or bowels (accidentally pee or poop on yourself)?

1. Yes

2. No

3. Not sure/Don’t remember

52. Did you see stars or spots or have blurred, double or tunnel vision?

1. Yes

2. No

3. Not sure/Don’t remember

52. Did you have ringing in your ears or experience decreased ability to hear?

4. Yes

5. No

6. Not sure/Don’t remember

52. Did you feel dizzy, clumsy, or have balance problems?

1. Yes

2. No

3. Not sure/Don’t remember