1.1: IPV Screener 1

Instrument 1.1

IPV Screener 1

Instrument 1

Staff Member Name: ____________________________

Case ID: ____________________________

Date: _____________________________

IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 1^st: Thank you again for being willing to participate. I’ll be asking you an initial set of questions today, which will take about 10 minutes, and then two more sets of questions sometime in the next two months. As we discussed, we will do our best to keep all of the answers to these questions private.

IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 2^nd: As part of the research study you are participating in with [PROGRAM NAME] and RTI, we’d like to ask you the next set of questions about your romantic relationships, including any experiences with unhealthy relationship behaviors and violence. The questions will take about 10 minutes. You do not have to be in a relationship to answer them, participation is voluntary, and we will do our best to keep all of the answers to these questions private. If you choose to answer them today, you will receive a $10 gift card as a token of appreciation.

IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 3^rd: As part of the research study you are participating in with [PROGRAM NAME] and RTI, we’d like to ask you one final set of questions about your romantic relationships, including any experiences with unhealthy relationship behaviors and violence. The questions will take about 10 minutes. You do not have to be in a relationship to answer them, participation is voluntary, and we will do our best to keep all of the answers to these questions private. If you choose to answer them today, you will receive a $10 gift card as a token of appreciation.First, I will ask you some questions and you can just answer yes or no.

	Answer
	No	Yes
1. Have you been in a relationship with a partner in the past year?		
2. If yes, within the past year has a partner:		
(a) Slapped, kicked, pushed, choked, or punched you?		
(b) Forced or coerced you to have sex?		
(c) Threatened you with a knife or gun to scare or hurt you?		
(d) Made you afraid that you could be physically hurt?		
(e) Repeatedly used words, yelled, screamed in a way that frightened you, or threatened you, put you down, or made you feel rejected?		

Next are a number of statements that people have used to describe their relationships with their partners. I will read each statement and ask you to give the answer that best describes how much you agree or disagree in general with each one as a description of your relationship with your partner. If you do not now have a partner, think about your last one. There are no right or wrong answers; just choose the answer that seems to best describe how much you agree or disagree with it.

	Agree Strongly	Agree Some-what	Agree a Little	Disagree a Little	Disagree Some-what	Disagree Strongly
3. S/he makes me feel unsafe even in my own home.	1	2	3	4	5	6
4. I feel ashamed of the things s/he does to me.	1	2	3	4	5	6
5. I try not to rock the boat because I am afraid of what s/he might do.	1	2	3	4	5	6
6. I feel like I am programmed to react a certain way to him/her.	1	2	3	4	5	6
7. I feel like s/he keeps me prisoner.	1	2	3	4	5	6
8. S/he makes me feel like I have no control over my life, no power, no protection.	1	2	3	4	5	6
9. I hide the truth from others because I am afraid not to.	1	2	3	4	5	6
10. I feel owned and controlled by him/her.	1	2	3	4	5	6
11. S/he can scare me without laying a hand on me.	1	2	3	4	5	6
12. S/he has a look that goes straight through me and terrifies me.	1	2	3	4	5	6

The Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 10 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: XXX ATTN: XXX (xxxx--xxxx). Do not return the completed form to this address.

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