Instrument 2.1
TDV Screener 1
Instrument 1
Case ID: ____________________________
Date: _____________________________
IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 1st: Thank you again for being willing to participate. Here is the first set of questions, which will take about 10 minutes. There will be 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 2nd: We have some more questions for you as part of the research study you are taking part in with [PROGRAM NAME] and RTI. The questions are about romantic relationships, including unhealthy relationship behaviors and violence. They will take about 10 minutes. You do not have to be in a relationship to answer the questions. It is your choice whether to answer them. If you choose to, you will receive a $10 gift card as a token of appreciation. We will do our best to keep all of your answers private.
IF INSTRUMENT 1 IS RANDOMIZED TO BE ADMINISTERED 3rd: We have one last set of questions for you as part of the research study you are taking part in with [PROGRAM NAME] and RTI. The questions are about romantic relationships, including unhealthy relationship behaviors and violence. They will take about 10 minutes. You do not have to be in a relationship to answer the questions. It is your choice whether to answer them. If you choose to, you will receive a $10 gift card as a token of appreciation. We will do our best to keep all of your answers private.
These questions ask about things that may have happened between you and any romantic partner in the past year. Partners can include anyone you have casually dated or gone out with, someone you hooked up with, someone you have been in a committed relationship with, or a boyfriend or girlfriend. They can include current or former partners.
How many times in the past year has any romantic partner done the following things to you? Only count it if they did it to you first. Don’t count it if they did it to you in self-defense.
|
|
10 or more times |
4 to 9 times |
1 to 3 times |
Never |
1. |
Scratched me |
3 |
2 |
1 |
0 |
2. |
Slapped me |
3 |
2 |
1 |
0 |
3. |
Physically twisted my arm |
3 |
2 |
1 |
0 |
4. |
Slammed me or held me against a wall |
3 |
2 |
1 |
0 |
5. |
Kicked me |
3 |
2 |
1 |
0 |
6. |
Bent my fingers |
3 |
2 |
1 |
0 |
7. |
Bit me |
3 |
2 |
1 |
0 |
8. |
Tried to choke me |
3 |
2 |
1 |
0 |
9. |
Pushed, grabbed, or shoved me |
3 |
2 |
1 |
0 |
10. |
Dumped me out of a car |
3 |
2 |
1 |
0 |
11. |
Threw something at me that hit me |
3 |
2 |
1 |
0 |
12. |
Burned me |
3 |
2 |
1 |
0 |
13. |
Hit me with a fist |
3 |
2 |
1 |
0 |
14. |
Hit me with something hard besides a fist |
3 |
2 |
1 |
0 |
15. |
Beat me up |
3 |
2 |
1 |
0 |
16. |
Assaulted me with a knife or gun |
3 |
2 |
1 |
0 |
How many times in the past year has any romantic partner done the following things to you?
|
|
Very Often |
Sometimes |
Seldom |
Never |
1. |
Damaged something that belonged to me |
3 |
2 |
1 |
0 |
2. |
Said things to hurt my feelings on purpose |
3 |
2 |
1 |
0 |
3. |
Insulted me in front of others |
3 |
2 |
1 |
0 |
4. |
Threw something at me but missed |
3 |
2 |
1 |
0 |
5. |
Would not let me do things with other people |
3 |
2 |
1 |
0 |
6. |
Threatened to start dating someone else |
3 |
2 |
1 |
0 |
7. |
Looked at my private communications with others (such as text messages or private Facebook messages)…………………………… |
3 |
2 |
1 |
0 |
8. |
Tried to control my online communications (such as Instagram or Facebook posts, text messages, or private Facebook messages)….. |
3 |
2 |
1 |
0 |
9. |
Told me I could not talk to someone of the opposite sex |
3 |
2 |
1 |
0 |
10. |
Started to hit me but stopped |
3 |
2 |
1 |
0 |
11. |
Did something just to make me jealous |
3 |
2 |
1 |
0 |
12. |
Blamed me for bad things they did |
3 |
2 |
1 |
0 |
13. |
Threatened to hurt me |
3 |
2 |
1 |
0 |
14. |
Made me describe where I was every minute of the day |
3 |
2 |
1 |
0 |
15. |
Brought
up something from the past to |
3 |
2 |
1 |
0 |
16. |
Put down my looks |
3 |
2 |
1 |
0 |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Hall, Terry |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |