This survey was created by the Southern Hilltown Domestic Violence Task Force. The goal of the survey is to understand how those who live or work in the hilltowns view and respond to domestic abuse, and to find out if community members know where to get help. The Task Force will use the results of this survey as the foundation for a community education and outreach campaign. Survey results are CONFIDENTIAL. If you choose to enter a RAFFLE for a $200 cash prize (must be 18 or older and live in one of the towns served by the Task Force), you will be asked to enter contact information at the end of this survey. Survey results will remain confidential if you enter the raffle. To learn more about the Task Force, contact us at southernhillsdvtaskforce@gmail.com or on Facebook at Southern Hilltown Domestic Violence Task Force.

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1. Which of the following do you consider to be forms of domestic abuse? (Check all that apply.)

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2. Do you agree or disagree with the following statements? (These statements ask what YOU believe, and then what you think OTHERS in the hilltowns believe.)

  strongly agree agree disagree strongly disagree
I believe it is possible to abuse someone without using physical violence.
Most people in the hilltowns believe it is possible to abuse someone without using physical violence.
I believe abuse is never the fault of the person being abused.
Most people in the hilltowns believe abuse is never the fault of the person being abused.

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3. Do you know someone from the hilltowns who is an: (Check all that apply.)

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4. If you or someone you cared about was in an abusive relationship who might you go to for help? (Check all that apply.)

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5. If you know someone who has been ABUSED, were you able to do or say anything about it? (Check all that apply.)

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6. If you know someone who has been ABUSIVE were you able to do or say anything about it? (Check all that apply.)

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7. Do you know of any programs, agencies or community groups that you could go to for help if you or someone you cared about was being abused?

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8. Have you heard of any of the following agencies/groups? (Check each agency you have heard.)

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9. Do you think the police who respond in the hilltowns would be helpful/responsive if you contacted them because you were being abused?

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10. How do you get information about events/happenings in your community? (Check all sources you use.)

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11. Please indicate if you live or work in the hilltowns. (Check more than one if needed.)

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12. Please place a check by your age group. (Optional)

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13. Please place a check by your gender. (Optional)

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14. If you would like to enter a raffle for a $200 cash prize, please enter your name and phone or email below. Survey results will remain confidential. To be eligible, you must be 18 or older and live in one of the towns served by the Southern Hilltown Domestic Violence Task Force (Chester, Russell, Huntington, Worthington, Middlefield, Blandford, Tolland, Granville, Montgomery). Entry deadline is 6/30/13.

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