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Domestic Violence Experience Survey
General Information
Please provide feedback about your experience with domestic violence along with any interactions you had with law enforcement, courts, medical providers, and victim service providers.
1.
Age:
2.
Gender
Female
Male
Other (please specify)
3.
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
4.
Race (Check all that apply)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
5.
What forms of domestic violence did you experience? (Select all that apply)
Physical abuse
Emotional/psychological abuse
Sexual abuse
Financial abuse
Other (please specify)
6.
Location (City/State):
7.
Relationship to the abuser?
Current or former dating relationship
Current or former spouse
Immediate family member (mom, dad, sister, etc)
Other (please specify)
8.
How long did you experience domestic violence before seeking help?
Less than 6 months
6 months to 1 year
1 to 2 years
More than 2 years
9.
Did your abuser ever strangle or attempt to strangle you?
Yes
No
I'm unsure
10.
If so, did you seek medical attention?
Yes
No
I'm unsure
