NCVS SVS Screener

INTRO -

Now, I would like to ask you some questions about times when you may have experienced unwanted
contacts or behaviors. I want to remind you that the information you provide is confidential. When
answering, please think about anyone who may have done these things, including current or former
spouses or partners, other people you may know, or strangers. However, please DO NOT include bill
collectors, solicitors, or other sales people.
SECTION I. NCVS SVS SCREENER QUESTIONS

SQ1. In the past 12 months, have you experienced any
unwanted contacts or behaviors?
By that I mean has anyone –
SQ_FOLLOWED
a. Followed you around and watched you?
____________________________________________________
SQ_SNEAKED
b. [Has anyone] Sneaked into your home, car, or any place
else and did unwanted things to let you know they had been
there?
____________________________________________________
SQ_WAITED
c. [Has anyone] Waited for you at your home, work, school,
or any place else when you didn’t want them to?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No

Still thinking about unwanted contacts and behaviors, in the
past 12 months, has anyone…
SQ_SHOWEDUP
d. Showed up, rode or drove by places where you were
when they had no business being there?
____________________________________________________
SQ_ITEMS
e. [Has anyone] Left or sent unwanted items, cards, letters,
presents, flowers, or any other unwanted items?
____________________________________________________
SQ_HARASSED
f. [Has anyone] Harassed or repeatedly asked your friends or
family for information about you or your whereabouts?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No

Now I want to ask about unwanted contacts or
behaviors using various technologies, such as your
phone, the Internet, or social media apps. Again, please
DO NOT include bill collectors, solicitors, or other
sales people. In the past 12 months, has anyone…
SQ_TELEPHONE
g. Made unwanted phone calls to you, left voice
messages, sent text messages, or used the phone
excessively to contact you?
____________________________________________________
SQ_TECHNOLOGY
h. [Has anyone] Spied on you or monitored your activities
using technologies such as a listening device, camera, or
computer or cell phone monitoring software?

Page 1

1  Yes
2  No
_______________________________________________
1  Yes
2  No

FORM SVS-1 (1/14/2016)

Still thinking about unwanted contacts and behaviors, in the
past 12 months, has anyone…
SQ_APPLICATION
i. Tracked your whereabouts with an electronic tracking
device or application, such as GPS or an application on your
cell phone?
____________________________________________________
SQ_POSTS
j. [Has anyone] Posted or threatened to post
inappropriate, unwanted, or personal information about
you on the Internet, this includes private photographs,
videos, or spreading rumors?
____________________________________________________
SQ_WEBSITES
k. [Has anyone] Sent unwanted e-mails or messages using
the Internet, for example, using social media apps or
websites like Instagram, Twitter, or Facebook?

1  Yes
2  No
_______________________________________________
1  Yes
2  No

_______________________________________________
1  Yes
2  No

SQ_SOCIALMEDIA
l. [Has anyone] Monitored your activities using social
media apps like Instagram, Twitter, or Facebook?
CHECK ITEM 1: If R answered “Yes” to one or more of SQ_FOLLOWED-SQ_SOCIALMEDIA, then skip to SQ2
(SQ_REPETITION). If R did not answer “Yes” to any of the above items, then skip to END INTERVIEW TEXT on page 3.
SQ_REPETITION
SQ2. Has anyone done (this/any of these things) to you more
than once in the past 12 months?

1  Yes [skip to SQ3a (SQ_FEAR)]
2  No [skip to CHECK ITEM 2]

CHECK ITEM 2: If R answered “Yes” to more than one of SQ_FOLLOWED-SQ_SOCIALMEDIA, then skip to SQ3a
(SQ_FEAR). If R answered “Yes” to only one of SQ_FOLLOWED-SQ_SOCIALMEDIA, then skip to END INTERVIEW TEXT on
page 3.
SQ_FEAR
SQ3a. Did any of these unwanted contacts or behaviors
make you fear for your safety or the safety of someone close
to you?
SQ_DISTRESS
SQ3b. Did any of these unwanted contacts or behaviors
cause you substantial emotional distress?

1  Yes
2  No

1  Yes
2  No

Now I have some additional questions about the time
someone {behavior1}, {behavior2}, and {behaviorx…}.
Thinking about the person or persons who committed these
unwanted contacts or behaviors in the past 12 months, did
any of the following occur –
SQ_PROPERTY
SQ4. Did this person or these people damage or attempt to
damage or destroy property belonging to you or someone
else in your household?

Page 2

1  Yes
2  No

FORM SVS-1 (1/14/2016)

SQ5. [Thinking about the person or persons who committed
these unwanted contacts or behaviors in the past 12 months…]
Did this person or these people…
SQ_ATTACK_SELF
Physically attack you?
____________________________________________________
SQ_ATTEMPT_SELF
Attempt to attack you?
____________________________________________________
SQ_THREAT_SELF
Threaten to attack you?

SQ6. [Thinking about the person or persons who committed
these unwanted contacts or behaviors in the past 12 months…]
Did this person or these people…
SQ_ATTACK_OTH
Physically attack someone close to you or a pet?
____________________________________________________
SQ_ATTEMPT_OTH
Attempt to attack someone close to you or a pet?
____________________________________________________
SQ_THREAT_OTH
Threaten to attack someone close to you or a pet?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No

SURVEY INSTRUCTIONS: See the table below for all combinations of the questions used to determine when the survey
should be ended or continued on to the questions about the incident.
NOTE: This information is programmed into the CAPI instrument and skip patterns are driven automatically.
Number of
Behaviors (SQ1a-k)
________________
1
1
1
1
1
1
1
1
2+
2+
2+
2+
2+
2+
2+
2+

Repetition
(SQ2)
_____________
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes

Actual Fear or Emotional
Distress (SQ3a and SQ3b)
______________________
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes

Reasonable Fear
(SQ4, SQ5, or SQ6)
________________
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes

Included in stalking
estimate/survey continuation?
________________________
No – end interview
No – end interview
No – end interview
No – end interview
No – end interview
Yes – continue
Yes – continue
Yes – continue
No – end interview
Yes – continue
Yes – continue
Yes – continue
No – end interview
Yes – continue
Yes – continue
Yes – continue

END INTERVIEW TEXT: “Thank you for your time, that ends the interview.”

Page 3

FORM SVS-1 (1/14/2016)

SECTION II. NCVS SVS OFFENDER INFORMATION
OFFENDER_NUMB
OFFENDER_NUMBSP
Q1. Thinking about the unwanted contacts or behaviors you
experienced in the past 12 months, how many different
people have done these things to you?

OFFENDER_ACT
Q2a. Did these people act alone or together as a team?

OFFENDER_MOST
Q2b. Of the people who did these things to you, is there ONE
person who you would consider to be the MOST responsible
for these unwanted contacts or behaviors?

1  One [skip to Q3 (OFFENDER1_SEX)]
2  Two [skip to Q2a (OFFENDER_ACT)]
3  Three or more – Enter number of people ________
[skip to Q2a (OFFENDER_ACT)]
4  Don’t know [skip to INTRO TEXT A]

1  Alone [skip to INTRO TEXT A]
2  Together [skip to Q2b (OFFENDER_MOST)]
3  Don’t know [skip to INTRO TEXT A]

1  Yes [skip to Q3 (OFFENDER1_SEX)]
2  No [skip to Q8a (OFFENDERS_SEX)]

SECTION III. SINGLE OFFENDER
INTRO TEXT A. Thinking about the person who has done this most recently…
OFFENDER1_SEX
Q3. Is this person male or female?

OFFENDER1_AGE
Q4. How old would you say this person is?

OFFENDER1_HISP
Q5. Is this person Hispanic or Latino/a?

OFFENDER1_RACE
Q6. What race or races is this person? You may select more
than one. Is this person… [Select one or more]

Page 4

1  Male
2  Female

1  Under 15
2  15-17
3  18-20
4  21-24
5  25-34
6  35-49
7  50-64
8  65+
9  Don’t know

1  Yes
2  No
3  Don’t know

1  White?
2  Black or African American?
3  American Indian or Alaska Native?
4  Asian?
5  Native Hawaiian or Other Pacific Islander?
3  Don’t know

FORM SVS-1 (1/14/2016)

OFFENDER1_REL
OFFENDER1_RELSP
OFFENDER1_NONSP
Q7. What was your relationship to the person who
committed these unwanted contacts or behaviors when they
first began?
[Instruction: Record the relationship at the time the unwanted
contacts or behaviors began and not at the time of the interview.]

RELATIVE – offender was the respondent’s –
01  Spouse or partner
02  Ex-spouse or ex-partner
03  Parent or step-parent
04  Own child or step-child
05  Sibling/step-sibling
06  Other relative – Specify __________
NONRELATIVE – offender was the respondent’s –
07  Boyfriend or girlfriend
08  Ex-boyfriend or ex-girlfriend
09  Other current romantic or sexual partner
10  Other former romantic or sexual partner
11  Friend or ex-friend
12  Acquaintance
13  In-laws or relative of spouse or ex-spouse
14  Roommate, housemate, boarder
15  Schoolmate
16  Neighbor
17  Customer/client
18  Student
19  Patient
20  Supervisor (current or former)
21  Employee (current or former)
22  Co-worker (current or former)
23  Teacher/school staff
24  Stranger
25  Other nonrelative – Specify __________
26  Unable to identify the person
[skip to Q14a (INC_DURATION)]

SECTION IV. MULTIPLE OFFENDERS
OFFENDERS_SEX
Q8a. Are these people male or female?

1  All male [skip to Q9 (OFFENDERS_AGE)]
2  All female [skip to Q9 (OFFENDERS_AGE)]
3  Don’t know sex of any offenders
[skip to Q9 (OFFENDERS_AGE)]
4  Both male and female [skip to CHECK ITEM 3]

CHECK ITEM 3: If only two offenders (OFFENDER_NUMB=2), then skip to Q9 (OFFENDERS_AGE). If more than two
offenders (OFFENDER_NUMB=3), then skip to Q8b (OFFENDERS_SEX2).
OFFENDERS_SEX2
Q8b. Are most of these people male or female?

Page 5

1  Most are male
2  Most are female
3  Evenly divided
4  Don’t know

FORM SVS-1 (1/14/2016)

OFFENDERS_AGE
Q9. How old would you say these people are? [Mark all that
apply]

OFFENDERS_HISP
Q10a. Are any of these people Hispanic or Latino/a?

1  Under 15
2  15-17
3  18-20
4  21-24
5  25-34
6  35-49
7  50-64
8  65+
9  Don’t know

1  Yes [skip to Q10b (OFFENDERS_HISP2)]
2  No [skip to Q11a (OFFENDERS_RACE)]
3  Don’t know [skip to Q11a (OFFENDERS_RACE)]

OFFENDERS_HISP2
Q10b. Are most of these people Hispanic, non-Hispanic, or an 1  Most are Hispanic or Latino/a
equal number of Hispanic and non-Hispanic?
2  Most are non-Hispanic
3  Equal number of Hispanic and non-Hispanic
4  Don’t know
OFFENDERS_RACE
Q11a. What race or races are these people? Are they…
[Select one or more]

1  White?
2  Black or African American?
3  American Indian or Alaska Native?
4  Asian?
5  Native Hawaiian or Other Pacific Islander?
6  Don’t know

CHECK ITEM 4: If more than one selection at Q11a (OFFENDERS_RACE), then skip to Q11b (OFFENDERS_RACE2). If only
one selection at Q11a (OFFENDERS_RACE), then skip to Q12 (OFFENDERS_REL).
OFFENDERS_RACE2
Q11b. What race are most of these people?

Page 6

1  Most are White
2  Most are Black or African American
3  Most are American Indian or Alaska Native
4  Most are Asian
5  Most are Native Hawaiian or Other Pacific
Islander
6  Equal number of each race
7  Don’t know

FORM SVS-1 (1/14/2016)

OFFENDERS_REL
OFFENDERS_RELSP
OFFENDERS_NONSP
Q12. What was your relationship to the people who
committed these unwanted contacts or behaviors when they
first began? [Mark all that apply]
[Instruction: Record the relationship at the time the unwanted
contacts or behaviors began and not at the time of the interview.]

RELATIVE – offenders were the respondent’s –
01  Spouse or partner
02  Ex-spouse or ex-partner
03  Parent or step-parent
04  Own child or step-child
05  Sibling/step-sibling
06  Other relative – Specify __________
NONRELATIVE – offenders were the respondent’s –
07  Boyfriend or girlfriend
08  Ex-boyfriend or ex-girlfriend
09  Other current romantic or sexual partner
10  Other former romantic or sexual partner
11  Friend or ex-friend
12  Acquaintance
13  In-laws or relative of spouse or ex-spouse
14  Friends of one of the offenders
15  Roommate, housemate, boarder
16  Schoolmate
17  Neighbor
18  Customer/client
19  Student
20  Patient
21  Supervisor (current or former)
22  Employee (current or former)
23  Co-worker (current or former)
24  Teacher/school staff
25  Stranger
26  Other nonrelative – Specify __________
27  Unable to identify the person

OFFENDERS_EACH
OFFENDERS_EACHSP
Q13. How do the people who committed these unwanted
contacts or behaviors know each other? Are they… [Mark all
that apply]

1  Friends?
2  Classmates or peers?
3  Co-workers?
4  In-laws or family members?
5  Members of a Fraternity or Sorority?
6  Members of a gang or other organized crime
group?
7  Or do they know each other in some other way?
– Specify ___________

SECTION V. DURATION OF STALKING
INC_DURATION
Q14a. How long have these unwanted contacts or behaviors
been happening to you?

Page 7

1  Less than one month
2  One month to less than six months
3  Six months to less than one year
4  One year to less than two years
5  Two years to less than three years
6  Three years to less than five years
7  Five years or more
8  Don’t know

FORM SVS-1 (1/14/2016)

INC_DISCOVER
Q14b. How did you find out that these unwanted contacts or
behaviors were happening to you?

1  The offender told me
2  Someone else told me
3  I figured it out on my own
4  Don’t know, don’t remember

SECTION VI. FREQUENCY OF STALKING
INC_TIMES
Q15. In the past 12 months, how many times would you say
these unwanted contacts or behaviors occurred? Would you
say…

Page 8

1  Two to ten times
2  Eleven to fifty times
3  More than fifty times
4  Too many times to count
5  Don’t know, don’t remember

FORM SVS-1 (1/14/2016)

SECTION VII. MOTIVE FOR STALKING
Q16. Why do you think (this person/these people) started
doing these things to you? Was it because…
INC_REVENGE
They wanted retaliation or revenge?
____________________________________________________
INC_AFFECTION
They wanted affection?
____________________________________________________
INC_REJECTED
They felt rejected?
____________________________________________________
INC_OBSESSED
They were obsessed with you?
____________________________________________________
INC_PLANNED
They planned to commit a crime?
____________________________________________________
INC_ALREADY
They had already committed a crime?
____________________________________________________
INC_POWER
They wanted power and control?
____________________________________________________
INC_FELT
They felt like they could do these things to you?
____________________________________________________
INC_OTHER
INC_OTHERSP
Any other reason?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

CHECK ITEM 5: If offender physically attacked or attempted to attack respondent (SQ_ATTACK_SELF=1 or
SQ_ATTEMPT_SELF=1), then skip to Q17a (INC_HIT). If offender only threatened to attack respondent
(SQ_THREAT_SELF=1 and SQ_ATTACK_SELF ne 1 and SQ_ATTEMPT_SELF ne 1), then skip to Q18a (INC_THREAT_HIT).
Else, skip to CHECK ITEM 6.

Page 9

FORM SVS-1 (1/14/2016)

SECTION VIII. REASONABLE FEAR FOLLOW-UP
Q17a. Earlier you indicated that (this person/these people)
physically attacked or attempted to attack you. Did they
attack or attempt to attack you…
INC_HIT
By hitting, slapping, pushing, or knocking you down?
____________________________________________________
INC_CHOKE
By choking or strangling you?
____________________________________________________
INC_RAPE
By raping or sexually assaulting you?
____________________________________________________
INC_OBJECT
With a weapon or other object?
____________________________________________________
INC_VEHICLE
By hitting, chasing, or dragging you with a vehicle?
____________________________________________________
INC_ATTACKOTH
INC_ATTACKOTHSP
Or did they attack you in some other way?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

CHECK ITEM 5a: If respondent answered “Yes” to being attacked with a weapon or other object (INC_OBJECT=1), then skip to
Q17b. If respondent answered “No” to being attacked with a weapon or other object and offender threatened to attack
respondent (INC_OBJECT=2 and SQ_THREAT_SELF=1), then skip to Q18a (INC_THREAT_HIT). Else, skip to CHECK ITEM
6.
INC_WEAPON
INC_WEAPONSP
Q17b. What was the weapon or object they used to attack or
attempt to attack you? Was there any other weapon or object
used? [Mark all that apply]

1  Hand gun (pistol, revolver, etc.)
2  Other gun (rifle, shotgun, etc.)
3  Knife
4  Other sharp object (scissors, ice pick, axe, etc.)
5  Blunt object (rock, club, bat, etc.)
6  Other – Specify _________________

CHECK ITEM 5b: If offender threatened to attack respondent (SQ_THREAT_SELF=1), then skip to Q18a (INC_THREAT_HIT).
Else, skip to CHECK ITEM 6.

Page 10

FORM SVS-1 (1/14/2016)

Q18a. Earlier you indicated that (this person/these people)
threatened to attack you. Did they threaten…
INC_THREAT_HIT
To hit, slap, push, or knock you down?
____________________________________________________
INC_THREAT_CHOKE
To choke or strangle you?
____________________________________________________
INC_THREAT_RAPE
To rape or sexually assault you?
____________________________________________________
INC_THREAT_OBJECT
To harm you with a weapon or other object?
____________________________________________________
INC_THREAT_VEHICLE
To hit, chase, or drag you with a vehicle?
____________________________________________________
INC_THREAT_KILL
To kill you?
____________________________________________________
INC_THREAT_ATTACKOTH
INC_THREAT_ATTACKOTHSP
Or did they threaten you in some other way?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

CHECK ITEM 5c: If respondent answered “Yes” to being threatened with harm with a weapon or other object
(INC_THREAT_OBJECT=1), then skip to Q18b (INC_THREAT_WEAPON). Else, skip to CHECK ITEM 6.
INC_THREAT_WEAPON
INC_THREAT_WEAPONSP
Q18b. What was the weapon or object they threatened to
use? Was there any other weapon or object used? [Mark all
that apply]

1
2
3
4
5
6

Hand gun (pistol, revolver, etc.)
Other gun (rifle, shotgun, etc.)
Knife
Other sharp object (scissors, ice pick, axe, etc.)
Blunt object (rock, club, bat, etc.)
Other – Specify _________________

CHECK ITEM 6: If offender physically attacked or attempted to attack someone close to respondent or a pet
(SQ_ATTACK_OTH=1 or SQ_ATTEMPT_OTH=1) then skip to Q19a. If offender only threatened to attack someone close to
respondent or a pet (SQ_THREAT_OTH=1 and SQ_ATTACK_OTH ne 1 and SQ_ATTEMPT_OTH ne 1), then skip to Q19b
(INC_THREAT_CHILD). Else, skip to Q20 (ASSIST_CALL).

Page 11

FORM SVS-1 (1/14/2016)

Q19a. Earlier you indicated that (this person/these people)
attacked or attempted to attack someone close to you or a
pet. Who did they physically attack or attempt to attack?
INC_ATTACK_CHILD
A child?
____________________________________________________
INC_ATTACK_SPOUSE
A spouse or partner?
____________________________________________________
INC_ ATTACK_SIGNOTH
A boyfriend or girlfriend?
____________________________________________________
INC_ATTACK_ FAMILY
Another family member?
____________________________________________________
INC_ATTACK_FRIEND
A friend or co-worker?
____________________________________________________
INC_ATTACK_PET
A pet or companion animal?
____________________________________________________
INC_ATTACK_OTHPERS
INC_ATTACK_OTHPERSSP
Someone else?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

CHECK ITEM 6a: If offender threatened to attack someone close to respondent or a pet (SQ_THREAT_OTH=1), then skip to
Q19b (INC_THREAT_CHILD). Else, skip to Q20 (ASSIST_CALL).

Page 12

FORM SVS-1 (1/14/2016)

Q19b. Earlier you indicated that (this person/these people)
threatened to physically attack someone close to you or a
pet. Who did they threaten?
INC_THREAT_CHILD
A child?
____________________________________________________
INC_THREAT_SPOUSE
A spouse or partner?
____________________________________________________
INC_ THREAT_SIGNOTH
A boyfriend or girlfriend?
____________________________________________________
INC_THREAT_ FAMILY
Another family member?
____________________________________________________
INC_THREAT_FRIEND
A friend or co-worker?
____________________________________________________
INC_THREAT_PET
A pet or companion animal?
____________________________________________________
INC_THREAT_OFFENDER
Himself/herself (offender)?
____________________________________________________
INC_THREAT_OTH
INC_THREAT_OTHSP
Someone else?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

SECTION IX. HELP-SEEKING
ASSIST_CALL
Q20. During the past 12 months did you or someone else call
or contact the police to report any of the unwanted contacts
or behaviors you experienced?

Page 13

1  Yes [skip to Q22 (ASSIST_YESREPORT)]
2  No [skip to Q21 (ASSIST_NOTREPORT)]

FORM SVS-1 (1/14/2016)

ASSIST_NOTREPORT
ASSIST_NOTREPORTSP
Q21. What was the reason these unwanted contacts or
behaviors were not reported to the police?
[Mark all that apply]
Structured Probe
Was the reason because you dealt with it another way, it
wasn’t important enough to you, police wouldn’t do
anything, police wouldn’t help, you fear the person, or was
there some other reason?

Dealt with it another way
01  Reported to another official (guard, apt. manager,
employer, hospital official, school official, military
official, etc.)
02  Private or personal matter (handled myself or family
member or friend handled it)
03  Told other non-officials (parents, friends, other family
members, etc.)
Not important enough to respondent
04  Too minor, not a police matter, not serious enough
05  Not clear it was a crime
06  Not sure that harm was intended
Police wouldn’t do anything
07  Didn’t think the police would be able to stop behaviors
08  Could not find or identify offender
09  Had no legal authority/wrong jurisdiction
10  Lacked or had incorrect restraining, protection, or nocontact order
11  Not enough evidence/lack of proof
Police wouldn’t help
12  Police wouldn’t believe respondent
13  Police would think it was respondent’s fault
14  Police didn’t think it was important enough, wouldn’t
want to be bothered or get involved
15  Offender was a police officer, justice officer
16  Police would be inefficient, ineffective
17  Had previous negative experience with the police
Feared offender
18  Afraid of reprisal or escalation of behavior by the
offender or others
Other reasons
19  Respondent does not trust or is afraid of police
20  Respondent felt ashamed or embarrassed
21  Didn’t want offender to get in trouble with the law
22  Offender was (ex)spouse or (ex)partner
23  Respondent obtained a restraining, protection, or nocontact order instead
24  Respondent moved away
25  Offender moved away
26  For the sake of the children
27  Unwanted contacts/behaviors stopped
28  Other – Specify __________
29  Don’t know

CHECK ITEM 6b: Skip to Q27 (ASSIST_AGENCYSEEK).

Page 14

FORM SVS-1 (1/14/2016)

ASSIST_YESREPORT
ASSIST_YESREPORTSP
Q22. During the past 12 months, who reported these
unwanted contacts or behaviors to the police? Anyone else?
[Mark all that apply]

ASSIST_ACTION
ASSIST_ACTIONSP
Q23. Taking into account all of the times the police were
contacted in the past 12 months regarding these unwanted
contacts or behaviors, what did the police do? Anything
else? [Mark all that apply]

01  Respondent
02  Respondent’s friend
03  Neighbor
04  Respondent’s family, in-laws, spouse, parents,
children, relatives
05  Respondent’s girl/boyfriend, partner
06  Doctor, nurse
07  Clergy or faith leader
08  Social worker, counselor, other mental health
professional
09  School official, teacher, faculty, or staff
10  Boss, employer, co-worker
11  Stranger, bystander
12  Security guard, security department
13  Police on scene
14  Other – Specify __________
15  Don’t know

01  Took a report
02  Talked to or warned offender
03  Arrested the offender or took the offender into
custody
04  Told respondent to get a restraining, protection, or
no-contact order
05  Referred respondent to a court or prosecutor’s office
06  Referred respondent to services, such as victim
assistance
07  Gave advice on how to protect self
08  Took respondent to another location, such as a
hospital or shelter
09  Asked for more information/evidence
10  Other – Specify __________
11  Don’t know
12  Took no action

CHECK ITEM 7: If the police took no action (ASSIST_ACTION=12), then skip to Q24 (ASSIST_NOACTION). Else, skip to Q25a
(ASSIST_CHARGES).

Page 15

FORM SVS-1 (1/14/2016)

ASSIST_NOACTION
ASSIST_NOACTIONSP
Q24. Why do you think the police took no action? Any other
reason? [Mark all that apply]

ASSIST_CHARGES
Q25a. Were criminal charges filed against the
(person/persons) who committed the unwanted contacts or
behaviors you experienced?
ASSIST_FILED
ASSIST_FILEDSP
ASSIST_FILEDBOTHSP
Q25b. What were the criminal charges filed?

ASSIST_OUTCOME
ASSIST_OUTCOMESP
Q26. What was the final outcome of the criminal charges
filed against the (person/persons) who committed these
unwanted contacts or behaviors? Anything else? [Mark all
that apply.]

ASSIST_AGENCYSEEK
Q27. In the past 12 months, did you seek any help or advice
concerning these unwanted contacts or behaviors from any
office or agency – other than police – that assists victims of
crime?

Page 16

01  Police did not think crime occurred
02  Could not find or identify offender
03  Had no legal authority/wrong jurisdiction
04  Respondent lacked or had incorrect restraining,
protection, or no-contact order
05  Didn’t have evidence/lack of proof
06  Didn’t believe respondent/take respondent seriously
07  Thought it was respondent’s fault
08  Didn’t think it was important enough, didn’t want to be
bothered or get involved
09  Were inefficient, ineffective
10  Offender was a police officer, justice officer
11  Offender was well-connected in the community, was
friend/relative with local authorities
12  Respondent was not old enough to file a report (i.e.
needed a guardian)
13  Other – Specify __________
14  Don’t know

1  Yes [skip to Q25b (ASSIST_FILED)]
2  No [skip to Q27 (ASSIST_AGENCYSEEK)]
3  Don’t know [skip to Q27 (ASSIST_ AGENCYSEEK)]

1  Stalking
2  Something else – Specify ________
3  Both, stalking and something else – Specify ________
4  Don’t know

01  Still pending
02  Dismissed/not guilty
03  Convicted/guilty
04  Plead to lesser charge
05  Fined
06  Court order intervention/counseling program
07  Criminal no-contact order
08  Probation
09  Jailed/imprisoned
10  Other – Specify __________
11  Don’t know

1  Yes [skip to Q28a (ASSIST_AGENCYHELP)]
2  No [skip to Q29 (ACTION_ACTIVITIES)]
3  Don’t know [skip to Q29 (ACTION_ACTIVITIES)]

FORM SVS-1 (1/14/2016)

ASSIST_AGENCYHELP
Q28a. Did you receive any services or assistance from this
or these offices or agencies?

1  Yes [skip to Q28b (ASSIST_HOTLINE)]
2  No [skip to Q28c (ASSIST_AREA)]
3  Don’t know [skip to Q29 (ACTION_ACTIVITIES)]

Q28b. What type of services did you receive?
ASSIST_HOTLINE
Crisis hotline counseling?
____________________________________________________
ASSIST_THERAPY
Counseling or therapy?
____________________________________________________
ASSIST_LEGAL
Legal or court services?
____________________________________________________
ASSIST_ORDER
Assistance getting a restraining, protection, or no-contact
order?
____________________________________________________
ASSIST_COMPENSATE
Federal or state victim compensation?
____________________________________________________
ASSIST_FINANCIAL
Short term or emergency financial assistance?
____________________________________________________
ASSIST_SHELTER
Shelter or safehouse services?
____________________________________________________
ASSIST_SAFETY
Safety planning?
____________________________________________________
ASSIST_RISK
Risk or threat assessment?
____________________________________________________
ASSIST_MEDICAL
Medical advocacy?
____________________________________________________
ASSIST_HELP_OTHER
ASSIST_HELP_OTHERSP
Any other services?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

CHECK ITEM 8: Skip to Q29 (ACTION_ACTIVITIES).

Page 17

FORM SVS-1 (1/14/2016)

Q28c. You reported that you sought services from an office
or agency that assists victims of crime, but did not receive
them. Why did you not receive these services? Was it
because…
ASSIST_AREA
Services were not available in your local area?
____________________________________________________
ASSIST_TRANSPORT
You did not have a means of transportation to and from the
service provider?
____________________________________________________
ASSIST_CHILDCARE
You did not have childcare to go to get services?
____________________________________________________
ASSIST_ACCOMODATE
The service provider could not accommodate you (e.g. no
beds available in shelter)?
____________________________________________________
ASSIST_WORK
You were unable to take time off of work or school to get
services?
____________________________________________________
ASSIST_LANGUAGE
There were language barriers?
____________________________________________________
ASSIST_ELIGIBLE
You were not eligible for services?
____________________________________________________
ASSIST_NOHELP_OTHER
ASSIST_NOHELP_OTHERSP
Some other reason?

Page 18

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify _____________
2  No

FORM SVS-1 (1/14/2016)

SECTION X. SELF-PROTECTIVE ACTIONS
Q29. There are things that people might try to do to protect
themselves or stop unwanted contacts or behaviors from
continuing. In the past 12 months, have you done any of the
following because of the unwanted contacts or behaviors
you experienced. Have you…
ACTION_ACTIVITIES
Changed your day to day activities?
____________________________________________________
ACTION_ACTIVITIESLST
ACTION_ACTIVITIESLSTSP
What day to day activities did you change?

____________________________________________________
ACTION_BLOCKED
[Have you] Blocked unwanted calls, messages, or other
communications?
____________________________________________________
ACTION_SECURITY
[Have you] Taken self-defensive actions or other security
measures?
____________________________________________________
ACTION_SECURITYLST
ACTION_SECURITYLSTSP
What self-defensive actions or security measures did you
take?
____________________________________________________
ACTION_INFO
[Have you] Changed your personal information?
____________________________________________________
ACTION_INFOLST
ACTION_INFOLSTSP
What personal information did you change?

____________________________________________________
ACTION _ORDER
[Have you] Applied for a restraining, protection, or no-contact
order?
____________________________________________________
ACTION _PROTECT
ACTION _PROTECTSP
[Have you] Did you do anything else to protect yourself or
stop the unwanted contacts or behaviors from continuing?

Page 19

1  Yes [skip to ACTION_ACTIVITIESLST]
2  No [skip to ACTION_BLOCKED]
_______________________________________________
1  Take time off from work or school?
2  Change or quit a job or school?
3  Change the way (route or method of transportation)
you went to work or school?
4  Avoid relatives, friends, or holiday celebrations?
5  Change your usual activities outside of work or school?
6  Stay with friends or relatives or had them stay with
you?
7  Move or change where you live?
8  Alter your appearance to be unrecognizable?
9  Other – Specify ___________
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes [skip to ACTION_SECURITYLST]
2  No [skip to ACTION_INFO]
_______________________________________________
1  Take self-defense or martial arts classes?
2  Get pepper spray?
3  Get a gun?
4  Get any other kind of weapon?
5  Change or install new locks or a security system?
6  Other – Specify ___________
_______________________________________________
1  Yes [skip to ACTION_INFOLST]
2  No [skip to ACTION_ORDER]
_______________________________________________
1  Change your social security number or name?
2  Change e-mail address?
3  Shut down or change information on social media
accounts?
4  Change telephone numbers?
5  Get a new phone or computer?
6  Other – Specify ___________
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify ___________
2  No

FORM SVS-1 (1/14/2016)

Q30. Some people might ask others for help in order to
protect themselves or to stop unwanted contacts or
behaviors from continuing. In the past 12 months, did you…
ACTION_ADVICE
Ask for advice or help from friends or family?
____________________________________________________
ACTION_REQUEST
Ask people not to release information about you?
____________________________________________________
ACTION_INVESTIGATE
Hire a private investigator?
____________________________________________________
ACTION_ATTORNEY
Ask for advice or help from an attorney?
____________________________________________________
ACTION_COUNSELOR
Talk to a counselor or therapist?
____________________________________________________
ACTION_DOCTOR
Talk to a doctor or nurse?
____________________________________________________
ACTION_FAITH
Talk to your Clergy or faith leader?
____________________________________________________
ACTION _BOSS
Talk to your boss or employer?
____________________________________________________
ACTION _SCHOOL
Talk to your teacher or school official?
____________________________________________________
ACTION _WORKPLACE
Contact your building or workplace security person?

ACTION_CURRENT
Q31. Are these unwanted contacts or behaviors still going
on?

Page 20

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No

1  Yes [skip to Q33 (ACTION_PEERS)]
2  No [skip to Q32 (ACTION_STOPPED)]
3  Don’t know [skip to Q33 (ACTION_PEERS)]

FORM SVS-1 (1/14/2016)

ACTION_STOPPED
ACTION_STOPPEDSP
ACTION_STOPPEDSP2
Q32. Why do you think these unwanted contacts or
behaviors stopped? Anything else? [Mark all that apply]

Respondent took measures
01  Got a restraining, protection, or no-contact order
02  Moved
03  Changed phone number, e-mail account, or social
media account
04  Got a new phone or computer
05  Talked to the offender
06  Got married or started a new relationship with
someone else
Offender stopped (because he/she…)
07  Was arrested
08  Was incarcerated
09  Started a new relationship with someone else
10  Moved
11  Died
12  Got help/counseling
Others intervened
13  Police intervened
14  Friend or relative intervened
15  Employer intervened
16  School official, faculty, or staff intervened
17  Clergy or faith leader intervened
18  Other – Specify __________
Other reason
19  Don’t know why it stopped
20  Other – Specify __________

SECTION XI. COST TO VICTIM
Unwanted contacts or behaviors may affect people in
different ways. Next I would like to ask you some questions
about how the unwanted contacts or behaviors you
experienced may have affected you.
ACTION_PEERS
Q33. Did experiencing these unwanted contacts or behaviors
lead you to have significant problems with your job or
schoolwork, or trouble with your boss, coworkers, or peers?
ACTION_FIGHTS
Q34. Did experiencing these unwanted contacts or behaviors
lead you to have significant problems with family members
or friends, including getting into more arguments or fights
than you did before, not feeling you could trust them as
much, or not feeling as close to them as you did before?
ACTION_DISTRESSING
Q35. How distressing were these unwanted contacts or
behaviors to you? Were they not at all distressing, mildly
distressing, moderately distressing, or severely distressing?

Page 21

1  Yes
2  No
3  N/A, does not attend school or does not have a job

1  Yes
2  No

1
2
3
4

Not at all distressing
Mildly distressing
Moderately distressing
Severely distressing

FORM SVS-1 (1/14/2016)

Q36a. Considering all of these unwanted contacts or
behaviors that have occurred over the past year, did you
feel…
ACTION_FEARFUL
Fearful or terrified?
____________________________________________________
ACTION_WORRIED
Worried or anxious?
____________________________________________________
ACTION_ANGRY
Angry or annoyed?
____________________________________________________
ACTION_SAD
Sad or depressed?
____________________________________________________
ACTION_HELPLESS
Vulnerable or helpless?
____________________________________________________
ACTION_TRUST
Like you couldn’t trust people?
____________________________________________________
ACTION_SICK
Sick?
____________________________________________________
ACTION_STRESSED
Stressed?
____________________________________________________
ACTION_UNSAFE
Unsafe?
____________________________________________________
ACTION_SUICIDAL
Suicidal?
____________________________________________________
ACTION_FEELOTHER
Or did you feel some other way?

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No

CHECK ITEM 9: If respondent reported feeling some other way at Q36a (ACTION_FEELOTHER=1), then skip to Q36b
(ACTION_FEELOTHERSP). Else, skip to Q37 (ACTION_KILLED).
ACTION_FEELOTHERSP
Q36b. What other way did these unwanted contacts or
behaviors make you feel?

Page 22

Specify ____________________________

FORM SVS-1 (1/14/2016)

Q37. What were you afraid of happening as these unwanted
contacts or behaviors were occurring? Were you afraid of…
ACTION_KILLED
Being killed?
____________________________________________________
ACTION_SELFHARM
Physical or bodily harm?
____________________________________________________
ACTION_OTHHARM
Someone close to you being harmed?
____________________________________________________
ACTION_JOB
Losing your job or job opportunities?
____________________________________________________
ACTION_FREEDOM
Losing your freedom?
____________________________________________________
ACTION_SOCIAL
Losing your social network, peers, or friends?
____________________________________________________
ACTION_FOREVER
The behaviors never stopping?
____________________________________________________
ACTION_UNSURE
Not knowing what might happen next?
____________________________________________________
ACTION_MENTAL
Losing your mind?
____________________________________________________
ACTION_AFRAIDOTHER
ACTION_AFRAIDOTHERSP
Anything else?

ACTION_FIRED
Q38. During the past 12 months, have you been fired from or
asked to leave a job because of these unwanted contacts or
behaviors?
ACTION_INSURANCE
Q39. During the past 12 months, did you lose any pay that
was not covered by unemployment insurance, paid leave, or
some other source because of these unwanted contacts or
behaviors?

Page 23

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify __________
2  No

1  Yes
2  No
3  N/A, does not have a job

1  Yes
2  No
3  N/A, does not have a job

FORM SVS-1 (1/14/2016)

ACTION_SUSPENDED
Q40. During the past 12 months, have you been suspended
or expelled from school because of these unwanted contacts
or behaviors?

1  Yes
2  No
3  N/A, does not attend school

Q41. Did you lose any time from work or school because of
these unwanted contacts or behaviors for such things as…
ACTION_TIMEFEAR
Fear or concern for your safety?
____________________________________________________
ACTION_TIMEPOLICE
Police-related activities?
____________________________________________________
ACTION_TIMECOURT
Court-related activities (i.e. getting a restraining/protection
order or testifying)?
____________________________________________________
ACTION_TIMEPHONE
Changing your phone number or personal information?
____________________________________________________
ACTION_TIMEMOVE
Moving?
____________________________________________________
ACTION_TIMEPROPERTY
Fixing or replacing damaged property?
____________________________________________________
ACTION_TIMEOTHER
ACTION_TIMEOTHERSP
Anything else?

Page 24

1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes
2  No
_______________________________________________
1  Yes – Specify __________
2  No

FORM SVS-1 (1/14/2016)