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Domestic violence
Thank you for participating in this survey. This survey is focused on violent behavior among intimate partners. We know your time is precious and we really appreciate your help. It should only take you 10-12 minutes to fill out this form. All of the information you fill out is confidential and anonymous. Your identity will not be revealed and the information you provide is going to contribute to scientific research.
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1.
Are you a
Woman
Man
2.
How old are you?
Votre réponse
3.
Do you have a partner?
Yes
No
4.
How long have you been together with your partner?
Votre réponse
5.
Are you married?
Yes
No
6.
Do you have children?
Yes
No
7.
Is your partner:
A woman
A man
8.
For women: Are you pregnant?
Yes
No
I do not know
9.
For men: Is your partner pregnant?
Yes
No
I do not know
10.
How many children do you have?
Votre réponse
11.
What is your education level?
Votre réponse
12.
What is your occupation? (e.g.student, house wife, maternity leave, retired, employed, .....)
Votre réponse
How often have you been subjected to the following things by your partner when he/she has been angry with you? Answer the questions by marking the alternative that comes closest to your own opinion.
0 = Never
1 = Almost never
2 = Seldom
3 = Sometimes
4 = Often
1-
Hit me
0
1
2
3
4
Effacer la sélection
2-
Locked me in
0
1
2
3
4
Effacer la sélection
3-
Locked me out
0
1
2
3
4
Effacer la sélection
4-
Shoved me
0
1
2
3
4
Effacer la sélection
5-
Bitten me
0
1
2
3
4
Effacer la sélection
6-
Scratched me
0
1
2
3
4
Effacer la sélection
7-
Spit at me
0
1
2
3
4
Effacer la sélection
8-
Thrown objects
0
1
2
3
4
Effacer la sélection
9-
Damaged something that was mine
0
1
2
3
4
Effacer la sélection
10-
Threatened to hurt me
0
1
2
3
4
Effacer la sélection
11-
Yelled at me
0
1
2
3
4
Effacer la sélection
12-
Quarreled with me
0
1
2
3
4
Effacer la sélection
13-
Purposely said nasty or hurting things to me
0
1
2
3
4
Effacer la sélection
14-
Called me bad names
0
1
2
3
4
Effacer la sélection
15-
Interrupted me when I was talking
0
1
2
3
4
Effacer la sélection
16-
Angrily nagged at me
0
1
2
3
4
Effacer la sélection
17-
Threatened to leave me
0
1
2
3
4
Effacer la sélection
18-
Purposely provoked a quarrel with me
0
1
2
3
4
Effacer la sélection
19-
Omitted doing things thta he/she usually does for both of us(e.g. household work), or done them less well
0
1
2
3
4
Effacer la sélection
20-
Been ironic towards me
0
1
2
3
4
Effacer la sélection
21-
Been contemptuous towards me
0
1
2
3
4
Effacer la sélection
22-
Spoken badly about me to someone else
0
1
2
3
4
Effacer la sélection
23-
Tried to influence someone (such as children, relatives) to dislike me
0
1
2
3
4
Effacer la sélection
24-
Ridiculed me in my absence
0
1
2
3
4
Effacer la sélection
25-
Tried to exclude me from social situations
0
1
2
3
4
Effacer la sélection
26-
Tried to make me feel guilty
0
1
2
3
4
Effacer la sélection
27-
Refused to talk to me
0
1
2
3
4
Effacer la sélection
28-
Refused to look at me
0
1
2
3
4
Effacer la sélection
29-
Refused to touch me
0
1
2
3
4
Effacer la sélection
30-
Put on a sulky face
0
1
2
3
4
Effacer la sélection
31-
Slammed doors
0
1
2
3
4
Effacer la sélection
32-
Refused to sleep in the same bed as me
0
1
2
3
4
Effacer la sélection
33-
Left the room in a demonstrative manner when I came in
0
1
2
3
4
Effacer la sélection
34-
Made nasty faces or gestures behind my back
0
1
2
3
4
Effacer la sélection
35-
Written angry text messages to me
0
1
2
3
4
Effacer la sélection
36-
written angry e-mails to me
0
1
2
3
4
Effacer la sélection
37-
Written nasty text messages about me to somebody else
0
1
2
3
4
Effacer la sélection
38-
Written nasty e-mails about me to someone else
0
1
2
3
4
Effacer la sélection
39-
Forced me to have sex when he/she was angry with me
0
1
2
3
4
Effacer la sélection
40-
Refused to have sex with me because he/she was angry with me
0
1
2
3
4
Effacer la sélection
41-
Been openly flirting with someone in order to anger me
0
1
2
3
4
Effacer la sélection
42-
Not let me know details about our household economy
0
1
2
3
4
Effacer la sélection
43-
Not allowed me to use money that belongs to both of us
0
1
2
3
4
Effacer la sélection
44- ( Please answer this question only if you have a pet otherwise skip it)
Hurt our pet in order to upset me
0
1
2
3
4
Effacer la sélection
45-
Hurt him/herself in order to upset me
0
1
2
3
4
Effacer la sélection
How often have you yourself done any of the following things towards your partner when you have been angry with him/her?
0 = Never
1 = Almost never
2 = seldom
3 = Sometimes
4 = Often
When I have been angry with my partner I have:
1-
Hit him/her
0
1
2
3
4
Effacer la sélection
2-
Locked him/her in
0
1
2
3
4
Effacer la sélection
3-
Locked him/her out
0
1
2
3
4
Effacer la sélection
4-
Shoved him/her
0
1
2
3
4
Effacer la sélection
5-
Bitten him/her
0
1
2
3
4
Effacer la sélection
6-
Scratched him/her
0
1
2
3
4
Effacer la sélection
7-
Spit at him/her
0
1
2
3
4
Effacer la sélection
8-
Thrown objects
0
1
2
3
4
Effacer la sélection
9-
Damaged something that was his/hers
0
1
2
3
4
Effacer la sélection
10-
Threatened to hurt him/her
0
1
2
3
4
Effacer la sélection
11-
Yelled at him/her
0
1
2
3
4
Effacer la sélection
12-
Quarreled with him/her
0
1
2
3
4
Effacer la sélection
13-
Purposely said nasty or hurting things to him/her
0
1
2
3
4
Effacer la sélection
14-
Called him/her bad names
0
1
2
3
4
Effacer la sélection
15-
Interrupted him/her when he/she was talking
0
1
2
3
4
Effacer la sélection
16-
Angrily nagged at him/her
0
1
2
3
4
Effacer la sélection
17-
Threatened to leave him/her
0
1
2
3
4
Effacer la sélection
18-
Purposely provoked a quarrel with him/her
0
1
2
3
4
Effacer la sélection
19-
Omitted doing things that I usually do for both of us (e.g. household work), or done them less well
0
1
2
3
4
Effacer la sélection
20-
Been ironic towards him/her
0
1
2
3
4
Effacer la sélection
21-
Been contemptuous towards him/her
0
1
2
3
4
Effacer la sélection
22-
Spoken badly about him/her to someone else
0
1
2
3
4
Effacer la sélection
23-
Tried to influence someone (such as children, relatives) to dislike him/her
0
1
2
3
4
Effacer la sélection
24-
Ridiculed him/her in his/her absence
0
1
2
3
4
Effacer la sélection
25-
Tried to exclude him/her from social situations
0
1
2
3
4
Effacer la sélection
26-
Tried to make him/her feel guilty
0
1
2
3
4
Effacer la sélection
27-
Refused to talk to him/her
0
1
2
3
4
Effacer la sélection
28-
Refused to look at him/her
0
1
2
3
4
Effacer la sélection
29-
Refused to touch him/her
0
1
2
3
4
Effacer la sélection
30-
Put on a sulky face
0
1
2
3
4
Effacer la sélection
31-
Slammed doors
0
1
2
3
4
Effacer la sélection
32-
Refused to sleep in the same bed as him/her
0
1
2
3
4
Effacer la sélection
33-
Left the room in a demonstrative manner when he/she came in
0
1
2
3
4
Effacer la sélection
34-
Made nasty faces or gestures behind his/her back
0
1
2
3
4
Effacer la sélection
35-
Written angry text messages to him/her
0
1
2
3
4
Effacer la sélection
36-
Written angry e-mails to him/her
0
1
2
3
4
Effacer la sélection
37-
Written nasty text messages about him/her to somebody else
0
1
2
3
4
Effacer la sélection
38-
Written nasty e-mails about him/her to someone else
0
1
2
3
4
Effacer la sélection
39-
Forced him/her to have sex when I was angry with him/her
0
1
2
3
4
Effacer la sélection
40-
Refused to have sex with him/her because I was angry with him/her
0
1
2
3
4
Effacer la sélection
41-
Been openly flirting with someone in order to anger him/her
0
1
2
3
4
Effacer la sélection
42-
Not let him/her know details about our household economy
0
1
2
3
4
Effacer la sélection
43-
Not allowed him/her to use money that belongs to both of us
0
1
2
3
4
Effacer la sélection
44- (Please answer this question only if you have a pet, otherise skip it)
Hurt our pet in order to upset him/her
0
1
2
3
4
Effacer la sélection
45-
Hurt myself in order to upset him/her
0
1
2
3
4
Effacer la sélection
Section II : Physical punishment scale
1- When you were a child , did an adult subject you to any of the following things? Choose the alternative that comes closest to your experience.
0 = Never
1 = Seldom
2 = Sometimes
3 = Often
4= Very often
a)
Pulled your hair
Never
0
1
2
3
4
Very often
Effacer la sélection
b)
Pulled your ear
Never
0
1
2
3
4
Very often
Effacer la sélection
c)
Slapped you with the hand
Never
0
1
2
3
4
Very often
Effacer la sélection
d)
Hit you with an object
Never
0
1
2
3
4
Very often
Effacer la sélection
2- Answer this if you have children. Do you yourself do any of the following things to your child/children? Choose the alternative that comes closest to your experience.
a)
I pull his/her hair
Never
0
1
2
3
4
Very often
Effacer la sélection
b)
I pull his/her ear
Never
0
1
2
3
4
Very often
Effacer la sélection
c)
I slap him/her with the hand
Never
0
1
2
3
4
Very often
Effacer la sélection
d)
I hit him/her with an object
Never
0
1
2
3
4
Very often
Effacer la sélection
3-
When you were a child, did an older sister or brother subject you to any of the following things? Choose the alternative that comes closest to your experience.
a)
Pulled your hair
Never
0
1
2
3
4
Very often
Effacer la sélection
b)
Pulled your ear
Never
0
1
2
3
4
Very often
Effacer la sélection
c)
Slapped you with hand
Never
0
1
2
3
4
Very often
Effacer la sélection
d)
Hit you with an object
Never
0
1
2
3
4
Very often
Effacer la sélection
4-
When you were a child, did you witness your mother being physically abused by her partner (boyfriend/husband)? Choose the alternative that comes closest to your experience.
a)
Shoved her
Never
0
1
2
3
4
Very often
Effacer la sélection
b)
Shook her
Never
0
1
2
3
4
Very often
Effacer la sélection
c)
Hit her with hand
Never
0
1
2
3
4
Very often
Effacer la sélection
d)
Hit her with an object
Never
0
1
2
3
4
Very often
Effacer la sélection
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