How often does anyone, including family, physically hurt you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
How often does anyone, including family, insult or talk down to you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
How often does anyone, including family, threaten you with harm?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
How often does anyone, including family, scream or curse
at you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.
How often does anyone, including family and friends, physically hurt you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
How often does anyone, including family and friends, insult or talk down to you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
How often does anyone, including family and friends, threaten you with harm?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
How often does anyone, including family and friends, scream or curse at you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
A score of 11 or more when the numerical values for answers to [the four questions] are added shows that the person might not be safe.
In the last 12 months, have you been hit, slapped, kicked or otherwise physically hurt by someone?
Yes/ No
Within the past 12 months, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
Yes/ No
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
Within the last year, have you been afraid of your partner or ex-partner?
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or expartner?
Please indicate which of the following describe a problem(s) with your personal and family stability. You may select none or more than one answer.
Are you afraid of someone you love?
Do you have guardianship or custody issues?
Are you concerned about the welfare of one of your children or a child that you live with?
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
Within the last year, have you been afraid of your partner or ex-partner?
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?
Do you feel physically or emotionally unsafe where you currently live?
Yes/ No
Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by anyone?
Yes/ No
Within the past 12 months, have you been humiliated or emotionally abused by anyone?
Yes/ No
In the past year, have you been afraid of your partner or ex-partner?
Is anyone trying to hurt you?
Do you feel unsafe in your daily life?
Is anyone in your home threatening or abusing you?
Optional: In the past 12 months, have you been physically or emotionally hurt or felt threatened by a current or former spouse/partner, a caregiver, or someone else you know?
Yes [Follow-up: Current spouse/partner; Former spouse/partner; Caregiver; Someone else]
No
Optional: Has a spouse/partner, family member or friend ever been financially abusive towards you? That is, stolen money from you, not paid back a loan, etc.?
Yes
No
University of San Francisco California