Survey on Determining Domestic Violence and Women Abuse among the Employees and Clients of CSU
This survey is intended for female employees, female students and female members of extension groups of Cagayan State University, who are and were in a relationship with a spouse, boyfriend, live-in partner or significant other. It aims to determine the occurrence of women abuse and domestic violence in the CSU community and its areas of concern.
1. What is your name (optional)?
2. How old are you? *
3. What is your birthdate? (e.g. January 01, 1992) *
4. What is your civil status? *
5. Where do you live? (e.g. Caritan Norte, Tuguegarao City) *
6. What is your monthly income? *
7. What is your educational attainment? *
8. Which organization of CSU do you belong to? *
If CSU Student, what is your course and year? (e.g. BSIT, Second Year) If this question is not applicable to you, kindly answer "N/A" *
If CSU Employee, what is your status of employment and position or rank? (e.g. Permanent, Associate Professor II) If this question is not applicable to you, kindly answer "N/A" *
If CSU External Client, which women's organizations or extension groups do you belong to? (If this question is not applicable to you, kindly answer "N/A") *
9. What is your occupation? (for external clients only, member or women's organizations or extension groups) If this question is not applicable to you, kindly answer "N/A" *
If none, are you self employed? (If this question isn't applicable to you, kindly choose the "N/A" option) *
If Yes, what business do you own or run? (if this question is not applicable to you, kindly answer "N/A") *
If No, what is your source of income? (if this question is not applicable to you, kindly answer "N/A") *
10. In general how would you describe your relationship with your partner? *
11. Do you and your partner work out arguments? *
12. Do arguments ever result in you feeling put down or bad about yourself? *
13. Do arguments do ever result in hitting, kicking or pushing? *
14. Do you ever feel frightened by what your partner says or does? *
15. Has your partner ever abused you physically? *
16. Has your partner ever abused you emotionally? *
17. Has your partner ever abused you sexually? *
18. Have you ever been threatened, hit, punched, slapped, or injured by a husband, boyfriend o significant other you had at any point in the past? *
19. Have you ever been hurt or frightened so badly by a husband, boyfriend, or significant other that you were in fear for your life? *
20. Have you been hit, punched, slapped, or injured by husband, boyfriend, or significant other within last month? *
21. Are you currently involved in a close relationship with a husband, boyfriend, or significant other? *
22. Have you received injuries from your husband, boyfriend, or significant other? *
23. Do you often feel stressed due to fear of threats of violent behavior from your current husband, boyfriend, or significant other? *
24. Has your current husband, boyfriend, or significant other ever hit, slapped, punched or injured you? *
25. Do you think it is likely that your husband, boyfriend, or significant other will hit, slap, punch, kick, or otherwise hurt you in the future? *
26. Do you think you will be safe if you go back home to your husband, boyfriend, or significant other at this time? *
Direction: Kindly rate the following items by ticking the choices that best suits your answer.
1-Strongly Disagree 2-Somewhat Disagree 3-Little Disagree
4-Little Agree 5-Somewhat Agree 6-Strongly Agree
Clear selection
1. He makes me feel unsafe even in my own home. *
2. I feel ashamed of the things he does to me. *
3. I try not to rock the boat because I am afraid of what he might do. *
4. I feel like I am programmed to react a certain way to him. *
5. I feel like he keeps me prisoner. *
6. He makes me feel like I have no control over my life, no power, no protection. *
7. I hide the truth from other because I am afraid not to. *
8. I feel owned and controlled by him. *
9. He can scare me without laying a hand on me. *
10. He has a look that goes straight through me and terrifies me. *
Direction: Kindly rate the following items by ticking the choices that best suits your answer.
1-None of the above 2-Very rarely 3-A little of the time 4-Some of the time
5-A good part of the time 6-Most of the time 7-All of the time
Clear selection
1. My partner pushes and shoves me around violently. *
2. My partner hits and punches my arms and body. *
3. My partner threatens me with a weapon like a gun or a knife. *
4. My partner beats me so hard I must seek medical help. *
5. My partner beats me me when we drink. *
6. My partner hits, punches, or kicks my face and head. *
7. My partner beats me in the face so badly that I’m ashamed to be seen in public. *
8. My partner try to choke, strangle or suffocate me. *
9. My partner knocks me down and kicks or stomps me. *
10. My partner throws dangerous objects at me. *
11. My partner injured me with a weapon like a gun, knife or other object. *
12. My partner has broken one or more of my bones *
13. My partner physically forces me to have sex. *
14. My partner badly hurts me while we are having sex. *
15. My partner injures my breast or genitals. *
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