Since you turned 18, how often has a romantic partner or spouse ever:
1. Slapped, hit, beat, kicked, or physically hurt you?
- Never
- Once
- More than once
2. Screamed at you or threatened you with harm?
- Never
- Once
- More than once
3. How often has anyone forced you to have sexual activities?
- Never
- Once
- More than once
If once or more than once, who? Please choose all that apply.
- Partner or spouse
- Relative
- Someone else you knew
- Stranger
The following questions refer to the time since you turned 18.
4. Have you ever been the victim of a violent crime like a robbery or assault? (This refers to any violent act by someone other than a spouse, partner, or household family member)
- Yes
- No
If yes, how many times?
5. Have you ever been the victim of a non-violent crime such as theft?
- Yes
- No
If yes, how many times?
6. Have you been in prison or jail?
- Yes
- No
7. Has a spouse, partner, or someone you have lived with been in prison or jail?
- Yes
- No
8. Has a spouse, partner, or someone you have lived with been a problem drinker or alcoholic?
- Yes
- No
9. Has a spouse, partner, or someone you have lived with used illegal street drugs or abused prescription medications?
- Yes
- No
10. Has a spouse, partner, or someone you have lived with been depressed, mentally ill, or suicidal?
- Yes
- No
11. Have you ever been divorced or separated?
- Yes,
- No, I’m married
- No, I’ve never been married
- No, my spouse is deceased
12. Have you experienced the loss of a pregnancy?
- Yes
- No
If yes, how many times?
13. Have you experienced the death of someone very close to you?
- Yes
- No
If yes, please choose all that apply.
- Partner or spouse
- Other relative
- Child
- Friend
- Parent
- Other
Since you turned 18 years of age:
14. How often have you experienced serious financial problems?
- Never
- Rarely
- Sometimes
- Often
- Very often
15. How often do you feel that you have been discriminated against?
- Never
- Rarely
- Sometimes
- Often
- Very often
16. How often have you and your family been hungry because you could not afford food?
- Never
- Rarely
- Sometimes
- Often
- Very often
17. How often have you been homeless*?
- Never
- Rarely
- Sometimes
- Often
- Very often
*“Homeless” means having to stay somewhere like a transitional housing program, a shelter, a hotel/motel paid by voucher, someone else’s home, a car or other vehicle, an abandoned building, anywhere outside, or anywhere else not meant for people to live.
18. Overall, how uncomfortable did you feel answering the questions on this survey?
- Not at all
- Slightly
- Moderately
- Very
- Extremely
For further information about this measure, contact: Dr. Joshua Mersky, University of Wisconsin-Milwaukee, mersky@uwm.edu