2.2: TDV Screener 2

Instrument 2.2

TDV Screener 2

Instrument 2

Case ID: ____________________________

Date: _____________________________

Is this your…

1^st session?

2^nd session?

3^rd session?

IF INSTRUMENT 2 IS RANDOMIZED TO BE ADMINISTERED 1^st: Thank you again for being willing to participate. Here is the first set of questions, which will take about 10 minutes. There will be two more sets of questions sometime in the next two months. As we discussed, we will do our best to keep all of the answers to these questions private.

IF INSTRUMENT 2 IS RANDOMIZED TO BE ADMINISTERED 2^nd: We have some more questions for you as part of the research study you are taking part in with [PROGRAM NAME] and RTI. The questions are about romantic relationships, including unhealthy relationship behaviors and violence. They will take about 10 minutes. You do not have to be in a relationship to answer the questions. It is your choice whether to answer them. If you choose to, you will receive a $5 gift card as a token of appreciation. We will do our best to keep all of your answers private.

IF INSTRUMENT 2 IS RANDOMIZED TO BE ADMINISTERED 3^rd: We have one last set of questions for you as part of the research study you are taking part in with [PROGRAM NAME] and RTI. The questions are about romantic relationships, including unhealthy relationship behaviors and violence. They will take about 10 minutes. You do not have to be in a relationship to answer the questions. It is your choice whether to answer them. If you choose to, you will receive a $5 gift card as a token of appreciation. We will do our best to keep all of your answers private.

The following questions ask you about things that may have happened to you with a romantic partner, including anyone you have casually dated or gone out with, someone you hooked up with, someone you have been in a committed relationship with, or a boyfriend or girlfriend. When answering these questions, please choose the answer that is your best estimate of how often these things have happened with a current or ex romantic partner in the last 12 months. As a guide use the following scale:

Never: this has never happened with a romantic partner

Seldom: this has happened 1-2 times with a romantic partner

Sometimes: this has happened 3-5 times with a romantic partner

Often: this has happened 6 times or more with a romantic partner

During a conflict or argument with a romantic partner in the past 12 months:

	Never	Seldom	Sometimes	Often	Prefer not to answer
1. I spoke to a partner in a hostile or mean tone of voice.					
A partner spoke to me in a hostile or mean tone of voice.					
2. I insulted a partner with put-downs.					
A partner insulted me with put-downs.					
3. I said things to a partner’s friends to try to turn them against him/her.					
A partner said things to my friends to try to turn them against me.					
4. I kicked, hit, or punched a partner.					
A partner kicked, hit, or punched me.					
5. I slapped or pulled a partner’s hair.					
A partner slapped me or pulled my hair.					
6. I threatened to hurt a partner.					
A partner threatened to hurt me.					
7. I threatened to hit or throw something at a partner.					
A partner threatened to hit or throw something at me.					
8. I spread rumors about a partner.					
A partner spread rumors about me.					
9. I told a partner whom they could and could not talk to.					
A partner told me whom I could and could not talk to.					
10. I used social media apps or websites, texting, or email to try to control what a partner was saying or doing.					
A partner used social media apps or websites, texting, or email to try to control what I was saying or doing.					
11. I used social media apps or websites, texting, or email to say or do hurtful things to a partner, embarrass a partner, or threaten a partner.					
A partner used social media apps or websites, texting, or email to say or do hurtful things to me, embarrass me, or threaten me.					

The Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: RTI International, 3040 E Cornwallis Rd, Durham NC, 27709 ATTN: Tasseli McKay (919-485-5747). Do not return the completed form to this address.