lifetime trauma and victimization history (ltvh...
TRANSCRIPT
LIFETIME TRAUMA AND VICTIMIZATION HISTORY (LTVH) INSTRUMENT
Widom, C.S., Dutton, M.A., DuMont, K.A., and Czaja, S.J.
Source: Widom, C.S., Dutton, M.A., Czaja, S.J., & DuMont, K.A. (2005) The development and validation of a new instrument to assess
lifetime trauma and victimization history. Journal of Traumatic Stress, 18(5), 519-532.
SECTION H.
The next questions are about serious events that may have happened to you during your lifetime.
Tally
Child
_____
Tally
Child
_____
H1. Have you ever been involved in a natural
disaster, such as a tornado, hurricane, flood,
or earthquake?
Yes ... 1
No .... 2 (Go to H2)
How old were
you when it
happened?
RECORD AGE:
____
OR
0-11 ..... 91
12-17.... 92
18+ ...... 93
Were you in
danger of death
or serious
injury?
Yes ... 1
No .... 2
Did you feel intense
fear, helplessness, or
horror?
Yes ... 1
No .... 2
Was there another time you were involved in a
natural disaster, such as a tornado, hurricane,
flood, or earthquake?
Yes ... 1 (COMPLETE ROW A)
No .... 2 H2
Tally
Child
_____
Tally
Child
_____
H1A How old were
you when it
happened?
RECORD AGE:
____
OR
0-11 ..... 91
12-17.... 92
18+ ...... 93
Were you in
danger of death
or serious
injury?
Yes ... 1
No .... 2
Did you feel intense
fear, helplessness, or
horror?
Yes ... 1
No .... 2
Was there another time you were involved in a
natural disaster, such as a tornado, hurricane,
flood, or earthquake?
Yes ... 1 (COMPLETE ROW B)
No .... 2 H2
Tally
Child
_____
Tally
Child
_____
H1B How old were
you when it
happened?
RECORD AGE:
____
OR
0-11 ..... 91
12-17.... 92
18+ ...... 93
Were you in
danger of death
or serious
injury?
Yes ... 1
No .... 2
Did you feel intense
fear, helplessness, or
horror?
Yes ... 1
No .... 2
Was there another time you were involved in a
natural disaster, such as a tornado, hurricane,
flood, or earthquake?
Yes ... 1 (COMPLETE ROW C)
No .... 2 H2
Tally
Child
____
Tally
Adult
____
H1C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious physical
injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there another time that you were
involved in a natural disaster, such as a
tornado, hurricane, flood, or earthquake?
Yes......1 (COMPLETE ROW D)
No.......2 H2
Tally
Child
____
Tally
Adult
____
H1D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H2
Tally
Child
____
Tally
Adult
____
H1E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H2
Tally
Child
____
Tally
Adult
____
H1F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1 No.... 2 Yes......1 (COMPLETE ROW G)
No.......2 H2
Tally
Child
____
Tally
Adult
____
H1G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H2. Have you ever been
involved in a man-
made disaster, such as
a fire, train crash, car
accident, or building
collapse?
Yes... 1
No.... 2 (Go to H3)
How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in a man-made disaster, such
as a fire, train crash, car accident, or
building collapse?
Yes... 1 (COMPLETE ROW A)
No.....2 H3
Tally
Child
____
Tally
Adult
____
H2A How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in a man-made disaster, such
as a fire, train crash, car accident, or
building collapse?
Yes......1 (COMPLETE ROW B)
No.......2 H3
Tally
Child
____
Tally
Adult
____
H2B How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in a man-made disaster, such
as a fire, train crash, car accident, or
building collapse?
Yes......1 (COMPLETE ROW C)
No.......2 H3
Tally
Child
____
Tally
Adult
____
H2C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in a man-made disaster, such
as a fire, train crash, car accident, or
building collapse?
Yes......1 (COMPLETE ROW D)
No.......2 H3
Tally
Child
____
Tally
Adult
____
H2D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H3
Tally
Child
____
Tally
Adult
____
H2E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H3
Tally
Child
____
Tally
Adult
____
H2F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H3
Tally
Child
____
Tally
Adult
____
H2G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H3. Have you ever been
involved in direct
combat experience in
a war?
[NOTE: INCLUDE
POLICE
SHOOTOUTS AND
GANG FIGHTS]
Yes... 1
No.... 2 (Go to H4)
How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in direct combat experience in a
war?
Yes... 1 (COMPLETE ROW A)
No......2 H4
Tally
Child
____
Tally
Adult
____
H3A How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in direct combat experience in a
war?
Yes......1 (COMPLETE ROW B)
No.......2 H4
Tally
Child
____
Tally
Adult
____
H3B How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in direct combat experience in a
war?
Yes......1 (COMPLETE ROW C)
No.......2 H4
Tally
Child
____
Tally
Adult
____
H3C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there another time where you were
involved in direct combat experience in a
war?
Yes......1 (COMPLETE ROW D)
No.......2 H4
Tally
Child
____
Tally
Adult
____
H3D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H4
Tally
Child
____
Tally
Adult
____
H3E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H4
Tally
Child
____
Tally
Adult
____
H3F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H4
Tally
Child
____
Tally
Adult
____
H3G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H4. Have you ever lived in a
war zone? (For
example, the Persian
Gulf or Bosnia).
Yes... 1
No.... 2 (Go to H5)
How old were you when you
lived in a war zone?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time that you lived in
a war zone?
Yes... 1 (COMPLETE ROW A)
No......2 H5
Tally
Child
____
Tally
Adult
____
H4A How old were you?
AGE ____
OR 0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 27
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time that you lived in
a war zone?
Yes......1 (COMPLETE ROW B)
No.......2 H5
Tally
Child
____
Tally
Adult
____
H4B How old were you?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time that you lived in
a war zone?
Yes......1 (COMPLETE ROW C)
No.......2 H5
Tally
Child
____
Tally
Adult
____
H4C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there another time that you lived in
a war zone?
Yes......1 (COMPLETE ROW D)
No.......2 H5
Tally
Child
____
Tally
Adult
____
H4D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H5
Tally
Child
____
Tally
Adult
____
H4E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 COMPLETE ROW F)
No.......2 H5
Tally
Child
____
Tally
Adult
____
H4F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H5
Tally
Child
____
Tally
Adult
____
H4G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H5. Have you ever had a
serious accident at
work, at home, or
somewhere else?
Yes... 1
No.... 2 (Go to H6)
How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time when you had a
serious accident at work, at home, or
somewhere else?
Yes... 1 (COMPLETE ROW A)
No...2 H6
Tally
Child
____
Tally
Adult
____
H5A How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time when you had a
serious accident at work, at home, or
somewhere else?
Yes......1 (COMPLETE ROW B)
No.......2 H6
Tally
Child
____
Tally
Adult
____
H5B How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time when you had a
serious accident at work, at home, or
somewhere else?
Yes......1 (COMPLETE ROW C)
No.......2 H6
Tally
Child
____
Tally
Adult
____
H5C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there another time when you had a
serious accident at work, at home, or
somewhere else?
Yes......1 (COMPLETE ROW D)
No.......2 H6
Tally
Child
____
Tally
Adult
____
H5D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H6
Tally
Child
____
Tally
Adult
____
H5E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H6
Tally
Child
____
Tally
Adult
____
H5F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H6
Tally
Child
____
Tally
Adult
____
H5G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H6. Have you ever been
exposed to dangerous
chemicals or
radioactivity?
Yes... 1
No.... 2 (Go to H7)
How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time that you were
exposed to dangerous chemicals or
radioactivity?
Yes... 1 (COMPLETE ROW A)
No...2 H7
Tally
Child
____
Tally
Adult
____
H6A How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time that you were
exposed to dangerous chemicals or
radioactivity?
Yes......1 (COMPLETE ROW B)
No.......2 H7
Tally
Child
____
Tally
Adult
____
H6B How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness, or horror?
Yes... 1
No.... 2
Was there another time that you were
exposed to dangerous chemicals or
radioactivity?
Yes......1 (COMPLETE ROW C)
No.......2 H7
Tally
Child
____
Tally
Adult
____
H6C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there another time that you were
exposed to dangerous chemicals or
radioactivity?
Yes......1 (COMPLETE ROW D)
No.......2 H7
Tally
Child
____
Tally
Adult
____
H6D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H7
Tally
Child
____
Tally
Adult
____
H6E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No......2 H7
Tally
Child
____
Tally
Adult
____
H6F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H7
Tally
Child
____
Tally
Adult
____
H6G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H7. Have you ever been
shot at, stabbed,
struck, kicked,
beaten, punched,
slapped around, or
otherwise
physically
harmed?
Yes... 1
No.... 2 (Go to
H8)
How old were
you when it
first
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
Has anyone else ever
shot at, stabbed, struck,
kicked, beaten,
punched, slapped
around, or otherwise
physically harmed you?
Yes... 1 (COMPLETE
ROW A)
No......2 H8
Tally
Child
____
Tally
Adult
____
H7A How old were
you when it
first
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else ever
shot at, stabbed, struck,
kicked, beaten,
punched, slapped
around, or otherwise
physically harmed you?
Yes.....1 (COMPLETE
ROW B)
No......2 H8
Tally
Child
____
Tally
Adult
____
H7B How old were
you when it
first
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else ever
shot at, stabbed, struck,
kicked, beaten,
punched, slapped
around, or otherwise
physically harmed you?
Yes.....1 (COMPLETE
ROW C)
No.......2 H8
Tally
Child
____
Tally
Adult
____
H7C How old were
you when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you
feel intense
fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD # of
TIMES:
________
How old were you the last time
this person did this to you?
RECORD AGE:
_____ OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once......94
Has anyone else ever
shot at, stabbed, struck,
kicked, beaten,
punched, slapped
around, or otherwise
physically harmed you?
Yes.....1 (COMPLETE
ROW D)
No......2 H8
Tally
Child
____
Tally
Adult
____
H7D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE:
_____ OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes.....1 (COMPLETE
ROW E)
No......2 H8
Tally
Child
____
Tally
Adult
____
H7E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE:
_____ OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes.....1 (COMPLETE
ROW F)
No......2 H8
Tally
Child
____
Tally
Adult
____
H7F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE:
____ OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes.....1 (COMPLETE
ROW G)
No.......2 H8
Tally
Child
____
Tally
Adult
____
H8. Have you ever
been
threatened
with any kind
of a weapon,
like a knife,
gun, baseball
bat, frying pan,
scissors, stick,
rock or bottle?
Yes... 1
No.... 2 (Go to
H9)
How old were
you the first
time it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
Has anyone else
threatened you with any
kind of weapon?
Yes... 1 (COMPLETE
ROW A)
No......2 H9
Tally
Child
____
Tally
Adult
____
H8A How old were
you the first
time it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Has anyone else
threatened you with any
kind of weapon?
Yes.....1 (COMPLETE
ROW B)
No......2 H9
Tally
Child
____
Tally
Adult
____
H8B How old were
you the first
time it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
Has anyone else
threatened you with any
kind of weapon?
Yes.....1 (COMPLETE
ROW C)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8C How old were
you when it
first
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Has anyone else
threatened you with any
kind of weapon?
Yes......1 (COMPLETE
ROW D)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8D RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW E)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8E RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW F)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8F RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW G)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8G RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Tally
Child
____
Tally
Adult
____
H8C How old were
you when it
first
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Has anyone else
threatened you with any
kind of weapon?
Yes......1 (COMPLETE
ROW D)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8D RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW E)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8E RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW F)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8F RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW G)
No.......2 H9
Tally
Child
____
Tally
Adult
____
H8G RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Tally
Child
____
Tally
Adult
____
H9. Has anyone ever
threatened you in a
face-to-face
confrontation?
Yes... 1
No.... 2 (Go to H10)
How old were
you the first
time it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
Has anyone else
threatened you in a face-
to-face confrontation?
Yes... 1 (COMPLETE
ROW A)
No...2 H10
Tally
Child
____
Tally
Adult
____
H9A How old were
you the first
time it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
Has anyone else
threatened in a face-to-
face confrontation?
Yes......1 (COMPLETE
ROW B)
No.......2 H10
Tally
Child
____
Tally
Adult
____
H9B How old were
you the first
time it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
Has anyone else
threatened in a face-to-
face confrontation?
Yes......1 (COMPLETE
ROW C)
No.......2 H10
Tally
Child
____
Tally
Adult
____
H9C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you
feel intense
fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last time
this person did this to you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Has anyone else
threatened you in a face-
to-face confrontation?
Yes......1 (COMPLETE
ROW D)
No.......2 H10
Tally
Child
____
Tally
Adult
____
H9D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW E)
No.......2 H10
Tally
Child
____
Tally
Adult
____
H9E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW F)
No.......2 H10
Tally
Child
____
Tally
Adult
____
H9F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW G)
No.......2 H10
Tally
Child
____
Tally
Adult
____
H9G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Tally
Child
____
Tally
Adult
____
H10. Have you ever been
actually assaulted
with any kind of a
weapon, like a knife,
gun, baseball bat,
frying pan, scissors,
stick, rock, or bottle?
Yes................... 1
No.................... 2 (Go to H11)
ALREADY TOLD YOU
ABOUT THIS....3,
SPECIFY Q#_______
How old were
you when it
first
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
_______
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else actually
assaulted you with any
kind of a weapon, like a
knife, gun, baseball bat,
frying pan, scissors, stick,
rock, or bottle?
Yes... 1 (COMPLETE ............................................................................................................................................. ROW A)
No...2 H11
Tally
Child
____
Tally
Adult
____
H10A How old were
you when it
first
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Was there a
particular
person that
caused this
to happen
to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else actually
assaulted you with any
kind of a weapon, like a
knife, gun, baseball bat,
frying pan, scissors, stick,
rock, or bottle?
Yes......1 (COMPLETE
ROW B)
No.......2 H11
Tally
Child
____
Tally
Adult
____
H10B How old were
you when it
first
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Was there a
particular
person that
caused this
to happen
to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else actually
assaulted you with any
kind of a weapon, like a
knife, gun, baseball bat,
frying pan, scissors, stick,
rock, or bottle?
Yes......1 (COMPLETE
ROW C)
No.......2 H11
Tally
Child
____
Tally
Adult
____
H10C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this
to you?
ENTER
CODE: ____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Has anyone else actually
assaulted you with any kind of
a weapon, like a knife, gun,
baseball bat, frying pan,
scissors, stick, rock, or bottle?
Yes......1 (COMPLETE
ROW D)
No.......2 H11
Tally
Child
____
Tally
Adult
____
H10D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW E)
No.......2 H11
Tally
Child
____
Tally
Adult
____
H10E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW F)
No.......2 H11
Tally
Child
____
Tally
Adult
____
H10F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW G)
No.......2 H11
Tally
Child
____
Tally
Adult
____
H10G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Tally
Child
____
Tally
Adult
____
H11. When you were a child--that
is, when you were in
elementary or middle
school, before about age
12--were you ever struck,
kicked, beaten, punched,
slapped around, or
otherwise physically
harmed?
Yes......................... 1
No.......................... 2 (Go to H12)
ALREADY TOLD YOU
ABOUT THIS..........3
SPECIFY Q#_________
How old were
you when it
first happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once........94
During your childhood-
were you struck, kicked,
beaten, punched,
slapped around, or
otherwise physically
harmed by anyone
else?
Yes... 1 (COMPLETE
ROW A)
No.....2 H12
Tally
Child
____
Tally
Adult
____
H11A How old were
you when it
first happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once....94
During your childhood-
were you struck, kicked,
beaten, punched,
slapped around, or
otherwise physically
harmed by anyone
else?
Yes......1 (COMPLETE
ROW B)
No.......2 H12
Tally
Child
____
Tally
Adult
____
H11B How old were
you when it
first happened?
RECORD
AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once.....94
During your childhood-
were you struck, kicked,
beaten, punched,
slapped around, or
otherwise physically
harmed by anyone
else?
Yes......1 (COMPLETE
ROW C)
No.......2 H12
Tally
Child
____
Tally
Adult
____
H11C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this
to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
During your childhood--
were you struck, kicked,
beaten, punched, slapped
around, or otherwise
physically harmed by
anyone else?
Yes... 1 (COMPLETE
ROW D)
No...2 H12
Tally
Child
____
Tally
Adult
____
H11D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW E)
No.......2 H12
Tally
Child
____
Tally
Adult
____
H11E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW F)
No.......2 H12
Tally
Child
____
Tally
Adult
____
H11F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW G)
No.......2 H12
Tally
Child
____
Tally
Adult
____
H11G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Tally
Child
____
Tally
Adult
____
H12. When you were a
child— that is,
when you were in
elementary or
middle school,
before about age
12—were you ever
physically abused?
Yes.............. 1
No............... 2 (Go to H13)
ALREADY TOLD
YOU ABOUT
THIS............3,
SPECIFY Q#_______
How old were
you when it
first happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this
to you?
ENTER
CODE: ____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
During your childhood--
has anyone else
physically abused you?
Yes... 1 (COMPLETE
ROW A)
No...2 H13
Tally
Child
____
Tally
Adult
____
H12A How old were
you when it
first happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this
to you?
ENTER
CODE: ____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
During your childhood--
has anyone else
physically abused you?
Yes......1 (COMPLETE
ROW B)
No.......2 H13
Tally
Child
____
Tally
Adult
____
H12B How old were
you when it
first happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this
to you?
ENTER
CODE: ____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
During your childhood--
has anyone else
physically abused you?
Yes......1 (COMPLETE
ROW C)
No.......2 H13
Tally
Child
____
Tally
Adult
____
H12C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once...94
During your childhood–
has anyone else physically
abused you?
Yes......1 (COMPLETE
ROW D)
No.......2 H13
Tally
Child
____
Tally
Adult
____
H12D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Yes......1 (COMPLETE
ROW E)
No.......2 H13
Tally
Child
____
Tally
Adult
____
H12E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW F)
No.......2 (NEXT PAGE)
Tally
Child
____
Tally
Adult
____
H12F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once ....94
Yes......1 (COMPLETE
ROW G)
No.......2 H13
Tally
Child
____
Tally
Adult
____
H12G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once.....94
Tally
Child
____
Tally
Adult
____
H13. Has anyone--male or female--
ever forced or coerced you to engage in
unwanted sexual activity?
PROBE: By unwanted sexual activity,
we mean vaginal, oral, or anal
intercourse, or has anyone inserted an
object or their fingers in your anus or
vagina?
Yes................................. 1
No.................................. 2 (Go to H14)
ALREADY TOLD YOU
ABOUT THIS............... 3,
SPECIFY Q#_______
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else--male
or female--ever forced
or coerced you to
engage in unwanted
sexual activity?
Yes... 1 (COMPLETE
ROW A)
No...2 H14
Tally
Child
____
Tally
Adult
____
H13A How old were
you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness,
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else--male
or female--ever forced
or coerced you to
engage in unwanted
sexual activity?
Yes...1 (COMPLETE
ROW B)
No.....2 H13
Tally
Child
____
Tally
Adult
____
H13B How old were
you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness,
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else--male
or female--ever forced
or coerced you to
engage in unwanted
sexual activity?
Yes....1 (COMPLETE
ROW C)
No.....2 H14
Tally
Child
____
Tally
Adult
____
H13C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this
to you?
RECORD # of
TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Has anyone else--male or
female--ever forced or
coerced you to engage in
unwanted sexual activity?
Yes......1 (COMPLETE
ROW D)
No.......2 H14
Tally
Child
____
Tally
Adult
____
H13D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW E)
No.......2 H14
Tally
Child
____
Tally
Adult
____
H13E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW F)
No.......2 H14
Tally
Child
____
Tally
Adult
____
H13F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once......94
Yes......1 (COMPLETE
ROW G)
No.......2 H14
Tally
Child
____
Tally
Adult
____
H13G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Tally
Child
____
Tally
Adult
____
H14. Other than what we just talked
about, did anyone, male or female ever
attempt to--but not actually-- force
you to engage in unwanted sexual
activity?
PROBE: By unwanted sexual activity,
we mean attempted vaginal, oral, or
anal intercourse, or attempted insertion
of their fingers in your anus or vagina?
Yes.................. 1
No................... 2 (Go to
H15)
ALREADY TOLD YOU
ABOUT THIS...............3,
SPECIFY Q#_______
How old were
you when it
first happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else--male or
female, attempted to--but
not actually--forced you
to engage in unwanted
sexual activity?
Yes... 1 (COMPLETE
ROW A)
No.....2 H15
Tally
Child
____
Tally
Adult
____
H14A AGE _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else--male or
female, attempted to--but
not actually--forced you
to engage in unwanted
sexual activity?
Yes......1 (COMPLETE
ROW B)
No.......2 H15
Tally
Child
____
Tally
Adult
____
H14B AGE _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were
you the last time
this person did
this to you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else--male or
female, attempted to--but
not actually--forced you
to engage in unwanted
sexual activity?
Yes......1 (COMPLETE
ROW C)
No.......2 H15
Tally
Child
____
Tally
Adult
____
H14C How old were
you when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this
to you?
ENTER
CODE: ____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How many
times did
this person
do this to
you?
RECORD #
of TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Has anyone else, male or
female, attempted to--but not
actually-- forced you to
engage in unwanted sexual
activity?
Yes......1 (COMPLETE
ROW D)
No.......2 H15
Tally
Child
____
Tally
Adult
____
H14D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW E)
No.......2 H15
Tally
Child
____
Tally
Adult
____
H14E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW F)
No.......2 H15
Tally
Child
____
Tally
Adult
____
H14F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW G)
No.......2 H15
Tally
Child
____
Tally
Adult
____
H14G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE: ____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD #
of TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Tally
Child
____
Tally
Adult
____
H15. Other than
what we just talked
about, has anyone
ever actually touched
private parts of your
body or made you
touch theirs against
your wishes?
Yes... 1
No.... 2 (Go to H16)
How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else ever
actually touched private
parts of your body or made
you touch theirs against your
wishes?
Yes..... 1 (COMPLETE
ROW A)
No.... .2 H16
Tally
Child
____
Tally
Adult
____
H15A How old were you
when it happened?
AGE ____ OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else ever
actually touched private
parts of your body or made
you touch theirs against your
wishes?
Yes......1 (COMPLETE
ROW B)
No.......2 H16
Tally
Child
____
Tally
Adult
____
H15B How old were you
when it happened?
AGE ____ OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many times
did this person do
this to you?
RECORD # of
TIMES:
________
How old were you
the last time this
person did this to
you?
RECORD AGE:
_____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else ever
actually touched private
parts of your body or made
you touch theirs against your
wishes?
Yes......1 (COMPLETE
ROW C)
No.......2 H16
Tally
Child
____
Tally
Adult
____
H15C How old were
you when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness
or horror?
Yes... 1
No.... 2
How many
times did this
person do this to
you?
RECORD # of
TIMES:
________
How old were you the last
time this person did this to
you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Has anyone else ever
actually touched private
parts of your body or made
you touch theirs against
your wishes?
Yes......1 (COMPLETE
ROW D)
No.......2 H16
Tally
Child
____
Tally
Adult
____
H15D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW E)
No.......2 H16
Tally
Child
____
Tally
Adult
____
H15E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW F)
No.......2 H16
Tally
Child
____
Tally
Adult
____
H15F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Yes......1 (COMPLETE
ROW G)
No.......2 H16
Tally
Child
____
Tally
Adult
____
H15G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD # of
TIMES:
________
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only once ......94
Tally
Child
____
Tally
Adult
____
H16. Have you ever had an
immediate family
member, romantic
partner, or very close
friend who was
murdered?
Yes... 1
No.... 2 (Go to H17)
How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was
murdered?
ENTER CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was anyone else who was an immediate
family member, romantic partner, or very
close friend murdered?
Yes... 1 (COMPLETE ROW A)
No......2 H17
Tally
Child
____
Tally
Adult
____
H16A How old were you
when it happened?
AGE ____ OR
0-11....... 91
12-17..... 92
18+ ........93
Who was
murdered?
ENTER CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was anyone else who was an immediate
family member, romantic partner, or very
close friend murdered?
Yes......1 (COMPLETE ROW B)
No.......2 H17
Tally
Child
____
Tally
Adult
____
H16B How old were you
when it happened?
AGE ____ OR
0-11....... 91
12-17..... 92
18+ ........93
Who was
murdered?
ENTER CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was anyone else who was an immediate
family member, romantic partner, or very
close friend murdered?
Yes......1 (COMPLETE ROW C)
No.......2 H17
Tally
Child
____
Tally
Adult
____
H16C How old were
you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was
murdered?
ENTER CODE:
______
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was anyone else who was an immediate
family member, romantic partner, or very
close friend murdered?
Yes......1 (COMPLETE ROW D)
No.......2 H17
Tally
Child
____
Tally
Adult
____
H16D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
______
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H17
Tally
Child
____
Tally
Adult
____
H16E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
______
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H17
Tally
Child
____
Tally
Adult
____
H16F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
______
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H17
Tally
Child
____
Tally
Adult
____
H16G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
______
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H17. Have you ever seen or
been present when
someone was
murdered or
seriously injured?
Yes... 1
No.... 2 (Go to H18)
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
[Who was murdered
or seriously injured?]
ENTER CODE: ____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you saw
or were present when someone was
murdered or seriously injured?
Yes... 1 (COMPLETE ROW A)
No.....2 H18
Tally
Child
____
Tally
Adult
____
H17A How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE: ____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you saw
or were present when someone was
murdered or seriously injured?
Yes......1 (COMPLETE ROW B)
No.......2 H18
Tally
Child
____
Tally
Adult
____
H17B How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE: ____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you saw
or were present when someone was
murdered or seriously injured?
Yes......1 (COMPLETE ROW C)
No.......2 H18
Tally
Child
____
Tally
Adult
____
H17C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when someone
was murdered or seriously injured?
Yes......1 (COMPLETE ROW D)
No.......2 H18
Tally
Child
____
Tally
Adult
____
H17D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H18
Tally
Child
____
Tally
Adult
____
H17E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H18
Tally
Child
____
Tally
Adult
____
H17F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H18
Tally
Child
____
Tally
Adult
____
H17G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H18. Have you ever had an
immediate family
member, romantic
partner, or very close
friend commit
suicide?
Yes... 1
No.... 2 (Go to H19)
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
[Who committed
suicide?]
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Did anyone else who was an
immediate family member, romantic
partner, or very close friend commit
suicide?
Yes... 1 (COMPLETE ROW A)
No...2 H19
Tally
Child
____
Tally
Adult
____
H18A How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Did anyone else who was an
immediate family member, romantic
partner, or very close friend commit
suicide?
Yes......1 (COMPLETE ROW B)
No.......2 H19
Tally
Child
____
Tally
Adult
____
H18B How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Did anyone else who was an
immediate family member, romantic
partner, or very close friend commit
suicide?
Yes......1 (COMPLETE ROW C)
No.......2 H19
Tally
Child
____
Tally
Adult
____
H18C How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Did anyone else who was an immediate
family member, romantic partner, or very
close friend commit suicide?
Yes......1 (COMPLETE ROW D)
No.......2 H19
Tally
Child
____
Tally
Adult
____
H18D RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H19
Tally
Child
____
Tally
Adult
____
H18E RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H19
Tally
Child
____
Tally
Adult
____
H18F RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H19
Tally
Child
____
Tally
Adult
____
H18G RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H19. Have you ever seen a
dead or mutilated
body?
PROBE: Other than
at a funeral, or in the
movies or
newspaper?
Yes... 1
No.... 2 (Go to H20)
How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
[Whose dead or
mutilated body did
you see?]
ENTER CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw a dead or mutilated body?
Yes... 1 (COMPLETE ROW A)
No..... 2 H20
Tally
Child
____
Tally
Adult
____
H19A AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw a dead or mutilated body?
Yes......1 (COMPLETE ROW B)
No.......2 H20
Tally
Child
____
Tally
Adult
____
H19B AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw a dead or mutilated body?
Yes......1 (COMPLETE ROW C)
No.......2 H20
Tally
Child
____
Tally
Adult
____
H19C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Were you in
danger of death
or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when
you saw a dead or mutilated
body?
Yes......1 (COMPLETE ROW D)
No.......2 H20
Tally
Child
____
Tally
Adult
____
H19D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H20
Tally
Child
____
Tally
Adult
____
H19E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H20
Tally
Child
____
Tally
Adult
____
H19F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H20
Tally
Child
____
Tally
Adult
____
H19G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H20. Have you ever seen or
been present when
another person was
shot at, stabbed,
struck, kicked,
beaten, slapped
around, or otherwise
physically harmed?
Yes... 1
No.... 2 (Go to H21)
How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
[Who was
physically harmed?]
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was shot at, stabbed, struck,
kicked, beaten, slapped around, or
otherwise physically harmed?
Yes... 1 (COMPLETE ROW A)
No...2 H21
Tally
Child
____
Tally
Adult
____
H20A How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was shot at, stabbed, struck,
kicked, beaten, slapped around, or
otherwise physically harmed?
Yes......1 (COMPLETE ROW B)
No.......2 H21
Tally
Child
____
Tally
Adult
____
H20B How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was shot at, stabbed, struck,
kicked, beaten, slapped around, or
otherwise physically harmed?
Yes......1 (COMPLETE ROW C)
No.......2 H21
Tally
Child
____
Tally
Adult
____
H20C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Were you
in danger
of death
or serious
physical
injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was shot at, stabbed, struck,
kicked, beaten, slapped around, or
otherwise physically harmed?
Yes......1 (COMPLETE ROW D)
No.......2 H21
Tally
Child
____
Tally
Adult
____
H20D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H21
Tally
Child
____
Tally
Adult
____
H20E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H21
Tally
Child
____
Tally
Adult
____
H20F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 h21
Tally
Child
____
Tally
Adult
____
H20G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H21. Have you ever seen or been present when
another person was raped, sexually
attacked, or made to engage in
unwanted sexual activity?
PROBE: By unwanted sexual activity, we mean
vaginal, oral, or anal intercourse; insertion of an
object or fingers in the anus or vagina; having
private parts of their body touched or being made
to touch other’s private parts against their wishes?
Yes..... 1
No...... 2 (Go to H22)
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
[Who was
raped or
sexually
attacked?]
ENTER
CODE: ____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was raped, sexually attacked, or
made to engage in unwanted sexual
activity?
Yes... 1 (COMPLETE ROW A)
No...2 H22
Tally
Child
____
Tally
Adult
____
H21A How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER
CODE: ____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was raped, sexually attacked, or
made to engage in unwanted sexual
activity?
Yes......1 (COMPLETE ROW B)
No.......2 H22
Tally
Child
____
Tally
Adult
____
H21B How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER
CODE: ____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
saw or were present when another
person was raped, sexually attacked, or
made to engage in unwanted sexual
activity?
Yes......1 (COMPLETE ROW C)
No.......2 H22
Tally
Child
____
Tally
Adult
____
H21C How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who was it?
ENTER CODE: ____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense fear,
helplessness or horror?
Yes... 1
No.... 2
Was there any other time when you saw or
were present when another person was
raped, sexually attacked, or made to engage
in unwanted sexual activity?
Yes......1 (COMPLETE ROW D)
No.......2 H22
Tally
Child
____
Tally
Adult
____
H21D RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H22
Tally
Child
____
Tally
Adult
____
H21E RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H22
Tally
Child
____
Tally
Adult
____
H21F RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H22
Tally
Child
____
Tally
Adult
____
H21G RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H22. Has anyone ever
intentionally
damaged or
destroyed property
owned by you or by
someone in your
household?
Yes... 1
No.... 2 (Go to H23)
How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else intentionally
damaged or destroyed property
owned by you or by someone in
your household?
Yes... 1 (COMPLETE ROW A)
No...2 H23
Tally
Child
____
Tally
Adult
____
H22A How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else intentionally
damaged or destroyed property
owned by you or by someone in
your household?
Yes......1 (COMPLETE ROW B)
No.......2 H23
Tally
Child
____
Tally
Adult
____
H22B How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else intentionally
damaged or destroyed property
owned by you or by someone in
your household?
Yes......1 (COMPLETE ROW C)
No.......2 H23
Tally
Child
____
Tally
Adult
____
H22C How old were you
when it happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this:
ENTER CODE:
_____
Were you
in danger
of death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else intentionally damaged or
destroyed property owned by you or by someone
in your household?
Yes......1 (COMPLETE ROW D)
No.......2 H23
Tally
Child
____
Tally
Adult
____
H22D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this:
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H23
Tally
Child
____
Tally
Adult
____
H22E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this:
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H23
Tally
Child
____
Tally
Adult
____
H22F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this:
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H23
Tally
Child
____
Tally
Adult
____
H22G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this:
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H23. Has anyone ever stolen
something from you
by using force or the
threat of force like in
a stick-up, mugging,
or car-jacking?
Yes... 1
No.... 2 (Go to H24)
How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever stolen something
from you by using force or the threat of
force like in a stick-up, mugging, or
car-jacking?
Yes... 1 (COMPLETE ROW A)
No...2 H24
Tally
Child
____
Tally
Adult
____
H23A How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever stolen something
from you by using force or the threat of
force like in a stick-up, mugging, or
car-jacking?
Yes......1 (COMPLETE ROW B)
No.......2 H24
Tally
Child
____
Tally
Adult
____
H23B How old were you
when it happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in danger of
death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever stolen something
from you by using force or the threat of
force like in a stick-up, mugging, or
car-jacking?
Yes......1 (COMPLETE ROW C)
No.......2 H24)
Tally
Child
____
Tally
Adult
____
H23C How old were you
when it happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to you?
ENTER CODE:
_____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever stolen something
from you by using force or the threat of
force like in a stick-up, mugging, or car-
jacking?
Yes......1 (COMPLETE ROW D)
No.......2 H24
Tally
Child
____
Tally
Adult
____
H23D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H24
Tally
Child
____
Tally
Adult
____
H23E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H24
Tally
Child
____
Tally
Adult
____
H23F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H24
Tally
Child
____
Tally
Adult
____
H23G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H24. Has anyone ever tried
to--but not actually--
steal something from
you by using force or
the threat of force
like in a stick-up,
mugging, or car-
jacking?
Yes... 1
No.... 2 (Go to H25)
How old were
you when it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to--but not
actually--steal something from you by
using force or the threat of force like in
a stick-up, mugging, or car-jacking?
Yes... 1 (COMPLETE ROW A)
No...2 H25
Tally
Child
____
Tally
Adult
____
H24A How old were
you when it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to--but not
actually--steal something from you by
using force or the threat of force like in
a stick-up, mugging, or car-jacking?
Yes......1 (COMPLETE ROW B)
No.......2 H25)
Tally
Child
____
Tally
Adult
____
H24B How old were
you when it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to--but not
actually--steal something from you by
using force or the threat of force like in
a stick-up, mugging, or car-jacking?
Yes......1 (COMPLETE ROW C)
No.......2 H25
Tally
Child
____
Tally
Adult
____
H24C How old were you
when it happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
_____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to--but not
actually--steal something from you by
using force or the threat of force like in a
stick-up, mugging, or car-jacking?
Yes......1 (COMPLETE ROW D)
No.......2 H25
Tally
Child
____
Tally
Adult
____
H24D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H25
Tally
Child
____
Tally
Adult
____
H24E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H25
Tally
Child
____
Tally
Adult
____
H24F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H25
Tally
Child
____
Tally
Adult
____
H24G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H25. Has anyone ever tried
to or actually broken
in to your house,
garage, shed, or
storage room when
you were not there?
Yes... 1
No.... 2 (Go to H26)
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house when you were
not there?
Yes... 1 (COMPLETE ROW A)
No...2 H26
Tally
Child
____
Tally
Adult
____
H25A How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house when you were
not there?
Yes......1 (COMPLETE ROW B)
No.......2 H26
Tally
Child
____
Tally
Adult
____
H25B How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house when you were
not there?
Yes......1 (COMPLETE ROW C)
No.......2 H26
Tally
Child
____
Tally
Adult
____
H25C How old were you
when it happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
_____
Were you
in danger
of death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house when you were
not there?
Yes......1 (COMPLETE ROW D)
No.......2 H26
Tally
Child
____
Tally
Adult
____
H25D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H26
Tally
Child
____
Tally
Adult
____
H25E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H26
Tally
Child
____
Tally
Adult
____
H25F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H26
Tally
Child
____
Tally
Adult
____
H25G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H26. Has anyone ever tried
to or actually broken
in to your house,
garage, shed, or
storage room when
you were there?
Yes... 1
No.... 2 (Go to H27)
How old were
you when it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house, garage, shed,
or storage room when you were there?
Yes... 1 (COMPLETE ROW A)
No...2 H27
Tally
Child
____
Tally
Adult
____
H26A How old were
you when it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house, garage, shed,
or storage room when you were there?
Yes......1 (COMPLETE ROW B)
No.......2 H27
Tally
Child
____
Tally
Adult
____
H26B How old were
you when it
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Was did this?
ENTER CODE:
____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or actually
broken in to your house, garage, shed,
or storage room when you were there?
Yes......1 (COMPLETE ROW C)
No.......2 H27
Tally
Child
____
Tally
Adult
____
H26C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE: ____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else ever tried to or
actually broken in to your house,
garage, shed, or storage room when
you were there?
Yes......1 (COMPLETE ROW D)
No.......2 H27
Tally
Child
____
Tally
Adult
____
H26D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H27
Tally
Child
____
Tally
Adult
____
H26E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H27
Tally
Child
____
Tally
Adult
____
H26F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2
Tally
Child
____
Tally
Adult
____
H26G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE: ____ Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H27. Has anyone ever stolen
something directly from you
without the threat or use of
force (for example purse-
snatching or pick-pocket)?
Yes... 1
No.... 2 (Go to H28)
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else stolen something
directly from you without the threat or
use of force?
Yes..... 1 (COMPLETE ROW A)
No....... 2 H28
Tally
Child
____
Tally
Adult
____
H27A How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else stolen something
directly from you without the threat or
use of force?
Yes......1 (COMPLETE ROW B)
No.......2 H28
Tally
Child
____
Tally
Adult
____
H27B
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Did you feel intense
fear, helplessness or
horror?
Yes... 1
No.... 2
Has anyone else stolen something
directly from you without the threat or
use of force?
Yes......1 (COMPLETE ROW C)
No.......2 H28
Tally
Child
____
Tally
Adult
____
H27C How old were you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Has anyone else stolen something
directly from you without the threat or
use of force?
Yes......1 (COMPLETE ROW D)
No.......2 H28
Tally
Child
____
Tally
Adult
____
H27D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H28
Tally
Child
____
Tally
Adult
____
H27E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H28
Tally
Child
____
Tally
Adult
____
H27F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H28
Tally
Child
____
Tally
Adult
____
H27G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this?
ENTER CODE:
____
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H28. Have you ever been
kidnapped or held
captive?
Yes... 1
No.... 2 (Go to H29)
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who
kidnapped
or held
you
captive?
ENTER
CODE:
____
How long were
you held or not
allowed to
leave?
# of hours:
_____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
were kidnapped or held captive?
Yes... 1 (COMPLETE ROW A)
No...2 H29
Tally
Child
____
Tally
Adult
____
H28A How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who
kidnapped
or held
you
captive?
ENTER
CODE:
____
How long were
you held or not
allowed to
leave?
# of hours:
_____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
were kidnapped or held captive?
Yes......1 (COMPLETE ROW B)
No.......2 H29
Tally
Child
____
Tally
Adult
____
H28B
How old were
you when it
happened?
RECORD
AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who
kidnapped
or held
you
captive?
ENTER
CODE:
____
How long were
you held or not
allowed to
leave?
# of hours:
_____
Were you in
danger of death or
serious physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
were kidnapped or held captive?
Yes......1 (COMPLETE ROW C)
No.......2 H29
Tally
Child
____
Tally
Adult
____
H28C How old were
you when it
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who
kidnapped
or held you
captive?
ENTER
CODE:
____
How long were
you held or not
allowed to
leave?
# of hours:
_____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
Was there any other time when you
were kidnapped or held captive?
Yes......1 (COMPLETE ROW D)
No.......2 H29
Tally
Child
____
Tally
Adult
____
H28D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
# of hours:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW E)
No.......2 H29
Tally
Child
____
Tally
Adult
____
H28E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
# of hours:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW F)
No.......2 H29
Tally
Child
____
Tally
Adult
____
H28F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
# of hours:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Yes......1 (COMPLETE ROW G)
No.......2 H29
Tally
Child
____
Tally
Adult
____
H28G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER
CODE:
____
# of hours:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
Tally
Child
____
Tally
Adult
____
H29. Have you ever been
stalked by anyone?
For example, has
anyone ever followed
or spied on you?
Yes... 1
No.... 2 (Go to H30)
How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How old were you the
last time this person
stalked you
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else stalked you?
Yes... 1 (COMPLETE ROW A)
No...2 H30
Tally
Child
____
Tally
Adult
____
H28A How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How old were you the
last time this person
stalked you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else stalked you?
Yes....1 (COMPLETE ROW B)
No.......2 H30
Tally
Child
____
Tally
Adult
____
H28B
How old were you
when it first
happened?
RECORD AGE:
_____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did
this to
you?
ENTER
CODE:
____
Were you in
danger of
death or
serious
physical
injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How old were you the
last time this person
stalked you?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Happened only
once ......94
Has anyone else stalked you?
Yes.....1 (COMPLETE ROW C)
No......2 H30
Tally
Child
____
Tally
Adult
____
H29C How old were
you when it first
happened?
AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
Who did this to
you?
ENTER CODE:
_____
Were you in danger
of death or serious
physical injury?
Yes... 1
No.... 2
Did you feel
intense fear,
helplessness or
horror?
Yes... 1
No.... 2
How old were you the last time
this person stalked you?
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once........94
Has anyone else stalked you?
Yes...1 (COMPLETE ROW D)
No....2 H30
Tally
Child
____
Tally
Adult
____
H29D AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once........94
Yes...1 (COMPLETE ROW E)
No....2 H30
Tally
Child
____
Tally
Adult
____
H29E AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once........94
Yes...1 (COMPLETE ROW F)
No...2 H30
Tally
Child
____
Tally
Adult
____
H29F AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once........94
Yes...1 (COMPLETE ROW G)
No....2 H30
Tally
Child
____
Tally
Adult
____
H29G AGE ____
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE:
_____
Yes... 1
No.... 2
Yes... 1
No.... 2
RECORD AGE: _____
OR 0-11....... 91
12-17..... 92
18+ ........93
Happened only once........94
Tally
Child
____
Tally
Adult
____
H30. Have you ever been in any other
situation in which you were in danger
of death or serious physical injury, or
in which you felt intense fear,
helplessness, or horror?
Yes... 1
SPECIFY: ______________________
No.... 2 (Go to H31)
How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Was there a particular person who
did this to you?
ENTER CODE: ____
Was there any other situation in which you
were in danger of death or serious physical
injury, or in which you felt intense fear,
helplessness, or horror?
Yes... 1 (COMPLETE ROW A)
No...2 H31
Tally
Child
____
Tally
Adult
____
H30A How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Was there a particular person who
did this to you?
ENTER CODE: ____
Was there any other situation in which you
were in danger of death or serious physical
injury, or in which you felt intense fear,
helplessness, or horror?
Yes......1 (COMPLETE ROW B)
No.......2 H31
Tally
Child
____
Tally
Adult
____
H30B How old were you when it
happened?
RECORD AGE: _____
OR
0-11....... 91
12-17..... 92
18+ ........93
Was there a particular person who
did this to you?
ENTER CODE: ____
Was there any other situation in which you
were in danger of death or serious physical
injury, or in which you felt intense fear,
helplessness, or horror?
Yes......1 (COMPLETE ROW C)
No.......2 H31
Tally
Child
____
Tally
Adult
____
H30C How old were you when it
happened?
RECORD AGE
OR
0-11....... 91
12-17..... 92
18+ ........93
Was there a particular person who did this to
you?
ENTER CODE _____
Was there any other situation in
which you were in danger of death
or serious physical injury, or in
which you felt intense fear,
helplessness, or horror?
Yes......1 (COMPLETE ROW D)
No.......2 H31
Tally
Child
____
Tally
Adult
____
H30D RECORDS AGE
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE _____ Yes......1 (COMPLETE ROW E)
No.......2 H31
Tally
Child
____
Tally
Adult
____
H30E RECORD AGE
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE _____ Yes......1 (COMPLETE ROW F)
No.......2 H31
Tally
Child
____
Tally
Adult
____
H30F RECORD AGE
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE _____ Yes......1 (COMPLETE ROW G)
No.......2 H31
Tally
Child
____
Tally
Adult
____
H30G RECORD AGE
OR
0-11....... 91
12-17..... 92
18+ ........93
ENTER CODE _____