Attachments A-Z with Table of Contents

All Attachments A-Z with TOC.pdf

Methodological Research to Support the NCVS: Self-Report Data on Rape and Sexual Assault: Pilot Test

Attachments A-Z with Table of Contents

OMB: 1121-0343

Document [pdf]

Download: pdf | pdf

List of Attachments
Attachment A: Assumptions and Calculation of Respondent Burden
Attachment B: Field Mail Cover Letter
Attachment B-1: Field Mail Reminder Postcard
Attachment B-2: Field Mail Reminder Letter
Attachment C: Field Mail Household Roster Survey
Attachment D: Advance Letter to Eligible Field Households with Incentive
Attachment D-1: Incentive Letter to Ineligible Field Households
Attachment E: Field ACASI Household Roster
Attachment F: CATI Advance Letter
Attachment G: CATI Landline Screener
Attachment H: CATI Cell Phone Screener
Attachment I: CATI Refusal Conversion Letter
Attachment J: NSHS Brochure
Attachment K: High Risk Recruitment Flyer
Attachment L: Craig’s List Recruitment Ad for High Risk Sample
Attachment M: High Risk Recruit Script
Attachment N: High Risk Scheduling Script
Attachment O: Sexual Assault Brochure
Attachment P: Service Provider Scheduling Script
Attachment Q-1: Westat IRB approval letter
Attachment Q-2: Field Consent Form ABS and High Risk
Attachment R: Field Consent Form Service Provider Sample
Attachment S: Phone Consent Form Landline and Cell
Attachment T: Phone Consent Form High Risk
Attachment U: Phone Consent Form Service Provider Sample
Attachment U1: Distress and Debriefing Procedures
Attachment V: CATI Full Interview
Attachment W: Field Full Interview
Attachment W-1: Event History Calendar
Attachment W-2: ACASI Tutorial
Attachment W-3: Demographic Questions
Attachment X: Interviewer FAQs with Household
Attachment Y: Interviewer FAQs with Selected Respondent
Attachment Z: Inaccessible Dwelling Unit Letter

Attachment A:
Assumptions and Calculation of Respondent Burden

Appendix A. Annual Respondent Burden for the NSHS Interviews – Detail
The table below presents the estimates of the number of responses and burden hours for the discreet tasks comprising the summary
categories from Table 1c. For each of the Test-mode groups shown in Table 1c, the table below provides each of the activities, the
relevant sample type the activity pertains to, the time to complete the task, the number of respondents, expected burden hours and cost.
For example, Table 1c shows 57.1 burden hours for the CATI group in the feasibility test. The table below breaks these 57.1 hours into
each of the activities used in this calculation.
We anticipate that respondents may be engaged in the following activities: reading flyers and pre-notification, recruitment and conversion
letters, contacting Westat by web or phone to volunteer for participation, completing the household roster screener survey by mail, by
phone, or in person, receiving post-survey letter and incentive, completing the respondent survey by phone or in person, and completing
the re-interview survey by phone or in person. These activities differ depending on which mode and sample the respondent is in. For
example, the Service Provider and High Risk sample will read recruitment flyers and screened to determine eligibility, while the general
population sample will not. The RDD-landline sample will be sent pre-notification letters, while the cellphone sample will not.

Table A-1. Assumptions used for calculation of respondent Burden

Feasibility Test

Description

Sample Type

Time to
Complete
Task

Number of
responses+

CATI Sample (Total)

57.1

Read flyer/respond via web or phone

Service Provider
High Risk

Read Pre-notification letter
Read conversion letter
Read extended conversion letter

RDD Landline

Read post-survey letter and receive incentive
Respondent selection
Complete survey by phone
Complete reinterview survey by phone

Total expected
burden hours*

Service Provider
High Risk
RDD Landline/Cell
RDD Landline
RDD Cell
Service Provider
High Risk
RDD Landline/Cell
High Risk
RDD Landline/Cell

0.067

0.017

0.083
0.050
0.565
0.307
0.289
0.307
0.289

24
48
320
115
48
20
45
45
34
29
20
40
40
5
5

1.6
3.2
5.3
1.9
0.8
0.3
0.8
0.8
2.8
1.5
11.3
12.3
11.5
1.5
1.4

Total
expected
burden cost
$1,370
$38
$77
$128
$46
$19
$8
$18
$18
$68
$35
$271
$295
$277
$37
$35

Table A-1. Assumptions used for calculation of respondent Burden (continued)
Time to
Complete
Description
Sample Type
Task

Number of
responses+

ACASI Sample (Total)
Read flyer/respond via web or phone
Read 1st advance letter and household roster
Read 2nd advance letter and household roster
Read post-survey letter and receive incentive
Complete household roster by mail
Complete household roster in person
Complete survey in person
Complete reinterview survey in person

Total expected
burden hours*
65.6

Service Provider
High Risk

0.067

General Population

0.017

General Population
General Population
Service Provider
High Risk
General Population
High Risk
General Population

0.083
0.117
0.598
0.341
0.324
0.341
0.324

Total expected
burden cost

24
48
200
170
46
46
70
20
40
40
5
5

1.6
3.2
3.3
2.8
0.8
3.8
8.2
12.0
13.6
13.0
1.7
1.6

$1,573
$38
$77
$80
$68
$18
$92
$196
$287
$327
$311
$41
$39

361
1,205
34,127
12,286
5,119
300
1,150
8,350
6,772
5,715
300
1,000
8,000
150
350

4,908.7
24.1
80.3
568.8
204.8
85.3
5..0
19.2
139.2
564.3
285.8
169.5
307.2
2,308.3
46.1
101.0

$117,710
$577
$1,926
$13,639
$4,910
$2,046
$120
$460
$3,337
$13,553
$6,852
$4,065
$7,366
$55,352
$1,105
$2,422

Pilot Test
CATI Sample (Total)
Read flyer/respond via web or phone

Service Provider
High Risk

Read Pre-notification letter
Read conversion letter
Read extended conversion letter

RDD Landline

Read post-survey letter and receive incentive
Respondent selection
Complete survey by phone
Complete reinterview survey by phone

Service Provider
High Risk
RDD Landline/Cell
RDD Landline
RDD Cell
Service Provider
High Risk
RDD Landline/Cell
High Risk
RDD Landline/Cell

0.067

0.017

0.083
0.050
0.565
0.307
0.289
0.307
0.289

Table A-1. Assumptions used for calculation of respondent Burden (continued)
Time to
Complete
Description
Sample Type
Task

Number of
responses+

Service Provider
High Risk
General Population
General Population
General Population
Service Provider
High Risk
General Population
High Risk
General Population

361
1,205
33,072
28,111
0.017
7,359
0.083
7,359
0.117
13,245
0.598
300
0.341
1,000
0.324
7,500
0.341
150
0.324
350
Total Respondent Burden
0.067

Total Burden (Agency plus respondent)

+Rounded to the nearest integer
*Rounded to the nearest tenth of a percent

Total expected
burden hours*
6,523.4
24.1
80.3
551.2
468.5
122.7
613.3
1,545.3
179.5
340.5
2,433.5
51.1
113.6

Total expected
burden cost

11,555

$156,431
$577
$1,926
$13,218
$11,235
$2,941
$14,706
$37,055
$4,304
$8,165
$58,355
$1,225
$2,723
$277,084

11,865

$283,721

Attachment B:
Field Mail Cover Letter

{BJS Letterhead}

<>
<>
<>
<>
<>

Dear Resident:
Your household has been randomly selected for an important study sponsored by the Bureau of Justice
Statistics, an agency in the U.S. Department of Justice. We are contacting over 20,000 households like
yours as part of the study about the health and safety of the U.S. population. The findings will help us
improve the information that we collect on these important topics.
We’re looking for people who may qualify to take part in the study. We ask that an adult in your
household complete the attached survey and return it in the postage-paid envelope. All information you
provide will be treated as confidential and is protected by federal statute (Title 42 USC, Section 3735
and 3789g). Your participation is voluntary. However, your cooperation is very important to the
success of this study. The answers you give us will help make sure that the study represents your
community and everyone who lives there. We will send you $5 as a thank you gift for completing this
short survey.
Based on answers to the attached survey, we may contact your household again to determine if anyone is
eligible to join our larger study. For participating in the larger study, the eligible person will receive a
monetary thank you gift.
Westat, a research firm located in Rockville, Maryland, is carrying out the survey for us. If you have
any questions about the survey, please contact them toll free at [PHONE].
We know that your time is valuable. Thank you in advance for your cooperation.
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
U.S. Department of Justice

Attachment B: Field Mail Cover Letter

Commonly Asked Questions
How long will it take to complete this survey?
The enclosed survey should take about 5 minutes to complete.
Am I required to complete this survey?
Your participation is voluntary, and there are no penalties for not answering.
How was my household chosen for this study?
Your household was selected at random from all residential addresses in this metropolitan area.
Why is random selection so important?
Random selection means that a diverse group of residents from this metropolitan area can represent the
experience and opinions of the entire area. For this survey to be truly scientific, all selected households
included should participate.
Who is the sponsor of this study?
The survey is sponsored by the Bureau of Justice Statistics (BJS), U.S. Department of Justice (DOJ).
The survey is conducted under the authority of Title 42 USC, Section 3735 and 3789g. To learn more
about BJS, you can visit them on the web at www.bjs.gov/.
What is the National Study on Health and Safety?
The purpose of this federally sponsored national study is to gather information about health and safety
issues in U.S. households. The results will be used to guide national policies.
Who will use this information?
The information will be used by policymakers and researchers. Therefore, it is vital that the survey
reflects an accurate picture of health and safety in the U.S.
How do I know you'll keep my information confidential?
The information you provide will be used for statistical purposes only and may not be disclosed, or used,
in identifiable form for any other purpose as required by law (Title 42, U.S. Code, Sections 3789g).
Your responses will be combined with those of others to produce statistical summaries about health and
safety. After the study is completed, identifying information - your address and phone number - are
destroyed.
Whom can I call with questions?
Further information can be obtained from our survey support center at [TOLL FREE].
OMB Control Number:

Expiration Date:

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Bureau of
Justice Statistics, Office of the Director, 810 7th Street, NW, Washington, DC 20531. The study reference number is “OMB
No. XXXX-XXXX”

Attachment B: Field Mail Cover Letter

INSERT WITH LETTER

Attachment B: Field Mail Cover Letter

Attachment B-1:
Field Mail Reminder Postcard

[OJP Logo]
[DATE]

Recently we mailed you a short questionnaire for a health and safety study
sponsored by the U.S. Department of Justice. If someone in your household has
already returned that survey, we thank you very much for your help.
If you have not yet completed and returned your survey, please do so right
away. We need to hear from everyone so your help is very important. We will
send you $5 as a thank you gift for completing this short survey.

Westat, a research firm located in Rockville, Maryland, is carrying out the
survey for us. If you have questions or need another copy of the survey, please
contact Westat at [TOLL-FREE].
Sincerely,

William Sabol, Acting Director
Bureau of Justice Statistics, U.S. Department of Justice

Important reminder about a study for
the U.S. Department of Justice

Attachment B-2:
Field Mail Reminder Letter

{BJS Letterhead}

<>
<>
<>
<>
<>

Dear Resident:
We recently sent you a letter and a brief survey concerning an important health and safety study being
sponsored by the Bureau of Justice Statistics, an agency in the U.S. Department of Justice. If you have
already returned your survey, thank you. If not, we are including a copy of the survey and a postagepaid envelope. Please take a few minutes to complete the survey and return it to Westat.
Based on your answers to the enclosed survey, we may contact your household again to determine if
anyone is eligible to join our larger study. For participating in the larger study, they will receive a
monetary thank you gift.
Your participation is voluntary. However, your cooperation is very important to the success of this
study. The answers you give us will help make sure that the study represents your community and
everyone who lives there. We will send you $5 as a thank you gift for completing this short survey.
One of our interviewers may contact you if we have not heard from you in a few weeks.
We know that your time is valuable. Thank you in advance for your cooperation.
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
U.S. Department of Justice

Attachment B1: Field Mail Reminder Letter

INSERT WITH LETTER

Attachment B1: Field Mail Reminder Letter

Attachment C:
Field Mail Household Roster Survey

National Study on Health and Safety
Start Here
Household Questions
 Please use a black or blue pen to complete this form.
 Mark  to indicate your answer.
 If you want to change your answer, darken the box

Please answer the following questions for each adult in the household, age 18 years or older. Include yourself as Person 1. If more than five persons, continue on back.
Include adults who usually stay at this address but are temporarily away on business, on vacation, or in a hospital. Do not include college students who live away from home.
4. How many adults age 18 years or older live in this household?

and mark the correct answer.

Person 1

About You
This survey may be completed by any household member
age 18 years or older. Completion of this survey is
voluntary.
Please answer the first questions about your own health
and safety behaviors.

Person 2

(You)

Person 3

Person 4

Person 5

5. What is the person's
first name or initials?

6. Is this person:

1
2

Male
Female

1
2

Male
Female

1
2

Male
Female

1
2

Male
Female

1. Woul
d
y
ou
s
a
y
i
n
g
ener
a
l
t
hat
y
our
hea
l
t
h
i
s
…?
Excellent........................................................
Very good......................................................
Good..............................................................
Fair.................................................................
Poor...............................................................

years

4
5

8. Is this person
of Hispanic or
Latino origin?

1
2

years

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

Yes
No

1
2
3
4
5

9. What is his/her race?
You may mark more
than one.

1
2
3
4
5

3. In the last 12 months, have you gone to a hospital
or emergency room because of an injury?
Yes..................................................................
No...................................................................

years

2. On average, during the last 12 months, how often
have you ridden public transportation?
Almost every day (or more frequently).........
At least once a week......................................
At least once a month...................................
Less often.......................................................
Never.............................................................

7. What is his/her age?

2
3
4
5

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1
2

Please provide us with your name and telephone number in case we need to contact you about this survey.
NAME
Thank you for completing this survey.

TELEPHONE

 Please continue on back if additional adults live in this household.

Household Questions
Please answer the following questions for each additional adult in the household, age 18 years or older.

OMB
#
:
x
x
x
x
‐
x
x
x
x
Exp Date: MM/DD/YYYY

Person 6

Person 7

Person 8

5. What is the
person's first
name or initials?
6. Is this person:

1
2

7. What is his/
her age?

8. Is this person
of Hispanic or
Latino origin?

9. What is his/
her race?
You may mark
more than one.

Male
Female

1
2

years

1
2

1
2
3
4
5

Male
Female

1
2

years

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

2
3
4
5

Male
Female

years

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

2
3
4
5

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

All of the information you provide will be kept strictly confidential and not disclosed to anyone but the study researchers.
Return completed survey to Westat, 1600 Research Blvd., RW2634, Rockville, MD 20850
FPO Barcode

Attachment D:
Advance Letter to Eligible Field Households with Incentive

{BJS Letterhead}

Date
<>
<>
<>
<>

Dear Resident:
Thank you for recently completing the short survey we sent as part of a study sponsored by the Bureau
of Justice Statistics. We have enclosed $5 to thank you for your response.
We have determined that your household is eligible for the National Study on Health and Safety. This
study is sponsored by the Bureau of Justice Statistics, an agency in the U.S. Department of Justice. In
the near future, an interviewer will stop by your home to answer questions about the study. At that time,
the interviewer will randomly select an adult in your household to participate in the survey. The person
selected for the study will be given $40 as a thank you for completing the interview.
If you would like more information about the study or, if you prefer certain days or times for the
interviewer to stop by, please contact us toll free at [TOLL-FREE].
Thank you for your assistance. We look forward to your participation in this important research.
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
U.S. Department of Justice

Attachment D: Advance Letter to Eligible Field Households

Attachment D-1:
Incentive Letter to Ineligible Field Households

{BJS Letterhead}

Date
<>
<>
<>
<>

Dear Resident:
Thank you for recently completing the short survey we sent as part of a study sponsored by the Bureau
of Justice Statistics. We have determined that your household is not eligible for the National Study on
Health and Safety.
We have enclosed $5 to thank you for your response.
Thank you for your assistance.
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
US Department of Justice

Attachment D1: Incentive Letter to Ineligible Field Households

Attachment E:
Field ACASI Household Roster

Household Screener
INTRO01 (IF HOUSEHOLD RETURNED ROSTER)
Hello, I am __________ from Westat. Someone from your household recently returned a brief survey
regarding an important health and safety study being conducted by the Bureau of Justice Statistics. We
have determined that your household is eligible to participate in the study
I have a few questions that will tell us whether anyone living here can take part in our study. . All
information you provide will be treated as confidential and is protected by federal statute (Title 42 USC,
Section 3735 and 3789g). Your participation is voluntary. However, your cooperation is very important
to the success of this study. If an adult is selected for the study, that person will receive $40 as a thank
you for completing a full interview.
INTRO02 (IF HOUSEHOLD DID NOT RETURN ROSTER)
Hello, I am __________ from Westat. We recently sent your household a brief survey regarding an
important health and safety study being conducted by the Bureau of Justice Statistics. I have a few
questions that will tell us whether anyone living here can take part in our study.
All information you provide will be treated as confidential and is protected by federal statute (Title 42
USC, Section 3735 and 3789g). Your participation is voluntary. However, your cooperation is very
important to the success of this study. If an adult is selected for the study, that person will receive $40
as a thank you for completing a full interview.
IF NOT OBVIOUS, ASK IF THE RESPONDENT IS 18 OR OLDER.
First let me verify, do you live at (ADDRESS)?
1
2

YOU ARE SPEAKING TO AN ADULT RESIDENT
GO TO INTRO03
YOU ARE NOT SPEAKING TO AN ADULT RESIDENT (ASK TO SPEAK
TO ADULT RESIDENT AND RESET TO INTRO01 OR INTRO02)

INTRO03
We would like to record some of the questions and answers for training and data quality. I’d like to
continue now, unless you have any questions.
1
7

CONSENT TO RECORDING
GO TO HM0001
DOES NOT CONSENT TO RECORDING GO TO INTRO04

INTRO04 (IF INTRO03=7)
That’s fine, the interview will not be recorded.

Attachment E: Field Household Roster

HM0001
I am going to ask some questions about the adults ages 18 or over who think of this address as their
main home.
This includes adults who usually stay at this address but are temporarily away on business, on vacation,
or in a hospital.
It does not include college students who live away from home.
(Including yourself,) How many adults live at this address and have no other place they usually live?
|__|__|__|

NUMBER OF PEOPLE

HM0002
[A]
What is [your first name | the first name of the adult, or one of the adults, who lives at this
address and owns or rents this home]?
________________________________________
[B]

Next, please tell me the first names of all other adults in this household.
______________________________________________________

HM0005
Just to confirm, {you are / NAME is} …?
1
2
-8
-7

MALE
FEMALE
DON’T KNOW
REFUSED

HM0006
How old {are you / is NAME}?
1
-8
-7

|__|__|__|
DON’T KNOW
REFUSED

HM0008 (IF DK OR REFUSED IN HM0006)
Please look at this list. [Are you/Is NAME] …
1
2
3
4
5
6
7
8
2

Under 18 years old,
18 to 24 years old,
25 to 29 years old,
30 to 39 years old,
40 to 49 years old,
50 to 59 years old,
60 to 64 years old,
65 years old or above
Attachment E: Field Household Roster

-8
-7

DON’T KNOW
REFUSED

HM0010
{Are you/Is NAME} Hispanic, Latina, or of Spanish origin?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

HM0010a
What is {your/NAME’s} origin? Please choose all that apply.
1
Mexican, Mexican American, Chicano or Chicana,
2
Puerto Rican,
3
Cuban, or
4
Another Hispanic, Latina, or Spanish origin?
-8
DON’T KNOW
-7
REFUSED
HM011
What is {your/NAME’s} race? Please choose all that apply.
1
2
3
4
5
-8
-7

White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
DON’T KNOW
REFUSED

HM0020
I just asked you questions about {NUMBER} adult household member(s): {LIST ALL HH
MEMBERS}.
Before we move on, I just want to confirm, are there any other adults who live at this address?
1
YES GO TO HM0001
2
NO
GO TO H2

H2
RUN THE SAMPLING ALGORITHM. ELIGIBILITY IS DETERMINED WHEN THE
ENUMERATION IS COMPLETED. SELECTION IS BASED ON RANDOM SELECTION OF
ADULT FEMALE AGES 18-49. SP=SAMPLED ADULT. IF AN SP HAS BEEN SELECTED, GO
TO HX0014. ELSE IF NO HOUSEHOLD MEMBER IS SELECTED, END SCREENER AND
DISPLAY:
“Thank you for your time today. Based on the information you’ve given us, your household has not
been selected for participation in the study.”
3

Attachment E: Field Household Roster

HX0014
Based on the information you have provided, we have selected {SP FILL 1} to participate in the study.
Can I just confirm that {SP FILL 1} is {GENDER} and {AGE} years old?

Contact Information
HL0001
I’d like to take a brief moment and get some of your contact information for my records.
HL0002
What is your telephone number, in case my office wants to check my work?
__________ _________________________
AREA CODE
PHONE NUMBER

_____
EXT.

HL0003
Is this a home or cell phone number?
1 HOME
2 CELL
3 OTHER
-8 DON’T KNOW
-7 REFUSED
HL0004
Is there a second telephone number where you can be reached?
__________ _________________________ _____
AREA CODE
PHONE NUMBER
EXT.
HL0005
Is this a home or cell phone number?
1 HOME
2 CELL
3 OTHER
-8 DON’T KNOW
4

Attachment E: Field Household Roster

-7 REFUSED

HL006
Thank you for the contact information.
IF {SP FILL 1} IS AVAILABLE, ATTEMPT TO ADMINISTER INTERVIEW.
IF {SP FILL 1} IS NOT AVAILABLE, ATTEMPT TO SCHEDULE APPOINTMENT FOR RETURN
VISIT.

Attachment E: Field Household Roster

Attachment F:
CATI Advance Letter

[BJS LETTERHEAD]

[DATE]
<>
<>
<>
<>
Dear Resident:
Your household has been randomly selected for an important study sponsored by the Bureau of Justice
Statistics, an agency in the U.S. Department of Justice. We are contacting over 20,000 households like
yours as part of this study about the health and safety of the U.S. population. The findings will be used
to improve the information that we collect on these important topics.
Adults over the age of 18 are eligible to participate. If someone in your home is eligible to participate
and completes the interview, we will send them $20 as a thank you for their participation. It will
take approximately 5 minutes to find out if there is someone eligible in the household.
Participation in the study is entirely voluntary and you may refuse to answer any question or stop at any
time. However, your participation is very important to the success of this study. The answers you give
us will help make sure that the study represents your community and everyone who lives there. All
information you provide will be treated as confidential and is protected by federal statute (Title 42 USC,
Section 3735 and 3789g).
Westat, a research firm located in Rockville, Maryland, is carrying out the survey for us. Someone from
Westat will call soon to discuss the study in more detail and complete the interview if there is an eligible
person in your household. If we call at a time that isn’t convenient, please tell us. We will be happy to
set up a better time. If you have any questions, please call Westat at [TOLL FREE].
Thank you for your assistance. The Bureau of Justice Statistics appreciates your help.
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
U.S. Department of Justice

Attachment F: CATI Advance Letter

Commonly Asked Questions
How long will it take to complete this survey?
The average time varies depending on your household’s experiences; the survey should take anywhere
from 15-30 minutes to complete.
Am I required to complete this survey?
Your participation is voluntary, and there are no penalties for not answering.
How was my household chosen for this study?
Your household was selected at random from all residential phone numbers in this metropolitan area.
Why is random selection so important?
Random selection means that a diverse group of residents from this metropolitan area can represent the
experience and opinions of the entire area. For this survey to be truly scientific, all selected households
included should participate.
Who is the sponsor of this study?
The survey is sponsored by the Bureau of Justice Statistics (BJS), U.S. Department of Justice (DOJ).
The survey is conducted under the authority of Title 42 USC, Section 3735 and 3789g. To learn more
about BJS, you can visit them on the web at www.bjs.gov/.
What is the National Study on Health and Safety?
The purpose of this federally sponsored national study is to gather information about health and safety
issues in U.S. households. The results will be used to guide national policies.
Who will use this information?
The information will be used by policymakers and researchers. Therefore, it is vital that the survey
reflects an accurate picture of health and safety in the U.S.
How do I know you'll keep my information confidential?
The information you provide will be used for statistical purposes only and may not be disclosed, or used,
in identifiable form for any other purpose as required by law (Title 42, U.S. Code, Sections 3789g).
Your responses will be combined with those of others to produce statistical summaries about health and
safety. After the study is completed, identifying information - your
address and phone number - are destroyed.
Whom can I call with questions?
Further information can be obtained from our survey support center at [TOLL FREE].
OMB Control Number:

Expiration Date:

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to: Bureau of Justice Statistics, Office of the Director, 810 7th Street, NW, Washington,
DC 20531. The study reference number is “OMB No. XXXX-XXXX”

Attachment F: CATI Advance Letter

Attachment G:
CATI Landline Screener

Landline Screener
SINTRO_1 (MOD)
Hello, my name is {INTERVIEWER NAME}. I am calling on behalf of the US Bureau of Justice
Statistics. We are doing a scientific study on health and safety. I am not asking for money--this is a
scientific study called the National Study of Health and Safety.
I am calling to see if you or someone in your household would be eligible to take part in this study.
Participants will answer questions about health and safety and will be sent a $20 in appreciation for their
time. It will take about 2 minutes to see if you or someone in your household qualifies for the study. (IF
LETTER WAS SENT:) Your household may have received a letter about this.
Are you a member of this household and at least 18 years old?
[A HOUSEHOLD EXCLUDES SCHOOL DORMITORIES, NURSING HOMES, VACATION
HOMES, AND ANY LIVING QUARTERS WITH MORE THAN 9 UNRELATED ADULTS. IF
YOU HAVE REACHED ONE OF THESE, CODE "NH. NOT A HOUSEHOLD"]
1. YES................................................................. [GO TO SINTRO_2]
2. NO................................................................... [GO TO S3A]
3. PROBABLE BUSINESS................................ [GO TO SINTRO_2]

SINTRO_2
In what county is this household?
PHOENIX-MESA-SCOTTSDALE:
1
Maricopa County, AZ
2
Pinal County, AZ
LOS ANGELES-LONG BEACH-ANAHEIM
3
Orange County, CA
4
Los Angeles County, CA
DALLAS-FORT WORTH-ABILENE, TX
5
Collin County, TX
6
Dallas County, TX
7
Delta County, TX
8
Denton County, TX
9
Ellis County, TX
10
Hunt County, TX
11
Johnson County, TX
12
Kaufman County, TX
13
Parker County, TX
14
Rockwall County, TX
15
Tarrant County, TX
16
Wise County, TX
MIAMI-FORT LAUDERDALE-WEST PALM
17
Broward County, FL
18
Miami-Dade County, FL
1

Attachment G: CATI Landline Screener

19
Palm Beach County, FL
NEW YORK-NY, NJ, PA
20
Bergen County, NJ
21
Essex County, NJ
22
Hudson County, NJ
23
Hunterdon County, NJ
24
Middlesex County, NJ
25
Monmouth County, NJ
26
Morris County, NJ
27
Ocean County, NJ
28
Passaic County, NJ
29
Somerset County, NJ
30
Sussex County, NJ
31
Union County, NJ
32
Bronx County, NY
33
Kings County, NY
34
Nassau County, NY
35
New York County, NY
36
Putnam County, NY
37
Queens County, NY
38
Richmond County, NY
39
Rockland County, NY
40
Suffolk County, NY
41
Westchester County, NY
42
Pike County, PA
99
Other
-7. REFUSED...........................................................
-8. DON'T KNOW.......................................................

[SKIP TO CTHANK02]
[SKIP TO CTHANK02]
[SKIP TO CTHANK02]

SINTRO_3
(DO NOT ASK UNLESS NECESSARY: CODE ONLY)
What is your gender?
GENDER
1. MALE...........................................................
2. FEMALE.......................................................
-7. REFUSED.............................................................
-8. DON'T KNOW..........................................................
SINTRO_4
Is this phone number used for…
1. Home use,........................................................... [GO TO SL5]
2. Home and business use, or..................................[GO TO SL5]
3. Business use only?.............................................. [GO TO THANK01]
GT. GO TO RESULT.............................................[GO TO RESULT]
THANK01
Thank you, but we are only interested in residences.

Attachment G: CATI Landline Screener

[GO TO RESULT; FINALIZE AS NR]
S3A
May I please speak with a household member who is at least 18 years old?
[HOUSEHOLD (HH) MEMBERS INCLUDE PEOPLE WHO THINK OF THIS HH AS THEIR
PRIMARY PLACE OF RESIDENCE. IT INCLUDES PERSONS WHO USUALLY STAY IN
THE HH BUT ARE TEMPORARILY AWAY ON BUSINESS, VACATION, IN A HOSPITAL,
OR LIVING AT SCHOOL IN A
DORM, FRATERNITY OR SORORITY.]
SRAVAIL
1. AVAILABLE................................................................ [GO TO SINTRO_1]
2. NOT AVAILABLE....................................................... [GO TO RESULT]
3. THERE ARE NONE..................................................... [GO TO RESULT]
GT. GO TO RESULT........................................................ [GO TO RESULT]
SL5
I have a few more questions to see if someone in your household qualifies for the study. This only takes
a few minutes.
[PRESS ENTER TO CONTINUE.]
SL5A
Including yourself, how many adults AGE 18 AND OLDER, currently live in this household?
[IF NEEDED: Include adults who think of this household as their primary place of residence.
Include adults who usually stay in the household but are temporarily away on business, vacation,
in a hospital, or living at school in a dorm, fraternity or sorority.]
_____ NUMBER OF ADULTS..................................................
-7. REFUSED................................................................. [GO TO PN SL6C]
-8. DON'T KNOW.......................................................... [GO TO PN SL6C]
PROGRAMMING NOTE SL5A-b:
SET ADLTCNT = SL5A
IF ADLTCNT=1 AND GENDER=1, GO TO THANK02;
ELSE CONTINUE.
SL5B
(IF GENDER=2: Including yourself) How many of those (SL5A) adults are male?
_____ NUMBER OF MALES..................................................
-7. REFUSED.............................................................
-8. DON'T KNOW..........................................................
SL5C
And just to confirm, how many of those (SL5A) adults are female?
_____ NUMBER OF FEMALES..................................................
-7. REFUSED.............................................................
-8. DON'T KNOW..........................................................
3

Attachment G: CATI Landline Screener

APPLY RIZZO SELECTION METHOD:
If Screener R is selected go to SL6A
If Non-Screener R has been selected, go to SL6B or SL6C, depending on count.
If cannot apply RIZZO method (because of too many females), then go to SL7

SL6A The computer has selected you to participate in this interview. Please tell me just your first
name and age.
SL6B The computer has selected the other female adult in your household to participate in this
interview. Please tell me just her first name and age.

SL6C The computer has selected the female adult in your household to participate in this interview.
Please tell me just her first name and age.
[IF FIRST NAME REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE, RELATION OR
OTHER IDENTIFYING INFORMATION.]
[PROBE: We need some way to ask for this person if we need to call back.]

(ALL IN SL6/SL6A/SL6B/SL6C SKIP TO SL8)

Attachment G: CATI Landline Screener

SL7. Starting with yourself, please tell me the age and gender of each adult, age 18 and older, who
normally lives in this household.
[IF FIRST NAME REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE, RELATION OR
OTHER IDENTIFYING INFORMATION.]
[IF NEEDED: We are only interviewing one adult in each household and asking this question helps the
computer decide which person that should be.]
Name
SL7a
SL7b
SL7c
SL7d
SL7e
SL7f
SL7g
SL7h

Gender

Age

RANDOMLY SELECT FEMALE ADULT FROM SL7
READ: (NAME/INITIAL S FROM SL7A-H) has been randomly chosen by my computer to
participate in this study.
SL8. I’d like to confirm that {you are/SELECTED RESPONDENT is} currently at least 18 years old.
Is that correct?
1
2
SL9.

Yes
No

IF NEEDED: May I please speak with {SELECTED RESPONDENT}?

1
Yes, available
2
No, not available
-7. REFUSED.............................................................
-8. DON'T KNOW..........................................................

Attachment G: CATI Landline Screener

RESULT
1. RING NO ANSWER......................................................
2. REFUSAL/BREAKOFF....................................................
3. BUSY, REGULAR SIGNAL................................................
4. CALLBACK/APPOINTMENT................................................
5. ANSWERING MACHINE...................................................
6. LANGUAGE/SPEECH/HEARING PROBLEM.....................................
7. QUESTIONABLE RING/TELEPHONE PROBLEM.................................
8. OTHER PROBLEM.......................................................
9. MAILOUT REQUESTED...................................................
10. TRACING.............................................................
NW. NON-WORKING.........................................................
NR. NON-RESIDENTIAL.....................................................
RP. PARENTAL REFUSAL....................................................

Attachment G: CATI Landline Screener

Attachment H:
CATI Cell Phone Screener

CELL PHONE SCREENER
PROGRAMMING NOTE:
IF THIS IS THE FIRST TIME AN ANSWERING MACHINE WAS REACHED AT THIS NUMBER,
CONTINUE WITH MESSAGE; ELSE GO TO NEXT CASE
[PLEASE READ THE FOLLOWING MESSAGE INTO THE ANSWERING MACHINE]
Hello, I'm calling from Westat, a social science research organization, on behalf of the US Bureau of
Justice Statistics. We are doing a study about health and safety. I am not asking for money--this is a
scientific study called the National Study of Health and Safety.
We will call you back in the next few days.

INTRODUCTION
Hello, my name is {INTERVIEWER NAME}. I'm calling from Westat, a social science research
organization, on behalf of the US Bureau of Justice Statistics. This is not a sales call. We are doing a
scientific study called the National Study of Health and Safety. If you are currently driving a car or
doing any activity that requires your full attention, I need to call you back at a later time.
[END CALL IMMEDIATELY IF R IS DRIVING OR DOING AN ACTIVITY AND SET
APPOINTMENT.]
SUBJECT NEEDS AN APPOINTMENT...................................... [SKIP TO RESULT]
In this part of the study, we are trying to reach people who use cell phones. Can you please confirm that
this number is for a cell phone?
NOT A CELL PHONE..................................................

[SKIP TO CELLVERF]

Thank you. I am calling to see if you or are eligible to take part in this study. It will take about 2 minutes
to see if you qualify for the study. If you are selected and complete the full questionnaire, you will
answer questions about health and safety and will be sent $20 in appreciation for your time.

C1.
CINTRO_1
Are you at least 18 years old?
1. YES...............................................................
2. NO................................................................
[SKIP TO THNKTEEN END]
-7. REFUSED........................................................... [SKIP TO THNKTEEN END]
-8. DON'T KNOW.................................................... [SKIP TO THNKTEEN END]
C2.
CINTRO (GENDER)
Are you male or female?
1
2
-7.
1

MALE................................................ [SKIP TO CTHANK02]
FEMALE
REFUSED........................................................... [SKIP TO CTHANK02]
Attachment H: CATI Cell Phone Screening

-8.

DON'T KNOW....................................................[SKIP TO CTHANK02]

C3.
CINTRO_2
In what county do you live?
PHOENIX-MESA-SCOTTSDALE:
1
Maricopa County, AZ
2
Pinal County, AZ
LOS ANGELES-LONG BEACH-ANAHEIM
3
Orange County, CA
4
Los Angeles County, CA
DALLAS-FORT WORTH-ABILENE, TX
5
Collin County, TX
6
Dallas County, TX
7
Delta County, TX
8
Denton County, TX
9
Ellis County, TX
10
Hunt County, TX
11
Johnson County, TX
12
Kaufman County, TX
13
Parker County, TX
14
Rockwall County, TX
15
Tarrant County, TX
16
Wise County, TX
MIAMI-FORT LAUDERDALE-WEST PALM
17
Broward County, FL
18
Miami-Dade County, FL
19
Palm Beach County, FL
NEW YORK-NY, NJ, PA
20
Bergen County, NJ
21
Essex County, NJ
22
Hudson County, NJ
23
Hunterdon County, NJ
24
Middlesex County, NJ
25
Monmouth County, NJ
26
Morris County, NJ
27
Ocean County, NJ
28
Passaic County, NJ
29
Somerset County, NJ
30
Sussex County, NJ
31
Union County, NJ
32
Bronx County, NY
33
Kings County, NY
34
Nassau County, NY
35
New York County, NY
36
Putnam County, NY
37
Queens County, NY
38
Richmond County, NY
39
Rockland County, NY
2

Attachment H: CATI Cell Phone Screening

40
Suffolk County, NY
41
Westchester County, NY
42
Pike County, PA
99
Other
-7. REFUSED...........................................................
-8. DON'T KNOW.......................................................

[SKIP TO CTHANK02]
[SKIP TO CTHANK02]
[SKIP TO CTHANK02]

C4.
Including yourself, how many adults AGE 18 AND OLDER, currently live in your household?
[IF NEEDED: Include adults who think of this household as their primary place of residence.
Include adults who usually stay in the household but are temporarily away on business, vacation,
in a hospital, or living at school in a dorm, fraternity or sorority.]
_____ NUMBER OF ADULTS..................................................
-7. REFUSED............................................................. [GO TO C7
-8. DON'T KNOW...................................................... [GO TO C7]
IF C4=1, GO TO C7.
ELSE CONTINUE.
C5.

How many of those (C4) adults are male?

_____ NUMBER OF MALES..................................................
-7. REFUSED.............................................................
-8. DON'T KNOW..........................................................
C6.
And just to confirm, (IF GENDER=2: including yourself) how many of those (C4) adults are
female?
_____ NUMBER OF FEMALES..................................................
-7. REFUSED.............................................................
-8. DON'T KNOW..........................................................

C7
Do you use this cell phone for . . .
1. personal use,.....................................................
2. personal and business use,........................................
3. business use only?................................................ [SKIP TO CTHANK01 END]
4. NOT A CELL PHONE......................................... [SKIP TO CELLVERF]
-7. REFUSED........................................................... [SKIP TO CTHANK01 END]
-8. DON'T KNOW....................................................[SKIP TO CTHANK01 END]
C8
You have been selected to participate in this interview.
CELLVERF
So, this is NOT a cell or mobile telephone number?
1. YES, IT IS A CELL PHONE........................................... [GO BACK TO THE LAST
QUESTION ASKED]
3

Attachment H: CATI Cell Phone Screening

2. NO, THIS IS NOT A CELL PHONE............................... [SKIP TO THANK1 END]
-7. REFUSED....................................................................... [SKIP TO THANK1 END]
-8. DON'T KNOW............................................................... [SKIP TO THANK1 END]
THANK1
Thank you, those are all the questions I have.
[PRESS ENTER TO CONTINUE]
[GO TO RESULT;
FINALIZE AS IP]
CTHANK01
Thank you, but we are only interested in residential use.
[PRESS ENTER TO CONTINUE]
[GO TO RESULT;
FINALIZE AS NR]
THNKTEEN
Thank you, but we are only interested in cell phones used by adults.
[PRESS ENTER TO CONTINUE]
[GO TO RESULT;
FINALIZE AS IP]
CTHANK02
Thank you, but you do not qualify for this study.
[PRESS ENTER TO CONTINUE]
[GO TO RESULT;
FINALIZE AS IP]
RESULT
[ENTER THE APPROPRIATE RESULT CODE.]
1. RING NO ANSWER....................................................
2. REFUSAL/BREAKOFF..................................................
3. BUSY, REGULAR SIGNAL..............................................
4. CALLBACK/APPOINTMENT..............................................
5. ANSWERING MACHINE.................................................
6. LANGUAGE/SPEECH/HEARING PROBLEM...................................
7. QUESTIONABLE RING/TELEPHONE PROBLEM...............................
8. OTHER PROBLEM.....................................................
9. MAILOUT REQUESTED.................................................
10. TRACING...........................................................
CS. COMPLETED SCREENER................................................
IP. INELIGIBLE SCREENER...............................................
NW. NON-WORKING.......................................................
NR. NON-RESIDENTIAL...................................................

Attachment H: CATI Cell Phone Screening

Attachment I:
CATI Refusal Conversion Letter

{BJS LETTERHEAD}

[DATE]
<>
<>
<>
<>

Dear Resident:
Your household has been randomly selected to participate in the National Study on Health and Safety,
sponsored by the Bureau of Justice Statistics, an agency in the U.S. Department of Justice.
An interviewer recently called your home, but was not able to complete the short, 2 minute interview.
We know your time is valuable; however, we encourage you to take just a few minutes to talk to the
interviewer when he or she calls again. If we happen to call at an inconvenient time, you can suggest a
time that is better for you. If someone in your home is eligible to participate and completes the
interview, we will send them $20 as a thank you for their participation.
Findings from this study will be used to improve the way we measure health and safety. This survey is
an important opportunity to have your voice heard.
If you have any questions, you may call toll free at [PHONE].
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
U.S. Department of Justice

Attachment I: CATI Refusal Conversion letter

Attachment J:
NSHS Brochure

Frequently Asked Questions
Q

Who should participate in this study?

Bureau of

3
39
Justice Statistics
9
3
25
24
14

The study is sponsored by the Bureau of
Justice Statistics, an agency within the U.S.
Department of Justice.

Women ages 18 to 39 are eligible to participate.

Who is conducting the study?

Westat, a social science research organization in Rockville,
Maryland, is working with the Bureau of Justice Statistics
(BJS) to develop and test these survey methods.

The study is being conducted by Westat,
an independent research organization.

How is the survey administered?

National Study on
Health and Safety

Participants will be assigned to one of two different
methods. Some will take the survey over the phone. Others
will be interviewed in person at a location convenient for
the participant.

Will participants be paid?

Participants will be paid $40 as a thank you for participating
in the survey.

How long will the survey last?

Between 15 and 30 minutes, depending on responses
to the questions.

When will participation occur?

The interviews will occur during 2014.

How will the confidentiality of participants
be protected?
All of the data are protected by Federal law. The study uses
specific security procedures to maintain confidentiality.

OMB No. XXX Expires XXX
Public reporting burden for this collection of information is
estimated to average 18 minutes. These estimates include the time for
reviewing instructions, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

37132.0913.89630204

What is this study about?

How can you help?

Why does your help matter?

The purpose of this federally sponsored national

Service organizations and academic institutions are
being asked to share information about the study
with women. The study has been designed carefully to
be sensitive to the privacy of your clients or students
and to be respectful of your staff resources.

Organizations and institutions that have direct
contact with women are in an ideal position to
provide information about the study. By assisting the
study, your organization or institution will support
the gathering of critical information that will have
an impact on how crime and victimization data are
gathered in the United States. These data are used by
decision makers, government officials, and those in
important positions to make significant changes that
improve the lives of women.

study is to improve the way information is collected
from women in the National Crime Victimization
Survey (NCVS). The NCVS is a national survey that
collects information from the general public on the
frequency, characteristics, and consequences of criminal
victimization in the United States. These data are
used to track trends in crime over time, as well as to
characterize the experience of victims. The information

We will work with each organization and institution
to tailor recruitment approaches. Your service
organization may choose to use any of the following
strategies to encourage participation in the study:

in the NCVS is used by policymakers, service providers,

• Talk directly with your clients about the study
by explaining its purpose

advocacy groups, and researchers. Therefore, it is

• Send emails to your clients about the study

vital that the survey reflects an accurate picture of

• Mail your clients information about the study,
using postage and letters provided by study staff

victimization in the United States.
The goal of this study is to test different ways of
gathering this information. The study will be conducted
in five metropolitan areas of the U.S., including Phoenix,
Dallas, New York City, Los Angeles, and Miami.
The Bureau of Justice Statistics has asked Westat, a
national social science research organization, to conduct
this study. We are seeking organizations and academic
institutions that are willing to help us recruit a sample
of women to participate in the study.

• Distribute posters and fliers developed by study
staff in waiting rooms or at other sites like
information fairs
• Share information about the study and recruitment
in newsletters or on web posts or blogs, using text
provided by the study
Your academic institution may choose to use any of
the following strategies to encourage participation in
the study:

For more information about this study, please contactDavid Cantor, Ph.D.
Principal Investigator
Westat
1600 Research Blvd.
Rockville, MD 20850
301-294-3814
DavidCantor@westat.com
Shannan Catalano, Ph.D.
Project Officer
Bureau of Justice Statistics
810 7th St., NW
Washington, DC 20531
202-616-3502
Shannan.Catalano@usdoj.gov

• Share information about the study and recruitment
on your web page or social media site using text
provided by the study

National Crime Victimization Survey (NCVS)

• Distribute posters and fliers developed by study
staff on campus bulletin boards or at other sites like
information fairs

Since the purpose of this study is to help form the
questions on the National Crime Victimization Survey,
you may wish to review the NCVS website:

• Send emails to your students about the study

http://www.bjs.gov//index.cfm?ty=dcdetail&iid=245

Attachment K:
High Risk Recruitment Flyer

NSHS
National Study on
Health and Safety

Female Research Participants Needed
Westat, a social science research organization, is recruiting female participants
for the National Study on Health and Safety on behalf of the U.S. Bureau of
Justice Statistics.

Women between the ages of 18 and 39
A confidential, 15-30 minute interview
Participants will receive $40
For more information or to participate:
www.website.com
Toll Free #
70

3
39
Justice Statistics
9
3
25
24
14

37166.0913.89630204

National Study on Health and Safety
www.website.com
Toll Free #

OMB No. XXX Expires XXX
Public reporting burden for this collection of information is estimated to average 18 minutes. These estimates include the time
for reviewing instructions, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

National Study on Health and Safety
www.website.com
Toll Free #

Bureau of

Attachment L:
Craig’s List Recruitment Ad for High Risk Sample

Sample Craigslist Ad

Female Research Participants Needed (RECEIVE $40)
Westat, a social science research organization (www.westat.com), is recruiting women between the ages
of 18 and 39 to participate in the National Study on Health and Safety. The study is being conducted for
the U.S. Bureau of Justice Statistics. Individuals will participate in a confidential, 15 to 30-minute
interview and will receive $40 as a thank you for completing the interview. The interviews will be
conducted in the [insert MSA area here] area. If you are interested in participating in this study, please
call 1-888-XXX-XXXX , or login to [insert link here].

Attachment L: Craig's List Recruitment Ad for High Risk Sample

Attachment M:
High Risk Recruit Script

RECRUITMENT SCREENER
Hello, may I speak to [Name]? My name is [Name], and I am calling from Westat, a social science
research organization in the Washington DC area. You recently called us to volunteer for a study we are
conducting related to women’s health and safety. The study is being sponsored by the Bureau of Justice
Statistics, an agency in the U.S. Department of Justice.
If you are eligible, you will be assigned to participate in the confidential interview either by telephone or
in-person, depending on the study protocol. The interview will take between 15 and 30 minutes
depending on your answers.
You will be given $40 as a thank you for completing the interview.
[IF NEEDED: If you have any questions about the legitimacy of the study or need more information,
you can contact the project director for this study, Leanne Heaton, at leanneheaton@westat.com or by
phone at 301-212-2106.]
[IF NEEDED: If you like, I can give you an address where you can send comments about the time and
burden you experienced for this research study. The address is:
Bureau of Justice Statistics
Office of the Director
810 7th Street, NW
Washington, DC 20531
The study reference number is “OMB No. XXXX-XXXX”.]
Would you be willing to participate in this interview?

IF YES:

Thank you very much. I need to ask you a few more questions to see if you meet
the eligibility criteria. If you do, we will collect contact information and get back
to you to schedule an interview. [GO TO SCREENER Q1.]

IF NO:

Thank you. I appreciate your taking the time to talk with me today. [END CALL]

Attachment M: High Risk Recruit Script

SCREENER QUESTIONS
Q1. (verify if needed) What is your gender?
□ FEMALE [GO TO Q2]
□ MALE Thank you. We are recruiting women for this
study. I appreciate your taking the time to talk with me today. [END CALL]
Q2. What is your age?
______ (in years)
If 18-39 – CONTINUE TO Q3.
If 40 OR MORE. Thank you. We are recruiting women who are between 18 to 39
I appreciate your taking the time to talk with me today. [END CALL]]
Q3. In what county and state do you live?
PHOENIX-MESA-SCOTTSDALE:
1
Maricopa County, AZ
2
Pinal County, AZ
LOS ANGELES-LONG BEACH-ANAHEIM
3
Orange County, CA
4
Los Angeles County, CA
DALLAS-FORT WORTH-ABILENE, TX
5
Collin County, TX
6
Dallas County, TX
7
Delta County, TX
8
Denton County, TX
9
Ellis County, TX
10
Hunt County, TX
11
Johnson County, TX
12
Kaufman County, TX
13
Parker County, TX
14
Rockwall County, TX
15
Tarrant County, TX
16
Wise County, TX
MIAMI-FORT LAUDERDALE-WEST PALM
17
Broward County, FL
18
Miami-Dade County, FL
19
Palm Beach County, FL
NEW YORK-NY, NJ, PA
20
Bergen County, NJ
21
Essex County, NJ
22
Hudson County, NJ
23
Hunterdon County, NJ
24
Middlesex County, NJ
25
Monmouth County, NJ
26
Morris County, NJ
2

Attachment M: High Risk Recruit Script

27
Ocean County, NJ
28
Passaic County, NJ
29
Somerset County, NJ
30
Sussex County, NJ
31
Union County, NJ
32
Bronx County, NY
33
Kings County, NY
34
Nassau County, NY
35
New York County, NY
36
Putnam County, NY
37
Queens County, NY
38
Richmond County, NY
39
Rockland County, NY
40
Suffolk County, NY
41
Westchester County, NY
42
Pike County, PA
99 Other
Thank you. We not recruiting any women who live in that county. I
appreciate your taking the time to talk with me today. [END CALL]]
Q4. How did you find out about this study?
□ CRAIGSLIST [GO TO Q5]
□ COLLEGE/UNIVERSITY FLYER/POSTING [GO TO Q5]
□ OTHER [GO TO Q5]

Q5. Are you currently a student, faculty, or staff at a college or university (either on campus
or online)?
□ YES [GO TO Q6]
□ NO [GO TO Q7]
Q6. Which college or university are you affiliated with? (WRITE IN RESPONSE)
____________________________________

Q7. Would you like to participate in the interview?
□ YES/ACCEPTED [GO TO Q8]
□ NO/DECLINED Thank you. I appreciate your taking the time to talk with me today.
[END CALL]

Attachment M: High Risk Recruit Script

Q8. Thank-you for this information. We will send your information to the interviewers. In
order to get in touch with you, could you give me some of your contact information?
NAME:
ADDRESS:
PHONE:
CELL
PHONE:
EMAIL:
[GO TO Q9]

Q9. In general, are there certain times or days that are best for the interviewer to contact
you?
DAYS/TIMES ________________________________

IF 18-29, SAY: “Thank you. We will be in touch to schedule an interview. If you have
any questions before the interview, please contact [PROJECT CONTACT NAME,
EMAIL AND PHONE #]. Thank you for your time!”
IF 30-39, SAY: “The study has received many calls, so we need to check to see if there is
still room for you to participate. If we still need your help, we will contact you to
schedule the interview.”

Attachment M: High Risk Recruit Script

Attachment N:
High Risk Scheduling Script

Telephone Script for Scheduling Interviews with High Risk Sample
Hello, may I speak with ____________________________?
If the participant is not there, do not leave a message with whoever is answering the phone. If the
participant is available, continue as follows:
Hello, ___________________________, my name is _____________________________ and I am
calling from Westat. Recently you spoke to a Westat interviewer about taking part in an interview about
health and safety issues for the U.S. Bureau of Justice Statistics. Is now a good time to talk?
NO: Can we schedule a better time for me to contact you? (Schedule another call and add information
to the contact log).
YES: Great.
You indicated that you would be interested in taking part in an interview. Let me tell you a little bit
about the study. The study is sponsored by the Bureau of Justice Statistics, an agency in the U.S.
Department of Justice. The goal is to improve the way the government collects information on rape and
sexual assault. We will ask you questions about sexual experiences that you may have had. All the
information collected as part of the study will be treated as confidential and you will be given $40 as a
thank you for completing the interview.
In-Person Interview: We would like to meet with you to explain the study and conduct it with you. If,
after we meet, you decide you don’t want to participate, that is completely fine. Would you be available
on (confirm date and time)?
NO: Is there another date and time you could meet me? [If no other time is convenient then thank
respondent for their time and hang up]
YES: Great. Most respondents prefer to respond to the survey in their home – if that’s ok with you, can
we meet at your home? Otherwise, can you suggest a location that is convenient and safe for you, but
that is private so that we are not distracted during the interview, such as a meeting room at your local
public library?
Just to confirm, I’ll see you at (location): ____________________________ On
(date)___________________ at (time)____________________________
If scheduled for more than one day later:
I’ll call you right before our meeting to make sure it’s still ok. Is this the best number to call you at?
Can I leave a message here? Is there anyone else who might answer this phone and if so, who should I
say is calling? Here is my phone number in case something comes up and you need to reschedule.

Attachment N: High Risk Scheduling Script

Attachment O:
Sexual Assault Brochure

Frequently Asked Questions
Q

Who should participate in this study?

Bureau of

3
39
Justice Statistics
9
3
25
24
14

National Study on Health and Safety

The study is sponsored by the Bureau of
Justice Statistics, an agency within the U.S.
Department of Justice.

Women who have had an unwanted sexual experience
are eligible to participate.

Who is conducting the study?

Westat, a social science research organization in Rockville,
Maryland, is working with the Bureau of Justice Statistics
(BJS) to develop and test these survey methods.

The study is being conducted by Westat,
an independent research organization.

How is the survey administered?

Participants will be assigned to one of two different
methods. Some will take the survey over the phone. Others
will be interviewed in person at a location convenient for
the participant.

Will participants be paid?

Participants will receive $50 as a token of appreciation.

How long will the survey last?

The survey will take approximately 30 minutes,
depending on responses to the questions.

When will participation occur?

The interviews will occur during 2014.

How will the confidentiality of participants
be protected?
All of the data are protected by Federal law. The study
uses specific security procedures to maintain confidentiality
and will be using staff trained to interview rape and
assault victims.

OMB No. XXX Expires XXX
Public reporting burden for this collection of information is
estimated to average 15 minutes. These estimates include the time for
reviewing instructions, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

37132.0913.89630204

Bureau of Justice Statistics
A Study on Rape and Sexual Assault

What is this study about?

How can your agency help?

Why does your help matter?

The purpose of this federally sponsored national
study is to improve the way information is collected
about rape and sexual assault. The National Crime
Victimization Survey (NCVS) is a national survey that
collects information from the general public on the
frequency, characteristics, and consequences of criminal
victimization in the United States. The NCVS is one of
the primary ways the Nation monitors the amount and
consequences of rape and sexual assault. These data are
used to track trends in crime over time, as well as to
characterize the experience of victims. The information
in the NCVS is used by policymakers, service providers,
advocacy groups, and researchers. Therefore, it is
vital that the survey reflects an accurate picture of
victimization in the United States.

Agencies are being asked to share information about
the study with women survivors. Agencies that have
direct contact with sexual assault survivors are the best
source for getting out the word about the opportunity
to participate. The study has been designed carefully
to be sensitive to the privacy of your clients and to be
respectful of your staff resources.

By assisting the study, your agency will support the
gathering of critical information that will have an
impact on how crime and victimization data are
gathered in the United States. These data are used by
decision makers, government officials, and those in
important positions to make significant changes that
improve the services to survivors.

We will work with each agency to tailor recruitment
approaches. Your agency may choose to use any of
the following strategies to encourage participation in
this study:

For more information about the NSHS Study on Rape
and Sexual Assault, please contact-

There is evidence that statistics on rape and sexual
assault can be improved. The goal of this study is to test
different ways of gathering this information. The study
will be conducted in five metropolitan areas of the U.S.,
including Phoenix, Dallas, New York City, Los Angeles,
and Miami.
The Bureau of Justice Statistics has asked Westat, a
national social science research organization, to conduct
this study. We are looking for agencies that are willing
to help recruit a sample of survivors to participate in
the study. We are including survivors of sexual assault in
these tests to make sure the NCVS accurately reflects
their experiences.

• Talk directly with your clients about the study
by explaining its purpose
• Send emails to your clients about the study
• Mail your clients information about the study,
using postage and letters provided by study staff
• Distribute posters and fliers developed by study
staff in waiting rooms or at other sites like
information fairs
• Share information about the study and recruitment
in newsletters or on web posts or blogs, using text
provided by the study

David Cantor, Ph.D.
Principal Investigator
Westat
1600 Research Blvd.
Rockville, MD 20850
301-294-3814
DavidCantor@westat.com
Shannan Catalano, Ph.D.
Project Officer
Bureau of Justice Statistics
810 7th St., NW
Washington, DC 20531
202-616-3502
Shannan.Catalano@usdoj.gov

National Crime Victimization Survey (NCVS)
Since the purpose of this study is to help form the
questions on the National Crime Victimization Survey,
you may wish to review the NCVS website:
http://www.bjs.gov//index.cfm?ty=dcdetail&iid=245

Attachment P:
Service Provider Scheduling Script

Attachment P: Service Provider Recruiting and Scheduling

Telephone Script for Scheduling Interviews with Service Provider Sample – Sexual Assault Flier
Version
Hello, may I speak with ____________________________?
If the participant is not there, do not leave a message with whoever is answering the phone. If the
participant is available, continue as follows:
Hello, ___________________________, my name is _____________________________ and I am
calling from Westat. Recently you [told service agency]/[called and left a message] that you are
interested in taking part in the National Study on Health and Safety to help improve the way information
about rape and sexual assault is collected for the U.S. Bureau of Justice Statistics. Is now a good time to
talk?
NO: Can we schedule a better time for me to contact you? (Schedule another call and add information
to the contact log).
YES: Great.
You indicated that you would be interested in taking part in an interview. Let me tell you a little bit
about the study. The study is sponsored by the Bureau of Justice Statistics, an agency in the U.S.
Department of Justice.. The goal is to improve the way the government collects information on rape and
sexual assault. We will ask you questions about sexual experiences that you may have had. All the
information collected as part of the study will be treated as confidential and you will be given $50 as a
thank you for completing the interview.
In-Person Interview: We would like to meet with you to explain the study and conduct it with you. If,
after we meet, you decide you don’t want to participate, that is completely fine. Would you be available
on (confirm date and time)?
Your privacy is very important so we need to do the interview where no one else can hear us. Would
you be able to meet us at [location at or near service agency]?
NO: Is there another date and time you could meet me at [location at or near service agency]? [If no
other time is convenient then thank respondent for their time and hang up]
YES: Great, I will meet you there. (give respondent directions if needed). Just to confirm, I’ll see you at:
____________________________ On (date)___________________ at
(time)____________________________

Attachment P: Service Provider Recruiting and Scheduling

Phone Interview: We would like to call you at a later time to explain the study and conduct it with you.
If at any point during that call you decide you don’t want to participate, that is completely fine. Would
you be available on (confirm date and time)?
Your privacy is very important so we need to do the interview where no one else can hear us. Would
you be able to be at a private location when I call you?
NO: Is there another date and time you could arrange to be at a private location to take the call? [If no
other time is convenient then thank respondent for their time and hang up]
YES: Great, so just to confirm, I’ll see you at: ___________________________________ On
(date)_____________________________ at (time)____________________________
Add notes to the contact log.
If scheduled for more than one day later:
I’ll call you right before our meeting to make sure it’s still ok, is this the best number to call you
at? Can I leave a message here? Is there anyone else who might answer this phone and if so, who
should I say is calling? Here is my phone number in case something comes up and you need to
reschedule.

Attachment P: Service Provider Recruiting and Scheduling

Attachment Q-1:
Westat IRB approval letter

Date:

July 15, 2013

To:

David Cantor, Project Director

From:

Kerry Levin, Chair Westat IRB

Subject:

Full Amendment Approval of Testing Alternative Survey Methods to Collect
Data on Rape and Sexual Assault, Project Number 8963 REVISED
FWA 0005551

On Tuesday, July 10, 2013, Testing Alternative Survey Methods to Collect Data on Rape and
Sexual Assault, Project Number 8963 was presented to the full Board. Pursuant to 45 CFR pt. 46,
the IRB reviews all studies involving research on human subjects. This study received initial
approval on August 14, 2012 to conduct cognitive interviews.
This request was to approve a pilot study to be conducted among 18,100 respondents in 5 core
based statistical areas (CBSA) of the country including; Los Angeles, Phoenix, Dallas, Miami, and
New York City. Respondents for the pilot interviews will be recruited from the general population
(n=15,500), respondents at a high risk for sexual assault (n=2,000), and a service provider sample
recruited from local rape crisis centers (n=600). Both ACASI and CATI administration modes will
be used for each sample.
This study will administer surveys via two different modes, random digit dial (RDD) using a landline
and cell phone telephone survey. The other will be selected using address based sampling, and will
have interviewers visit in person to administer the initial questions (e.g., collecting personal
characteristics) via a computer assisted personal interview (CAPI) and have the respondent answer
the sexual assault questions using an audio computer assisted self-interview (ACASI).
Preceding the pilot study will be a small feasibility study to pretest the protocol and to identify any
outstanding operational issues.
During the discussion, the following information was presented to the Board:





If accepted by OMB, the research team would like to promise a $5 incentive for respondents
completing the mail survey.
The higher incentive amounts proposed are associated with in-person interviews, or when
there is an increased level of intrusiveness placed on the respondent.
The ACASI program automatically sends a message to the respondent to request the
interviewer’s assistance any time the respondent lingers on an ACASI screen for at least 30
seconds. The interviewer will be trained to check in with the respondent at this point.
Female interviewers will be used for this study.




Rape, Abuse & Incest National Network (RAINN), the nation's largest anti-sexual violence
organization, is the crisis line used for this study. It is operated by volunteers and overseen
by licensed clinicians.
The research team will make a conscientious effort to schedule the same interviewer for the
2 week re-interview.

Action Requested: Review materials for the feasibility and pilot studies including the protocols,
surveys, recruitment and pre-notification materials, informed consent scripts, and FAQs.
Action Taken: Per 45 CFR 46, the Westat IRB determined that this research met criteria for
classification as minimal risk and assigned it a full approval. (For: 8; Against: 0; Abstain: 0).
The following is a list of recommended changes to project materials made by the Board and
responses reviewed and accepted under expedited authority on July 15, 2013:
Project Summary
1. Add information about the different incentive amounts and methods of payment (i.e., check,
cash, and debit card) to be provided to the respondents.
PD Response: Information was added to the Project Summary (pages 5 and 6) to illustrate
the different incentive amounts being offered.
2. Confirm whether or not the field interviewers are considered mandatory reporters in the
CBSAs.
PD Response: Regardless of state requirements, mandatory reporting procedures will be
followed in all CBSAs. Informed consent forms will be revised accordingly in order to
include this information.
Informed Consent Process
3. Revise consent scripts (Appendix N-R) to include a statement about the protection of
collected data under the federal statute (see Appendix N for preferred language).
PD Response: The proposed language differs by mode of administration. For the
telephone interview, the consent script is already very long. The PD felt that by adding
specific citations of federal statutes would make this even longer and with minimal benefit –
respondents won’t really hear this. The telephone script does mention the federal
protection; it just doesn’t cite the specific statutes. In-person, the respondent sees this
language and can actually get a copy of the consent form. The PD added language to
Appendix O, CATI CONSENT: Cell Phone and LANDLINE regarding the federal statute
as optional language for the telephone interviewer to read, if asked. It reads, “IF
RESPONDENT ASKS WHICH FEDERAL LAW, SAY: Federal law 42 U.S.C. Section
3789g).”
4. Confirm the purpose of the study in the following documents:
a. Appendix A: Field Mail Cover Letter (Page 18) - The sentence has been revised to
say, “This study will help improve the way we monitor and measure health and safety
issues in the communities like yours.”
2

b. Appendix N: Field Consent Form ABS and High Risk (Page 233) - This study will
help improve the way we monitor and measure health and safety issues in the
communities like yours.
PD Response: Appendix A has been revised accordingly.
5. Replace “answer” with “ask” on Appendix C, Advance Letter to Eligible Field Households
(page 21).
PD Response: language has been revised to say, “"In the near future, an interviewer
will stop by your home to answer any questions you might have about the study."
Interviewer Training Materials
6. Upload training materials to your document library and notify the IRB when the materials
are final. These materials must be reviewed and approved by the IRB.
PD Response: In process
7. Add instructions to the interviewer training that the interview should be stopped
momentarily or rescheduled when a third person enters the area.
PD Response: In process
8. Investigate further whether or not it is in the respondents’ best interest that they use the
project cell phone when the protocol warrants connecting them to a crisis counselor. If the
respondent agrees, add instruction for the interviewer to remain with the respondent or to
step into another room.
PD Response: A script and instructions have been added to Appendix S (distress protocol)
that provides respondents with a choice of which phone to use. A part of the script
indicates that using the respondent’s phone will result in a record of the call. Instructions
for the interviewer have also been added depending on which of the phone options the
respondent chooses.
The Project Director also informed the Board that a toll free number has been added to the
informed consent document for a participant to use for questions about the study.
As the Project Director you are responsible for the following:


cc:

Please submit this study for continuing review three months following the beginning
of data collection or before August 14th 2014, whichever comes first.
In the interim, notify the IRB Office as soon as possible if there are any injuries to subjects
as well as problems or changes with the study that relate to human subjects.
Institutional Review Board
Mark Freedman

Attachment Q-2:
Field Consent Form ABS and High Risk

Introduction
We are conducting a study called the National Survey on Health and Safety. This is a study being
conducted for the US Bureau of Justice Statistics, which is part of the US Justice Department. I work
for Westat, a social science research firm that is conducting the study for BJS.
We are conducting this study with women ages 18 to 49. Can you confirm that you fall into this
category?
1
2

Yes
No

This study will help improve the way we monitor and measure health and safety issues in communities
like yours. In order to give you more information about the study, please review this short description of
the study on the computer. If you would like me to read this aloud to you or if have any questions,
please let me know. At the end I will also ask if you have any questions. (TURN LAPTOP OVER TO
RESPONDENT. ONCE THEY HAVE REVIEWED IT, INTERVIEWER ASKS IF THEY HAVE ANY
QUESTIONS ABOUT IT. RESPONDENT CLICKS “ACCEPT” AND INTERVIEWER ENTERS ID
TO ACKNOWEDGE CONSENT. HARD COPY OF CONSENT FORM IS AVAILABLE IF
RESPONDENT WOULD LIKE IT)

Attachment N: Field Consent Form ABS and High Risk

CONSENT FORM
ABS and High Risk Sample
Screen 1
Westat is conducting this research for the U.S. Department of Justice, Bureau of Justice Statistics (BJS).
We are developing a survey about the health and safety issues associated with unwanted sexual
experiences and the consequences associated with these experiences. Your participation will help us
improve the way we monitor these health and safety issues around the country. Over the next few
screens we will provide you with a description of what is involved with taking this survey.
Screen 2
•
The interview should take approximately 15-30 minutes, depending on how you answer the
questions.
•
Your participation is voluntary, and you can withdraw at any time. If you don’t want to
answer particular questions, you can skip them.
•
We will give you $40 in a debit card as a thank you for completing the survey.
Screen 3
•
Later in the interview, you will be asked questions about health and safety issues related to
unwanted sexual experiences. You will answer these questions by yourself on a computer.
Some of the language used on the survey is explicit and some people may find it
uncomfortable, but it is important that we ask the questions this way so that you are clear
about what we mean.
•
If you become upset during the interview or want to stop the interview at any time, please let
the interviewer know. We can provide access to resources to help you.
Screen 4
•
All information obtained during this study will be treated as confidential and will only be used
to analyze study results. The data are collected under federal statute (Title 42 USC, Section
3735 and 3789g) and are protected from any request by a law enforcement or any other
agency, organization, or individual.
•
Your answers will be combined with responses from other study participants when writing up
reports and conducting analyses. Pursuant to 42 U.S.C. Sec. 3789g, neither BJS nor Westat
will publish any data identifiable specifically to a private person.
•
There are two exceptions to this. One is if we feel that you are a danger to yourself or
others. The other is if we think that a child is being abused or neglected in this home. In both
cases, in order to protect your safety and the safety of others, we would report this to a mental
health provider or law enforcement/child protection agency.

Attachment N: Field Consent Form ABS and High Risk

Screen 5
•
If you have questions about this research, please contact the National Study on Health and
Safety Information Line at (xxx-xxx-xxxx). If you have questions about your rights and
welfare as a research participant, please contact Westat’s Human Subjects Protection Office at
1-888-920-7631.
•
The beginning of this interview will be recorded for quality control purposes. If you do not
want to have this recorded, please let us know.
•
If you wish, the interviewer can provide a copy of this consent form for your records.
If you agree to participate in this interview, please click on the red check box to indicate your consent.

Attachment N: Field Consent Form ABS and High Risk

Attachment R:
Field Consent Form Service Provider Sample

Introduction
We are conducting a study called the National Survey on Health and Safety. This is a study being
conducted for the Bureau of Justice Statistics, which is part of the U.S. Department of Justice. I work
for Westat, a social science research firm that is conducting the study for BJS.
This study will help improve the way we monitor and measure health and safety issues in communities
like yours. In order to give you more information about the study, please review this short description of
the study on the computer. If you would like me to read this aloud to you or if you have any questions,
please let me know. At the end I will also ask if you have any questions. (TURN LAPTOP OVER TO
RESPONDENT. ONCE THEY HAVE REVIEWED IT, INTERVIEWER ASKS IF THEY HAVE ANY
QUESTIONS ABOUT IT. RESPONDENT CLICKS “ACCEPT” AND INTERVIEWER ENTERS ID
TO ACKNOWEDGE CONSENT. HARD COPY OF CONSENT FORM IS AVAILABLE IF
RESPONDENT WOULD LIKE IT)

Attachment R: Field Consent Form Service Provider sample

CONSENT FORM
Service Provider Sample
Screen 1
Westat is conducting this research for the U.S. Department of Justice, Bureau of Justice Statistics (BJS).
We are developing a survey about the health and safety issues associated with unwanted sexual
experiences and the consequences associated with these experiences. Your participation will help us
improve the way we monitor these health and safety issues around the country. Over the next few
screens we will provide you with a description of what is involved with taking this survey.
Screen 2
•
The interview should take approximately 15-30 minutes, depending on how you answer the
questions.
•
Your participation is voluntary, and you can withdraw at any time. If you don’t want to
answer particular questions, you can skip them.
•
We will give you $50 in a debit card as a thank you for completing the survey.
Screen 3
•
Later in the interview, you will be asked questions about health and safety issues related to
unwanted sexual experiences. You will answer these questions by yourself on a computer.
Some of the language used on the survey is explicit and some people may find them
uncomfortable, but it is important that we ask the questions this way so that you are clear
about what we mean.
•
If you become upset during the interview or want to stop the interview at any time, please let
the interviewer know. We can provide access to resources to help you.
Screen 4
•
All information obtained during this study will be treated as confidential and will only be used
to analyze study results. The data are collected under federal statute (Title 42 USC, Section
3735 and 3789g) and are protected from any request by a law enforcement or any other
agency, organization, or individual.
•
Your answers will be combined with responses from other study participants when writing up
reports and conducting analyses. Pursuant to 42 U.S.C. Sec. 3789g, neither BJS nor Westat
will publish any data identifiable specifically to a private person.
•
There are two exceptions to this. One is if we feel that you are a danger to yourself or
others. The other is if we think that a child is being abused or neglected in this home. In both
cases, in order to protect your safety and the safety of others, we would report this to a mental
health provider or law enforcement/child protection agency.

Attachment R: Field Consent Form Service Provider sample

Screen 5
•
If you have questions about this research, please contact the National Study on Health and
Safety Information Line at (xxx-xxx-xxxx). . If you have questions about your rights and
welfare as a research participant, please contact Westat’s Human Subjects Protection Office at
1-888-920-7631.
•
The beginning of this interview will be recorded for quality control purposes. If you do not
want to have this recorded, please let us know.
•
If you wish, the interviewer can provide you with a copy of this consent form for your
records.
If you agree to participate in this interview, please click on the red check box to indicate your consent.
(INTERVIEWER ENTERS INTID TO CONTINUE)
(ONCE RESPONDENT HAS AGREED TO PARTICIPATE) If it’s OK with you, I would like to record
our conversation, just so that I can review it later when we’re analyzing all the interview data. If it is
OK, I’d like to get your agreement on the recording.

Attachment R: Field Consent Form Service Provider sample

Attachment S:
Phone Consent Form Landline and Cell

CATI CONSENT: LANDLINE GENERAL POPULATION
Hello, my name is {NAME}. I am calling from Westat, a company that conducts research on many
different topics. This particular project is for the Department of Justice, specifically, the Bureau of
Justice Statistics. Westat has been contracted to develop a survey about unwanted sexual experiences
and the health and safety consequences of these experiences. We will be interviewing thousands of
people for this survey in communities like yours. Your participation will help us improve the way we
monitor these health and safety issues.
You have been randomly selected to participate in this study. Your participation is completely
voluntary. If you decide to participate, you can also refuse to answer any particular question. The
interview takes about 15 to 30 minutes to complete, depending on responses to questions. Your answers
will be treated as confidential and they are protected by federal law – no one outside the study staff will
know your answers to these questions or that you participated in this study. The one exception is that if
you express that you are a danger to yourself or to others. If that happens in order to help protect your
safety and the safety of others, we would report this to the appropriate healthcare or law enforcement
agencies.
(IF RESPONDENT ASKS WHICH FEDERAL LAW, SAY: Federal law 42 U.S.C. Section 3789g)

In appreciation for your help, we will send you $20 after we complete the interview.
Some of the language used on the survey is explicit and some people may find it uncomfortable, but it is
important that we ask the questions this way so that you are clear about what we mean.
If you become upset during the interview or want to stop the interview at any time, please let me know.
We can provide access to resources to help you.
If it is OK with you this interview will be recorded for quality control purposes.
Since some of the questions are personal, you should go to a private area where you feel comfortable
taking this survey. We want to make sure that your answers are confidential.

WHEN RESPONDENT IS IN A PRIVATE AREA, CONTINUE TO INTRODUCTORY QUESTIONS.

Attachment S: Phone Consent Landline and Cell

CATI CONSENT: CELL PHONE GENERAL POPULATION
Again, this project is for the Department of Justice, specifically, the Bureau of Justice Statistics. Westat
has been contracted to develop a survey about unwanted sexual experiences and the health and safety
consequences of these experiences. We will be interviewing thousands of people for this survey in
communities like yours. The information you provide will help guide national policies.
You have been randomly selected to participate in this study. Your participation is completely
voluntary. If you decide to participate, you can also refuse to answer any particular question. The
interview takes about 15 to 30 minutes to complete, depending on responses to questions. Your answers
will be treated as confidential and they are protected by federal law – no one outside the study staff will
know your answers to these questions or that you participated in this study. The one exception is that if
you express that you are a danger to yourself or to others. If that happens in order to help protect your
safety and the safety of others, we would report this to the appropriate healthcare or law enforcement
agencies.
(IF RESPONDENT ASKS WHICH FEDERAL LAW, SAY: Federal law 42 U.S.C. Section 3789g)
In appreciation for your help, we will send you $20 after we complete the interview.
Later in the interview, you will asked questions about health and safety issues related to unwanted
sexual experiences. Some of the language used on the survey is explicit and some people may find it
uncomfortable, but it is important that we ask the questions this way so that you are clear about what we
mean.
If you become upset during the interview or want to stop the interview at any time, please let me know.
We can provide access to resources to help you.
If it is OK with you this interview will be recorded for quality control purposes.
Since some of the questions are personal, you should go to a private area where you feel comfortable
taking this survey. We want to make sure that your answers are confidential.
WHEN RESPONDENT IS IN A PRIVATE AREA, CONTINUE.
To get started, please tell me just your first name and age.

NAME ____________________ AGE _____..................... [SKIP TO DEMOGRAPHICS]
-7. REFUSED........................................................... [SKIP TO DEMOGRAPHICS]

Attachment S: Phone Consent Landline and Cell

Attachment T:
Phone Consent Form High Risk

CATI CONSENT: HIGH RISK
Hello, my name is {NAME}. I am calling from Westat. Thank you for volunteering to participate in this
study for the Department of Justice, specifically, the Bureau of Justice Statistics. Westat has been
contracted to develop a survey about unwanted sexual experiences and the health and safety
consequences of these experiences. We will be interviewing thousands of people for this survey in
communities like yours. Your participation will help us improve the way we monitor these health and
safety issues.
Your participation is completely voluntary. If you decide to participate, you can also refuse to answer
any particular question. The interview takes about 15 to 30 minutes to complete, depending on responses
to questions. Your answers will be treated as confidential and they are protected by federal law – no one
outside the study staff will know your answers to these questions or that you participated in this study.
The one exception is that if you express that you are a danger to yourself or to others. If that happens in
order to help protect your safety and the safety of others, we would report this to the appropriate
healthcare or law enforcement agencies.
(IF RESPONDENT ASKS WHICH FEDERAL LAW, SAY: Federal law 42 U.S.C. Section 3789g)
In appreciation for your help, we will send you $40 after we complete the interview.
Some of the language used later in the survey is explicit and some people may find it uncomfortable. It
is important that we ask the questions this way so that you are clear about what we mean.
If you become upset during the interview or want to stop the interview at any time, please let me know.
We can provide access to resources to help you.
If it is okay with you this interview will be recorded for quality control purposes.
Because some of the questions are personal, you should go to a private area where you feel comfortable
taking this survey. We want to make sure that your answers are confidential.
WHEN RESPONDENT IS IN A PRIVATE AREA, CONTINUE TO INTRODUCTORY QUESTIONS.

Attachment T: Phone Consent High Risk

Attachment U:
Phone Consent Form Service Provider Sample

CATI CONSENT: SERVICE PROVIDER SAMPLE

Hello, my name is {NAME}. I am calling from Westat. Thank you for volunteering to participate in this
study for the Department of Justice, specifically, the Bureau of Justice Statistics. Westat has been
contracted to develop a survey about unwanted sexual experiences and the health and safety
consequences of these experiences. We will be interviewing thousands of people for this survey in
communities like yours. Your participation will help us improve the way we monitor these health and
safety issues.
Your participation is completely voluntary. If you decide to participate, you can also refuse to answer
any particular question. The interview takes about 15 to 30 minutes to complete, depending on responses
to questions. Your answers will be treated as confidential and they are protected by federal law – no one
outside the study staff will know your answers to these questions or that you participated in this study.
The one exception is that if you express that you are a danger to yourself or to others. If that happens in
order to help protect your safety and the safety of others, we would report this to the appropriate
healthcare or law enforcement agencies.
In appreciation for your help, we will send you $50 after we complete the interview.
Some of the language used later in the survey is explicit and some people may find it uncomfortable. It
is important that we ask the questions this way so that you are clear about what we mean.
If you become upset during the interview or want to stop the interview at any time, please let me know.
We can provide access to resources to help you.
If it is okay with you, this interview will be recorded for quality control purposes.
Because some of the questions are personal, you should go to a private area where you feel comfortable
taking this survey. We want to make sure that your answers are confidential.

WHEN RESPONDENT IS IN A PRIVATE AREA, CONTINUE TO INTRODUCTORY QUESTIONS.

Attachment U: Phone Service Provider Consent

Attachment U1:
Distress and Debriefing Procedures

Attachment U1:
Distress Protocol and Debriefing to Assess Stress

This Attachment provides:
1.

The general procedures interviewers will follow when encountering respondents who are
experiencing distress

The debriefing questions that will come at the end of the interview. These are primarily for the
interviewer to check in to make sure the respondent is emotionally stable.

Attachment U1: Distress and Debriefing Protocol

Distress Protocol
During the interview administration, all interviewers will be trained to identify and respond
appropriately to varying levels of distress. All interviewers will be trained to take notice of the
Respondent’s emotional state and follow the step by step procedures using the 2 levels of intervention
outlined below. These step by step instructions are designed to respond to the elevated emotional states
while also providing the respondent the opportunity to continue with the interview if she so chooses.
I. LOW TO MODERATE EMOTIONAL STATE: Respondent is showing some signs of
emotional distress but there is no perceived or expressed threat to her own safety or the safety of
others. These signs may include:
•
•
•
•
•
•
•
•

Crying
Change in mood
Change in tone
Voice is shaking or trembling
Frequently getting off task allowing distractions to interrupt the pace of the interview
Suddenly feeling intense fear or a sensation of being trapped
Appearing to be “zoned out” – non responsive to questions
Experiencing flashbacks (like responding to a bad dream)

Step 1: If respondent is exhibiting any of these signs of distress: The interviewer will ask one of the
following questions:
• How are you doing?
• Are you ok?
• Do you have any questions?
If respondent indicates she is “ok” and does not have any questions: The interviewer will continue
with the interview.
Step 2: If the respondent does not respond or indicates she is distressed: The interview will ask:
•
•

Do you need to take a short break?
Do you need to stop the interview?

If the respondent answers “no” to these questions: The interviewer will continue with the interview.
Step 3: If the respondent answers “yes” to these questions: the interviewer will allow the respondent
to take a short break. Some participants may need a minute or two to collect themselves and will be
willing to proceed.
Step 4: AFTER THE BREAK the interviewer will ASK: “Do you want to keep going?”
If “yes”, the interviewer will continue with the interview.

Attachment U1: Distress and Debriefing Protocol

Step 5: If “no”, the interviewer will SAY: Thank you for participating and for sharing such sensitive
information that will be used to help inform future research with survivors of sexual assault.
The interviewer will also ASK: Would you like to continue the interview at a later date?
If “YES”, the interviewer will SET UP AN APPOINTMENT.
If “NO”, the interviewer will SAY: Thank you again for participating and I would like to provide
you with some names of resources you can call if you would like to talk to someone.
II. ELEVATED EMOTIONAL STATE, the interviewer will assess the type of distress and respond
using the step by step instructions listed for each of the three scenarios: extreme distress without
intent to harm self or others, expressed self-harm, or expressed harm to others.
a) Extreme distress without intent to harm self or others:






Uncontrollable crying
Emotional outbursts, including expressions of rage
Respondent isn’t making sense when she’s talking
Dissociation (can’t remember time/place)
Experiencing flashbacks (like responding to a bad dream) that continue after
following the procedures for low to moderate distress

b) Expressions of self-harm:






Plans to hurt herself
Plans to kill herself
Statements indicating she might hurt herself
Statements indicating she might kill herself
Statements indicating she has lost a reason to live or that life has no purpose

c) Expressions of harm to others:






Plans to hurt someone else
Plans to kill someone else
Expressed statements that she might hurt someone else
Expressed statements that she might kill someone else
Expressed statements about planning or thinking about using a firearm or other
weapon

Attachment U1: Distress and Debriefing Protocol

a. EXTREME CASES OF DISTRESS WITHOUT INTENT TO HARM
The interviewer will stop the interview.
If interviewing at a home or in the community (non agency setting) or on the phone, the
interviewer will say:
It seems you are upset and it may be helpful to talk to a trained counselor. I can connect you
with a counselor now or I can provide you with some resources that you can contact on your
own, which would you prefer?
The interviewer will be sure to provide the incentive to the respondent before connecting her to
the counselor.
If interviewing in the home or community (non-agency setting):
If the respondent does not want to be connected to a counselor, the interviewer will leave
the resources list (unless the respondent declines to accept) and end the interview session.
If the respondent wants to be connected with a counselor, the interviewer will ask the
respondent if she would like for the call to be placed on her own phone or by using the
interviewer’s phone. The interviewer will then place the call to the RAINN hotline.
If the call takes place on the respondent’s phone, the interviewer will end the
session and leave the interview site.
If the call takes place on the interviewer’s phone, the interviewer will move to a
location (e.g. another room, step outside) so the interviewer cannot hear the
specifics of the call. Once the call is over, the interviewer will collect her study
issued phone.
If interviewing over the phone:
If the respondent does not want to be connected to a counselor, the interviewer will read
the telephone numbers and email addresses for the RAINN hotline and National Suicide
Hotline.
If the respondent wants to be connected with a counselor, the interviewer will place the
call to the RAINN hotline and disconnect from the call once a counselor is on the line.
If interviewing at a rape crisis center, the interviewer will ask the respondent for permission to
get a counselor:
The interviewer will SAY: It seems you are upset and it may be helpful to talk to a
trained counselor. I would like to get a counselor for you.
If permission is granted, obtain assistance from the Rape Crisis Center and end the
interview session.
4

Attachment U1: Distress and Debriefing Protocol

If permission is not granted, provide the respondent with a list of resources and end the
session.
b. SELF-HARM:
PHONE INTERVIEWS
Step 1: The interviewer will immediately instant message the team leader/supervisor and let
him/her know the situation. The interviewer will not provide any personally identifiable
information in the instant message - she will just make the supervisor aware of the situation. The
team leader/supervisor will tap into the conversation via the live monitoring feature to support
the interviewer and provide guidance via the instant message feature.
Step 2: The interviewer will say: I am concerned about you and I need to get a trained counselor
to speak with you before we can continue the interview. I am going to contact a counselor right
now and I would like for you to stay on the line.
Step 3: When contact is made with the National Suicide Hotline or local RAINN affiliate crisis
center counselor the interviewer will say: My name is [provide your first and last name] and I am
a data collector with the National Health and Safety Study and I have [say respondent’s first
name] on the phone. During the interview [say respondent’s first name] expressed statements
that made me concerned for her safety. I would like for a counselor to speak with her and I have
her on the phone now. We will seek cooperation from local RAINN service provider affiliates to
provide crisis assessment invention. We will also have the National Suicide Hotline information
available to our interviewers as an additional resource.

Attachment U1: Distress and Debriefing Protocol

IN PERSON INTERVIEWS IN HOME/ COMMUNITY (NON AGENCY SETTING)
Step 1: The interviewer will say: I am concerned about you and I need to get a trained counselor
to speak with you before we can continue the interview. I am going to contact a counselor right
now. I can call with my phone or I can call with your phone and just stay on long enough to
make sure someone is available to speak with you- which would you prefer?
Step 2: When contact is made with a crisis center counselor the interviewer will say: My name
is [provide your first and last name] and I am a data collector with the National Health and
Safety Study and I here with [say respondent’s first name]. During the interview [say
respondent’s first name] expressed statements that made me concerned for her safety. I would
like for a counselor to speak with her and I am handing her the phone now.
Step 3: After connecting the Respondent to the crisis counselor, the interviewer will notify the
on-call project staff member/supervisor that a referral to a crisis line was made. The project staff
member/supervisor will ensure that the appropriate protocol was followed.
IN PERSON INTERVIEWS AT SERVICE PROVIDER
Step 1: The interviewer will say: I am concerned about you and I need to get a trained
counselor to speak with you before we can continue the interview. I am going to get a counselor
right now.
Step 2: After connecting the Respondent to the Rape Crisis Center counselor, the interviewer
will notify the on-call project staff member/supervisor that a referral to the Rape Crisis Center
counselor was made. The project staff member/supervisor will ensure that the appropriate
protocol was followed.
c. HARM TO OTHERS
PHONE INTERVIEWS
Step 1: The interviewer will immediately instant message the team leader/supervisor and let
him/her know she has a situation. The interviewer will provide the respondent’s name, phone
number, location of the respondent (if known), and the name/relationship of the potential target
of expressed harm to the team leader/supervisor. The team leader/supervisor will tap into the
conversation via the live monitoring feature to support the interviewer and provide guidance via
the instant message feature.
Step 2: The interview will say: I am concerned that you are talking about harming someone
else. I need to get a trained counselor to speak with you before we can continue the interview. I
am going to get a counselor right now.
Step 3: When contact is made with a crisis center counselor the interviewer will say:
My name is [provide your first and last name] and I am a data collector with the National Health
and Safety Study and I have a respondent on the line who expressed explicit statements to harm
another individual.
6

Attachment U1: Distress and Debriefing Protocol

The interviewer will provide the respondent’s name, phone number, location of the respondent
(if known), and the name/relationship of the potential target of expressed harm. If instructed by
the crisis line to contact 911, the interviewer will contact 911 and repeat the same script and
provide the information to the 911 operator.
Step 4: If respondent refuses to talk a counselor, the interviewer will terminate the call and
contact 911 and then notify the on-call project staff member/supervisor that a referral to 911 was
made.

IN PERSON INTERVIEWS IN THE COMMUNITY (NON AGENCY SETTING)
Step 1: The interview will say: I am concerned that you are talking about harming someone
else. I am going to contact a counselor right now. I can call with my phone or I can call with
your phone and just stay on long enough to make sure someone is available to speak with youwhich would you prefer?
Step 2: When contact is made with crisis center counselor the interviewer will say: My name is
[provide your first and last name] and I am a data collector with the National Health and Safety
Study and I am here with a respondent who expressed explicit statements to harm another
individual.
The interviewer will provide the respondent’s name, phone number, location of the respondent,
and the name/relationship of the potential target of expressed harm. If instructed by the crisis
center counselor to contact 911, the interviewer will contact 911 and repeat the same script and
provide the information to the 911 operator.
Step 3: After connecting the Respondent to the crisis counselor, the interviewer will notify the
on-call project staff member/supervisor that a referral to a crisis line was made. The project staff
member/supervisor will ensure that the appropriate protocol was followed.
Step 4: If at any time the interviewer feels unsafe or respondent refuses to talk a counselor, the
interviewer will leave the home before placing the call. After leaving the premises, the
interviewer will immediately (as soon as is feasible to ensure the safety of the interviewer)
contact 911 and then notify the on-call project staff member/supervisor that a referral to 911 was
made.

Attachment U1: Distress and Debriefing Protocol

IN PERSON INTERVIEWS AT A SERVICE PROVIDER
Step 1: The interviewer will say: I am concerned that you are talking about harming someone
else. I need to get a trained counselor to speak with you before we can continue the interview. I
am going to get a counselor right now.
Step 2: After connecting the Respondent to the Rape Crisis Center counselor, the interviewer
will notify the on-call project staff member/supervisor that a referral to a crisis counselor was
made. The project staff member/supervisor will ensure that the appropriate protocol was
followed.

Westat Protocol for Internal Notification for Extreme Distress Events:
1. The interviewer will ensure that her designated supervisor is made aware of the distress event per
the protocol outlined above.
2. The supervisor will immediately (within 24 hours) inform the Westat Operations Manager
supervising data collection (or designated backup).
3. The Westat Operations Manager will then immediately inform one of the Westat Project
Directors (or designated backup), and the project IRB representative.
4. The Westat Project Director or IRB representative will inform the Westat IRB in accordance
with the IRB protocol.
5. Interviewers will complete a Distress and Safety Concern Log to document all instances of
distress that resulted in stopping the interview even for a short break, recording the survey item
that triggered the distress, a narrative of what happened, the steps taken to support the respondent
and whether any further contact with the study will continue (e.g., if sampled for a re-interview).

Attachment U1: Distress and Debriefing Protocol

Debriefing Protocol and Distribution of Incentive
Those are all of the questions that we will be asking you today. Before we end the interview, there are
just a few last things to go over.
First, I want to thank you helping us today. Your responses will help us test this very important survey.
I appreciate that you were willing to talk with me about your personal experiences and answer questions
about some very private and sensitive issues.
Debriefing questions
The following questions are about your reaction to this survey.
Please indicate how strongly you agree or disagree with each statement.
1
2
3
4
5
Strongly
Disagree
Neutral
Agree
Strongly
Disagree
Agree
DQ1. You experienced intense emotions while completing the survey.
DQ2. The research made you think about things you didn’t want to think about.
DQ3. The research raised unpleasant emotional issues for you that you had NOT expected.
DQ4. You believe you have been able to help others by participating in this study.
DQ5. You were glad to have had the opportunity to participate.
DQ6. You feel you gained something positive from participating.
DQ7. Now that you know what the survey is about, you would have made the same choice to
participate.
DQ8. How easy or hard were the questions on this survey to understand?
1
2
3
4
5
Very Easy
Easy
Neutral
Hard
Very Hard
First Interview:
IF DQ8 = 1-3, skip to end screen.
Else continue with DQ9.
Re-Interview:
IF DQ8=1-3, go to DQ10.
Else Continue with DQ9

Attachment U1: Distress and Debriefing Protocol

DQ9. Which kinds of questions were hard to understand? Mark all that apply.

□ A. Questions about your background (e.g., education, employment).
□ B. Questions about whether you had a specific type of unwanted sexual experience.
□ C. (IF DETAILED INCIDENT FORM WAS COMPLETED) Questions about the details of a
specific unwanted sexual experience.

□ D. Questions about the fictional situations
□ E. Something else. [text box]
If this is a first interview, skip to end.
If this is re-interview, go to dq10.
DQ10. These next questions ask about the resources you were offered at the end of the first
interview. Did you use any of the resources that were shared with you?

□ Yes
□ No

 Continue to DQ11
 Skip to question DQ12

DQ11. Did you find these resources helpful?

□ Yes
□ No

 Skip to End Screen
 Skip to End Screen

DQ12. Do you plan to use any of these resources in the future?

□ Yes  Skip to End Screen
□ No  Continue to question DQ13
□ Don’t know  Skip to End Screen

DQ13. Please indicate the reason you do not plan on using these resources:

□ Do not need or want to use these type of resources
□ Am not ready to use these type of resource
□ Already have access to similar resources and do not need additional resources
□ Do not think these particular resources would be helpful
□ Other [text box]

END SCREEN (ACASI ONLY)
This is the end of the survey—thank you for your participation. Please inform the interviewer that
you have completed all of the questions.

Attachment U1: Distress and Debriefing Protocol

Distress Check-In
IF RESPONDENT ANSWERED “STRONGLY AGREE” TO ITEMS DQ1-3 OR “STRONGLY
DISAGREE” TO DQ7, say:
DB1. In the last set of questions, you indicated that the survey may have brought up strong emotions.
That is a normal reaction to sensitive topics. Before we finish, I just want to check and see how
you are doing right now. Are you feeling in a good place for us to finish the interview?
[IF YES, GO TO DB3]
[IF NO, GO TO DB2]
IF RESPONDENT ANSWERED DID NOT ANSWER “STRONGLY AGREE” TO ITEMS DQ1-3 OR
“STRONGLY DISAGREE” TO DQ7, say:
DB1. Before we finish, I just want to check and see how you are doing right now. Are you feeling in a
good place for us to finish the interview?
[IF YES, GO TO DB3]
[IF NO, GO TO DB2]
DB2. I’m not a counselor, but I want to make sure that you are able to connect with resources that can
help you with any difficult thoughts or emotions that may have come up. Is there a safe person
(a counselor, friend, or relative) that you can talk to about how you’re feeling?
[IF YES, say “OK, it sounds like you have someone that you feel comfortable talking to
about this.” THEN THEN GO TO DB3]
[IF NO, GO TO DB3]

DB3. I’d like to give you contact information for local and national organizations that you can use if
you want to talk about any feelings or emotions you experience. Is that OK?
[PROVIDE RESOURCE INFORMATION, THEN GO TO DB4/Assessment of
Emotional State]

DB4. Assessment of Emotional State
[INTERVIEWER NOTE: Before closing the interview, silently take notice of the Respondent’s
emotional state and use the following 3 levels to guide your next steps:]
11

Attachment U1: Distress and Debriefing Protocol

III.

NEUTRAL EMOTIONAL STATE: Respondent seems relatively calm, does not appear to be
in distress. >>> GO TO INCENTIVE.

IV.

LOW TO MODERATE EMOTIONAL STATE: Respondent is showing some signs of
emotional distress, such as crying or anger, but there is no perceived or expressed threat to
her own safety or the safety of others.
>>> say: “You seem upset and I want to make sure that you’re in a good place before we finish
today. I can connect you with a counselor if you want to talk with someone about how you’re
feeling.
Would you like to speak to a counselor?
IF IN-PERSON INTERVIEW:
[IF YES, AND YOU ARE ON-SITE AT A CRISIS AGENCY: “OK, I’ll help you to
get connected with someone that you can speak with.” DISTRIBUTE INCENTIVE
PAYMENT, THEN CONNECT RESPONDENT WITH ON- SITE COUNSELING
CONTACT.]
[IF YES, AND YOU ARE NOT ON-SITE AT A CRISIS AGENCY: “OK, I’ll help you
to get connected with someone that you can speak with. I’m going to call [name of crisis
line]. I can call with my phone or I can call with your phone and just stay long enough to
make sure someone is available to speak with you—which would you prefer? Do you
have any questions before I make the call to [name of crisis line]?” ANSWER
QUESTIONS, DISTRIBUTE INCENTIVE PAYMENT, AND THEN CONNECT
RESPONDENT WITH DESIGNATED CRISIS LINE FOR YOUR AREA. WHEN
SOMEONE ANSWERS say: “My name is [provide your first and last name]. I am a data
collector with the National Health and Safety Study and I have [say respondent’s first
name] on the phone. During the interview [respondent’s first name] expressed statements
that made me concerned for her safety/safety of others. I would like for a counselor to
speak with her and I have her on the phone now.” IF USING RESPONDENT’S PHONE,
LEAVE THE HOUSE WHEN RESPONDENT IS CONNECTED TO THE
COUNSELOR.]
[IF NO, GO TO INCENTIVE]

Attachment U1: Distress and Debriefing Protocol

IF TELEPHONE INTERVIEW
[IF YES, say, “OK, I’ll help you to get connected with someone that you can speak with.
I’m going to call [name of crisis line]. I will remain on the line long enough to make sure
someone is available to speak with you. But before I do that, I just want to mention that
we will be sending your incentive payment by mail and you should receive it within XX
days. Do you have any questions before I make the call to [name of crisis line]?”
ANSWER QUESTIONS AND THEN CONNECT RESPONDENT WITH
DESIGNATED CRISIS LINE FOR YOUR AREA. WHEN SOMEONE ANSWERS say:
“My name is [provide your first and last name]. I am a data collector with the National
Health and Safety Study and I have [say respondent’s first name] on the phone. During
the interview [respondent’s first name] expressed statements that made me concerned for
her safety/safety of others. I would like for a counselor to speak with her and I have her
on the phone now.” WHEN RESPONDENT IS CONNECTED TO THE COUNSELOR,
REMOVE YOURSELF FROM THE CALL.]
[IF NO, GO TO INCENTIVE]
V.

ELEVATED EMOTIONAL STATE: Follow the protocol for managing extreme cases of
distress outlined in the distress protocol.

Attachment U1: Distress and Debriefing Protocol

INCENTIVE FOR TELEPHONE RESPONDENTS
CI1. I appreciate your taking the time to talk with me today. We would like to mail you a [$20/$40/$50]
check in appreciation of your time today. Can I please collect your name as you’d like it to appear on
the check and your mailing address?
FIRST NAME
LAST NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE
ZIP
Thank you. The incentive will be mailed sometime in the next week.

INCENTIVE FOR IN-PERSON RESPONDENTS
CI1. I appreciate your taking the time to talk with me today. I would like to give you this $40/$50 debit
card in appreciation of your time today. The card is available for use in 3 days but after 1 month, it
starts decreasing in value, so I’d recommend using it soon. There is more information on this sheet
about how to use the card. (HAND CARD CARRIER SHEET TO RESPONDENT)

CLOSING: Thank you for participating in this important study. We appreciate your time. (IF
RESPONSE PROVIDED IN CR2, say:) We look forward to talking to you again in a few weeks.

Attachment U1: Distress and Debriefing Protocol

Attachment V:
CATI Full Interview

CATI

SV Screener

Introduction
The next questions ask about unwanted sexual situations that you may have experienced in the past 12 months
or in your lifetime. Your answers will be used to help determine how often these things happen to women.
Some of the language used in this survey is explicit and may be uncomfortable to you, but it is important that
the questions are asked in this way so that you are clear about what is meant.

Unwanted sexual experiences can occur in all different types of situations. These situations may involve
strangers, but they also may involve someone you know well, such as a romantic partner, friend, acquaintance,
teacher, coworker, supervisor, or family member. Please keep this in mind when answering these questions.

Most of the questions just require you to say ‘yes’ or ‘no’ to answer, and you may be asked for a month or year
as a response. As I told you before, the information you are providing will be kept private. Also remember that
you can skip questions that you don’t want to answer and you can stop at anytime.

If at any time you do not feel physically or emotionally safe, you can just say “goodbye”. I will understand and
I will not call you back.

Attachment V: CATI Questionnaire

CATI
PART ONE:
Questions about your lifetime and the last 12 months

The first questions ask you to recall any incidents that have happened against your will. For
incidents that happened in the last 12 months, I will ask you to count how many separate incidents
happened and to list the month when they occurred. The questions begin with the most serious
types of incidents and then move to less serious incidents.
SV1. Has a male ever used force or threats of force to make you have vaginal sex against your will? By
vaginal sex, it means putting his penis in your vagina against your will.

□ Yes
□ No

 Continue to SV1A
 Skip to question SV2

SV1A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV1B
 Skip to question SV1D

SV1B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV1C
 Skip to question SV1C
 Continue
 Continue

SV1B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?
2

Attachment V: CATI Questionnaire

CATI

SV1C. In what month and year did (this incident/these incidents/(IF SV1B>4 or SV1B1>=5
TIMES: the four most recent incidents)) happen? (INTERVIEWER: FILL IN MONTH AND
YEAR FOR EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED
MORE THAN ONCE IN A MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV1B=once and “DON’T KNOW” IS MARKED IN SV1C, OR IF
SV1B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV1C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV1C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to SV2
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV1B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV1C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV1C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV1C] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)
3

 CONTINUE
Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV1Ca-d or SV1C_1=No or
SV1C_2>0, delete response and reduce SV1B by appropriate amount. If SV1B was once, and it gets
reduced to zero, change SV1A to no, delete all data in B and C follow-ups, and CONTINUE TO SV1D.
ELSE SKIP TO SV2.

SV1D. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV2
 Continue to SV1E.

SV1E. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI
SV2. Has anyone, male or female, ever used force or threats of force to make you have oral sex
against your will? By oral sex, it means that someone penetrated your vagina or anus with their
mouth or tongue, or you were forced to use your mouth or tongue on someone else’s genitals or
anus against your will.

□
□

Yes

 Continue to SV2A

 Skip to question SV3

SV2A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV2B
 Skip to question SV2F

SV2B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV2C
 Skip to question SV2C
 Continue
 Continue

SV2B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV2C. In what month and year did (this incident/these incidents/(IF SV2B>4 or SV2B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV2B=once and “DON’T KNOW” IS MARKED IN SV2C, OR IF
SV2B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV2C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV2C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV2B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV2C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV2C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV2C] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV2Ca-d or SV2C_1=No or
SV2C_2>0, delete response and reduce SV2B by appropriate amount. If SV2B was once, and it gets
reduced to zero, change SV2A to no, delete all data in B and C follow-ups, and SKIP TO SV2F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV2C match a month listed in SV1C,
if any are marked as DK and an incident has been reported in a previous question,
Continue. Otherwise, go to SV3.
For each month that matches, if month is only listed once in SV2C, GO TO SV2D1. If
month is listed twice in SV2C, GO TO SV2D2. If month is listed three or more times in
SV2C, GO TO SV2D3.
If one of the months is marked as “don’t know”, go to SV2D1. If two of the months are
marked as “Don’t Know”, go to SV2D2. If three or more of the months are listed as
“Don’t Know”, go to SV2D3.
Repeat this instruction for each month that matches with SV1C.
SV2D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV3
 Skip to question SV3

SV2D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV3

Yes, both are part of the other incidents Skip to question SV3
No, separate incidents

 Skip to question SV3

SV2D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV3

Attachment V: CATI Questionnaire

CATI
SV2E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV3

SV2F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV3
 Continue to SV2G.

SV2G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI

SV3. Has a male ever used force or threats of force to make you have anal sex against your will? By
anal sex, it means that a man or boy put his penis in your anus against your will.

□ Yes
□ No

 Continue to SV3A
 Skip to question SV4

SV3A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV3B
 Skip to question SV3F

SV3B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV3C
 Skip to question SV3C
 Continue
 Continue

SV3B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV3C. In what month and year did (this incident/these incidents/(IF SV3B>4 or SV3B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV3B=once and “DON’T KNOW” IS MARKED IN SV3C, OR IF
SV3B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV3C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV3C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV3B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV3C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV3C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV3C] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV3Ca-d or SV3C_1=No or
SV3C_2>0, delete response and reduce SV3B by appropriate amount. If SV3B was once, and it gets
reduced to zero, change SV3A to no, delete all data in B and C follow-ups, and SKIP TO SV3F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV3C match a month listed in SV1C OR
SV2C,
if any are marked as DK and an incident has been reported in a previous question,
Continue. Otherwise, go to SV4.
For each month that matches, if month is only listed once in SV3C, GO TO SV3D1. If
month is listed twice in SV3C, GO TO SV3D2. If month is listed three or more times in
SV3C, GO TO SV3D3.
If one of the months is marked as “don’t know”, go to SV3D1. If two of the months are
marked as “Don’t Know”, go to SV3D2. If three or more of the months are listed as
“Don’t Know”, go to SV3D3.
Repeat this instruction for each month that matches with SV1C or SV2C.

SV3D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV4
 Skip to question SV4

SV3D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV4

Yes, both are part of the other incidents Skip to question SV4
No, separate incidents

 Skip to question SV4

Attachment V: CATI Questionnaire

CATI
SV3D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV4

SV3E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV4

SV3F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV4
 Continue to SV3G

SV3G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI

SV4. Has a male or female ever used force or threats of force to put fingers or a foreign object in
your vagina or anus against your will?

□ Yes
□ No

 Continue to SV4A
 Skip to question SV5

SV4A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV4B
 Skip to question SV4F

SV4B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV4C
 Skip to question SV4C
 Continue
 Continue

SV4B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI

SV4C. In what month and year did (this incident/these incidents/(IF SV4B>4 or SV4B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV4B=once and “DON’T KNOW” IS MARKED IN SV4C, OR IF
SV4B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV4C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV4C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV4B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV4C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV4C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV4C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV4Ca-d or SV4C_1=No or
SV4C_2>0, delete response and reduce SV4B by appropriate amount. If SV4B was once, and it gets
reduced to zero, change SV4A to no, delete all data in B and C follow-ups, and SKIP TO SV4F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV4C match a month listed in SV1C ,
SV2C, OR SV3C,if any are marked as DK and an incident has been reported in a
previous question, Continue. Otherwise, go to SV5.
For each month that matches, if month is only listed once in SV4C, GO TO SV4D1. If
month is listed twice in SV4C, GO TO SV4D2. If month is listed three or more times in
SV4C, GO TO SV4D3.
If one of the months is marked as “don’t know”, go to SV4D1. If two of the months are
marked as “Don’t Know”, go to SV4D2. If three or more of the months are listed as
“Don’t Know”, go to SV4D3.
Repeat this instruction for each month that matches with SV1C, SV2C, or SV3C.

SV4D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV5
 Skip to question SV5

SV4D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV5

Yes, both are part of the other incidents Skip to question SV5
No, separate incidents

 Skip to question SV5

SV4D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV5

Attachment V: CATI Questionnaire

CATI
SV4E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV5

SV4F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV5
 Continue to SV4G.

SV4G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI
When answering these next questions, please consider all the types of sex acts that you have been asked
about so far; including vaginal sex, oral sex, anal sex, or putting fingers or a foreign object in your vagina
or anus.
These questions will now focus on other types of unwanted sexual experiences that may not have involved
force, but that were against your will.

SV5. (Other than the incidents you have already mentioned), has anyone ever made you have any type
of sex when you were unable to consent because you were too drunk, high or passed out?

□
□

Yes

 Continue to SV5A

 Skip to SV6

SV5A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV5B
 Skip to question SV5F

SV5B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV5C
 Skip to question SV5C
 Continue
 Continue

SV5B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI

SV5C. In what month and year did (this incident/these incidents/(IF SV5B>4 or SV5B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV5B=once and “DON’T KNOW” IS MARKED IN SV5C, OR IF
SV5B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV5C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV5C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV5B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV5C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV5C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV5C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV5Ca-d or SV5C_1=No or
SV5C_2>0, delete response and reduce SV5B by appropriate amount. If SV5B was once, and it gets
reduced to zero, change SV5A to no, delete all data in B and C follow-ups, and SKIP TO SV5F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV5C match a month listed in SV1C ,
SV2C, SV3C, or SV4C, if any are marked as DK and an incident has been reported in a
previous question, Continue. Otherwise, go to SV6.
For each month that matches, if month is only listed once in SV5C, GO TO SV5D1. If
month is listed twice in SV5C, GO TO SV5D2. If month is listed three or more times in
SV5C, GO TO SV5D3.
If one of the months is marked as “don’t know”, go to SV5D1. If two of the months are
marked as “Don’t Know”, go to SV5D2. If three or more of the months are listed as
“Don’t Know”, go to SV5D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, or
SV4C.

SV5D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV6
 Skip to question SV6

SV5D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV6

Yes, both are part of the other incidents Skip to question SV6
No, separate incidents

 Skip to question SV6

SV5D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
19

Yes
No, separate incidents

 Skip to question SV6
Attachment V: CATI Questionnaire

CATI
SV5E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV6

SV5F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV6
 Continue to SV5G.

SV5G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI

SV6. (Other than the incidents you have already mentioned,) has anyone ever made you have any
type of sex against your will by threatening to cause problems for you, such as at your job or
school, at home, in your relationships or in any other way? Remember to think about all the
types of sex mentioned before.

□
□

Yes

 Continue to SV6A

 Skip to question SV7

SV6A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV6B
 Skip to question SV6F

SV6B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV6C
 Skip to question SV6C
 Continue
 Continue

SV6B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV6C. In what month and year did (this incident/these incidents/(IF SV6B>4 or SV6B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV6B=once and “DON’T KNOW” IS MARKED IN SV6C, OR IF
SV6B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV6C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV6C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV6B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV6C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV6C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV6C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)
22

 CONTINUE
Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV6Ca-d or SV6C_1=No or
SV6C_2>0, delete response and reduce SV6B by appropriate amount. If SV6B was once, and it gets
reduced to zero, change SV6A to no, delete all data in B and C follow-ups, and SKIP TO SV6F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV6C match a month listed in SV1C ,
SV2C, SV3C, SV4C, or SV5C, if any are marked as DK and an incident has been
reported in a previous question, Continue. Otherwise, go to SV7.
For each month that matches, if month is only listed once in SV6C, GO TO SV6D1. If
month is listed twice in SV6C, GO TO SV6D2. If month is listed three or more times in
SV6C, GO TO SV6D3.
If one of the months is marked as “don’t know”, go to SV6D1. If two of the months are
marked as “Don’t Know”, go to SV6D2. If three or more of the months are listed as
“Don’t Know”, go to SV6D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
or SV5C.

SV6D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV7
 Skip to question SV7

SV6D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV7

Yes, both are part of the other incidents Skip to question SV7
No, separate incidents

 Skip to question SV7

SV6D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
23

Yes
No, separate incidents

 Skip to question SV7
Attachment V: CATI Questionnaire

CATI

SV6E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV7

SV6F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV7
 Continue to SV6G.

SV6G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI
SV7. (Other than the incidents you have already mentioned), have you ever been in any other situations
where someone made you have any type of sex against your will? Remember to think about all the types
of sex mentioned before.

□
□

Yes

 Continue to SV7A

 Skip to SV8

SV7A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV7B
 Skip to question SV7F

SV7B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV7C
 Skip to question SV7C
 Continue
 Continue

SV7B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV7C. In what month and year did (this incident/these incidents/(IF SV7B>4 or SV7B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV7B=once and “DON’T KNOW” IS MARKED IN SV7C, OR IF
SV7B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV7C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV7C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV7B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV7C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV7C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV7C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV7Ca-d or SV7C_1=No or
SV7C_2>0, delete response and reduce SV7B by appropriate amount. If SV7B was once, and it gets
reduced to zero, change SV7A to no, delete all data in B and C follow-ups, and SKIP TO SV7F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV7C match a month listed in SV1C ,
SV2C, SV3C, SV4C, SV5C, or SV6C, if any are marked as DK and an incident has
been reported in a previous question, Continue. Otherwise, go to SV8.
For each month that matches, if month is only listed once in SV7C, GO TO SV7D1. If
month is listed twice in SV7C, GO TO SV7D2. If month is listed three or more times in
SV7C, GO TO SV7D3.
If one of the months is marked as “don’t know”, go to SV7D1. If two of the months are
marked as “Don’t Know”, go to SV7D2. If three or more of the months are listed as
“Don’t Know”, go to SV7D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, or SV6C.

SV7D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV8
 Skip to question SV8

SV7D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV8

Yes, both are part of the other incidents Skip to question SV8
No, separate incidents

 Skip to question SV8

Attachment V: CATI Questionnaire

CATI
SV7D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV8

SV7E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV8

SV7F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV8
 Continue to SV7G.

SV7G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI

SV8. Thinking about all the different types of situations you have been asked about so far, has anyone
ever tried, but did not succeed at making you have any type of sex against your will? Remember to think
about all the types of sex mentioned before.

□
□

Yes

 Continue to SV8A

 Skip to SV9

SV8A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV8B
 Skip to question SV8F

SV8B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV8C
 Skip to question SV8C
 Continue
 Continue

SV8B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV8C. In what month and year did (this incident/these incidents/(IF SV8B>4 or SV8B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV8B=once and “DON’T KNOW” IS MARKED IN SV8C, OR IF
SV8B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV8C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV8C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV8B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV8C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV8C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV8C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV8Ca-d or SV8C_1=No or
SV8C_2>0, delete response and reduce SV8B by appropriate amount. If SV8B was once, and it gets
reduced to zero, change SV8A to no, delete all data in B and C follow-ups, and SKIP TO SV8F. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV8C match a month listed in SV1C,
SV2C, SV3C, SV4C, SV5C, SV6C, or SV7C, if any are marked as DK and an incident
has been reported in a previous question, Continue. Otherwise, go to SV9.
For each month that matches, if month is only listed once in SV8C, GO TO SV8D1. If
month is listed twice in SV8C, GO TO SV8D2. If month is listed three or more times in
SV8C, GO TO SV8D3.
If one of the months is marked as “don’t know”, go to SV8D1. If two of the months are
marked as “Don’t Know”, go to SV8D2. If three or more of the months are listed as
“Don’t Know”, go to SV8D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, SV6C, or SV7C.

SV8D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV9
 Skip to question SV9

SV8D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV9

Yes, both are part of the other incidents Skip to question SV9
No, separate incidents

 Skip to question SV9

Attachment V: CATI Questionnaire

CATI
SV8D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV9

SV8E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Skip to question SV9

SV8F. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ Don’t Know

 Skip to question SV9
 Continue to SV8G.

SV8G. [If “don’t know”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment V: CATI Questionnaire

CATI

SV9. (Other than the incidents you have already mentioned,) has anyone, male or female, ever kissed
you in a sexual way against your will?

□
□

Yes

 Continue to question SV9A

 Skip to question SV10

SV9A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV9B
 Skip to question SV10

SV9B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV9C
 Skip to question SV9C
 Continue
 Continue

SV9B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV9C. In what month and year did (this incident/these incidents/(IF SV9B>4 or SV9B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV9B=once and “DON’T KNOW” IS MARKED IN SV9C, OR IF
SV9B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV9C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV9C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV9B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV9C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV9C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV9C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV9Ca-d or SV9C_1=No or
SV9C_2>0, delete response and reduce SV9B by appropriate amount. If SV9B was once, and it gets
reduced to zero, change SV9A to no, delete all data in B and C follow-ups, and SKIP TO SV10. ELSE
CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV9C match a month listed in SV1C ,
SV2C, SV3C, SV4C, SV5C, SV6C, SV7C, or SV8C, if any are marked as DK and an
incident has been reported in a previous question, Continue. Otherwise, go to SV10.
For each month that matches, if month is only listed once in SV9C, GO TO SV9D1. If
month is listed twice in SV9C, GO TO SV9D2. If month is listed three or more times in
SV9C, GO TO SV9D3.
If one of the months is marked as “don’t know”, go to SV9D1. If two of the months are
marked as “Don’t Know”, go to SV9D2. If three or more of the months are listed as
“Don’t Know”, go to SV9D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, SV6C, SV7C, or SV8C.
SV9D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV10
 Skip to question SV10

SV9D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV10

Yes, both are part of the other incidents Skip to question SV10
No, separate incidents

 Skip to question SV10

Attachment V: CATI Questionnaire

CATI
SV9D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV10

SV9E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV10

Attachment V: CATI Questionnaire

CATI
SV10. (Other than the incidents you have already mentioned,) has anyone, male or female, ever fondled,
groped, grabbed, or touched you against your will?

□
□

Yes

 Continue to question SV10A

 Skip to question SV11

SV10A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV10B
 Skip to question SV11

SV10B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV10C
 Skip to question SV10C
 Continue
 Continue

SV10B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV10C. In what month and year did (this incident/these incidents/(IF SV10B>4 or SV10B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV10B=once and “DON’T KNOW” IS MARKED IN SV10C, OR IF
SV10B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV10C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV10C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV10B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV10C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV10C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV10C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV10Ca-d or SV10C_1=No
or SV10C_2>0, delete response and reduce SV10B by appropriate amount. If SV10B was once, and it
gets reduced to zero, change SV10A to no, delete all data in B and C follow-ups, and SKIP TO SV11.
ELSE CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV10C match a month listed in SV1C ,
SV2C, SV3C, SV4C, SV5C, SV6C, SV7C, SV8C, or SV9C, if any are marked as DK
and an incident has been reported in a previous question, Continue. Otherwise, go to
SV11.
For each month that matches, if month is only listed once in SV10C, GO TO SV10D1. If
month is listed twice in SV10C, GO TO SV10D2. If month is listed three or more times
in SV10C, GO TO SV10D3.
If one of the months is marked as “don’t know”, go to SV10D1. If two of the months
are marked as “Don’t Know”, go to SV10D2. If three or more of the months are listed
as “Don’t Know”, go to SV10D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, SV6C, SV7C, SV8C, or SV9C.

SV10D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV11
 Skip to question SV11

SV10D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV11

Yes, both are part of the other incidents Skip to question SV11
No, separate incidents

 Skip to question SV11

Attachment V: CATI Questionnaire

CATI
SV10D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV11

SV10E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV11

Attachment V: CATI Questionnaire

CATI
SV11. (Other than the incidents you have already mentioned,) has anyone, male or female, ever made you
watch against your will while they exposed their sexual body parts to you, flashed you, or masturbated in
front of you?

□
□

Yes  Continue to question SV11A
No

 Skip to question SV12

SV11A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV11B
 Skip to question SV12

SV11B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV11C
 Skip to question SV11C
 Continue
 Continue

SV11B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV11C. In what month and year did (this incident/these incidents/(IF SV11B>4 or SV11B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV11B=once and “DON’T KNOW” IS MARKED IN SV11C, OR IF
SV11B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV11C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV11C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV11B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV11C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV11C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV11C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV11Ca-d or SV11C_1=No
or SV11C_2>0, delete response and reduce SV11B by appropriate amount. If SV11B was once, and it
gets reduced to zero, change SV11A to no, delete all data in B and C follow-ups, and SKIP TO SV12.
ELSE CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV11C match a month listed in SV1C ,
SV2C, SV3C, SV4C, SV5C, SV6C, SV7C, SV8C, SV9C, or SV10C, if any are marked as
DK and an incident has been reported in a previous question, Continue. Otherwise, go
to SV12.
For each month that matches, if month is only listed once in SV11C, GO TO SV11D1. If
month is listed twice in SV11C, GO TO SV11D2. If month is listed three or more times
in SV11C, GO TO SV11D3.
If one of the months is marked as “don’t know”, go to SV11D1. If two of the months
are marked as “Don’t Know”, go to SV11D2. If three or more of the months are listed
as “Don’t Know”, go to SV11D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, SV6C, SV7C, SV8C, SV9C, or SV10C.

SV11D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV12
 Skip to question SV12

SV11D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV12

Yes, both are part of the other incidents Skip to question SV12
No, separate incidents

 Skip to question SV12

Attachment V: CATI Questionnaire

CATI
SV11D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV12

SV11E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV12

Attachment V: CATI Questionnaire

CATI
SV12. (Other than the incidents you have already mentioned,) has anyone, male or female, ever made you
show your sexual body parts to them against your will?

□
□

Yes  Continue to question SV12A
No

 Skip to question SV13

SV12A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV12B
 Skip to question SV13

SV12B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV12C
 Skip to question SV12C
 Continue
 Continue

SV12B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV12C. In what month and year did (this incident/these incidents/(IF SV12B>4 or SV12B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV12B=once and “DON’T KNOW” IS MARKED IN SV12C, OR IF
SV12B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV12C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV12C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV12B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV12C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV12C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV12C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV12Ca-d or SV12C_1=No
or SV12C_2>0, delete response and reduce SV12B by appropriate amount. If SV12B was once, and it
gets reduced to zero, change SV12A to no, delete all data in B and C follow-ups, and SKIP TO SV13.
ELSE CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV12C match a month listed in SV1C ,
SV2C, SV3C, SV4C, SV5C, SV6C, SV7C, SV8C, SV9C, SV10C, or SV11C, if any are
marked as DK and an incident has been reported in a previous question, Continue.
Otherwise, go to SV13.
For each month that matches, if month is only listed once in SV12C, GO TO SV12D1. If
month is listed twice in SV12C, GO TO SV12D2. If month is listed three or more times
in SV12C, GO TO SV12D3.
If one of the months is marked as “don’t know”, go to SV12D1. If two of the months
are marked as “Don’t Know”, go to SV12D2. If three or more of the months are listed
as “Don’t Know”, go to SV12D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, SV6C, SV7C, SV8C, SV9C, SV10C, or SV11C.

SV12D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to question SV13
 Skip to question SV13

SV12D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV13

Yes, both are part of the other incidents Skip to question SV113
No, separate incidents

 Skip to question SV13

SV12D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
47

Yes
Attachment V: CATI Questionnaire

CATI

□

No, separate incidents

 Skip to question SV13

SV12E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV13

Attachment V: CATI Questionnaire

CATI
SV13. (Other than the incidents you have already mentioned,) has anyone, male or female, ever made you
look at or participate in sexual photos or movies against your will?

□ Yes
□ No

 Continue to question SV13A
 Skip to Programmer Note at end of screener

SV13A. Has this happened at any time since [MONTH/YEAR]?

□ Yes
□ No

 Continue to question SV13B
 Skip to Programmer Note at end of screener

SV13B. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV13C
 Skip to question SV13C
 Continue
 Continue

SV13B1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 or more times?

Attachment V: CATI Questionnaire

CATI
SV13C. In what month and year did (this incident/these incidents/(IF SV13B>4 or SV13B1>=5
TIMES: the four most recent incidents)) happen? (FILL IN MONTH AND YEAR FOR
EACH TIME THIS HAPPENED IN PAST 12 MONTHS; IF THIS HAPPENED MORE THAN
ONCE IN A PARTICULAR MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT
HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV13B=once and “DON’T KNOW” IS MARKED IN SV13C, OR IF
SV13B=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV13C, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2.
SV13C_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV13B=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV13C, CONTINUE. ELSE SKIP TO NEXT PROGRAMMER NOTE.

SV13C_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV13C] incidents. Can you confirm how many of these incidents – if any - took place
before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV13Ca-d or SV13C_1=No
or SV13C_2>0, delete response and reduce SV13B by appropriate amount. If SV13B was once, and it
gets reduced to zero, change SV13A to no, delete all data in B and C follow-ups, and SKIP TO END OF
SCREENER. ELSE CONTINUE TO PROGRAMMER NOTE #4.
PROGRAMMER NOTE#4 : If any of the months listed in SV13C match a month listed in SV1C ,
SV2C, SV3C, SV4C, SV5C, SV6C, SV7C, SV8C, SV9C, SV10C, SV11C, or SV12C, if
any are marked as DK and an incident has been reported in a previous question,
Continue. Otherwise, go to end of screener.
For each month that matches, if month is only listed once in SV13C, GO TO SV13D1. If
month is listed twice in SV13C, GO TO SV13D2. If month is listed three or more times
in SV13C, GO TO SV13D3.
If one of the months is marked as “don’t know”, go to SV13D1. If two of the months
are marked as “Don’t Know”, go to SV13D2. If three or more of the months are listed
as “Don’t Know”, go to SV13D3.
Repeat this instruction for each month that matches with SV1C, SV2C, SV3C, SV4C,
SV5C, SV6C, SV7C, SV8C, SV9C, SV10C, SV11C, or SV12C.

Attachment V: CATI Questionnaire

CATI

SV13D1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the
other incident(s) already discussed

□ No, separate incidents

 Skip to Programmer Note at end of screener
 Skip to Programmer Note at end of screener

SV13D2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to Programmer Note at end of screener

Yes, both are part of the other incidents Skip to Programmer Note at end of screener
No, separate incidents

 Skip to Programmer Note at end of screener

SV13D3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to Programmer Note at end of screener

SV13E3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to Programmer Note at end of screener

Attachment V: CATI Questionnaire

CATI
PROGRAMMER NOTE:
• IF “NO” TO ALL QUESTIONS SV1, SV2, SV3, SV4, SV5, SV6, SV7, SV8, SV9, SV10,
SV11, SV12, SV13, SKIP TO VIGNETTES.
•

IF “YES” TO ANY QUESTIONS SV1, SV2, SV3, SV4, SV5, SV6, SV7, SV8, SV9, SV10,
SV11, SV12, SV13, CONTINUE.

1) CREATE A LIST OF ALL DEDUPLICATED INCIDENTS REPORTED BY RESPONDENT
EXAMPLE:
SV1
5/13
SV1
DON’T KNOW
SV4
10/13
SV6
8/13
SV8
5/13
SV8
6/13
SV8
6/13
SV8
10/13
SV10
9/13
SV12
1/14
2) ASSIGN GROUP CODE TO EACH INCIDENT USING THE FOLLOWING CRITERIA:
• GROUP=1 IF INCIDENT FALLS IN SV1 THROUGH SV5
• GROUP=2 IF INCIDENT FALLS IN SV6 THROUGH SV8
• GROUP=3 IF INCIDENT FALLS IN SV9 THROUGH SV13
3) SORT INCIDENTS WITHIN GROUP:
• MOST RECENT DATE HAS HIGHEST PRIORITY
• IF THERE IS A TIE IN DATES WITHIN A GROUP, MOST SERIOUS GETS HIGHER PRIORITY
(WHERE SV1 IS MOST SERIOUS, SV13 IS LEAST SERIOUS)
• IF THERE IS A TIE IN BOTH DATES AND TYPE OF INCIDENT, RANDOMLY SELECT ONE.
• IF THERE IS A DON’T KNOW RESPONSE TO MONTH/YEAR, IT TAKES LOWEST PRIORITY
WITHIN THAT GROUP
BY THIS LOGIC, THE EXAMPLE ABOVE WOULD BE SORTED AS FOLLOWS:
SV4
10/13
SV1
5/13
SV1
DON’T KNOW
SV8
10/13
SV6
8/13
SV8
6/13
SV8
6/13
SV8
5/13
SV12
1/14
SV10
9/13
4) ASSIGN A NUMBER TO THE SORTED INCIDENTS WHERE 1 IS MOST SERIOUS. DETAILED
INCIDENT FORM WILL BE ASKED OF INCIDENT #1, THEN INCIDENT #2 (IF APPLICABLE), THEN
INCIDENT #3 (IF APPLICABLE).
53

Attachment V: CATI Questionnaire

CATI

PROGRAMMER NOTE:
• USE THE FOLLOWING SHORT-TEXT FOR (INCIDENT) SELECTED:
o SV1: “you had vaginal sex against your will”
o SV2: “you had oral sex against your will”
o SV3: “you had anal sex against your will”
o SV4: “someone put fingers or a foreign object in your vagina or anus against your
will”
o SV5: “you had some type of sex while you were drunk, high or passed out”
o SV6: “you were coerced into having some type of sex”
o SV7: “you had some type of sex against your will”
o SV8: “someone tried to make you have some type of sex against your will, but did not
succeed”
o SV9: “someone kissed you in a sexual way against your will”
o SV10: “someone groped or fondled you against your will”
o SV11: “someone exposed sexual body parts to you against your will”
o SV12: “someone made you expose your sexual body parts against your will”
o SV13: “someone made you look at or participate in sexual photos or videos”

Before we move on, I just want to make sure you’re doing ok (DISTRESS CHECK IN – if not
ok, jump to distress.)

Attachment V: CATI Questionnaire

CATI

PART TWO:
DETAILED INCIDENT FORM

SECTION A:
Anchoring the Incident
PROGRAMMER NOTE: CAPTURE WHICH SV ITEM HAS TRIGGERED THE DETAILED
INCIDENT FORM.

A1.
Earlier, you said that (INCIDENT) in (MONTH/YEAR). The next questions ask you for details
about this incident.

SECTION B:
Recall of the Incident

B1.

Can you recall enough details about this incident to answer some questions about it? You
may skip any question if you don’t recall a particular detail or don’t want to answer the
question.
Yes.................................................................... 1 (GO TO SECTION C)
No ..................................................................... 2 (GO TO PROGRAMMER NOTE AT END OF
DETAILED INCIDENT FORM)

Attachment V: CATI Questionnaire

CATI
SECTION C:
When and where did it happen?

C1.

About what time of day did this incident happen?

C2.

Did this incident happen …?

□ Between 6 a.m. and 12 noon
□ Between 12 noon and 6 p.m.
□ Between 6 p.m. and 12 midnight
□ Between 12 midnight and 6 a.m.
□ Don’t know whether it was day or night
□ REFUSED
□ Inside a home or building
□ Outside a home or building
□ Started outside and moved inside
□ Started inside and moved outside
□ REFUSED
□ DON’T KNOW

 Continue to C3
 Skip to question C4
 Continue to C3
 Continue to C3
 Skip to section D
 Skip to section D

Attachment V: CATI Questionnaire

CATI
C3.
Where (inside) did the incident happen? Please tell me the number that corresponds to your answer.
(READ NUMBERS AND RESPONSE CHOICES)

□ 1. In your home or dorm room
□ 2. In someone else’s home or dorm room
□ 3. At work
□ 4. In a Sorority or Fraternity house
□ 5. At a business such as a restaurant, bar or store
□ 6. Some other place (Please specify) _______________________________________
□ REFUSED
□ DON’T KNOW

IF C3= “IN YOUR HOME OR DORM ROOM” OR “IN SOMEONE ELSE’S HOME OR DORM ROOM”,
CONTINUE. ELSE, SKIP TO C4.
C3a.

Was it in {your/a} home or in {your/a} dorm room?

□ Home
□ Dorm room
□ REFUSED
□ DON’T KNOW

IF C2= “STARTED OUTSIDE AND MOVED INSIDE” OR “STARTED INSIDE AND MOVED OUTSIDE”,
CONTINUE. ELSE, IF C3=1, 2, OR 4, SKIP TO C5. ELSE, SKIP TO SECTION D.

Attachment V: CATI Questionnaire

CATI
C4.
Where (outside) did the incident happen? Please tell me the number that corresponds to your answer.
(READ NUMBERS AND RESPONSE CHOICES)

□ 1. On your property, but not inside your home
□ 2. On someone else’s property, but not inside the home
□ 3. On the property of your workplace, but not inside
□ 4. On the grounds of a school or university
□ 5. On public transportation
□ 6. In another type of open area, such as the street
□ 7. In a motor vehicle
□ 8. Some other place (Please specify) _______________________________________
□ REFUSED
□ DON’T KNOW

IF THE INCIDENT HAPPENED IN A HOME (C3=1, 2, OR 4 OR C4=1, 2), CONTINUE. ELSE SKIP TO
SECTION D.

Attachment V: CATI Questionnaire

CATI
C5.

Did the person who did this to you live (here/there)?

□ Yes
 Skip to section D
□ No
□ REFUSED
□ DON’T KNOW

C6.
How did this person get in? Please tell me the number that corresponds to your answer. (READ
NUMBERS AND RESPONSE CHOICES)

□ 1. Let in
□ 2. Pushed his/her way in after door opened
□ 3. Through OPEN DOOR or other opening
□ 4. Through UNLOCKED door or window
□ 5. Through LOCKED door or window
□ 6. Some other way (Please specify) ___________________________________________
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
SECTION D:
Description of Incident

The next set of questions asks about what actually happened during this incident (IF MONTH PROVIDED: in
(MONTH/YEAR)). It may seem like you’ve already answered these questions, but we want to be sure we
understand what happened to you during this incident.

D1. Please focus only on the parts of the incident that were unwanted. For each unwanted act that
happened to you, please indicate if the person:
•
•
•
•

One… Threatened to do this – meaning the person verbally threatened to do it but did not
physically try to do it
Two… Attempted to do this – meaning the person physically tried to do it but did not succeed
Three… Actually did this – meaning the person physically did this act, OR
Four… Did not do this

Did the person 1 - threaten to, 2- attempt to, or 3 -actually put a penis in your vagina when you
didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No
b.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually put their mouth on your vagina or anus
or make you put your mouth on their genitals or anus when you didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No

Attachment V: CATI Questionnaire

CATI

c.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually put a penis in your anus when you
didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No
d.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually put fingers or another object in your
vagina or anus when you didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No

D2. Please continue to only think about aspects of the incident that were unwanted and indicate if the
person 1 - threaten to, 2- attempt to, or 3 -actually did any of the following during this incident.

a.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually kiss or lick you when you didn’t want it
to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No

Attachment V: CATI Questionnaire

CATI
b.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually touch, grab, or fondle your breasts,
genitals, or buttocks over or under your clothes when you didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No
c.

Did the person 1 - threaten to, 2- attempt to, or 3 -actually expose their sexual body parts or make
you expose your sexual body parts when you didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No
d.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually make you look at or participate in
sexual photos or movies when you didn’t want it to happen?

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No
e.
Did the person 1 - threaten to, 2- attempt to, or 3 -actually make you do something else when you
didn’t want it to happen?(Please specify _____________________________________________)

□ 1. Yes, threatened to do this
□ 2. Yes, attempted to do this
□ 3. Yes, actually did this
□ 4. No

Attachment V: CATI Questionnaire

CATI
(IF YOU MARKED YES TO ANY ITEM IN D1 OR D2, CONTINUE. ELSE, SKIP TO SECTION E)

D3. Please tell me if the person did any of the following at any point leading up to this incident.
Yes
DK

REFUSED

a. Verbally pressure you or continually argue with you

□

b. Threaten to cut off financial support

□

c. Threaten to cause problems at your job, at school,
in your relationships, or to cause some other problem

□

d. Promise rewards in your relationship,
your job, your grades, or something else

□

D4.

Please tell me if the person did any of the following at any point during this incident.
Yes
DK

REFUSED

Hold you or pin you so you had difficulty moving

□

Use a weapon, or threaten to use a weapon

□

Physically attack you or threaten to attack
you, but not with a weapon

□

Physically attack, or threaten to attack,
someone else

□

Use any other type of coercion or force
(SPECIFY)___________________________________

□

(IF YOU MARKED YES TO D4B – USE OR THREATEN TO USE A WEAPON, CONTINUE. ELSE SKIP
TO NOTE BEFORE D8)

Attachment V: CATI Questionnaire

CATI
D5.

Was the weapon a…
Yes

REFUSED

DK
a.

Gun, such as a pistol, revolver, rifle or shotgun?

□

Knife or other sharp object?

□

Some other weapon? (Please specify)
________________________________________________

□

(IF D5A=YES (WEAPON WAS A GUN), CONTINUE TO D6. ELSE SKIP TO NOTE BEFORE D7.)
D6.

Were you shot or did the person try to shoot you?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

(IF D5B=YES (WEAPON WAS A KNIFE OR SHARP OBJECT), CONTINUE TO D7. ELSE SKIP TO
NOTE BEFORE D8.)
D7.

Were you stabbed or did the person try to stab you?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
(IF YOU MARKED YES TO D4A, B, C or D (PHYSICAL FORCE), CONTINUE. ELSE SKIP TO SECTION
E.)
D8.

Did the person do any of the following to you during the incident? Did they…
Yes

REFUSED

DK
a.

slap, hit or punch you?

□

kick, bite or scratch you?

□

choke or suffocate you?

□

hit you with an object?

□

grab, hold, trip, jump on, or push you?

□

f.
do any other physical things to you?
(Please specify) _________________________________

Attachment V: CATI Questionnaire

CATI
SECTION E:
Injuries and Hospital Care

E1.

Did you experience any physical injuries as a result of this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

E1a.

 Continue to E1a
 Skip to E5a
 Skip to E5a
 Skip to E5a

Please indicate if you experienced any of the following physical injuries.

Yes

REFUSED

□
□
□
□
□
□

□

h. Other injuries (Please specify) _________________ □

□

a. Injury from sexual intercourse, such as
vaginal or anal tearing
b. Knife or stab wounds
c. Gun shot, bullet wounds
d. Broken bones or teeth knocked out
e. Internal injuries
f. Knocked unconscious
g. Bruises, black-eye, cuts, scratches, swelling,
chipped teeth

E2.

Did you receive any medical care as a result of this incident, including self- treatment?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
66

 Continue to E3
 Skip to E5a
 Skip to E5a
 Skip to E5a
Attachment V: CATI Questionnaire

CATI

E3.

Where did you receive this care? Did you receive it…
Yes
□

No
□

REFUSED
□

DK
□

□

d. At another medical setting such as a clinic, hospital
or doctor’s office?

□

e. Some other place? (Please specify)
_______________________________________

□

a. At the scene?
b. At home, at a neighbor's or a friend's?
c. At an emergency room at a hospital or
emergency clinic?

IF RECEIVED CARE AT ANOTHER MEDICAL SETTING OR SOME OTHER PLACE (E3D OR
E3E=YES) , CONTINUE TO E4. ELSE GO TO E5A.
E4.

Did you stay overnight in the hospital?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI

E5a.

E5b.

In the days following the incident, how distressed were you by this incident? Were you…

□ Not at all distressed?
□ Mildly distressed?
□ Moderately distressed?
□ Severely distressed?
□ REFUSED
□ DON’T KNOW

Sometimes people’s feelings change over time. Thinking about it now, how distressed are you by
this incident? Are you…

□ Not at all distressed?
□ Mildly distressed?
□ Moderately distressed?
□ Severely distressed?
□ REFUSED
□ DON’T KNOW

PROGRAMMER NOTE: IF “NOT AT ALL DISTRESSED” OR “REFUSED” TO BOTH E5A AND E5B,
SKIP TO E7. ELSE CONTINUE.

E6.

Please indicate if you felt any of the following ways for less than one month, for one month or
longer as a result of this incident, or if you did not feel that way.

a.
b.
c.
d.
e.
f.
g.
h.
68

worried or anxious
angry
sad or depressed
vulnerable
violated
like you couldn’t trust people
fearful
some other way

Yes
<1 Mo
□
□
□
□
□
□

Yes
1 Mo+
□
□
□
□
□
□

No
□
□
□
□
□
□

REFUSED
□
□
□
□
□
□

DK
□
□
□
□
□
□

Attachment V: CATI Questionnaire

CATI
(Please specify) ____________________□

E7.

E8.

□

Did you lose time from work or school because of the incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to E8
 Skip to Section F
 Skip to Section F
 Skip to Section F

How much time did you lose because of injuries?

□ Less than one day
□ One day
□ More than one day
□ REFUSED
□ DON’T KNOW

 Skip to Section F
 Skip to Section F
 Continue to E8a
 Skip to Section F
 Skip to Section F

E8a. How many days was it? (Enter a number)
_____________ days

□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
SECTION F:
Offender Characteristics

The next questions are about who did this to you.

F1.

F2.

Did one or more than one person do this to you?

□ One
□ More than one
□ REFUSED
□ DON’T KNOW

 Continue to F2
 Skip to F12
 Continue to F2
 Continue to F2

Was this person male or female?

□ Male
□ Female
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
F3.

How old would you say this person was? (READ CATEGORIES)

F4a.

Was this person Hispanic or Latino/a?

□ Under 18
□ 18-29
□ 30-39
□ 40-49
□ 50+
□ REFUSED
□ DON’T KNOW
□ Yes
□ No
□ REFUSED
□ DON’T KNOW

F4b.

What race or races was this person? Was this person…

a.
b.
c.
d.
e.

F5.

White?
Black or African American?
American Indian or Alaska Native?
Asian?
Native Hawaiian or Other Pacific Islander?

Yes
□
□
□
□
□

No
□
□
□
□
□

REFUSED
□
□
□
□
□

DK
□
□
□
□
□

Was this person someone you knew, or a stranger you had never seen before?

□ Knew or had seen before
□ Stranger
□ REFUSED
□ DON’T KNOW
71

Skip to F7
 Continue to F6
 Continue to F6
 Continue to F6

Attachment V: CATI Questionnaire

CATI

F6.

F7.

Would you be able to recognize this person if you saw him/her?

□ Yes
□ Not sure
□ No
□ REFUSED
□ DON’T KNOW

 Skip to F8
 Skip to F8
 Skip to Section G
 Skip to F8
 Skip to F8

How well did you know this person? Please tell me the number that corresponds with your
answer.

□ 1. By sight only
□ 2. Casual acquaintance
□ 3. Well known
□ REFUSED
□ DON’T KNOW
F8.

 Skip to F9
 Skip to F9
 Skip to F9
 Skip to F9

Would you have been able to tell the police how they might find this person, for instance, where
he/she lived, worked, went to school, or spent time?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
F9.

 Continue to F8

 Skip to Section G
 Skip to Section G
 Skip to Section G
 Skip to Section G

Was this person a relative or nonrelative?

□ Relative
□ Nonrelative
□ REFUSED
□ DON’T KNOW
72

 Continue to F10
 Skip to F11
 Skip to F11
 Skip to F11
Attachment V: CATI Questionnaire

CATI

F10. How was this person related to you? Please tell me the number that corresponds to your answer.
(READ NUMBERS AND RESPONSE CHOICES)

□ 1. spouse
□ 2. ex-spouse
□ 3. parent or step-parent
□ 4. own child or step-child
□ 5. brother or sister
□ 6. some other relation to you (Please specify)
___________________________________________________

□ REFUSED
□ DON’T KNOW
(IF YOU ANSWERED “RELATIVE” TO QUESTION F9, SKIP TO SECTION G. OTHERWISE CONTINUE
TO QUESTION F11.)

F11.

Was this person a …

a.
b.
c.
d.
e.
f.
g.

boyfriend or girlfriend?
ex-boyfriend or ex-girlfriend?
friend?
someone who used to be a friend?
roommate or boarder?
schoolmate?
something else? (Please specify)
_______________________________________

Yes
□
□
□
□
□
□

No
□
□
□
□
□
□

REFUSED
□
□
□
□
□
□

DK
□
□
□
□
□
□

□

IF THE PERSON WAS A BOYFRIEND/GIRLFRIEND (F11A=YES), SKIP TO F24.
OTHERWISE, SKIP TO SECTION G

Attachment V: CATI Questionnaire

CATI
F12.

How many people did this to you?
_______________ (enter number)

□ REFUSED
□ DON’T KNOW
F13.

Were they male or female?

□ All male
□ All female
□ Both male and female
□ REFUSED
□ DON’T KNOW
F14.

 Skip to F14a
 Skip to F14a
 Continue to F14
 Skip to F14a
 Skip to F14a

Were they mostly male or mostly female?

□ Mostly male
□ Mostly female
□ Evenly divided
□ REFUSED
□ DON’T KNOW
F14a. Were any of the persons Hispanic or Latino/a?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to F14b
 Skip to F14c
 Skip to F14c
 Skip to F14c

Attachment V: CATI Questionnaire

CATI
F14b. Were they mostly Hispanic, mostly non-Hispanic or an equal number of Hispanic and nonHispanic?

□ Mostly Hispanic
□ Mostly non-Hispanic
□ Equal number of Hispanic and non-Hispanic
□ REFUSED
□ DON’T KNOW
F14c. What were the race or races of the persons? Were they…
Yes
a. White?
□
b. Black or African American?
□
c. American Indian or Alaska Native?
□
d. Asian?
□
e. Native Hawaiian or Other Pacific Islander?
□

No
□
□
□
□
□

REFUSED
□
□
□
□
□

DK
□
□
□
□
□

IF YOU SELECTED MORE THAN ONE RACE IN QUESTION F14C, CONTINUE TO QUESTION
F14D.
OTHERWISE, SKIP TO QUESTION F15.
F14d. What race were most of the persons? Please tell me the number that corresponds to your answer.
(READ NUMBERS AND RESPONSE CHOICES)

□ 1. White
□ 2. Black or African American
□ 3. American Indian or Alaska Native
□ 4. Asian
□ 5. Native Hawaiian or Other Pacific Islander
□ 6. Equal number of each race
□ REFUSED
□ DON’T KNOW
75

Attachment V: CATI Questionnaire

CATI
F15. How old would you say the youngest was? I’m going to read you some age categories. When I get to
the correct answer, please say yes.

□ 18-24
□ 25-39
□ 40-49
□ 50+
□ REFUSED
□ DON’T KNOW
F16. How old would you say the oldest was? I’m going to read you some age categories. When I get to the
correct answer, please say yes.

□ 18-24
□ 25-39
□ 40-49
□ 50+
□ REFUSED
□ DON’T KNOW
F17.

Were any of these persons 1) someone you knew or had seen before, or 2) were they all strangers
you had never seen before?

□ 1. Knew or had seen before
□ 2. All strangers
□ REFUSED
□ DON’T KNOW

 Skip to F19
 Continue to F18
 Continue to F18
 Continue to F18

Attachment V: CATI Questionnaire

CATI
F18.

Would you be able to recognize any of these persons if you saw him/her?

□ Yes
□ Not sure
□ No
□ REFUSED
□ DON’T KNOW

 Skip to F20
 Skip to F20
 Skip to Section G
 Skip to F20
 Skip to F20

F19. Please tell me how well you knew the people who did this to you.

a. Was at least one well known to you?
b. Was at least one a casual acquaintance?
c. Did you know at least one by sight only?

Yes
□
□
□

No
□
□
□

REFUSED
□
□
□

DK
□
□
□

IF (F19C=YES AND F19A=NO, REFUSED/DK AND F19B=NO, REFUSED/DK) OR (F19A, F19B, F19C
ARE ALL REFUSED/DK), CONTINUE. ELSE, SKIP TO F21.
F20.

Would you have been able to tell the police how they might find any of these persons, for instance,
where he/she lived, worked, went to school, or spent time?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 SKIP TO SECTION G
IF YOU ANSWERED F19A=YES (WELL KNOWN) OR F19B=YES (CASUAL ACQUAINTANCE),
CONTINUE TO F21. OTHERWISE, SKIP TO SECTION G.
F21.

Were any of these persons a relative?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
77

 Continue to F22
 Skip to F23
 Skip to F23
 Skip to F23
Attachment V: CATI Questionnaire

CATI

F22.

Were any of these persons your…
a.
b.
c.
d.
e.
f.

spouse?
ex-spouse?
parent or step-parent?
own child or step-child?
brother or sister?
some other relation to you? (Please specify)

Yes
□
□
□
□
□
□

No
□
□
□
□
□
□

REFUSED
□
□
□
□
□
□

DK
□
□
□
□
□
□

___________________________________________________
 SKIP TO SECTION G
F23.

Were any of these persons a …
Yes
a.
b.
c.
d.
e.
f.
g.

boyfriend or girlfriend?
□
ex-boyfriend or ex-girlfriend
□
friend?
□
someone who used to be a friend?
□
roommate or boarder?
□
schoolmate?
□
something else? (Please specify)
____________________________________ □

REFUSED

□
□
□
□
□
□

□

 IF ANY OF THE PERSONS WAS A BOYFRIEND/GIRLFRIEND (F23A=YES), CONTINUE TO
F24. OTHERWISE, SKIP TO SECTION G
F24.

Earlier you said the person who did this to you was your boyfriend/girlfriend. Approximately how
long had you been dating this person?
_______________

□ REFUSED
□ DON’T KNOW

F25.

days/months/years

Are you currently dating or romantically involved with this person?

□ Yes
□ No
□ REFUSED
78

Attachment V: CATI Questionnaire

CATI

□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
SECTION G:
Circumstances of Incident
The next questions are about the circumstances related to the incident.

G1.

Did this occur while you were in the military?

G2.

Did this occur while you were a student?

□ Yes
□ No
□ Does not apply, was not in military
□ REFUSED
□ DON’T KNOW
□ Yes
□ No
□ REFUSED
□ DON’T KNOW

(IF C3=1, SKIP TO G4. ELSE CONTINUE.)
G3.

Which of the following best describes what were you doing at the time of the incident? Please tell
me the number that corresponds with your answer. (READ NUMBERS AND RESPONSE
CHOICES)

□ 1. On your way to or from some place, or in transit
□ 2. Hanging out at someone’s home, or at a party or gathering
□ 3. At a restaurant, bar, movie, sporting event, or other public activity
□ 4. Working or at school
□ 5. Something else (Please specify _______________)
□ REFUSED
□ DON’T KNOW
80

Attachment V: CATI Questionnaire

CATI

G4.

Had (the person/any of the people) who did this to you been using alcohol or drugs in the hours
leading up to the incident? Please tell me the number that corresponds with your answer

□ 1. Alcohol
□ 2. Drugs
□ 3. Both alcohol and drugs
□ 4. Neither alcohol nor drugs
□ REFUSED
□ DON’T KNOW

G5.

Had you been using alcohol or drugs in the hours leading up to the incident? Please tell me the
number that corresponds with your answer.

□ 1. Alcohol
□ 2. Drugs
□ 3. Both alcohol and drugs
□ 4. Neither alcohol nor drugs
□ REFUSED
□ DON’T KNOW

G6.

 Continue to G6
 Continue to G6
 Continue to G6
 Skip to G16
 Skip to G16 – inconsistent with ACASI
 Skip to G16

Did the (person/any of the people who did this to you) give you (alcohol/drugs/alcohol or drugs)
without your knowledge?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
G7.

Do you think the person was trying to get you (drunk/high/drunk or high) so (he/she) could
sexually take advantage of you?

□ Yes
□ No
□ Not Sure
□ REFUSED
□ DON’T KNOW

 Continue to G8
 Skip to G10
 Continue to G8
 Continue to G8
 Continue to G8

G8. Did the person keep giving you (drinks/drugs/drinks or drugs) without you asking for it?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
G9. Did the person keep giving you (drinks/drugs/drinks and drugs) after you were clearly very
(drunk/high/drunk or high)?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
G10. Were you passed out for all or parts of this incident, or not? By passed out, it means that you were
unconscious or asleep because of the (alcohol/drugs/alcohol or drugs).

□ Yes, for all of the incident
□ Yes, for parts of the incident
□ No
□ Not sure
□ REFUSED
□ DON’T KNOW

 Skip to G16
 Skip to G12
 Continue to G11
 Continue to G11
 Continue to G11
 Continue to G11

G11. Were there any parts of the incident you could not remember because of the (alcohol/drugs/alcohol
or drugs)?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
G12. Please answer the following questions on how (alcohol/drugs/alcohol and drugs) affected what
happened.
Yes

REFUSED

DK
a. Did the (alcohol/drugs/alcohol or drugs
make you unable to give consent?
□
b. Did it make you less able to physically resist?
□
c. Did it lead you to make decisions that you
would not have made otherwise?
□
d. Did it affect you in some other way?
(Please specify) __________________________________□

□
□

□

Attachment V: CATI Questionnaire

CATI
G13. Were you too (drunk/high/drunk or high) to walk by yourself?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
G14. Were you too (drunk/high/drunk or high) to speak without slurring your words?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to G16
 Continue to G15
 Continue to G15
 Continue to G15

G15. Were you able to communicate clearly to others?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
These next questions are about what you did when this incident occurred.
Please remember that people may react differently to certain situations and that there are no right or wrong ways
to react in these situations. Everyone is different. These questions will help to get a better picture of what the
range of things women in similar situations have done.
Collecting this information will help develop better policies and advice for women who have these experiences
in the future.

G16. Please tell me whether you did any of the following at any point during the incident? Did you...

a. physically resist, or try to physically resist the
person?
b. say “no”, “stop”, or that you did not want the act
to happen?
c. leave or stop the situation before the act occurred?
d. attack or threaten the person?
e. try to persuade, plead or argue with the person?
f. try to escape or get away?
g. try to get help?
h. do something else? (Please specify)

YES

REFUSED DK

□

□
□
□
□
□
□
□

___________________________________________________

IF YOU ANSWERED “NO” TO ALL QUESTIONS G16A-H, THEN SKIP TO QUESTION G18.
IF YOU ANSWERED ‘YES’ TO G16B (SAID ‘NO’ OR ‘STOP’) CONTINUE.
OTHERWISE SKIP TO SECTION H.

Attachment V: CATI Questionnaire

CATI
G17. Did the person immediately stop after you said that you didn’t want it to happen?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Skip to Section H
Skip to Section H
Skip to Section H
Skip to Section H

G18. You answered “no” to all of the actions that I asked about. Were any of the following reasons why
you did not take any actions?
Yes
a. You were afraid that he/she would physically
hurt you
b. You were afraid that he/she would physically
hurt someone else
c. You were afraid that he/she would carry out
other threats he/she made
d. You were too (drunk/high/drunk or high) to
either physically or verbally resist
e. You did not want to hurt the person’s feelings
f. You were surprised or it happened too quickly
for you to take any action
g. Other reason (Please specify)

REFUSED

□

□
□

___________________________________________________

Attachment V: CATI Questionnaire

CATI

SECTION H:
Follow-up with Service Providers and Friends

H1.

Did you ever talk to a psychologist, psychiatrist, counselor, or other mental health professional
about this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
H2.

Have you ever talked to a crisis hotline operator about what (this person/these persons) did?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment V: CATI Questionnaire

CATI
SECTION I:
Follow-up with the Police

I1a.

At the time, did you consider this incident to be a crime?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to I1c
 Continue to I1b
 Skip to I1c
 Skip to I1c

PROGRAMMER NOTE: IF NO IN I1a, CONTINUE. ELSE SKIP TO I1c.

I1b. Please tell me whether any of the following are the reasons why you did not consider this
incident to be a crime.
Yes
No REFUSED DK
a. Because the person stopped when you resisted
□
□
□
□
b. Because you didn’t think the person intended harm
□
□
□
□
c. Because you didn’t think it was against the law
□
□
□
□
d. Because you had been using alcohol or drugs at the time
□
□
□
□
e. Other reason (Please specify) __________________________□
□
□
□

I1c.

Now, looking back, do you consider this incident to be a crime?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to I2
 Continue to programmer note before I1d
 Skip to I2
 Skip to I2

PROGRAMMER NOTE: IF NO IN I1c AND YES/DK/RF IN I1a, CONTINUE. ELSE SKIP TO I2.
88

Attachment V: CATI Questionnaire

CATI

I1d. Please tell me whether any of the following are the reasons why, looking back, you do not
consider this incident to be a crime.
Yes
No REFUSED DK
a. Because the person stopped when you resisted
□
□
□
□
b. Because you don’t think the person intended harm
□
□
□
□
c. Because you don’t think it was against the law
□
□
□
□
d. Because you had been using alcohol or drugs at the time
□
□
□
□
e. Other reason (Please specify) __________________________□
□
□
□

I2.

Were the police informed or did they find out about this incident in any way?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to I3
 Skip to I4
 Skip to I4
 Skip to I4

I3.
How did the police find out about it? Please tell me the number that corresponds with your
answer. (READ NUMBERS AND RESPONSE CHOICES)

□ 1. You contacted the police
□ 2. Another household member contacted the police
□ 3. Some official contacted police (guard,
apt. manager, school official, etc)

□ 4. Someone else contacted the police
□ 5. Police were at the scene
□ 6. Some other way (Please specify)

 Skip to I5
 Skip to I5
 Skip to I5
 Skip to I5
 Skip to I7
 Skip to I5

___________________________________________________

□ REFUSED
□ DON’T KNOW

 Skip to I5
 Skip to I5

IF YOU ANSWERED “NO” TO QUESTION I1A, SKIP TO I5. OTHERWISE, CONTINUE TO I4.
89

Attachment V: CATI Questionnaire

CATI

I4.

Please tell me if any of the following are the reasons you did not report it to the police?

a.
b.
c.
d.
e.
f.
g.
h.

Yes
You did not want anyone else to know
□
It was your word against the person
□
Police wouldn’t think it was a crime
□
Fear of being treated hostilely by police or lawyers
□
Fear of retaliation by the person or others
□
You did not think it was serious enough to report
□
You reported it somewhere else
□
Other reason (SPECIFY) _________________________________□

No
□
□
□
□
□
□
□
□

REFUSED DK
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

 SKIP TO QUESTION I8

Attachment V: CATI Questionnaire

CATI
IF YOU ANSWERED “YES” TO I2, CONTINUE TO QUESTION I5. OTHERWISE, SKIP TO QUESTION
I8.
I5.

I6.

I7.

Did the police come to your location when they found out about the incident?

□ Yes
□ No
□ You went to the police
□ REFUSED
□ DON’T KNOW

 Skip to I8
 Skip to I7
 Skip to I8
 Skip to I8

How soon after the police found out did they come to your location?

□ Within 30 minutes
□ Within an hour
□ Within a day
□ Longer than a day
□ REFUSED
□ DON’T KNOW

Did the police do any of the following while (they/you) were (at the scene/there)?

a.
b.
c.
d.
e.
f.
g.
h.

I8.

 Continue to I6

Yes
Take a report
□
Search/looked around
□
Take evidence (fingerprints, inventory, etc.)
□
Question witnesses or suspects
□
Promise surveillance
□
Promise to investigate
□
Make an arrest
□
Something else (Please specify)_________________________□

No
□
□
□
□
□
□
□
□

REFUSED
□
□
□
□
□
□
□
□

DK
□
□
□
□
□
□
□
□

(Not counting the police) Is there any other person you have told about this incident?

□ Yes
91

 Continue to I8a
Attachment V: CATI Questionnaire

CATI

□ No
□ REFUSED
□ DON’T KNOW
I8a.
a.
b.
c.
d.
e.
f.
g.

I9.

 Skip to I9
 Skip to I9
 Skip to I9

Who have you told? Have you told…

Yes
Parents or a parent?
□
Husband, boyfriend, or partner?
□
A family member other than parents?
□
A friend?
□
Roommate, suitemate, or housemate?
□
Clergy, rabbi, or other spiritual leader?
□
Other person? (Please specify) _________________________□

No
□
□
□
□
□
□
□

REFUSED
□
□
□
□
□
□
□

DK
□
□
□
□
□
□
□

(Not counting the police) Is there any other organization you have told about this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
I9a.

 Continue to I9a
 Skip to I10
 Skip to I10
 Skip to I10

What organization have you told? Have you told a…

Yes
a. Women's program or service?
□
b. Rape crisis center or victim services hotline?
□
c. Counselor or therapist not associated with a
rape crisis center or victim services hotline?
□
d. Some other organization? (Please specify) ____________________□

No
□
□
□
□

REFUSED DK
□
□
□
□
□
□

Attachment V: CATI Questionnaire

□
□

CATI
I10. Have you received any help from any office or agency (other than the police) that deals with
victims of crime?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
I11.

 Continue to I11
 Skip to I12
 Skip to I12
 Skip to I12

We are interested in the type of help that you have received. Have you received…

a.
b.
c.
d.

psychological or emotional counseling?
compensation for your injury?
help to remove you from danger?
legal advice or advocacy?

Yes
□
□
□
□

No
□
□
□
□

REFUSED
□
□
□
□

DK
□
□
□
□

Attachment V: CATI Questionnaire

CATI
I12. Thank you for providing this information about the incident.
In order to make sure that you have been able to describe the incident as accurately as possible, would
you be willing to describe it in your own words?

□ Yes
□ No

 Continue
 Skip to Programmer Note

[CATI] Thank you for being willing to describe the incident in your own words. Before you start, are
you sure that you can speak freely and in a private place where no one can overhear what you are
saying?

□ Yes
□ No

 Continue
 Skip to Programmer Note

Thank you. Could you please describe what happened, including the circumstances leading up the
incident, where and when it happened, who was involved, whether there was a weapon, if alcohol or
drugs were used, and any other details you feel are important to understand what happened. Do not
share any names of individuals.

PROGRAMMER NOTE:
AT END OF FIRST DETAILED INCIDENT FORM: Return to “Programmer Note” at end of screener.
If there is another incident to report, return to part 2, section A. If there is no other incident to report,
skip to Part 3.
AT END OF SECOND DETAILED INCIDENT FORM: Return to “Programmer Note” at end of
screener. If there is another incident to report, return to part 2, section A. If there is no other incident to
report, skip to Part 3.
AT END OF THIRD DETAILED INCIDENT FORM: Continue to Part 3.

Attachment V: CATI Questionnaire

CATI
PART THREE:
VIGNETTES

Thank you for your responses so far. The interview is almost done. In this next part, I’m going to read you two
fictional situations about a woman and a man, and then I will ask you questions about the woman in the
situation. Here is the first situation.
Alcohol Vignettes
Tom and Sue {INSERT RELATIONSHIP} last week. They both drank alcohol. {INSERT
DRINKING BEHAVIOR} They then went back {home/to Tom’s place}. {INSERT CONSENT}.
RELATIONSHIP
1. went on their first date
2. have been in a sexual relationship for three months and went on a date
3. have been married for five years and went out for dinner
DRINKING BEHAVIOR
1. Both Sue and Tom ordered drinks throughout the date, but neither became drunk.
2. Both Sue and Tom ordered drinks throughout the date. Sue eventually became very drunk and
was slurring her words.
3. Sue kept telling Tom she was not thinking straight and wanted to stop drinking. However,
Tom kept on drinking. Sue kept on drinking because she wanted to be social and eventually
became very drunk and was slurring her words.
4. Sue kept telling Tom she got drunk very easily and would prefer not to drink. Tom kept
refilling Sue’s wine glass saying that he would never take advantage of her. Sue eventually
became very drunk and was slurring her words.
[ONLY SELECT WHEN RELATIONSHIP = 1 or 2]
5. Tom knew that Sue got drunk very easily and decided to try to get her as drunk as possible. He
continued to buy Sue drinks and she became very drunk and was slurring her words.
[ONLY SELECT WHEN RELATIONSHIP = 3]
CONSENT
1. Tom asked if she wanted to have sex. Sue said yes and they proceeded to have sexual
intercourse.
2. Tom kissed Sue and they proceeded to have sexual intercourse. Sue did not say anything at the
time, but she did not want to have sex.
3. Tom kissed Sue. She tried to push Tom away, but did not actually say no. They proceeded to
have sexual intercourse.
4. Tom kissed Sue. Sue said she did not want to have sex, but Tom ignored her and they
proceeded to have sexual intercourse. Sue did not resist again because she was afraid Tom
would hurt her.

Attachment V: CATI Questionnaire

CATI
How would you answer the following questions about Sue?
1.

Within the past 12 months, that is since [MONTH/YEAR], has a male used force or threats of force to
make Sue have vaginal sex against her will? By vaginal sex, it means putting his penis in her vagina
against her will.
1
2

Since [MONTH/YEAR], has anyone made Sue have sex when she was unable to consent because she was
too drunk, high or passed out? By sex, it means vaginal sex, oral sex, anal sex, or putting fingers or a
foreign object in her vagina or anus.
1
2

Yes
No

Did the alcohol make Sue unable to give consent?
1
2

Yes
No

Do you think Tom was trying to get Sue drunk so he could sexually take advantage of her?
1
2

Yes
No

On a scale from 1 to 10 where 1 means Sue definitely did not give consent and 10 means she definitely
gave consent, to what extent did Sue give consent?
1
2
Definitely did not
give consent

10
Definitely
gave consent

Attachment V: CATI Questionnaire

CATI
Thank you. Here is the second situation. This one is about Mike and Becky.
Coercion Vignettes
{INSERT RELATIONSHIP}. After dinner they went {home/to Mike’s home} to watch a
movie together. During the movie, Mike began to kiss Becky and asked her if she would have
sex with him. Becky said no, because she didn’t feel like having sex. {INSERT GENTLE
FORCE} {INSERT COERCION} They eventually had sexual intercourse.
RELATIONSHIP
1. Mike and Becky went on their first date last week.
2. Mike is Becky’s manager at work and he tells Becky that he really values their work
relationship. They went on their first date last week.
3. Mike and Becky have been in a sexual relationship for three months and went on a
date last week.
4. Mike is Becky’s manager at work and he tells Becky that he really values their work
relationship. They have been in a sexual relationship for three months and went on a
date last week.
5. Mike and Becky have been married for five years and went out for dinner last week.
GENTLE FORCE
1. {Blank}
2. Mike began to remove Becky’s clothes.
COERCION
1. Mike then said that he was going to end the romantic relationship if she did not have
sex with him.
2. Mike then said, “You’re so beautiful. I really want us to share something special.”
3. Mike also tried several times to persuade her to have sex.

Attachment V: CATI Questionnaire

CATI
How would you answer the following questions about Becky?
1. Within the past 12 months, that is since [MONTH/YEAR], has a male used force or threats of force to
make Becky have vaginal sex against her will? By vaginal sex, it means putting his penis in her vagina
against her will.
1
Yes
2
No
2. Since [MONTH/YEAR], has anyone made Becky have any type of sex against her will by threatening to
cause problems for her, such as at her job or school, at home, in her relationships or in any other way?
By sex, it means vaginal sex, oral sex, anal sex, or putting fingers or a foreign object in her vagina or
anus.
1
Yes
2
No
4. On a scale from 1 to 10 where 1 means Becky was definitely not pressured and 10 means she was
definitely pressured, to what extent was Becky pressured to have sexual intercourse?
1
2
Definitely not
pressured

10
Definitely
pressured

Attachment V: CATI Questionnaire

Attachment W:
Field Full Interview

Introduction
The next questions ask about unwanted sexual situations that you may have experienced in the past 12 months
and in your lifetime. Your answers will be used to help determine how often these things happen to women.
Some of the language used in this survey is explicit and may be uncomfortable to you, but it is important that
the questions are asked in this way so that you are clear about what is meant.

As we told you before, the information you are providing will be kept private. Also remember that you can skip
questions that you don’t want to answer and you can stop at anytime.

Attachment W: ACASI Questionnaire

PART ONE:
Questions about the last 12 months

These first few questions ask you to recall any incidents in the past 12 months that happened
against your will. You will be asked to count how many separate incidents happened to you over
the past year and to list the month when they occurred. The questions begin with the most serious
types of incidents and then move to less serious incidents.
SV1. Within the past 12 months, that is since [MONTH/YEAR], has a male used force or threats of force
to make you have vaginal sex against your will? By vaginal sex, it means putting his penis in your
vagina against your will.

□ Yes
□ No

 Continue to SV1A
 Skip to question SV2

SV1A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV1B
 Skip to question SV1B
 Continue
 Continue

SV1A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

Attachment W: ACASI Questionnaire

SV1B. In what month and year did (this incident/these incidents/(IF SV1A>4 OR SV1A1>=5
TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS
HAPPENED TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN
ONCE IN A MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV1A=once and “DON’T KNOW” IS MARKED IN SV1B, OR IF
SV1A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV1B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV1B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV1A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV1B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV1B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV1B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV1Ba-d or SV1B_1=No or
SV1B_2>0, Delete response and reduce SV1A by appropriate amount. If SV1A was once, and it gets
reduced to zero, change SV1 to no and delete all data in A and B follow-ups.
SV2. Since [MONTH/YEAR], has anyone, male or female, used force or threats of force to make you
have oral sex against your will? By oral sex, it means that someone penetrated your vagina or
anus with their mouth or tongue, or you were forced to use your mouth or tongue on someone
else’s genitals or anus against your will.

□
□

Yes

 Continue to SV2A

 Skip to question SV3

SV2A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV2B
 Skip to question SV2B
 Continue
 Continue

SV2A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

Attachment W: ACASI Questionnaire

SV2B. In what month and year did (this incident/these incidents/(IF SV2A>4 OR
SV2A1>=5 TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV2A=once and “DON’T KNOW” IS MARKED IN SV2B, OR IF
SV2A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV2B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV2B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV2A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV2B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV2B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV2B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV2Ba-d or SV2B_1=No or
SV2B_2>0, Delete response and reduce SV2A by appropriate amount. If SV2A was once, and it gets
reduced to zero, change SV2 to no and delete all data in A and B follow-ups.
PROGRAMMER NOTE #4: If any of the months listed in SV2B match a month listed in SV1B, if any
are marked as DK and an incident has been reported in a previous question, Continue.
Otherwise, go to SV3.
For each month that matches, if month is only listed once in SV2B, GO TO SV2C1. If
month is listed twice in SV2B, GO TO SV2C2. If month is listed three or more times in
SV2B, GO TO SV2C3.
If one of the months is marked as “DON’T KNOW”, go to SV2C1. If two of the months
are marked as “DON’T KNOW”, go to SV2C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV2C3.

Repeat this instruction for each month that matches with SV1B.
SV2C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV3
 Skip to question SV3

SV2C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV3

Yes, both are part of the other incidents

 Skip to question SV3

No, separate incidents

 Skip to question SV3

SV2C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV3

SV2D3. How many of these are part of an incident that you already reported?

Attachment W: ACASI Questionnaire

___ ___ (enter number)  Continue to question SV3

Attachment W: ACASI Questionnaire

SV3. Since [MONTH/YEAR], has a male used force or threats of force to make you have anal sex
against your will? By anal sex, it means that a man or boy put his penis in your anus against
your will.

□ Yes
□ No

 Continue to SV3A
 Skip to question SV4

SV3A. How many times did this happen to you since [MONTH/YEAR]?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV3B
 Skip to question SV3B
 Continue
 Continue

SV3A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV3B. In what month and year did (this incident/these incidents/(IF SV3A>4 OR
SV3A1>=5 TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW
Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #1: IF SV3A=once and “DON’T KNOW” IS MARKED IN SV3B, OR IF
SV3A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV3B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV3B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV3A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV3B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV3B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV3B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV3Ba-d or SV3B_1=No or
SV3B_2>0, Delete response and reduce SV3A by appropriate amount. If SV3A was once, and it gets
reduced to zero, change SV3 to no and delete all data in A and B follow-ups.
PROGRAMMER NOTE#4 : If any of the months listed in SV3B match a month listed in SV1B OR
SV2B,
if any are marked as DK and an incident has been reported in a previous question,
Continue. Otherwise, go to SV4.
For each month that matches, if month is only listed once in SV3B, GO TO SV3C1. If
month is listed twice in SV3B, GO TO SV3C2. If month is listed three or more times in
SV3B, GO TO SV3C3.
If one of the months is marked as “DON’T KNOW”, go to SV3C1. If two of the months
are marked as “DON’T KNOW”, go to SV3C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV3C3.

Attachment W: ACASI Questionnaire

SV3C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV4
 Skip to question SV4

SV3C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV4

Yes, both are part of the other incidents

 Skip to question SV4

No, separate incidents

 Skip to question SV4

SV3C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV4

SV3D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV4

Attachment W: ACASI Questionnaire

SV4. Since [MONTH/YEAR], has a male or female used force or threats of force to put fingers or a
foreign object in your vagina or anus against your will?

□ Yes
□ No

 Continue to SV4A
 Skip to question SV5

SV4A. How many times did this happen to you since [MONTH/YEAR]?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV4B
 Skip to question SV4B
 Continue
 Continue

SV4A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV4B.In what month and year did (this incident/these incidents/(IF SV4A>4 OR SV4A1>=5
TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

Attachment W: ACASI Questionnaire

(MONTH/YEAR)

□ DON’T KNOW

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #1: IF SV4A=once and “DON’T KNOW” IS MARKED IN SV4B, OR IF
SV4A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV4B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV4B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV4A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV4B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV4B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV4B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV4Ba-d or SV4B_1=No or
SV4B_2>0, Delete response and reduce SV4A by appropriate amount. If SV4A was once, and it gets
reduced to zero, change SV4 to no and delete all data in A and B follow-ups.
PROGRAMMER NOTE #4: If any of the months listed in SV4B match a month listed in SV1B, SV2B
or SV3B, Continue. if any are marked as DK and an incident has been reported in a
previous question, Continue. Otherwise, go to SV5.
For each month that matches, if month is only listed once in SV4B, GO TO SV4C1. If
month is listed twice in SV4B, GO TO SV4C2. If month is listed three or more times in
SV4B, GO TO SV4C3.

If one of the months is marked as “DON’T KNOW”, go to SV4C1. If two of the months
are marked as “DON’T KNOW”, go to SV4C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV4C3.

Repeat this instruction for each month that matches with SV1B, SV2B or SV3B.

Attachment W: ACASI Questionnaire

SV4C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV5
 Skip to question SV5

SV4C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV5

Yes, both are part of the other incidents

 Skip to question SV5

No, separate incidents

 Skip to question SV5

SV4C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV5

SV4D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV5

Attachment W: ACASI Questionnaire

When answering these next questions, please consider all the types of sex acts that you have been asked
about so far; including vaginal sex, oral sex, anal sex, or putting fingers or a foreign object in your vagina
or anus.
These questions will now focus on other types of unwanted sexual experiences that may not have involved
force, but that were against your will.
SV5. (Other than the incidents you have already mentioned), since [MONTH/YEAR] has anyone made
you have any type of sex when you were unable to consent because you were too drunk, high or passed
out?

□
□

Yes

 Continue to SV5A

 Skip to SV6

SV5A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV5B
 Skip to question SV5B
 Continue
 Continue

SV5A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

Attachment W: ACASI Questionnaire

SV5B. In what month and year did (this incident/these incidents/(IF SV5A>4 OR SV5A1>=5
TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV5A=once and “DON’T KNOW” IS MARKED IN SV5B, OR IF
SV5A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV5B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV5B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV5A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV5B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV5B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV5B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV5Ba-d or SV5B_1=No or
SV5B_2>0, Delete response and reduce SV5A by appropriate amount. If SV5A was once, and it gets
reduced to zero, change SV5 to no and delete all data in A and B follow-ups.
16
Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #4: If any of the months listed in SV5B match a month listed in SV1B, SV2B,
SV3B, or SV4B, if any are marked as DK and an incident has been reported in a
previous question, Continue. Otherwise, go to SV6.
For each month that matches, if month is only listed once in SV5B, GO TO SV5C1. If
month is listed twice in SV5B, GO TO SV5C2. If month is listed three or more times in
SV5B, GO TO SV5C3.
If one of the months is marked as “DON’T KNOW”, go to SV5C1. If two of the months
are marked as “DON’T KNOW”, go to SV5C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV5C3.

Repeat this instruction for each month that matches with SV1B, SV2B, SV3B or SV4B.
SV5C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV6
 Skip to question SV6

SV5C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV6

Yes, both are part of the other incidents

 Skip to question SV6

No, separate incidents

 Skip to question SV6

SV5C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV6

SV5D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV6
17

Attachment W: ACASI Questionnaire

SV6. (Other than the incidents you have already mentioned,) since [MONTH/YEAR], has anyone
made you have any type of sex against your will by threatening to cause problems for you,
such as at your job or school, at home, in your relationships or in any other way? [Remember
to think about all the types of sex mentioned before].

□
□

Yes

 Continue to SV6A

 Skip to question SV7

SV6A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV6B
 Skip to question SV6B
 Continue
 Continue

SV6A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

Attachment W: ACASI Questionnaire

SV6B.In what month and year did (this incident/these incidents/(IF SV6A>4 OR SV6A1>=5
TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV6A=once and “DON’T KNOW” IS MARKED IN SV6B, OR IF
SV6A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV6B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV6B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV6A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV6B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV6B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV6B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV6Ba-d or SV6B_1=No or
SV6B_2>0, Delete response and reduce SV6A by appropriate amount. If SV6A was once, and it gets
reduced to zero, change SV6 to no and delete all data in A and B follow-ups.
19

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #4: If any of the months listed in SV6B match a month listed in SV1B, SV2B,
SV3B, SV4B, or SV5B, if any are marked as DK and an incident has been reported in a
previous question, Continue. Otherwise, go to SV7.
For each month that matches, if month is only listed once in SV6B, GO TO SV6C1. If
month is listed twice in SV6B, GO TO SV6C2. If month is listed three or more times in
SV6B, GO TO SV6C3.
If one of the months is marked as “DON’T KNOW”, go to SV6C1. If two of the months
are marked as “DON’T KNOW”, go to SV6C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV6C3.

Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B, or
SV5B.
SV6C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV7
 Skip to question SV7

SV6C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV7

Yes, both are part of the other incidents

 Skip to question SV7

No, separate incidents

 Skip to question SV7

SV6C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV7

SV6D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV7
20

Attachment W: ACASI Questionnaire

SV7. (Other than the incidents you have already mentioned), since [MONTH/YEAR], have you been
in any other situations where someone made you have any type of sex against your will? [Remember to
think about all the types of sex mentioned before].

□
□

Yes

 Continue to SV7A

 Skip to SV8

SV7A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV7B
 Skip to question SV7B
 Continue
 Continue

SV7A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV7B. In what month and year did (this incident/these incidents/(IF SV7A>4 OR
SV7A1>=5 TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

Attachment W: ACASI Questionnaire

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV7A=once and “DON’T KNOW” IS MARKED IN SV7B, OR IF
SV7A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV7B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV7B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV7A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV7B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV7B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV7B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV7Ba-d or SV7B_1=No or
SV7B_2>0, Delete response and reduce SV7A by appropriate amount. If SV7A was once, and it gets
reduced to zero, change SV7 to no and delete all data in A and B follow-ups.

PROGRAMMER NOTE #4: If any of the months listed in SV7B match a month listed in SV1B, SV2B,
SV3B, SV4B, SV5B or SV6B, if any are marked as DK and an incident has been
reported in a previous question, Continue. Otherwise, go to SV8.
For each month that matches, if month is only listed once in SV7B, GO TO SV7C1. If
month is listed twice in SV7B, GO TO SV7C2. If month is listed three or more times in
SV7B, GO TO SV7C3.
If one of the months is marked as “DON’T KNOW”, go to SV7C1. If two of the months
are marked as “DON’T KNOW”, go to SV7C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV7C3.
Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B or SV6B.
22

Attachment W: ACASI Questionnaire

SV7C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV8
 Skip to question SV8

SV7C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV8

Yes, both are part of the other incidents

 Skip to question SV8

No, separate incidents

 Skip to question SV8

SV7C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV8

SV7D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV8

Attachment W: ACASI Questionnaire

SV8. Thinking about all the different types of situations you have been asked about so far, since
[MONTH/YEAR], has anyone tried, but did not succeed at making you have any type of sex against your
will? Remember to think about all the types of sex mentioned before].

□
□

Yes

 Continue to SV8A

 Skip to SV9

SV8A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV8B
 Skip to question SV8B
 Continue
 Continue

SV8A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

Attachment W: ACASI Questionnaire

SV8B.In what month and year did (this incident/these incidents/(IF SV8A>4 OR SV8A1>=5
TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV8A=once and “DON’T KNOW” IS MARKED IN SV8B, OR IF
SV8A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV8B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV8B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV8A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV8B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV8B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV8B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV8Ba-d or SV8B_1=No or
SV8B_2>0, Delete response and reduce SV8A by appropriate amount. If SV8A was once, and it gets
reduced to zero, change SV8 to no and delete all data in A and B follow-ups.
25

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #4: If any of the months listed in SV8B match a month listed in SV1B, SV2B,
SV3B, SV4B, SV5B, SV6B or SV7B, Continue. Otherwise, go to SV9.
For each month that matches, if month is only listed once in SV8B, GO TO SV8C1. If
month is listed twice in SV8B, GO TO SV8C2. If month is listed three or more times in
SV8B, GO TO SV8C3.
Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B SV6B or SV7B.
SV8C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV8
 Skip to question SV8

Attachment W: ACASI Questionnaire

SV8C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV8

Yes, both are part of the other incidents

 Skip to question SV8

No, separate incidents

 Skip to question SV8

SV8C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV8

SV8D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)  Continue to question SV8

Attachment W: ACASI Questionnaire

SV9. (Other than the incidents you have already mentioned,) since [MONTH/YEAR] has anyone,
male or female, kissed you in a sexual way against your will?

□
□

Yes

 Continue to question SV9A

 Skip to question SV10

SV9A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV9B
 Skip to question SV9B
 Continue
 Continue

SV9A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV9B.In what month and year did (this incident/these incidents/(IF SV9A>4 OR SV9A1>=5
TIMES: the four most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW
Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #1: IF SV9A=once and “DON’T KNOW” IS MARKED IN SV9B, OR IF
SV9A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV9B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV9B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV9A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV9B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV9B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV9B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV9Ba-d or SV9B_1=No or
SV9B_2>0, Delete response and reduce SV9A by appropriate amount. If SV9A was once, and it gets
reduced to zero, change SV9 to no and delete all data in A and B follow-ups.

PROGRAMMER NOTE #4: If any of the months listed in SV9B match a month listed in SV1B, SV2B,
SV3B, SV4B, SV5B, SV6B, SV7B or SV8B, if any are marked as DK and an incident
has been reported in a previous question, Continue. Otherwise, go to SV10.
For each month that matches, if month is only listed once in SV9B, GO TO SV9C1. If
month is listed twice in SV9B, GO TO SV9C2. If month is listed three or more times in
SV9B, GO TO SV9C3.
If one of the months is marked as “DON’T KNOW”, go to SV9C1. If two of the months
are marked as “DON’T KNOW”, go to SV9C2. If three or more of the months are
listed as “DON’T KNOW”, go to SV9C3.
Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B, SV6B, SV7B or SV8B.

Attachment W: ACASI Questionnaire

SV9C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV10
 Skip to question SV10

SV9C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV10

Yes, both are part of the other incidents

 Skip to question SV10

No, separate incidents

 Skip to question SV10

SV9C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV10

SV9D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)

 Continue to question SV10

Attachment W: ACASI Questionnaire

SV10. (Other than the incidents you have already mentioned,) since [MONTH/YEAR], has anyone, male
or female, fondled, groped, grabbed, or touched you against your will?

□
□

Yes

 Continue to question SV10A

 Skip to question SV11

SV10A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV10B
 Skip to question SV10B
 Continue
 Continue

SV10A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV10B.In what month and year did (this incident/these incidents/(IF SV10A>4 OR
SV10A1>=5 TIMES: the four most recent incidents)) happen? (REFER TO EVENT
HISTORY CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS
HAPPENED TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN
ONCE IN A MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW
Attachment W: ACASI Questionnaire

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV10A=once and “DON’T KNOW” IS MARKED IN SV10B, OR IF
SV10A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV10B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV10B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV10A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV10B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV10B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV10B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV10Ba-d or SV10B_1=No
or SV10B_2>0, Delete response and reduce SV10A by appropriate amount. If SV10A was once, and it
gets reduced to zero, change SV10 to no and delete all data in A and B follow-ups.

PROGRAMMER NOTE #4: If any of the months listed in SV10B match a month listed in SV1B,
SV2B, SV3B, SV4B, SV5B, SV6B, SV7B SV8B, or SV9B, if any are marked as DK and
an incident has been reported in a previous question, Continue. Otherwise, go to SV11.
For each month that matches, if month is only listed once in SV10B, GO TO SV10C1. If
month is listed twice in SV10B, GO TO SV10C2. If month is listed three or more times
in SV10B, GO TO SV10C3.
If one of the months is marked as “DON’T KNOW”, go to SV10C1. If two of the
months are marked as “DON’T KNOW”, go to SV10C2. If three or more of the
months are listed as “DON’T KNOW”, go to SV10C3.

Attachment W: ACASI Questionnaire

Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B, SV6B, SV7B or SV8, or SV9B.

Attachment W: ACASI Questionnaire

SV10C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes, happened at the same time as the other incident(s) already discussed
 Skip to question SV11
No, separate incidents

 Skip to question SV11

SV10C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV11

Yes, both are part of the other incidents

 Skip to question SV11

No, separate incidents

 Skip to question SV11

SV10C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV11

SV10D3. How many of these are part of an incident that you already reported?
___ ___ (enter number)

 Continue to question SV11

Attachment W: ACASI Questionnaire

SV11. (Other than the incidents you have already mentioned,) since [MONTH/YEAR], has anyone,
male or female, made you watch against your will while they exposed their sexual body parts to
you, flashed you, or masturbated in front of you?

□
□

Yes  Continue to question SV11A
No

 Skip to question SV12

SV11A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV11B
 Skip to question SV11B
 Continue
 Continue

SV11A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV11B. In what month and year did (this incident/these incidents/(IF SV11A>4 OR
SV11A1>=5 TIMES: the four most recent incidents)) happen? (REFER TO EVENT
HISTORY CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS
HAPPENED TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN
ONCE IN A MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

Attachment W: ACASI Questionnaire

(MONTH/YEAR)

□ DON’T KNOW

PROGRAMMER NOTE #1: IF SV11A=once and “DON’T KNOW” IS MARKED IN SV11B, OR IF
SV11A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV11B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV11B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV11A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV11B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV11B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV11B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV11Ba-d or SV11B_1=No
or SV11B_2>0, Delete response and reduce SV11A by appropriate amount. If SV11A was once, and it
gets reduced to zero, change SV11 to no and delete all data in A and B follow-ups.
PROGRAMMER NOTE #4: If any of the months listed in SV11B match a month listed in SV1B,
SV2B, SV3B, SV4B, SV5B, SV6B, SV7B, SV8B, SV9B or SV10B if any are marked as
DK and an incident has been reported in a previous question, Continue. Otherwise, go
to SV12.
For each month that matches, if month is only listed once in SV11B, GO TO SV11C1. If
month is listed twice in SV11B, GO TO SV11C2. If month is listed three or more times
in SV11B, GO TO SV11C3.
If one of the months is marked as “DON’T KNOW”, go to SV11C1. If two of the
months are marked as “DON’T KNOW”, go to SV11C2. If three or more of the
months are listed as “DON’T KNOW”, go to SV11C3.

Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B, SV6B, SV7B, SV8B, SV9B or SV10B.

Attachment W: ACASI Questionnaire

SV11C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV12
 Skip to question SV12

SV11C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV12

Yes, both are part of the other incidents

 Skip to question SV12

No, separate incidents

 Skip to question SV12

SV11C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV12

SV11D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)

 Continue to question SV12

Attachment W: ACASI Questionnaire

SV12. (Other than the incidents you have already mentioned,) since (MONTH/YEAR), has anyone,
male or female, made you show your sexual body parts to them against your will?

□
□

Yes  Continue to question SV12A
No

 Skip to question SV13

SV12A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV12B
 Skip to question SV12B
 Continue
 Continue

SV12A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV12B. In what month and year did (this incident/these incidents/(IF SV12A>4 OR
SV12A1>=5 TIMES: the most recent incidents)) happen? (REFER TO EVENT HISTORY
CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS HAPPENED
TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN ONCE IN A
MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW
Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #1: IF SV12A=once and “DON’T KNOW” IS MARKED IN SV12B, OR IF
SV12A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV12B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV12B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV12A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV12B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV12B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV12B] incidents. Can you confirm how many of these incidents – if any - took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV12Ba-d or SV12B_1=No
or SV12B_2>0, Delete response and reduce SV12A by appropriate amount. If SV12A was once, and it
gets reduced to zero, change SV12 to no and delete all data in A and B follow-ups.
PROGRAMMER NOTE #4: If any of the months listed in SV12B match a month listed in SV1B,
SV2B, SV3B, SV4B, SV5B, SV6B, SV7B, SV8B, SV9B, SV10B or SV11B, if any are
marked as DK and an incident has been reported in a previous question, Continue.
Otherwise, go to SV13.
For each month that matches, if month is only listed once in SV12B, GO TO SV12C1. If
month is listed twice in SV12B, GO TO SV12C2. If month is listed three or more times
in SV12B, GO TO SV12C3.
If one of the months is marked as “DON’T KNOW”, go to SV12C1. If two of the
months are marked as “DON’T KNOW”, go to SV12C2. If three or more of the
months are listed as “DON’T KNOW”, go to SV12C3.
Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B, SV6B, SV7B, SV8B, SV9B, SV10B or SV11B.

Attachment W: ACASI Questionnaire

SV12C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to question SV13
 Skip to question SV13

SV12C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to question SV13

Yes, both are part of the other incidents

 Skip to question SV13

No, separate incidents

 Skip to question SV13

SV12C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to question SV13

SV12D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)

 Continue to question SV13

Attachment W: ACASI Questionnaire

SV13. (Other than the incidents you have already mentioned,) since [MONTH/YEAR], has anyone,
male or female, made you look at or participate in sexual photos or movies against your will?

□ Yes
□ No

 Continue to question SV13A
 Skip to Part 2

SV13A. Since [MONTH/YEAR], how many times did this happen to you?

□ Once
□ Two or more ___ ___ (enter number)
□ DON’T KNOW
□ REFUSED

 Skip to question SV13B
 Skip to question SV13B
 Continue
 Continue

SV13A1. Do you remember if it was…

□ 2-4 times?
□ 5-9 times?
□ 10-14 times?
□ 15 more times?

SV13B. In what month and year did (this incident/these incidents/(IF SV13A>4 OR
SV13A1>=5 TIMES: the four most recent incidents)) happen? (REFER TO EVENT
HISTORY CALENDAR IF NEEDED. FILL IN MONTH AND YEAR FOR EACH TIME THIS
HAPPENED TO YOU IN PAST 12 MONTHS; IF THIS HAPPENED TO YOU MORE THAN
ONCE IN A MONTH, REPEAT THE MONTH/YEAR FOR EACH TIME IT HAPPENED)

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

(MONTH/YEAR)

□ DON’T KNOW

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE #1: IF SV13A=once and “DON’T KNOW” IS MARKED IN SV13B, OR IF
SV13A=two or more AND ONLY ONE “DON’T KNOW” IS MARKED IN SV13B, CONTINUE. ELSE
SKIP TO PROGRAMMER NOTE #2
SV13B_1 You indicated you are not sure of the month and year. Can you confirm that this
incident took place since [MONTH/YEAR]?

□ Yes
□ No

 Skip to Programmer Note #4
 Skip to Programmer Note #3

PROGRAMMER NOTE #2: IF SV13A=two or more and “DON’T KNOW” TO MORE THAN ONE IN
SV13B, CONTINUE. ELSE SKIP TO PROGRAMMER NOTE #3

SV13B_2 You indicated you are not sure of the month and year for [count number of DK’s
in SV13B] incidents. Can you confirm how many of these incidents – if any – took
place before [MONTH/YEAR]?
(ENTER NUMBER)

 CONTINUE

PROGRAMMER NOTE #3: If month/year is greater than 12 months ago in SV13Ba-d or SV13B_1=No
or SV13B_2>0, Delete response and reduce SV13A by appropriate amount. If SV13A was once, and it
gets reduced to zero, change SV13 to no and delete all data in A and B follow-ups.
PROGRAMMER NOTE #4: If any of the months listed in SV13B match a month listed in SV1B,
SV2B, SV3B, SV4B, SV5B, SV6B, SV7B, SV8B, SV9B, SV10B, SV11B or SV12B, if any
are marked as DK and an incident has been reported in a previous question, Continue.
Otherwise, go to PART 2.
For each month that matches, if month is only listed once in SV13B, GO TO SV13C1. If
month is listed twice in SV13B, GO TO SV13C2. If month is listed three or more times
in SV13B, GO TO SV13C3.

If one of the months is marked as “DON’T KNOW”, go to SV13C1. If two of the
months are marked as “DON’T KNOW”, go to SV13C2. If three or more of the
months are listed as “DON’T KNOW”, go to SV13C3.

Repeat this instruction for each month that matches with SV1B, SV2B, SV3B, SV4B,
SV5B, SV6B, SV7B, SV8B, SV9B, SV10B, SV11B or SV12B.
42

Attachment W: ACASI Questionnaire

SV13C1. Is this part of the other incident(s) you already reported in (MONTH/YEAR)?

□ Yes, happened at the same time as the other incident(s) already discussed
□ No, separate incidents

 Skip to PART 2
 Skip to PART 2

SV13C2. Are either of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□
□

Yes, one is part of the other incident

 Skip to PART 2

Yes, both are part of the other incidents

 Skip to PART 2

No, separate incidents

 Skip to PART 2

SV13C3. Are any of these part of the other incident(s) you already reported in (MONTH/YEAR)?

□
□

Yes
No, separate incidents

 Skip to PART 2

SV13D3. How many of these are part of an incident that you already reported?

___ ___ (enter number)

 Continue to PART 2

Attachment W: ACASI Questionnaire

PART 2
Lifetime Questions

Continue if you skipped or answered “no” to any questions SV1 through SV8 in Part 1
If you answered “yes” to all questions SV1 through SV8 in part 1, please skip to Programmer Note at end
of screener.
These next questions ask about whether you have had any of these same types of experiences at any point in
your life, not just in the past 12 months.
ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV1 IN PART 1.
OTHERWISE SKIP TO NOTE BEFORE QUESTION SV2EVER.
SV1Ever. At any time in your life, has a male used force or threats of force to make you have vaginal
sex against your will?

□
□

Yes

 Continue to SV1EV_A

 Skip to note before SV2Ever

SV1EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV2Ever
 Continue to SV1EV_B.

SV1EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV2 IN PART 1.
OTHERWISE, SKIP TO NOTE BEFORE QUESTION SV3EVER.
SV2Ever At any time in your life, has anyone, male or female, used force or threats of force to make
you have or give oral sex against your will?

□
□

Yes

 Continue to SV2EV_A

 Skip to note before SV3Ever

SV2EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV3Ever
 Continue to SV2EV_B.

SV2EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV3 IN PART 1.
OTHERWISE SKIP TO NOTE BEFORE QUESTION SV4EVER.
SV3Ever At any time in your life, has a male used force or threats of force to make you have anal sex
against your will?

□
□

Yes

 Continue to SV3EV_A

 Skip to note before SV4Ever

SV3EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV4Ever
 Continue to SV3EV_B.

SV3EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV4 IN PART 1.
OTHERWISE SKIP TO NOTE BEFORE QUESTION SV5EVER.
SV4Ever At any time in your life, has anyone, male or female, ever used force or threats of force to
put fingers or a foreign object in your vagina or anus against your will?

□
□

Yes

 Continue to SV4EV_A

 Skip to note before SV5Ever

SV4EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV5Ever
 Continue to SV4EV_B

SV4EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

When answering these next questions, please consider all types of sex acts including vaginal sex, oral sex,
anal sex, or putting fingers or a foreign object in your vagina or anus.
These questions will now focus on about other types of unwanted sexual experiences that may not have
involved force, but that were against your will.
ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV5 IN PART 1.
OTHERWISE SKIP TO NOTE BEFORE SV6EVER.
SV5Ever

□
□

At any time in your life, has anyone ever made you have sex against your will when you
were unable to consent because you were too drunk, high or passed out?

Yes

 Continue to SV5EV_A

 Skip to note before SV6Ever

SV5EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV6Ever
 Continue to SV5EV_B.

SV5EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV6 IN PART 1.
OTHERWISE SKIP TO NOTE BEFORE SV7EVER.
SV6Ever At any time in your life, has anyone made you have sex against your will by threatening
to cause problems for you, such as at your job or school, at home, in your relationships,
or in any other ways? Remember to think about all the types of sex mentioned before.

□
□

Yes

 Continue to SV6EV_A

 Skip to note before SV7Ever

SV6EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV7Ever
 Continue to SV6EV_B

SV6EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV7 IN PART 1.
OTHERWISE SKIP TO NOTE BEFORE SV8EVER.
SV7Ever At any time in your life, have you been in any other situations where someone made you
have any type of sex against your will? Remember to think about all the types of sex
mentioned before.

□
□

Yes

 Continue to SV7EV_A

 Skip to note before SV8Ever

SV7EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred
□ DON’T KNOW

 Skip to note before SV8EVER
 Continue to SV7EV_B

SV7EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

ANSWER ONLY IF YOU SKIPPED OR RESPONDED “NO” TO QUESTION SV8 IN PART 1.
OTHERWISE SKIP TO PROGRAMMER NOTE AT END OF SCREENER.
SV8Ever
Thinking about all the different types of situations you have been asked about so
far, at any time in your life, has anyone ever tried, but did not succeed at making you have
any type of sex against your will? Remember to think about all the types of sex mentioned
before.

□
□

Yes

 Continue to SV8EV_A

 Skip to Programmer Note at end of screener

SV8EV_A. About how old were you when this happened (the first time)?

□ ___ ___ age first time occurred

 Skip to Programmer Note at end of

screener

□ DON’T KNOW

 Continue to SV8EV_B

SV8EV_B. [If “DON’T KNOW”]: Do you recall if you were …

□ 11 years old or younger?
□ Between 12 and 17 years old?
□ Between 18 and 24 years old?
□ Between 25 and 34 years old?
□ 35 or older?

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE:
• IF “NO” TO ALL QUESTIONS SV1, SV2, SV3, SV4, SV5, SV6, SV7, SV8, SV9, SV10,
SV11, SV12, SV13, SKIP TO VIGNETTES.
•

IF “YES” TO ANY QUESTIONS SV1, SV2, SV3, SV4, SV5, SV6, SV7, SV8, SV9, SV10,
SV11, SV12, SV13, CONTINUE.

Attachment W: ACASI Questionnaire

PART 3: DETAILED INCIDENT FORM
SECTION A:
Anchoring the Incident
PROGRAMMER NOTE: CAPTURE WHICH SV ITEM HAS TRIGGERED THE DETAILED
INCIDENT FORM.

A1.
Earlier, you said that (INCIDENT) in (MONTH/YEAR). The next questions ask you for details
about this incident.
SECTION B:
Recall of the Incident

B1.

Attachment W: ACASI Questionnaire

SECTION C:
When and where did it happen?

C1.

About what time of day did this incident happen? (Mark one response)

C2.

Did this incident happen …? (Mark one response)

C3.

□ Between 6 a.m. and 12 noon
□ Between 12 noon and 6 p.m.
□ Between 6 p.m. and 12 midnight.
□ Between 12 midnight and 6 a.m.
□ DON’T KNOW whether it was day or night
□ REFUSED
□ Inside a home or building
□ Outside a home or building
□ Started outside and moved inside
□ Started inside and moved outside
□ REFUSED
□ DON’T KNOW

 Continue to C3
 Skip to question C4
 Continue to C3
 Continue to C3
 Skip to section D
 Skip to section D

Where (inside) did the incident happen? (Mark one response)

□ In your home or dorm room
□ In someone else’s home or dorm room
□ At work
□ In a Sorority or Fraternity house
□ At a business such as a restaurant, bar or store
□ Some other place (Please specify) _______________________________________
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

IF C3= “IN YOUR HOME OR DORM ROOM” OR “IN SOMEONE ELSE’S HOME OR DORM ROOM”,
CONTINUE. ELSE, SKIP TO C4.
C3a.

Was it in {your/a} home or in {your/a} dorm room?

□ Home
□ Dorm room

IF C2= “STARTED OUTSIDE AND MOVED INSIDE” OR ”STARTED INSIDE AND MOVED OUTSIDE”,
CONTINUE. ELSE, IF C3=1, 2, OR 4, SKIP TO C5. ELSE, SKIP TO SECTION D.
C4.

Where (outside) did the incident happen? (Mark one response)

□ On your property, but not inside your home ..
□ On someone else’s property , but not inside the home
□ On the property of your workplace, but not inside
□ On the grounds of a school or university
□ On public transportation
□ In another type of open area, such as the street
□ In a motor vehicle
□ Some other place (Please specify) _______________________________________
□ REFUSED
□ DON’T KNOW

IF THE INCIDENT HAPPENED IN A HOME (C3=1, 2 OR 4 OR C4=1, 2), CONTINUE. ELSE SKIP TO
SECTION D.

Attachment W: ACASI Questionnaire

C5.

C6.

Did the person who did this to you live (here/there)?

□ Yes
 Skip to section D
□ No
□ REFUSED
□ DON’T KNOW

How did this person get in? (Mark one response)

□ Let in
□ Pushed his/her way in after door opened
□ Through OPEN DOOR or other opening
□ Through UNLOCKED door or window
□ Through LOCKED door or window
□ Some other way (Please specify) ___________________________________________
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

SECTION D:
Description of Incident

The next set of questions ask about what actually happened during this incident (IF MONTH PROVIDED: in
(MONTH/YEAR)). It may seem like you’ve already answered these questions, but we want to be sure we
understand what happened to you during this incident.

D1. Please focus only on the parts of the incident that were unwanted. For each unwanted act that
happened to you, please indicate if the person:
•
•
•
•

Threatened to do this – meaning the person verbally threatened to do it but did not physically try
to do it
Attempted to do this – meaning the person physically tried to do it but did not succeed, OR
Actually did this – meaning the person physically did this act, OR
Did not do this

a. Did the person threaten to, attempt to, or actually put a penis in your vagina when you didn’t want it
to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No
b.

Did the person threaten to, attempt to, or actually put their mouth on your vagina or anus or
make you put your mouth on their genitals or anus when you didn’t want it to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No

Attachment W: ACASI Questionnaire

Did the person threaten to, attempt to, or actually put a penis in your anus when you didn’t want
it to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No
d.

Did the person threaten to, attempt to, or actually put fingers or another object in your vagina or
anus when you didn’t want it to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No

Attachment W: ACASI Questionnaire

D2. Please continue to only think about aspects of the incident that were unwanted and indicate if the
person threatened, attempted to or actually did any of the following during this incident.

Did the person threaten to, attempt to, or actually kiss or lick you when you didn’t want it to
happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No
b.

Did the person threaten to, attempt to, or actually touch, grab, or fondle your breasts, genitals, or
buttocks over or under your clothes when you didn’t want it to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No
c.

Did the person threaten to, attempt to, or actually expose their sexual body parts or make you
expose your sexual body parts when you didn’t want it to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No

Attachment W: ACASI Questionnaire

Did the person threaten to, attempt to, or actually make you look at or participate in sexual photos
or movies when you didn’t want it to happen?

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No

Did the person threaten to, attempt to, or actually make you do something else when you didn’t
want it to happen?(Please specify _____________________________________________)

□ Yes, threatened to do this
□ Yes, attempted to do this
□ Yes, actually did this
□ No

(IF YOU MARKED YES TO ANY ITEM IN D1 OR D2, CONTINUE. ELSE, SKIP TO SECTION E)
D3.

Did the person do any of the following at any point leading up to this incident?
YES

Refuse/DK

Verbally pressure you or continually argue with you

□

Threaten to cut off financial support

□

Threaten to cause problems at your job, at school,
in your relationships, or to cause some other problem

□

Promise rewards in your relationship,
your job, your grades, or something else

□

Attachment W: ACASI Questionnaire

D4.

Did the person do any of the following at any point during this incident?

Hold you or pin you so you had difficulty moving

YES
□

NO
□

Use a weapon, or threaten to use a weapon

□

Physically attack you or threaten to attack
you, but not with a weapon

□

Physically attack, or threaten to attack,
someone else

□

Use any other type of coercion or force
(PLEASE SPECIFY)

□

Refuse/DK
□

(IF YOU MARKED YES TO D4B – USE OR THREATEN TO USE A WEAPON, CONTINUE. ELSE SKIP
TO NOTE BEFORE D8)

Attachment W: ACASI Questionnaire

D5.

What was the weapon? (Mark all that apply)

□ Gun, such as a pistol, revolver, rifle or shotgun
□ Knife or other sharp object
□ Some other weapon (Please specify)
____________________________________________

□ REFUSED
□ DON’T KNOW
(IF WEAPON WAS A GUN, CONTINUE TO D6. ELSE SKIP TO NOTE BEFORE D7.)

D6.

Were you shot or did the person try to shoot you?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

(IF WEAPON WAS A KNIFE OR SHARP OBJECT, CONTINUE TO D7. ELSE SKIP TO NOTE BEFORE
D8.)

D7.

Were you stabbed or did the person try to stab you?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

(IF YOU MARKED YES TO D4A,B, C, or D (PHYSICAL FORCE), CONTINUE. ELSE SKIP TO SECTION
E)

D8.

Did the person do any of the following to you during the incident? (Mark all that apply)

□ slap, hit or punch you?
□ kick, bite or scratch you?
□ choke or suffocate you?
□ hit you with an object?
□ grab, hold, trip, jump on or push you?
□ do any other physical things to you? (Please specify)
_____________________________________

□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

SECTION E:
Injuries and Hospital Care

E1.

Did you experience any physical injuries as a result of this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
E1a.

 Continue to E1a
 Skip to E5a
 Skip to E5a
 Skip to E5a

What were those injuries? (Mark all that apply)

□ Injury from sexual intercourse, such as vaginal or anal tearing
□ Knife or stab wounds
□ Gun shot, bullet wounds
□ Broken bones or teeth knocked out
□ Internal injuries
□ Knocked unconscious
□ Bruises, black-eye, cuts, scratches, swelling, chipped teeth
□ Other injuries (Please specify) ____________________________________
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

E2.

E3.

Did you receive any medical care as a result of this incident, including self- treatment?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to E3
 Skip to E5a
 Skip to E5a
 Skip to E5a

Where did you receive this care? (Mark all that apply)

□ At the scene
□ At home, at a neighbor’s or a friend’s
□ At an emergency room at a hospital or emergency clinic
□ At another medical setting such as a clinic, hospital
or doctor’s office

□ Some other place (Please specify)
_____________________________________________________

□ REFUSED
□ DON’T KNOW

IF RECEIVED CARE AT ANOTHER MEDICAL SETTING OR SOME OTHER PLACE, CONTINUE TO
E4. ELSE GO TO E5A.

E4.

Did you stay overnight in the hospital?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

E5a.

E5b.

In the days following the incident, how distressed were you by this incident?

□ Not at all distressed
□ Mildly distressed
□ Moderately distressed
□ Severely distressed
□ REFUSED
□ DON’T KNOW

Sometimes people’s feelings change over time. Thinking about it now, how distressed are you by
this incident?

□ Not at all distressed
□ Mildly distressed
□ Moderately distressed
□ Severely distressed
□ REFUSED
□ DON’T KNOW

PROGRAMMER NOTE: IF “NOT AT ALL DISTRESSED”, OR “REFUSED” DON’T KNOW TO BOTH
E5A AND E5B, SKIP TO E7. ELSE CONTINUE.

Attachment W: ACASI Questionnaire

E6.

As a result of this incident, please indicate if you felt any of the following ways for less than one
month, for one month or longer , or if you did not feel that way.
YES
YES
<1 MO
1 MO+
NO
Refuse/DK
a. worried or anxious?
□
□
□
□
b. angry?
□
□
□
□
c. sad or depressed?
□
□
□
□
d. vulnerable?
□
□
□
□
e. violated?
□
□
□
□
f. like you couldn’t trust people?
□
□
□
□
g. fearful?
□
□
□
□
h. some other way? (Please specify)
□
□
□
□

E7.

Did you lose time from work or school because of the incident?

E8.

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to E8
 Skip to Section F
 Skip to Section F
 Skip to Section F

How much time did you lose because of injuries?

□ Less than one day
□ One day
□ More than one day
□ REFUSED
□ DON’T KNOW

 Skip to Section F
 Skip to Section F
 Continue to E8a
 Skip to Section F
 Skip to Section F

E8a. How many days was it? (Enter a number)
_____________ days

□ REFUSED
□ DON’T KNOW
SECTION F:
68

Attachment W: ACASI Questionnaire

Offender Characteristics
The next questions are about who did this to you.

F1.

Did one or more than one person do this to you?

□ One
□ More than one
□ REFUSED
□ DON’T KNOW

 Continue to F2
 Skip to F12
 Continue to F2
 Continue to F2

F2.

Was this person male or female?

F3.

How old would you say this person was?

□ Male
□ Female
□ REFUSED
□ DON’T KNOW
□ Under 18
□ 18-24
□ 25-39
□ 40-49
□ 50+
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

F4a.

Was this person Hispanic or Latina/Latino?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
F4b.

What race or races was this person? Was this person… (Mark all that apply)

F5.

Was this person someone you knew, or a stranger you had never seen before?

F6.

□ White?
□ Black or African American?
□ American Indian or Alaska Native?
□ Asian?
□ Native Hawaiian or Other Pacific Islander?
□ REFUSED
□ DON’T KNOW
□ Knew or had seen before
□ Stranger
□ REFUSED
□ DON’T KNOW

Skip to F7
 Continue to F6
 Continue to F6
 Continue to F6

Would you be able to recognize this person if you saw him/her?

□ Yes
□ Not sure
□ No
□ REFUSED
□ DON’T KNOW

 Skip to F8
 Skip to F8
 Skip to Section G
 Skip to F8
 Skip to F8

Attachment W: ACASI Questionnaire

F7.

How well did you know this person – by sight only, casual acquaintance, or well known?

□ Sight only
□ Casual acquaintance
□ Well known
□ REFUSED
□ DON’T KNOW
F8.

 Continue to F8
 Skip to F9
 Skip to F9
 Skip to F9
 Skip to F9

Would you have been able to tell the police how they might find this person, for instance, where
he/she lived, worked, went to school, or spent time?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to Section G
 Skip to Section G
 Skip to Section G
 Skip to Section G

Attachment W: ACASI Questionnaire

F9.

Was this person a relative or nonrelative?

□ Relative
□ Nonrelative
□ REFUSED
□ DON’T KNOW
F10.

 Continue to F10
 Skip to F11
 Skip to F11
 Skip to F11

How was this person related to you? Was this person your …

□ spouse?
□ ex-spouse?
□ parent or step-parent?
□ own child or step-child?
□ brother or sister?
□ some other relation to you (Please specify)
□ REFUSED
□ DON’T KNOW
IF YOU ANSWERED “RELATIVE” TO QUESTION F9, SKIP TO SECTION G. OTHERWISE CONTINUE
TO QUESTION F11.
F11.

Was this person a … (Mark all that apply)

□ boyfriend or girlfriend?
□ ex-boyfriend or ex-girlfriend?
□ friend?
□ someone who used to be a friend?
□ roommate or boarder?
□ schoolmate?
□ something else? (Please specify)
_______________________________________________________

□ REFUSED
□ DON’T KNOW
72

 IF THE PERSON WAS A BOYFRIEND/GIRLFRIEND (F11A=YES), SKIP TO F24.
Attachment W: ACASI Questionnaire

OTHERWISE, SKIP TO SECTION G

F12.

How many people did this to you?
_______________ (enter number)

□ REFUSED
□ DON’T KNOW
F13.

Were they male or female?

□ All male
□ All female
□ Both male and female
□ REFUSED
□ DON’T KNOW
F14.

 Skip to F14a
 Skip to F14a
 Continue to F14
 Skip to F14a
 Skip to F14a

Were they mostly male or mostly female?

□ Mostly male
□ Mostly female
□ Evenly divided
□ REFUSED
□ DON’T KNOW
F14a. Were any of the persons Hispanic or Latino?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to F14b
 Skip to F14c
 Skip to F14c
 Skip to F14c

Attachment W: ACASI Questionnaire

F14b. Were they mostly Hispanic, mostly non-Hispanic or an equal number of Hispanic and nonHispanic?

□ Mostly Hispanic
□ Mostly non-Hispanic
□ Equal number of Hispanic and non-Hispanic
□ REFUSED
□ DON’T KNOW
F14c. What were the race or races of the persons? Were they… (Mark all that apply)

□ White?
□ Black or African American?
□ American Indian or Alaska Native?
□ Asian?
□ Native Hawaiian or Other Pacific Islander?
□ REFUSED
□ DON’T KNOW
IF YOU SELECTED MORE THAN ONE RACE IN QUESTION F14C,CONTINUE TO QUESTION F14D .
OTHERWISE, SKIP TO QUESTION F15.
F14d. What race were most of the persons?

□ White
□ Black or African American
□ American Indian or Alaska Native
□ Asian
□ Native Hawaiian or Other Pacific Islander
□ Equal number of each race
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

F15.

How old would you say the youngest was?

□ Under 18
□ 18-24
□ 25-39
□ 40-49
□ 50+
□ REFUSED
□ DON’T KNOW
F16.

How old would you say the oldest was?

□ Under 18
□ 18-24
□ 25-39
□ 40-49
□ 50+
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

F17.

Were any of these persons someone you knew, or were they all strangers you had never seen
before?

□ Knew or had seen before
□ All strangers
□ REFUSED
□ DON’T KNOW
F18.

F19.

 Skip to F19
 Continue to F18
 Continue to F18
 Continue to F18

Would you be able to recognize any of these persons if you saw him/her?

□ Yes
□ Not sure
□ No
□ REFUSED
□ DON’T KNOW

 Skip to F20
 Skip to F20
 Skip to Section G
 Skip to F20
 Skip to F20

Which of the following describes how you knew the people who did this to you? (Mark all that
apply)

□ At least one was well known
□ At least one was a casual acquaintance
□ I knew at least one by sight only
□ REFUSED
□ DON’T KNOW

IF THE ONLY RESPONSE IN F19 IS “BY SIGHT ONLY”, REFUSED OR DON’T KNOW, CONTINUE.
OTHERWISE SKIP TO F21
F20.

Would you have been able to tell the police how they might find any of these persons, for instance,
where he/she lived, worked, went to school, or spent time?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 SKIP TO SECTION G

Attachment W: ACASI Questionnaire

IF YOU ANSWERED “WELL KNOWN” OR “CASUAL ACQUAINTANCE” TO QUESTION
F19, CONTINUE TO F21. OTHERWISE, SKIP TO SECTION G.

F21.

Were any of these persons a relative?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
F22.

 Continue to F22
 Skip to F23
 Skip to F23
 Skip to F23

Were any of these persons your… (Mark all that apply)

□ spouse?
□ ex-spouse?
□ parent or step-parent?
□ own child or step-child?
□ brother or sister?
□ some other relation to you? (Please specify)
□ REFUSED
□ DON’T KNOW
 SKIP TO SECTION G
F23.

Were any of these persons a … (Mark all that apply)

□ boyfriend or girlfriend?
□ ex-boyfriend or ex-girlfriend?
□ friend?
□ someone who used to be a friend?
□ roommate or boarder?
□ schoolmate?
□ something else? (Please specify)
77

_______________________________________________________
Attachment W: ACASI Questionnaire

□ REFUSED
□ DON’T KNOW
 IF ANY OF THE PERSONS WAS A BOYFRIEND/GIRLFRIEND (F23A=YES), CONTINUE TO F24.
OTHERWISE, SKIP TO SECTION G

F24.

You said the person who did this to you was your boyfriend/girlfriend. Approximately how long
had you been dating this person?
_______________

□ REFUSED
□ DON’T KNOW

F25.

days/months/years

Are you currently dating or romantically involved with this person?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

SECTION G:
Circumstances of Incident
The next questions are about the circumstances related to the incident.

G1.

Did this occur while you were in the military?

G2.

Did this occur while you were a student?

□ Yes
□ No
□ Does not apply, was not in military
□ REFUSED
□ DON’T KNOW

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

IF C3=1, SKIP TO G4. ELSE CONTINUE.
G3.

Which of the following best describes what were you doing at the time of the incident?

□ On your way to or from some place, or in transit
□ Hanging out at someone’s home , or at a party or gathering
□ At a restaurant, bar, movie, sporting event, or other public activity
□ Working or at school
□ Something else (Please specify _______________)
□ REFUSED
□ DON’T KNOW
G4.

Had (the person/any of the people) who did this to you been using alcohol or drugs in the hours
leading up to the incident?

□ Alcohol
□ Drugs
□ Both alcohol and drugs
□ Neither alcohol nor drugs
□ REFUSED
□ DON’T KNOW

G5.

Had you been using alcohol or drugs in the hours leading up to the incident?

□ Alcohol
□ Drugs
□ Both alcohol and drugs
□ Neither alcohol nor drugs
□ REFUSED
□ DON’T KNOW
G6.

 Continue to G6
 Continue to G6
 Continue to G6
 Skip to G16
 Skip to G16
 Skip to G16

Did the (person/any of the people who did this to you) give you (alcohol/drugs/alcohol or drugs)
without your knowledge?

□ Yes
80

Attachment W: ACASI Questionnaire

□ No
□ REFUSED
□ DON’T KNOW
G7.

Do you think the person was trying to get you (drunk/high/drunk or high) so (he/she) could
sexually take advantage of you?

□ Yes
□ No
□ Not Sure
□ REFUSED
□ DON’T KNOW

 Continue to G8
 Skip to G10
Continue to G8
 Continue to G8
 Continue to G8

Attachment W: ACASI Questionnaire

G8. Did the person keep giving you (drinks/drugs/drinks or drugs) without you asking for it?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
G9. Did the person keep giving you (drinks/drugs/drinks and drugs) after you were clearly very
(drunk/high/drunk or high)?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
G10. Were you passed out for all or parts of this incident, or not? By passed out, it means that you were
unconscious or asleep because of the (alcohol/drugs/alcohol or drugs).

□ Yes, for all of the incident
□ Yes, for parts of the incident
□ No
□ Not sure
□ REFUSED
□ DON’T KNOW
G11. Were there any parts of the
(alcohol/drugs/alcohol or drugs)?

 Skip to G16
 Skip to G12
 Continue to G11
 Continue to G11
 Continue to G11
 Continue to G11

incident

you could not

remember

because

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
82

Attachment W: ACASI Questionnaire

the

G12. Please answer the following questions on how (alcohol/drugs/alcohol and drugs) affected what
happened.
YES
a. Did the (alcohol/drugs/alcohol or drugs)
make you unable to give consent?
b. Did it make you less able to physically resist?
c. Did it lead you to make decisions that you
would not have made otherwise?
d. Did it affect you in some other way? (Please specify)

□
□

□□
□□

□
□

□□
□□

RF/DK

____________________________________________________________

G13. Were you too (drunk/high/drunk or high) to walk by yourself?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

G14. Were you too (drunk/high/drunk or high) to speak without slurring your words?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to G16
 Continue to G15
 Continue to G15
 Continue to G15

G15. Were you able to communicate clearly to others?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

These next questions are about what you did when this incident occurred.
83

Attachment W: ACASI Questionnaire

Please remember that people may react differently to certain situations and that there are no right or wrong ways
to react in these situations. Everyone is different. These questions will help to get a better picture of what the
range of things women in similar situations have done.
Collecting this information will help develop better policies and advice for women who have these experiences
in the future.

G16. Did you do any of the following at any point during the incident? Did you...

a.
b.
c.
d.
e.
f.
g.
h.

physically resist, or try to physically resist the person
say “no”, “stop”, or that you did not want the act to happen
leave or stop the situation before the act occurred
attack or threaten the person
try to persuade, plead, or argue with the person
try to escape or get away
try to get help
do something else (Please specify)

YES
□
□
□
□
□
□
□
□

NO
□
□
□
□
□
□
□
□

RF/DK
□
□
□
□
□
□
□
□

___________________________________________________
IF YOU ANSWERED “NO” TO ALL QUESTIONS G16A-H, THEN SKIP TO QUESTION G18.
IF YOU ANSWERED ‘YES’ TO G16B (SAID ‘NO’ OR ‘STOP’) CONTINUE.
OTHERWISE SKIP TO SECTION H.

G17. Did the person immediately stop after you said that you didn’t want it to happen?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Skip to Section H
Skip to Section H
Skip to Section H
Skip to Section H

G18. You answered “no” to all of the actions that were listed on the previous screen. Were any of the
following reasons why you did not take any actions?

□ I was afraid that he/she would physically hurt me
84

Attachment W: ACASI Questionnaire

□ I was afraid that he/she would physically hurt someone else
□ I was afraid that he/she would carry out other threats he/she made
□ I was too (drunk/high/drunk or high) to either physically or verbally resist
□ I did not want to hurt the person’s feelings
□ I was surprised or it happened too quickly for me to take any action.
□ Other reason (Please specify)
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

SECTION H:
Follow-up with Service Providers and Friends

H1.

Did you ever talk to a psychologist, psychiatrist, counselor or other mental health professional
about this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
H2.

Have you ever talked to a crisis hotline operator about what (this person/these persons) did?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

SECTION I:
Follow-up with the Police

I1a.

At the time, did you consider this incident to be a crime?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to I1c
 Continue to I1b
 Skip to I1c
 Skip to I1c

PROGRAMMER NOTE: IF NO IN I1a, CONTINUE. ELSE SKIP TO I1c.
I1b.

Why did you not consider this incident to be a crime? (Mark all that apply)

□ Because the person stopped when I resisted
□ Because I didn’t think the person intended harm
□ Because I didn’t think it was against the law
□ Because I had been using alcohol or drugs at the time
□ Other reason (PLEASE SPECIFY)
_____________________________________________________

I1c.

Now, looking back, do you consider this incident to be a crime?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Skip to I2
 Continue to programmer note before I1d
 Skip to I2
 Skip to I2

PROGRAMMER NOTE: IF NO IN I1c AND YES/DK/RF IN I1a, CONTINUE. ELSE SKIP TO I2.
I1d.
87

Looking back, why do you not consider this incident to be a crime? (Mark all that apply)
Attachment W: ACASI Questionnaire

□ Because the person stopped when I resisted
□ Because I don’t think the person intended harm
□ Because I don’t think it was against the law
□ Because I had been using alcohol or drugs at the time
□ Other reason (PLEASE SPECIFY)
_____________________________________________________
I2.

I3.

Were the police informed or did they find out about this incident in any way?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

 Continue to I3
 Skip to I4
 Skip to I4
 Skip to I4

How did the police find out about it?

□ I contacted the police
□ Another household member contacted the police
□ Some official contacted police (guard,
apt. manager, school official, etc)

□ Someone else contacted the police
□ Police were at the scene
□ Some other way (Please specify)

 Skip to I5
 Skip to I5
 Skip to I5
 Skip to I5
 Skip to I7
 Skip to I5

________________________________________

□ REFUSED
□ DON’T KNOW

 Skip to I5
 Skip to I5

Attachment W: ACASI Questionnaire

IF YOU ANSWERED “NO” TO QUESTION I1A, SKIP TO I5. OTHERWISE, CONTINUE TO I4.
I4.

Which of the following are the reasons you did not report it to the police? (Mark all that apply)

□ Did not want anyone else to know
□ It was my word against the person
□ Police wouldn’t think it was a crime
□ Fear of being treated hostilely by police or lawyers
□ Fear of retaliation by the person or others
□ Did not think it was serious enough to report
□ Reported it somewhere else
□ Other reason (Please specify)
□ REFUSED
□ DON’T KNOW
 SKIP TO QUESTION I8

Attachment W: ACASI Questionnaire

IF YOU ANSWERED “YES” TO I2, CONTINUE TO QUESTION I5. OTHERWISE, SKIP TO QUESTION
I8.
I5.

I6.

Did the police come to your location when they found out about the incident?

□ Yes
□ No
□ I went to the police
□ REFUSED
□ DON’T KNOW

 Continue to I6
 Skip to I8
 Skip to I7
 Skip to I8
 Skip to I8

How soon after the police found out did they come to your location?

□ Within 30 minutes
□ Within an hour
□ Within a day
□ Longer than a day
□ REFUSED
□ DON’T KNOW

I7.
Did the police do any of the following while (they/you) were (at the scene/there)? (Mark all that
apply)

□ Take a report
□ Search/look around
□ Take evidence (fingerprints, inventory, etc.)
□ Question witnesses or suspects
□ Promise surveillance
□ Promise to investigate
□ Make an arrest
□ Something else (Please specify) __________________________________________
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

I8.

(Not counting the police) Is there any other person you have told about this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
I8a.

 Continue to I8a
 Skip to I9
 Skip to I9
 Skip to I9

Who have you told? (Mark all that apply)

□ Parents or a parent
□ Husband, boyfriend, or partner
□ A family member other than parents
□ A friend
□ Roommate, suitemate, or housemate
□ Clergy, rabbi, or other spiritual leader
□ Other person (Please specify)
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

I9.

(Not counting the police) Is there any other organization you have told about this incident?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW
I9a.

 Continue to I9a
 Skip to I10
 Skip to I10
 Skip to I10

What organization have you told? (Mark all that apply)

□ Women’s program or service
□ Rape crisis center or victim services hotline
□ Counselor or therapist not associated with a rape crisis center or victim services hotline
□ Some other organization (Please specify)
□ REFUSED
□ DON’T KNOW

Attachment W: ACASI Questionnaire

I10.

Have you received any help from any office or agency (other than the police) that deals with
victims of crime?

□ Yes
□ No
□ REFUSED
□ DON’T KNOW

I11.

 Continue to I11
 Skip to I12
 Skip to I12
 Skip to I12

We are interested in the type of help that you have received. Have you received…

a.
b.
c.
d.

psychological or emotional counseling?
compensation for your injury?
help to remove you from danger?
legal advice or advocacy?

YES
□
□
□
□

NO
□
□
□
□

RF/DK
□
□
□
□

I12. Thank you for providing this information about the incident.
In order to make sure that you have been able to describe the incident as accurately as possible, would
you be willing to describe it in your own words?

□ Yes
□ No

 Continue
 Skip to Programmer Note

Attachment W: ACASI Questionnaire

PROGRAMMER NOTE:
AT END OF FIRST DETAILED INCIDENT FORM: Return to “Programmer Note” at end of Part 2. If
there is another incident to report, return to part 3, section A. If there is no other incident to report, skip
to Part 4.
AT END OF SECOND DETAILED INCIDENT FORM: Return to “Programmer Note” at end of Part 2.
If there is another incident to report, return to part 3, section A. If there is no other incident to report,
skip to Part 4.
AT END OF THIRD DETAILED INCIDENT FORM: Continue to Part 4.

Attachment W: ACASI Questionnaire

PART 4: VIGNETTES

Thank you for your responses so far. The interview is almost done. In this next part, you will be shown two
fictional situations about a woman and a man, and then you will be asked questions about the woman in the
situation. Here is the first situation.
Alcohol Vignettes
Tom and Sue {INSERT RELATIONSHIP} last week. They both drank alcohol. {INSERT
DRINKING BEHAVIOR} They then went back {home/to Tom’s place}. {INSERT CONSENT}.
RELATIONSHIP
1. went on their first date
2. have been in a sexual relationship for three months and went on a date
3. have been married for five years and went out for dinner
DRINKING BEHAVIOR
1. Both Sue and Tom ordered drinks throughout the date, but neither became drunk.
2. Both Sue and Tom ordered drinks throughout the date. Sue eventually became very drunk and
was slurring her words.
3. Sue kept telling Tom she was not thinking straight and wanted to stop drinking. However,
Tom kept on drinking. Sue kept on drinking because she wanted to be social and eventually
became very drunk and was slurring her words.
4. Sue kept telling Tom she got drunk very easily and would prefer not to drink. Tom kept
refilling Sue’s wine glass saying that he would never take advantage of her. Sue eventually
became very drunk and was slurring her words.
[ONLY SELECT WHEN RELATIONSHIP = 1 or 2]
5. Tom knew that Sue got drunk very easily and decided to try to get her as drunk as possible. He
continued to buy Sue drinks and she became very drunk and was slurring her words.
[ONLY SELECT WHEN RELATIONSHIP = 3]
CONSENT
1. Tom asked if she wanted to have sex. Sue said yes and they proceeded to have sexual
intercourse.
2. Tom kissed Sue and they proceeded to have sexual intercourse. Sue did not say anything at the
time, but she did not want to have sex.
3. Tom kissed Sue. She tried to push Tom away, but did not actually say no. They proceeded to
have sexual intercourse.
4. Tom kissed Sue. Sue said she did not want to have sex, but Tom ignored her and they
proceeded to have sexual intercourse. Sue did not resist again because she was afraid Tom
would hurt her.

Attachment W: ACASI Questionnaire

How would you answer the following questions about Sue?
1.

Yes
No

Do you think Tom was trying to get Sue drunk so he could sexually take advantage of her?
1
2

Yes
No
Did the alcohol make Sue unable to give consent?
1
2

Yes
No

On a scale from 1 to 10 where 1 means Sue definitely did not give consent and 10 means she definitely
gave consent, to what extent did Sue give consent?

1
2
3
4
Definitely did not give consent

10
Definitely gave consent

Attachment W: ACASI Questionnaire

Thank you. Here is the second situation. This one is about Mike and Becky.
Coercion Vignettes
{INSERT RELATIONSHIP}. After dinner they went {home/to Mike’s home} to watch a
movie together. During the movie, Mike began to kiss Becky and asked her if she would have
sex with him. Becky said no, because she didn’t feel like having sex. {INSERT GENTLE
FORCE} {INSERT COERCION} They eventually had sexual intercourse.
RELATIONSHIP
1. Mike and Becky went on their first date last week.
2. Mike is Becky’s manager at work and he tells Becky that he really values their work
relationship. They went on their first date last week.
3. Mike and Becky have been in a sexual relationship for three months and went on a
date last week.
4. Mike is Becky’s manager at work and he tells Becky that he really values their work
relationship. They have been in a sexual relationship for three months and went on a
date last week.
5. Mike and Becky have been married for five years and went out for dinner last week.
GENTLE FORCE
1. {Blank}
2. Mike began to remove Becky’s clothes.
COERCION
1. Mike then said that he was going to end the romantic relationship if she did not have
sex with him.
2. Mike then said, “You’re so beautiful. I really want us to share something special.”
3. Mike also tried several times to persuade her to have sex.

Attachment W: ACASI Questionnaire

How would you answer the following questions about Becky?
1.

Within the past 12 months, that is since [MONTH/YEAR], has a male used force or threats of force to
make Becky have vaginal sex against her will? By vaginal sex, it means putting his penis in her vagina
against her will.
1
2

Yes
No

Since [MONTH/YEAR], has anyone made Becky have any type of sex against her will by threatening to
cause problems for her, such as at her job or school, at home, in her relationships or in any other way?
By sex, it means vaginal sex, oral sex, anal sex, or putting fingers or a foreign object in her vagina or
anus.
1
2

Yes
No

4. On a scale from 1 to 10 where 1 means Becky was definitely not pressured and 10 means she was
definitely pressured, to what extent was Becky pressured to have sexual intercourse?
1
2
Definitely not
pressured

10
Definitely
pressured

Attachment W: ACASI Questionnaire

Attachment W-1:
Event History Calendar

Calendar of last 12 months

Resp ID _____

Birthday
or birth of
new child
Change in
marital
status
Death in
family

Vacation

New job or
promotion

Moved to
new house
or
apartment
Other
(WRITE
IN)

Attachment W1: Event History Calendar

Event History Calendar

Introduction: Before we move on to questions about health and safety, let’s spend a few minutes talking about
what you did and things that happened to you over the last year. It might be difficult to remember things that
happened as long as a year ago. Sometimes people find it helpful to think about a calendar to remember things.
Let’s put some things that are specific to you on the calendar.
PROMPT 1: What are some of the things you did or things that happened to you this past year, that is, since
{MONTH/YEAR}?
RECORD RESPONDENT’S EVENTS ON CALENDAR. READ PROMPT 2 IF RESPONDENT HAS NOT
PRODUCED A BOUNDARY EVENT:
Things that you did or things that happened to you around one year ago from today will be helpful in this
interview.
PROMPT 2: Is there anything that happened in {MONTH/YEAR} that we can note on the calendar? It doesn’t
have to be anything unusual or important, just anything that you remember from around that time.
RECORD RESPONDENT’S EVENTS ON CALENDAR. ASK A GENERAL PROMPT SUCH AS “ANYTHING
ELSE?” TO ELICIT MORE EVENTS.
READ PROMPTS 3-6 IF RESPONDENT HAS NOT PRODUCED A BOUNDARY EVENT:
IF RESPONDENT HAS NOT MENTIONED A FAMILY MILESTONE, READ:
PROMPT 3. Were there any family events, such as a birth or birthday celebration, a wedding, or a death in the
family?
IF RESPONDENT HAS NOT MENTIONED A VACATION OR FAMILY EVENT, READ:
PROMPT 4. Did you or anyone in your family go on vacation or to a special event?
IF RESPONDENT HAS NOT MENTIONED A WORK-RELATED EVENT, READ:
PROMPT 5. Did you change jobs, or get a promotion?
IF RESPONDENT HAS NOT MENTIONED CHANGING RESIDENCES, READ:
PROMPT 6. Did you move to a different house or apartment?
MARK EVENTS ON THE CALENDAR.

Attachment W1: Event History Calendar

Attachment W-2:
ACASI Tutorial

TASM ACASI Tutorial
T5

Introduction
Thank you for agreeing to participate in this study. Before you start, we have some sample
questions and instructions for completing this survey on the computer.
Each question will be shown one at a time and read aloud to you. Once you select your answer,
the audio will stop until you move on to the next question. You have the option of turning off or
adjusting the volume of the audio by pressing the three volume control buttons located on the
bottom right-hand corner of the computer monitor. The first (or left) button allows you to mute
the audio; the second (or middle) button allows you to decrease the audio’s volume; the third (or
right) button allows you to increase the audio’s volume.
You will select an answer to each question by touching your answer choice on the screen. You
can move to the next screen by touching the NEXT button.
Touch the NEXT button now to move to the next screen.

T10

Sample Question That Allows Only One Answer
Here is an example of a question that allows for only one answer.
Do you like orange juice?
Yes
No
To answer this question, touch YES or NO.
Touch the NEXT button to move to the next screen.
Programming Note: If the respondent does not select an answer to this question, the “why you
did not provide an answer to this question” screen should not appear.

T15

How to Change Your Answer
If you want to change your answer, you can touch the ERASE button and enter your new
answer.
Touch the ERASE button now to clear your answer to the previous question.
Do you like orange juice?
Yes
No
Now touch YES or NO to select a new answer.
Touch the NEXT button to move to the next screen.

Attachment W2: ACASI Tutorial

Programming Notes: Display question and answer from T10 on new screen for T15. In T15, the
respondent is learning how to change their answer to a previous question (i.e., the question and
answer from T10).
If the respondent does not select an answer to this question, the “why you did not provide an
answer to this question” screen should not appear.

T20

Sample Question That Allows for More Than One Answer
Some questions allow you to select more than one answer.
To answer this question, touch each answer choice that describes a beverage you like to drink.
Which of the following beverages do you like? Choose all that apply.
Water
Juice
Lemonade
Milk
Tea
Coffee
When you are finished selecting the beverages you like, touch the NEXT button to move to the
next screen.
Programming Note: If the respondent does not select an answer to this question, the “why you
did not provide an answer to this question” screen should not appear.

T25

Sample Question That Asks for a Number Answer
Sometimes you will be asked a question that requires you to answer with a number.
For example:
How many times during the past week did you drink orange juice?
Use the laptop keyboard to enter your answer.
Your number answer will appear on the screen.
Touch the NEXT button to move to the next screen.

Programming Note:
2

Attachment W2: ACASI Tutorial

If the respondent does not select an answer to this question, the “why you did not provide an
answer to this question” screen should not appear.

T35

Sample Question with Several Parts
Sometimes, you will be asked to answer “Yes” or “No” to several questions:

Have you tried any of the following types of juice?
a. Orange
Yes
No
b. Apple
Yes
No
c. Grape
Yes
No
d. Cranberry
Yes
No
e. Grapefruit
Yes
No
To answer each question, touch the YES or NO answer choice next to each item.
When you have selected an answer for each question, touch the NEXT button to move to the
next screen.

Programming Note: If the respondent does not select an answer to a question, the “why you did
not provide an answer to this question” screen should not appear.

T40

To Hear a Question Again
To hear a question again, you can touch the question on the screen once the computer has
stopped reading.
Do you like orange juice?
Yes
No
To hear the question again, touch the words on the screen now.
Touch the NEXT button to move to the next screen.
Programming Note: Respondents should be able to touch each question’s text and the computer
should re-read the question and answer choices. If the respondent does not select an answer to
this question, the “why you did not provide an answer to this question” screen should not
appear.

T45
3

To Go Back to a Previous Question
Attachment W2: ACASI Tutorial

To go back to a previous question, you can touch the BACK button. You can use the BACK
button if you want to go back and change or look at your answer to an earlier question.
Touch the BACK button to return to the previous screen.
Do you like orange juice?
Yes
No
Touch the NEXT button to return to the current screen.
Touch the NEXT button again when you are ready to continue.
Programming Note: If the respondent does not select an answer to this question, the “why you
did not provide an answer to this question” screen should not appear.

T50

What Happens if You Don’t Select an Answer to a Question
If you touch the NEXT button to continue before answering a question, you will be asked the
following:
Can you tell us why you did not provide an answer to the previous question?
I really meant to answer the question
I’d rather not answer
I don’t know the answer
During the survey, you can select the answer choice that best describes why you did not provide
an answer to the previous question.
Touch the NEXT button to move to the next screen.
Programming Note: The respondent may or may not answer this question. Regardless of the
response chosen, proceed to T55.

T55

Questions You May Have
You have now finished answering the sample questions and learning how to use this computer.
If you have any questions or problems while completing this survey, please ask the interviewer
for assistance.
Touch the NEXT button to continue.

T60

Return Computer to Interviewer
Monitor Password: _____

Attachment W2: ACASI Tutorial

The interviewer must now enter the Monitor Password into the computer.
After the Monitor Password is entered, you can begin the survey.
INTERVIEWER ENTERS MONITOR PASSWORD: 8963
PROGRAMMERS: TRANSITION SCREEN SHOULD APPEAR ON THE COMPUTER (see
transition screen text below)
INTERVIEWER RETURNS COMPUTER TO RESPONDENT
TEXT FOR TRANSITION SCREEN:
Press NEXT when you are ready to begin the survey.
PROGRAMMERS: FIRST SCREEN OF SURVEY APPEARS AFTER RESPONDENT
PRESSES NEXT ON THE TRANSITION SCREEN.

Attachment W2: ACASI Tutorial

Attachment W-3:
Demographic Questions

Demographics
This first set of questions is about you and your household.
IQ1. In what month and year were you born?
IQ2. What is your current age?
|__|__|
IQ2a. (IF DK or REFUSED to IQ2) Are you… (CATI READ CATEGORIES 1-8)
1.
2.
3.
4.
5.
6.
7.
8.

Under 18 years old
18 to 24 years old
25 to 29 years old
30 to 39 years old
40 to 49 years old
50 to 59 years old
60 to 64 years old
65 years old or above

(IF GEN POP ACASI, AND AGE<18 or >49 OR IF HIGH RISK AND AGE<18 OR >39 OR IF
SERVICE PROVIDER OR CATI AND AGE<18, INTERVIEWER READ: Thank you for your time
today. We are conducting this study with women ages (18 to 39/18 to 49/18 and older). You are not
eligible for participation in the study.
IQ3. What is your current marital status? Are you …. (CATI READ CATEGORIES 1-5)
1 Now married –SKIP to IQ6
2 Widowed
3 Divorced
4 Separated
5 Never married
IQ4. Are you currently living in this household with a girlfriend, boyfriend or romantic partner?
1 Yes – SKIP TO IQ6
2 No
IQ5. In the last year, have you been involved in a romantic relationship?
1 Yes
2 No
IQ6. What is the highest level of school you have completed or the highest degree you have
received? (DO NOT READ CATEGORIES)
1 Never attended
2 Elementary (grades 1 – 8)
3 High school (grades 9 – 11)
1

Attachment W3: Demographics

4 12th grade (No diploma)
5 High school graduate or GED (Diploma or equivalent)
6 Some college, trade or vocational school (No Degree)
7 Associate’s degree or trade/vocational school diploma
8 Bachelor’s degree (e.g., BA, AB, BS)
9 Master’s degree (e.g., MA, MS, MEng, MSW, MBA)
10 Professional school degree (e.g., MD, DDS, DVM, LLB, JD)
11 Doctorate degree (e.g., PhD, EdD)
IQ7. Are you currently attending or enrolled in a regular school such as elementary or high school
or enrolled either full-time or part-time in college or university, trade, or vocational school?
1 Elementary or high school – GO TO IQ9
2 College/University/Graduate school – GO TO IQ8
3 Trade School– GO TO IQ9
5 Vocational school– GO TO IQ9
6 None of the above schools– GO TO IQ9

IQ8. (IF ATTENDING COLLEGE OR UNIVERSITY) Are you currently a member of a
sorority?
1 Yes
2 No
IQ9. Are you currently, or have you ever served on active duty in the military?
1
2
3

Yes currently
Yes, in the past
No, never

IQ9a. Did you have a job or work at a business LAST WEEK? (Do not include volunteer work or
work around the house.)
1 Yes
2 No
IQ10. Are you Hispanic, Latina, or of Spanish origin?
1
2

YES – GO TO IQ11
NO – GO TO IQ12

IQ11. What is your origin? Please choose all that apply. (CATI READ CATEGORIES 1-4)
1
2
3

Mexican, Mexican American, Chicano or Chicana
Puerto Rican
Cuban
2

Attachment W3: Demographics

Another Hispanic, Latina, or Spanish origin

IQ12. What is your race? Please choose all that apply. (CATI READ CATEGORIES 1-5)
1
2
3
4
5

White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander

IQ13. The next questions are about your USUAL activities. We have found that people’s lifestyles
may be related to their overall safety. On average, during the last 12 months, how often have you
gone shopping? For example at drug, clothing, grocery, hardware and convenience stores? (CATI
READ CATEGORIES 1-5)
1 Almost every day (or more frequently)
2 At least once a week
3 At least once a month
4 Less often
5 Never
IQ14. On average, during the last 12 months, how often have you spent the evening out away from
home - for work, school or entertainment? (CATI READ CATEGORIES 1-5)
1 Almost every day (or more frequently)
2 At least once a week
3 At least once a month
4 Less than once a month
5 Never
IQ15. On average, during the last 12 months, how often did you use public transportation? (CATI
READ CATEGORIES 1-5)
1 Almost every day (or more frequently)
2 At least once a week
3 At least once a month
4 Less often
5 Never
CATI ONLY: (IF SPEAKING TO RESPONDENT ON LANDLINE, CONTINUE. ELSE SKIP
TO NOTE BEFORE IQ17)
IQ16. I won't ask you for the number, but do you have a working cell phone?
1
2
3

Yes - CONTINUE
No – SKIP TO IQ20
Attachment W3: Demographics

(ACASI ONLY)
IQ16a. What is the area code of that cell phone?
____________

- SKIP TO IQ20

CATI ONLY:
(IF SPEAKING TO RESPONDENT ON CELL PHONE, CONTINUE. ELSE SKIP TO
PROGRAMMER NOTE BEFORE IQ19)
IQ17. Is there a regular or landline telephone in your household?
1
2

Yes
No

IQ18. Is that telephone for personal use or business use only?
1
2
3

Personal use only
Business use only
Both personal and business use

IF LANDLINE RESPONDENT HAS CELL PHONE OR CELL PHONE RESPONDENT HAS
LANDLINE IS FOR PERSONAL USE OR LANDLINE IS FOR BOTH PERSONAL AND
BUSINESS USE , CONTINUE;
ELSE SKIP TO IQ20.
IQ19. Of all the telephone calls that you receive, are …(CATI READ CATEGORIES 1-3)
1
2
3

All or almost all calls received on cell phones
Some received on cell phones and some on regular phones, or
Very few or none on cell phones

IQ20. Is this home….(CATI READ CATEGORIES 1-3)
1
2
3

Owned by you or someone in this household free and clear?
Rented?
Occupied without payment of rent?

IQ21. How long have you lived at this address?
_________ years (enter 0 if less than 1 year)
if IQ21 is DK or refused go to IQ22. Else Go to IQ23
IQ22. Have you lived here….(CATI READ CATEGORIES 1-4)
1
2
4

Less than 6 months
6 months to less than a year
Attachment W3: Demographics

3
4

One year to less than 5 years
5 years or more

IQ23. What was the total income from ALL household members during 2013, before taxes.
Include income from all sources such as work, investments, child support and public
assistance. Was it ..
IQ23a Less than $25,000?
1. Yes
2. No Skip to IQ23e
IQ23b Less than $20,000?
1. Yes
2. No Skip to SV Screener
IQ23c Less than $15,000?
1. Yes
2. No Skip to SV Screener
IQ23d Less than $10,000?
1. Yes Skip to SV Screener
2. No Skip to SV Screener
IQ23e Less than $35,000?
1. Yes Skip to SV Screener
2. No Skip to IQ23f
IQ23f Less than $50,000?
1. Yes Skip to SV Screener
2. No Skip to IQ23g
IQ23g Less than $75,000?
1. Yes Skip to SV Screener
2. No Skip to IQ23h
IQ23h $75,000 or more?
1. Yes Skip to SV Screener
2. No Skip to SV Screener
98 (VOL) DK
5

Attachment W3: Demographics

99 (VOL) RF

Attachment W3: Demographics

Attachment X:
Interviewer FAQs with Household

NSHS Frequently Asked Questions (FAQs)
QUESTIONS ABOUT SURVEY PURPOSE/TOPIC
“What’s the purpose of this survey?” “I need more information.” “What will be done with this
data?”
♦ This is a survey about health and safety issues in communities in the U.S. We’ll ask an adult in
your household about various experiences they have had in the past 12 months related to these
topics. The data we are collecting are very important. They will be used to monitor these issues
and develop policies.
“What am I going to get out of this?”
♦ This survey will provide a better picture of health and safety in communities such as yours, and
improve the government’s understanding of these issues in your area.
♦ If someone in your household is selected to participate, they will receive a monetary gift as a
thank you for completing this survey.
“What questions will you ask?”
♦ This survey begins with some background questions (such as gender and age) about the adults
living in your household. We will then randomly select an adult in your household to participate
in the survey.

“We don’t have anyone who has had health and safety issues in this household.” “I am healthy/I
feel safe where I live!”
♦ That’s important to know. It helps us understand the whole picture in communities like yours.
Your participation is important because the answers you provide represent many other
households in similar communities.
♦ Actually your input is very valuable to this study. Valid research requires that we have input
from those who have no experience with safety issues as well as those who have had safety
issues. There are fewer questions, and this should go quickly. [IMMEDIATELY CONTINUE.]

HOW WAS MY HOUSEHOLD SELECTED
“How was my household chosen for this study?” “Do we have to do this?”
♦ Your household was selected at random {using 2010 U.S. Census information about this
community/by randomly selecting phone numbers}.
♦ Because this is a scientific study, your answers represent not only you and your household, but
also hundreds of households like yours – for this reason your voluntary cooperation is very
important.

Attachment X: Interviewer FAQs with Household

NOT DOING IT /CALL SOMEONE ELSE
“Just skip me and have someone else do it.” “Why have I been singled out?” “I won’t be able to
help you.”
♦ Your participation is important because you were uniquely selected to participate in this study.
Scientific procedures were used to select participants for the survey, and the requirements of
sampling do not allow us to replace your household with another.
♦ The scientific method used to select your household does not allow for replacement; because
you were selected to represent not just yourself but similar people in the United States. Your
participation is the only way to insure that results from the study will provide and accurate
representation of your community.
♦ You’re representing a lot of other people like you, and you will be speaking for them as well as
representing your household.
“How will you choose who in my household does this?”
♦ We use a statistical selection procedure to choose respondents, so that a wide variety of
individuals are included in order for the findings to be valid and representative. Your household
cannot be replaced.
“Do we have to do this?” “We don’t want to do this!” “What will happen if we don’t do this?”
♦ Your participation is voluntary, but it will contribute greatly to the success of the study and will
help improve the government’s ability to assess health and safety in communities like yours.
♦ As you represent other households in your area and cannot be replaced, valuable information
would be lost without your participation. (We need your help and appreciate your time
answering our questions.) (IMMEDIATELY CONTINUE WITH INTERVIEW.)
“I’m not interested !”
♦ Please let me take a minute to explain how important this research study is and how you can
help.
o This is your household’s chance to be heard and to contribute to an important research
effort, to have your experiences with health and safety issues included in an important
effort to understand communities such as yours.
o Without your information, the picture would not be complete.
o [USE OTHER APPROPRIATE PHRASES.]
“But I don’t live in {Los Angeles/Phoenix/Dallas/Miami/New York City}!”
♦ This survey is being conducted in the {Los Angeles/Phoenix/Dallas/Miami/New York City}
metropolitan statistical area. We are calling households in counties near these cities, but not
necessarily in them. The survey is intended to measure and describe crime victimization in this
wider area, you don’t need to live in the city of Los Angeles/Phoenix/Dallas/Miami/New York
City} to participate.

Attachment X: Interviewer FAQs with Household

ALLEVIATING SUSPICIONS & FEARS/ ASSURING CONFIDENTIALITY & LEGITIMACY

“What is going to happen to the information I give you?” “How do I know you will keep my
information confidential?
♦ This interview is confidential by law – this means that the information you provide will not be
shared with any individual, organization or agency. Your name will never appear in any report
or associated with any findings.
♦ (IF RESPONDENT ASKS WHICH FEDERAL LAW, SAY: Federal law 42 U.S.C. Section
3789g)
♦ Your responses will be combined with those of others to produce statistical summaries about
health and safety.
♦ As telephone interviewers at Westat, we are all required to sign statements of confidentiality
regarding all information provided by anyone we interview.

“We don’t do surveys!” “Take us off your list.”
♦ This is not a marketing survey or a sales call. This is for the Bureau of Justice Statistics, a part of
the U.S. Department of Justice. The survey is about health and safety in communities like yours.
All information gathered is strictly confidential.

“No thanks. I’ve had a bad experience doing a survey.”
♦ I’m sorry that you’ve had a bad experience. I hope that your experience with me will be a
pleasant one. This is a special research effort and by participating in the study, you will help us
learn more about health and safety in communities such as yours. . . . . It is your chance to have
some of your opinions heard.

“How can I trust that this is legitimate?”
♦ My company, Westat, is a social science research company hired by the Bureau of Justice
Statistics to conduct this survey. [REPEAT APPROPRIATE PARTS OF THE
INTRODUCTION OR PURPOSE.]
♦ [IF RESPONDENT EXPRESSES A WISH TO CALL OR REQUESTS A NUMBER, GIVE
THE TOLL-FREE # [TOLL FREE]. ASK IF THEY ARE READY TO TAKE DOWN THE
NUMBER. READ THE NUMBER SLOWLY, AND THEN REPEAT IT. ATTEMPT TO
CONTINUE THE INTERVIEW IF POSSIBLE – IF NOT POSSIBLE, TRY TO DETERMINE
A CALLBACK TIME.]

Attachment X: Interviewer FAQs with Household

TIME

“How long will this take?”
♦ It will take about 5 minutes to determine if anyone in your household is eligible to participate.
♦ If an adult in your household is eligible to respond to the survey, the amount of time varies from
person to person, but it typically takes around 15 to 30 minutes, depending on the answers.

“I just have no time for this.” “I’m just too busy.”
♦ It only takes about 5 minutes for me to determine if someone in your household is eligible. I’d
like to start the interview now – I can call you back to finish it at a more convenient time. Your
input is very important to the successful results of the study. I’ll move through as quickly as
possible.
[IMMEDIATELY START OR CONTINUE AT A BRISK BUT COMPREHENSIBLE PACE
FOR THE RESPONDENT.]
o [RETAIN CONTROL OF THE SITUATION. IF THE SUBJECT NEEDS TO GO
ESTABLISH A GOOD APPOINTMENT DATE/TIME: ]


Let me call you back at a more convenient time. What is the best day to reach
you? What time on [DAY] would be good for you?

 Thanks a lot. We’ll look forward to your help at that time.
[LEAVE AN APPROPRIATE MESSAGE FOR YOUR COLLEAGUES.]
QUESTIONS ABOUT SPONSOR (CLIENT) OR WESTAT
“Who do you work for?”
♦ I work for Westat, a large and respected research firm in Rockville, Maryland. Westat has been
contracted by the Department of Justice’s Bureau of Justice Statistics to conduct this study.
“What is the BJS (Bureau of Justice Statistics)”?
♦ The Bureau of Justice Statistics (BJS) is the primary statistical agency of the Department of
Justice. BJS collects, analyzes, publishes, and disseminates information on crime, criminal
offenders, crime victims, and criminal justice operations. BJS also provides financial and
technical support to state, local, and tribal governments to improve their statistical capabilities
and the quality and the utility of their criminal history records. BJS provides statistical
information to the President, Congress, other officials, and the public with accurate, timely, and
objective data about crime and the management of criminal justice.
“Are you calling from the Department of Justice, Bureau of Justice Statistics?
♦ While I do not work for the Department of Justice or the Bureau of Justice Statistics, the study is
4

Attachment X: Interviewer FAQs with Household

being conducted for them. All information is kept confidential, and BJS will not receive
information that can be linked to your name.

“Do you have a website?”
♦ Are you ready to take down that information? (PROVIDE BJS OR WESTAT WEBSITE AS
APPROPRIATE)
o You can find information about the Bureau of Justice Statistics at www.bjs.gov
o Information about this BJS survey can be found on the BJS website.
o Westat’s website address is www.westat.com

INFORMATIONAL REQUESTS /STUDY RESULTS
IF ASKED A PERSONAL QUESTION:
♦ I’m unable to discuss my own personal opinions or situation because that may influence your
responses to the questions and the study results. My job requires that I ask only the questions as
they are worded.

“Can I get a copy of the results?”
♦ Results from this study will be published eventually on the Bureau of Justice Statistics website
at www.bjs.gov.

“What is this study’s OMB (Office of Management and Budget) number?”/ “Who do I contact if I
have concerns about the burden of this study?”
♦ All of the questions and materials associated with this study have been approved by OMB.
♦ The OMB number is [XXXX]
FOR THOSE WHO SAY THEY’VE ALREADY COMPLETED THE STUDY BY MAIL
“I already filled out this survey and returned it in the mail - I already did this!"
♦ The short mail survey that you completed was the first step in this research project – this
interview is what the Bureau of Justice Statistics will use to produce estimates of health and
safety issues for your community. This survey will ask different questions than the survey you
already filled out.

Attachment X: Interviewer FAQs with Household

Attachment Y:
Interviewer FAQs with Selected Respondent

NSHS Frequently Asked Questions (FAQs)
QUESTIONS ABOUT SURVEY PURPOSE/TOPIC
“What’s the purpose of this survey?” “I need more information.” “What will be done with this
data?”
♦ The study is sponsored by the Bureau of Justice Statistics (BJS) of the U.S. Department of
Justice. The purpose of this survey is to help improve the way we collect information about the
health and safety consequences of unwanted sexual experiences. Females age 18 or older will be
asked questions about their experiences. The data we are collecting are very important. They
will be used to guide national policies.
“What am I going to get out of this?”
♦ We will give you ($50/$40/$20) as a thank you for completing the study.
Your participation will help us understand the health and safety issues associated with unwanted sexual
experiences and the consequences associated with these experiences. It will help us improve the way we
monitor these health and safety issues around the country.
“What questions will you ask?”
♦ This survey begins with some background questions (such as marital status and education). Next
we ask questions about possible unwanted sexual experiences you may have experienced and the
consequences associated with those experiences.
“I have never been raped/I have never had unwanted sexual experiences/I do not want to answer
questions about this.”
♦ Actually your input is very valuable to this study. Valid research requires that we have input
from those who have no experience with these issues as well as those who have had these
experiences. That way we can find out an accurate portrait of everyone in your community.
[IMMEDIATELY CONTINUE.]
“What if the questions make me feel uncomfortable or I want to stop? What if I can’t continue the
interview in private?”
•
•

•

If any of the questions make you feel uncomfortable, you can skip them and move to the next
question.
You can stop at any time. Please let me know at any point if you would like to stop. (Phone: If
you are concerned about your safety, or think someone may be listening in, you can simply say
“Goodbye” and I’ll try to call you back at a more convenient time. Field: if you do not wish to
continue the survey, you can simply tell me that you are finished.) We can stop the interview
and can finish it at another time, or if you want to stop altogether, that’s fine.
If you feel like you need to talk with someone, I can provide resources for you to access or I can
stay on the line with you while I connect you to a trained professional who can help you with
these feelings.

HOW WAS MY HOUSEHOLD SELECTED (GENERAL POPULATION ONLY)
1

Attachment Y: Interviewer FAQs with Selected Respondent

“How was I chosen for this study?” “Do I have to do this?”
♦ Your household was selected at random {using 2010 U.S. Census information about this
community/by randomly selecting phone numbers}, and you were randomly selected from the
adults living in your household. Because this is a scientific study, your answers represent not
only you and your household, but also hundreds of households like yours – for this reason your
voluntary cooperation is very important.

NOT DOING IT /CALL SOMEONE ELSE
“Just skip me and have someone else do it.” “Why have I been singled out?” “I won’t be able to
help you.”
♦ Your participation is important because you were uniquely selected to participate in this study.
Scientific procedures were used to select participants for the survey, and the requirements of
sampling do not allow us to replace your household with another.
♦ The scientific method used to select your household does not allow for replacement; because you
were selected to represent not just yourself but similar people in the United States. Your
participation is the only way to insure that results from the study will provide and accurate
representation of your community.
♦ You’re representing a lot of other people like you, and you will be speaking for them as well as
representing your household.
“Why did I, and not someone else in the household, get selected to do this?”
♦ We use a statistical selection procedure to choose respondents, so that a wide variety of ages and
sexes are included in the study. We do this so that the findings are valid and representative. You
cannot be replaced by someone else in your household.
“Do I have to do this?” “I’m not doing this!” “What will happen if I don’t do this?”
♦ Although your participation is voluntary, if you choose not to participate the will affect the
findings of the survey. Your participation will contribute greatly to the success of the study and
will help improve the government’s ability to assess health and safety in communities like yours.
♦ As you represent other households in your area and cannot be replaced, valuable information
would be lost without your participation. (We need your help and appreciate your time
answering our questions.) (IMMEDIATELY CONTINUE WITH INTERVIEW.)
“I’m not interested!”
♦ Please let me take a minute to explain how important this research study is and how you can
help.
o This is your chance to be heard and to contribute to an important research effort, to have
your experiences with health and safety issues included in an important effort to
understand communities such as yours.
o Without your information, the picture would not be complete.
o [USE OTHER APPROPRIATE PHRASES.]
2

Attachment Y: Interviewer FAQs with Selected Respondent

“But I don’t live in {Los Angeles/Phoenix/Dallas/Miami/New York City}!”
♦ This survey is being conducted in the {Los Angeles/Phoenix/Dallas/Miami/New York City}
metropolitan statistical area. We are calling households in counties near these cities, but not
necessarily in them. The purpose of this survey is to improve how information on issues of
health and safety are gathered in this wider area, you don’t need to live in the city of Los
Angeles/Phoenix/Dallas/Miami/New York City} to participate.

ALLEVIATING SUSPICIONS & FEARS/ ASSURING CONFIDENTIALITY & LEGITIMACY
“What is going to happen to the information I give you?” “How do I know you will keep my
information confidential?
♦ This interview is confidential by law – this means that the information you provide will not be
shared with any individual, organization or agency. Your name will never appear in any report
or associated with any findings.
♦ (IF RESPONDENT ASKS WHICH FEDERAL LAW, SAY: Federal law 42 U.S.C. Section
3789g)
♦ Your responses will be combined with those of others to produce statistical reports that
summarize issues related to health and safety.
♦ As telephone interviewers at Westat, we are all required to sign statements of confidentiality
regarding all information provided by anyone we interview.

“How can I trust that this is legitimate?”
♦ My company, Westat, is a major social science research company hired by the Bureau of Justice
Statistics to conduct this survey. [REPEAT APPROPRIATE PARTS OF THE
INTRODUCTION OR PURPOSE.]
♦ [IF RESPONDENT EXPRESSES A WISH TO CALL OR REQUESTS A NUMBER, GIVE
THE TOLL-FREE # [TOLL FREE]. ASK IF THEY ARE READY TO TAKE DOWN THE
NUMBER. READ THE NUMBER SLOWLY, AND THEN REPEAT IT. ATTEMPT TO
3

Attachment Y: Interviewer FAQs with Selected Respondent

CONTINUE THE INTERVIEW IF POSSIBLE – IF NOT POSSIBLE, TRY TO DETERMINE
A CALLBACK TIME.]
TIME
“How long will this take?”
♦ The amount of time varies from person to person, but it typically takes around 15 to 30 minutes,
depending on your answers.
“I just have no time for this.” “I’m just too busy.”
♦ The interview won’t take very long, and I’d like to start the interview now or I can call you back
to finish it at a more convenient time if you like. Your input is very important to the success of
this study. I’ll move through the interview as quickly as possible.
[IMMEDIATELY START OR CONTINUE AT A BRISK BUT COMPREHENSIBLE PACE
FOR THE RESPONDENT.]
o [RETAIN CONTROL OF THE SITUATION. IF THE SUBJECT NEEDS TO GO
ESTABLISH A GOOD APPOINTMENT DATE/TIME: ]


Let me call you back at a more convenient time. What is the best day to reach
you? What time on [DAY] would be good for you?

 Thanks a lot. We’ll look forward to your help at that time.
[LEAVE AN APPROPRIATE MESSAGE FOR YOUR COLLEAGUES.]

SCREENER QUESTIONNAIRE IS REDUNDANT/REPETITIVE
“Why are you asking me so many questions about my sexual behaviors – I already told you
nothing’s happened to me!”
“Didn’t you already ask me that?”
♦ The purpose of this research is to try to determine how often different types of unwanted sexual
situations happen to women. Some of the language used in this survey is explicit and may be
uncomfortable to you, but it is important that the questions are asked in this way so that you are
clear about what is meant.
♦ People think about these unwanted sexual situations in many different ways. I understand you
are saying that nothing happened to you, but sometimes people remember things if we ask the
questions in different ways. You can skip any question you don’t want to answer.
♦ These questions are designed to help people remember events, but because people remember
experiences in different ways, we ask the questions in many different ways. The Bureau of
Justice Statistics asks all of these questions to help people remember and to make sure that all
different types of incidents are counted.

Attachment Y: Interviewer FAQs with Selected Respondent

QUESTIONS ABOUT SPONSOR (CLIENT) OR WESTAT
“Who do you work for?”
♦ I work for Westat, a large research firm in Rockville, Maryland. Westat has been contracted by
the U.S. Department of Justice’s Bureau of Justice Statistics to conduct this study.
“Why is the Government collecting data on my sexual experiences?”
“What is the BJS (Bureau of Justice Statistics)?”
♦ Unwanted sexual experiences are often not reported to the police, and this study will help BJS
better understand how often this is happening so they can develop better policies and programs
to address it. Please be assured that all information we gather for this survey is strictly
confidential.
♦ The Bureau of Justice Statistics (BJS) is the primary statistical agency of the Department of
Justice. BJS collects, analyzes, publishes, and disseminates information on crime, criminal
offenders, crime victims, and criminal justice operations. BJS also provides financial and
technical support to state, local, and tribal governments to improve their statistical capabilities
and the quality and the utility of their criminal history records. BJS provides statistical
information to the President, Congress, other officials, and the public with accurate, timely, and
objective data about crime and the management of criminal justice.
“Are you calling from the Department of Justice, Bureau of Justice Statistics?
♦ While I do not work for the Department of Justice or the Bureau of Justice Statistics, the study is
being conducted for them. All information related to this study will be treated as confidential.

INFORMATIONAL REQUESTS /STUDY RESULTS IF ASKED A PERSONAL QUESTION:
♦ I’m unable to discuss my own personal opinions or situation because that may influence how you
respond to the questions and affect the results of the study.My job requires that I ask only the
study questions as they are worded.

“Who can I call to get help with my situation?” “You mentioned a list of hotline numbers – can I
get those?”
[REFERRAL TELEPHONE NUMBERS]
5

Attachment Y: Interviewer FAQs with Selected Respondent

♦

The National Domestic Violence Hotline: 1-800-799-7233 (1-800-799-SAFE)

♦

The National Suicide Prevention Hotline: 1-800-273-8255

♦

The National Sexual Assault Hotline: 1-800-656-4673 (1-800-656-HOPE)

♦

Westat TRC: 1-888-544-1070

“Can I get a copy of the results?”
♦ Results from this study will be published eventually on the Bureau of Justice Statistics website
at www.bjs.gov.

“What is this study’s OMB (Office of Management and Budget) number?”
♦ All of the questions and materials associated with this study have been approved by OMB.
♦ The OMB number is xxxx

FOR THOSE WHO SAY THEY’VE ALREADY COMPLETED THE STUDY BY MAIL
“I already filled out this survey and returned it in the mail - I already did this!"
♦ The short mail survey that you completed was the first step in this research project – this
interview is what the Bureau of Justice Statistics will use to produce estimates of unwanted
sexual experiences for your community. This survey asks different questions than the survey
you already filled out.

Attachment Y: Interviewer FAQs with Selected Respondent

Attachment Z:
Inaccessible Dwelling Unit Letter

{BJS LETTERHEAD}

[DATE]
<>
<>
<>
<>

Dear Building Manager/Superintendent,
An address at this location has been selected for an important research study being sponsored by the
Bureau of Justice Statistics, an agency in the U.S. Department of Justice. Westat, a research firm, is
carrying out the survey.
Our researcher is requesting your assistance to allow her to directly contact the residents of this address
to inform them of the study or leave a card if no one is home.
Our researchers wear Westat photo ID badges, verifying their employment.
We would greatly appreciate any help you can provide. If you need additional information or to verify
this request, please contact us at [TOLL FREE].
Thank you in advance for assisting us with this important study.
Sincerely,

William Sabol
Acting Director
Bureau of Justice Statistics
U.S. Department of Justice

Attachment Z: Letter to Inaccessible Dwelling Units

File Type	application/pdf
Author	Margo Tercy
File Modified	2013-11-05
File Created	2013-11-05