9/22/06

Draft Survey

Domestic Violence

Circle the answer that applies to you.

  1. Age: 18-20 21-25 26-30 31-35 35-older
  1. Relationship Status: Single Married Divorced Live Together Long Term Dating
  1. Have you ever been hit/kicked/pushed/etc. by a male? Yes No
  1. How often? 0 1-2 times per month, 3-4 times per month, or more
  1. Have you ever been emotionally abused by a male?
  1. How often? 0 1-2 times per month, 3-4 times per month or more
  1. Have you ever been yelled at/cussed at/talked to inappropriately by a male?
  1. How often? 0, 1-2 times per month, 3-4 times per month, or more
  1. When I’m abused I feel that it is my fault.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

  1. When I’m abused I’m afraid to fight back

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

  1. When I’m abused I’m afraid to fight back because I think my significant other will leave me.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

  1. When I’m abused I’m afraid to fight back because I think my significant other will cut me off financially.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree Not abused

  1. When I’m abused I’m afraid to fight back because I think my significant other will take my children from me.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree Not abused

  1. Women abuse men as well.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

15. Have you ever called the police when you were being abused? Yes No

  1. If not, why? ______

17. Men have more control in my relationships.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

Generally, who has more control in your relationships?

The man it is usually equal me

  1. When I’m abused, my significant other is under the influence of alcohol or drugs.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree Not abused

  1. My significant other is a very jealous person.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

  1. I know that there are domestic violence shelters for women.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

  1. I would like to have counseling after getting out of a violent relationship.

5-strongly agree 4-agree 3-neutral 2- disagree 1-strongly disagree

This is an interesting & very important questionnaire. I would like to see you go beyond simply surveying to find out how much abuse there is. Can you add on another dimension, or possibly expand some of the things you merely touch on: importance of finances? Do women “select” abusers? How do they get out? Why do they stay? Any of these or more, would be good, but as it is, your survey is mostly about cataloging the amount of abuse & it would actually add something to the discussion /solution if you could go beyond that.

GRADE: 100