1. Have you been troubled or injured by any kind of abuse or violence (e.g.‚ hit by partner‚ forced sex)?
Yes _____ No _____ Not sure ______ Refused ______
If yes‚ check one:
By someone in your family ______
By an acquaintance or stranger ______
2. If yes‚ has something like this ever happened before?
Yes _____ No _____ If yes‚ when? ___________
3. Do you have anyone you can turn to or rely on now to protect you from possiblefurther injury?
Yes _____ No _____ If yes‚ who? ____________
4. Do you feel so badly now that you have thought of hurting yourself/suicide?
Yes _____ No _____
If yes‚ what have you thought about doing?
5. Are you so angry about what’s happened that you have considered hurting someone else?
Yes _____ No _____
If yes‚ describe briefly: _____________________________
1 = No experience of physical violence or abuse.
2 = Experience of abuse/violence with minor physical and/or emotional trauma (e.g.‚ verbal arguments that occasionally escalate to pushing and shoving or mild slapping.History may include past victimization that is no longer problematic.)
3 = Experience of abuse/violence with moderate physical and/or emotional trauma (e.g.‚ abused several times a month in recent years resulting in moderate trauma oremotional distress. No threat to life‚ no weapons available. History may include pastvictimization that is still somewhat problematic.)
4 = Experience of abuse/violence with severe physical and/or emotional trauma (e.g.‚ violently attacked or physically abused in recent years‚ resulting in physical injuryrequiring medical treatment. Threats to kill‚ no guns available. History may includeserious victimization requiring medical and/or physical treatment.)
5 = Life-threatening or prolonged abuse/violence with very severe physical and/or emotional trauma (e.g.‚ recent or current life-threatening physical abuse‚ potentially lethal assault or threats with available deadly weapons. History may include severe abuse requiring medical treatment‚ frequent or ongoing sexual abuse‚ recent rape‚ other physical attack requiring extensive medical treatment.)
This instrument can be found at: http://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf