Intimate Partner Violence 

and Sexual Violence 

Victimization Assessment 

Instruments for Use in 

Healthcare Settings
Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments 

for Use in Healthcare Settings: Version 1 is a publication of the Centers for Disease 

Control and Prevention, National Center for Injury Prevention and Control.

Centers for Disease Control and Prevention

Julie L. Gerberding, MD, MPH, Director

Coordinating Center for Environmental Health and Injury Prevention

Henry Falk, MD, MPH, Director

National Center for Injury Prevention and Control

Ileana Arias, PhD, Director

Division of Violence Prevention

W. Rodney Hammond, PhD, Director

Editing services were provided by the Office of Communication Resources, National 

Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Suggested Citation: Basile KC, Hertz MF, Back SE. Intimate Partner Violence and 

Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: 

Version 1. Atlanta (GA): Centers for Disease Control and Prevention, National Center 

for Injury Prevention and Control; 2007.
Intimate Partner Violence and 

Sexual Violence Victimization 

Assessment Instruments for Use in 

Healthcare Settings

Version 1.0

Compiled and Edited by:

Kathleen C. Basile, Ph.D.

Marci F. Hertz, M.S.

Sudie E. Back, Ph.D.
ACKNOWLEDGMENTS 

We acknowledge the contributions of several CDC colleagues 

who reviewed the document and provided expert advice: Linda E. 

Saltzman, PhD; Tom Simon, PhD; Jim Mercy, PhD, and Joanne 

Klevens, MD. In addition, we would like to thank the numerous 

external experts in the fields of intimate partner violence and 

sexual violence who provided feedback on the scales identified for 

this compendium. 

DEDICATION

We dedicate this document to the memory of Linda E. Saltzman, 

PhD, our colleague, mentor, and friend, whose influential work 

in the fields of intimate partner violence and sexual violence has 

improved the lives of many women and children.
CONTENTS 

Introduction 5 

Section A. Intimate Partner Violence 11

Section B. Sexual Violence 81

7

Intimate Partner Violence and Sexual Violence Victimization 

Assessment Instruments for Use in Healthcare Settings

Purpose of this document

This document is a compilation of existing tools for assessing intimate partner violence (IPV) and 

sexual violence (SV) victimization (defined below) in clinical/healthcare settings. 

The purpose of this compilation of assessment instruments is: 1) to provide practitioners and 

clinicians with the most current inventory of assessment tools for determining IPV and/or SV 

victimization and 2) to supply information on the psychometric properties of these instruments, 

when available, to inform decisions about which instruments are most appropriate for use with 

a given population. This document should serve as a guide to aid in the selection of assessment 

instruments for use in health care settings to identify victims requiring additional services. The 

identification can help practitioners make appropriate referrals for both victims and perpetrators. 

Contents of this document

The document is divided into two sections. Section A includes intimate partner violence 

victimization tools. Section B includes sexual violence victimization tools. A table is included at 

the beginning of each section that lists each of the instruments included in the section. The actual 

instruments follow the table. Some instruments found in Section A are repeated in Section B if 

they include at least one item pertaining to sexual violence victimization. 

When available, the following information is provided for each instrument:

 • Instrument characteristics, such as how many items are included and what is specifically 

 being measured;

 • Administration method, such as whether information is collected through self-report or 

 through clinician administration;

 • Scoring procedures, such as what score constitutes victimization;

 • Follow-up procedures, such as referral to services;

 • Populations studied, such as whether the instrument was used with males or females, 

 and with specific racial groups;

 • Psychometric properties, including:

 o Reliability - the extent to which a scale’s items are consistently measuring the same 

 characteristic and are responded to similarly over time by the same individual 

 o Validity - the extent to which a scale measures what it is supposed to measure

 o Specificity - the proportion of all “true” negative cases in a target population that are 

 correctly identified by a particular scale

 o Sensitivity - the proportion of all “true” positive cases in a target population that are 

 correctly identified by a particular scale;

 • The author(s) who developed the instrument, including the relevant citation;

 • Any recent articles published at the time of this writing that discuss the instrument.
8

Intimate Partner Violence and Sexual Violence Definitions

In the context of this document, intimate partner violence (IPV) is defined as actual or threatened 

physical, sexual, psychological, emotional, or stalking abuse by an intimate partner. An intimate 

partner can be a current or former spouse or non-marital partner, such as a boyfriend, girlfriend, 

or dating partner (Saltzman, et al., 1999). Intimate partners can be of the same or opposite sex 

(National Center for Injury Prevention and Control, 2002). 

For the purposes of this document, sexual violence (SV) includes nonconsensual completed or 

attempted penetration of the vagina or anus, nonconsensual completed or attempted oral sex, 

nonconsensual intentional touching of a sexual nature, or nonconsensual non-contact acts of a 

sexual nature such as voyeurism and verbal or behavioral sexual harassment. SV can be perpetrated 

by anyone, such as a friend/acquaintance, a current or former spouse/partner, a family member, or 

a stranger (Basile and Saltzman, 2002). 

Methods used to collect assessment instruments

To identify potential scales, we conducted an intensive literature search that involved a review of 

the articles published and indexed in PsycInfo and Medline and on Yahoo or Google internet sites. 

Search terms used included: IPV, intimate partner violence, DV, domestic violence, abuse screening, 

assault screening, spouse abuse, partner abuse, dating violence, date rape, rape, wife rape, marital rape, 

sexual abuse, sexual assault, sexual victimization, youth violence, sexual violence, woman abuse, teen 

violence, acquaintance rape, psychological abuse, risk assessment, danger assessment, sexual offense, spousal 

assault risk, violent offense, sexual perpetrators, sexual predator, DV perpetrators, IPV perpetrators, 

perpetrator, propensity, interpersonal violence perpetrator, stalking perpetrator, and stalking.

Articles identified through the search were used to gather information about the characteristics of 

the scale, the population(s) for which it was developed, and the psychometric properties.

Inclusion Criteria

Only assessment instruments for clinical purposes (as opposed to solely for research purposes) 

were considered for this document. Such assessment tools were limited to those that contained 

20 items or fewer, as longer tools would be infeasible in many health care settings due to time 

constraints. In addition, while we prefer published assessment tools with reliability and validity 

information available, unpublished measures (particularly for topic areas in which few published 

assessment tools are available) that met the other inclusion criteria were also included. 

Expert review 

Once an initial list of scales was compiled, it was e-mailed to 14 expert clinicians and researchers 

in sexual and/or intimate partner violence prevention. The draft was also distributed to rape 

prevention and education program coordinators at state and territory departments of health, using 

the Rape Prevention and Education listserv. This listserv represents all 50 states, the District of 

Columbia, Puerto Rico, and seven U.S. territories. The reviewers were asked to comment on the 

selected scales, indicate if any scales were missing, and indicate whether the included scales could 

reasonably be used in a clinical setting. The comments were used to identify new scales and to 

improve the summary information provided. 
9

Definitions of terms used

The following technical terms are used in this document:

Construct: An unobserved characteristic on which people vary and which scales are intended to 

measure. 

Construct validity: The extent to which a scale’s items measure the hypothesized underlying 

construct. One type is convergent validity.

 Convergent validity: The extent to which responses on a scale are correlated to responses on 

 another scale that assesses a similar underlying construct.

Internal consistency reliability: Internal consistency reliability is typically measured using 

the Cronbach’s alpha coefficient, which assesses the degree to which responses to items 

within a scale are correlated. Scores can range from 0 to 1.0, with higher scores reflecting

greater homogeneity among the items. A general guideline for evaluating the adequacy 

of alpha coefficients is that scores greater than or equal to .80 reflect “exemplary” internal

consistency reliability, scores ranging from .70 to .79 indicate “extensive” internal consistency

reliability, scores ranging from .60 to .69 indicate “moderate” internal consistency reliability,

and scores less than .60 reflect minimal reliability (Robinson, Shaver, & Wrightsman, 1991).

Test-retest reliability: The extent to which an individual’s responses on a scale provided at one 

point in time correlate with his or her responses on the same scale at another point in time. 

The sources for these definitions include Ghiselli, Campbell, and Zedeck (1981), Rathus and 

Feindler (2004), Robinson, Shaver, and Wrightsman (1991), and Teutsch and Churchill (2000).

Uses and limitations 

The scales presented in this compilation represent all of the instruments known to the authors 

that met the inclusion criteria. This document is not intended to provide an exhaustive list of 

instruments. It should also be noted that the CDC is not endorsing any particular assessment 

instrument presented, but only provides information to help practitioners and clinicians make 

informed decisions about choosing instruments that assess exposure to IPV and SV victimization. 

These assessment instruments should only be used if there are resources available to distribute 

to clients for primary prevention purposes (preventing violence before it starts); and if there are 

mechanisms in place to refer clients exposed to IPV or SV for a comprehensive assessment and 

appropriate victim services. Further, at this time the U.S. Preventive Service Task Force has 

concluded that there is insufficient evidence to recommend routine IPV screening in healthcare 

settings (U.S. Preventive Task Force, 2004). More research is needed to further our understanding 

of the benefits and consequences of assessing exposure to IPV and SV in the healthcare setting 

(Chamberlain, 2005). We also hope that this document will aid in the field’s efforts to increase the 

knowledge base around the pros and cons of assessing exposure to IPV and SV in the healthcare 

setting. 
10

This document focuses on assessment tools for SV and IPV victimization, but there are several 

other types of interpersonal violence for which assessment in a clinical setting would be worthwhile. 

For example, although an attempt was made to include scales for SV and IPV perpetration, none 

met the selected criteria. Furthermore, this document does not include scales pertaining to the 

abuse of the elderly, children, or the disabled. While including these areas went beyond the scope 

of this project, future projects should address these and other special populations.

REFERENCES

Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and 

 recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and 

 Prevention, National Center for Injury Prevention and Control.

Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: 

 What we can learn from it and what can we do about it. Family Violence Prevention and 

 Health Practice, 1, 1-24.

Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. 

 New York: W.H. Freeman and Company.

National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. 

 Atlanta (GA): Centers for Disease Control and Prevention.

Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers 

 and practitioners. Washington DC: American Psychological Association.

Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social 

 psychological attitudes. San Diego, CA: Academic Press, Inc.

Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence 

 surveillance: Uniform definitions and recommended data elements. Version 1.0

 Atlanta, GA: CDC, National Center for Injury Prevention and Control.

Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance 

 (2nd ed.). New York, NY: Oxford University Press, Inc.

US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ 

 uspsfamv.htm 


SECTION A.

INTIMATE PARTNER VIOLENCE (IPV)
14

DESCRIPTION OF IPV MEASURES

Scale/Assessment Characteristics Administration Method Populations Studied* 

*This list is not exhaustive.

Abuse Assessment

Screen (AAS)

5 items assess frequency and perpetrator of physical, sexual, and 

emotional abuse by anyone. Body 

map to document area of injury. 

Clinician administered Abused pregnant and nonpregnant

African-American, Hispanic, and 

white women in health and prenatal 

clinics and emergency departments.

AAS - Spanish Version 5 items assess frequency and perpetrator of physical, sexual, and 

emotional abuse by anyone. 

Body map to document 

area of injury. 

Clinician administered Abused pregnant and nonpregnant

African-American, Hispanic, and 

white women in health and 

prenatal clinics and emergency

departments.

American Medical

Association Screening

Questions

10 sample items inquire about 

physical, sexual, and emotional 

IPV to be asked in physician’s 

own words.

Physician or clinician

administered

Women patients in health

 care settings. 

Assessment of 

Immediate Safety

Screening Questions

11 items assess physical safety 

of patients who disclose current 

IPV.

Clinician administered or

self report

Women and men patients in 

health care settings. 

Bartlett Regional 

Hospital Domestic

Violence Assessment

18 items assess IPV, patient 

safety, and referral options. Body 

map to document site of injury.

Clinician administered Female patients over 16 in a 

hospital setting.

Computer Based IPV

Questionnaire

14 items assess physical and 

emotional IPV, suicidal ideation, 

perpetration, sexual violence 

victimization, and access 

to handguns.

Self report via a computer

in emergency department

African-American and white men

 and women in emergency

 departments.

Danger Assessment 15 items assess a woman’s 

potential danger of homicide by 

an intimate male partner.

Available in English

Characteristics and Spanish. 

Self report Abused women in the community,

battered women shelters, prenatal

clinics, and primary care clinics. 

African-American, white, and 

Hispanic women.

Domestic Violence Initiative

Screening Questions

6 items assess physical,

and emotional IPV,

and desire for professional

assistance.

Clinician administered Obstetric patients during their initial

visit to a hospital based maternity

clinic.

Domestic Violence

Screening for Pediatric

Settings

6 items (3 from American 

Medical Association and 3

new items) screen for IPV 

and availability of handguns 

in the home. 

Clinician administered 

checklist

African-American and white women

in a hospital-based pediatric clinic.

Domestic Violence

Screening/

Documentation Form

20 items assess physical 

IPV, patient safety, 

handguns in the home, 

substance use, and

referral/reporting options. 

Designed to be administered

by home care nurses

Women and men patients

in home care settings.

 
15

Reliability/Validity Sensitivity/Specificity Developer Articles

Test/retest reliability

across the same

trimester for pregnant

women was 83%. 

Sensitivity: 93%;

Specificity: 55%

(Using the Index of Spouse 

Abuse [ISA] as the gold 

standard) 

McFarlane, Parker,

Soeken, & Bullock, 1992

Norton, Peipert, Zierler, 

Lima, & Hume, 1995; 

Soeken, McFarlane, 

Parker, & Lominack,1998; 

Weiss, Ernst, Cham, & Nick, 2003

Unavailable Unavailable

Unavailable Unavailable American Medical

Association, 1992

Unavailable

Unavailable Unavailable Family Violence

Prevention Fund, 2002

Unavailable

Unavailable Unavailable Bartlett Regional

Hospital

Bartlett Regional Hospital

Domestic Violence Protocol

Unavailable Unavailable Rhodes, Lauderdale, 

He, Howes, &

Levinson, 2002

Heron & Kellermann, 2002

Internal consistency:

0.66 -0.86. Test/retest

reliability: 0.89 -0.94.

Construct validity 

convergent with the 

Conflict Tactics Scale 

(CTS), r = 0.49 - 0.55 and 

ISA, r = 0.44 - 0.75.

Unavailable Campbell, 1986 Campbell, 1989, 1995; 

Goodman, Dutton, 

& Bennett, 2000; 

McFarlane, Greenberg, 

Weltge, & Waston, 1995

Unavailable Unavailable Queensland

Government, 1998

Webster, Stratigos,

& Grimes, 2001;

Webster & Holt, 2004

Unavailable Unavailable Siegel, Hill,

Henderson, Ernst, 

& Boat, 1999

Unavailable

Unavailable Unavailable Family Violence

Prevention Fund,1996

Cassidy, 1999; 

Family Violence Prevention 

Fund, 2002
16

DESCRIPTION OF IPV MEASURES

Scale/Assessment Characteristics Administration Method Populations Studied* 

*This list is not exhaustive.

Emergency Department

Domestic Violence Screening 

Questions

5 items assess violence

in the home.

Self report Canadian women in 

emergency departments.

Falmouth Pediatric

Associates Violence

Handout

5 items adapted from the 

American Medical 

Association and Siegel et 

al. 1999 assess IPV, handguns in 

the home, and previous 

discussions with health care

providers about IPV. 

Self report Mothers of young children

in a pediatric group practice.

HITS 4 items assess the 

frequency of IPV.

Self report or clinician

administered

Female patients in family practice

settings; male patients in health 

care settings.

Minnesota Tool 13 items and color-coded

stickers assess physical, emotional, 

and sexual IPV.

Self report Women and men in a community

hospital setting.

New South Wales

Department of Health

Survey

3 items assess IPV in

the last year and 

current safety.

Clinician administered Australian women, predominantly 

white, in emergency departments.

Ongoing Abuse Screen

(OAS)

5 items adapted from the 

AAS assess ongoing physical, 

sexual, emotional IPV, and fear.

Self report Women and men in emergency 

departments. Tested on African 

Americans, Hispanics, and whites.

Ongoing Violence

Assessment Tool

(OVAT)

4 items assess ongoing

physical and emotional IPV.

Self report Women and men in emergency 

departments. Tested on African 

Americans, Hispanics, and whites.

Partner Violence

Screen (PVS)

3 items assess physical IPV in the 

last year and current safety.

Clinician administered Women and men in emergency room

settings in the United States 

and Canada.

Patient Satisfaction

and Safety Survey

(PSSS)

4 items adapted from AAS

assess physical, sexual, 

and emotional IPV.

Self report or clinicianadministeredWomen in emergency room

settings.
17

Reliability/Validity Sensitivity/Specificity Developer Articles

Unavailable Unavailable Morrison, Allan, & 

Grunfeld, 2000

Unavailable

Unavailable Unavailable Parkinson, Adams, & 

Emerling, 2001

Unavailable

For women: internal 

consistency 0.80;

concurrent validity: 

correlation with the CTS 

of 0.85.

Internal consistency 0.76

for English version and 

0.61 for Spanish; correlation of 0.76 with ISA-P

and 0.75 with Woman 

Abuse Screening Tool

(WAST).

For men: concurrent 

validity: correlation with

CTS of 0.86.

For women: English version,

Sensitivity: 86%-96%;

Specificity: 91%-99%

(using cut off score of 10.5, 

using CTS or ISA as gold

standard); Spanish version,

Sensitivity: 100%;

Specificity: 86%

(using cut off score of 5.5, 

using WAST as gold standard).

For men: English version,

Sensitivity: 88%;

Specificity: 97%

(using cut-off score of 11,

using CTS as gold standard).

Sherin, Sinacore, 

Li, Zitter, & Shakil,

1998

Punukollu, 2003;

Shakil, Donald, Sinacore,

& Krepcho, 2005;

Chen, Rovi, Vega, Jacobs,

& Johnson, 2005

Unavailable Unavailable md4peace@earthlink.net Family Violence Prevention

Fund, 2003

Unavailable Unavailable Ramsden & Bonner,

2002

Unavailable

Inter-item correlation: 0.23;

Cronbach’s alpha: 0.59.

Sensitivity: 30%-60%;

Specificity: 90%-100%

(Using the ISA as the gold

standard).

Weiss et al., 2003 Ernst, Weiss, Cham, &

Marquez, 2002

Inter-item correlation: 0.38-

0.44;

Cronbach’s alpha: 0.60-0.72.

Sensitivity: 86%-93%;

Specificity: 83%-86%

(Using the ISA as the gold

standard).

Weiss et al., 2003 Ernst, Weiss, Cham, Hall,

& Nick, 2004

Unavailable Sensitivity: 64.5%-71.4%

Specificity: 80.3%-84.4%

(Using ISA and CTS, 

respectively, as gold

 standards).

Feldhaus, Koziol-McLain,

Amsbury, Norton,

Lowenstein, & Abbott, 1997

Davis, Parks, Kaups,

Bennink, Biello, 2003; 

Morrison, Allan, &

Brunfeld, 2000

Unavailable Unavailable Glass, Dearwater, & 

Campbell, 2001

Unavailable
18

DESCRIPTION OF IPV MEASURES

Scale/Assessment Characteristics Administration Method Populations Studied* 

*This list is not exhaustive.

RADAR 5 areas to help physicians

recognize and discuss 

physical IPV and safety.

Physician administered Female and male patients

in health care settings.

RADAR for Men 5 areas to help physicians 

recognize and discuss 

physical IPV victimization

and perpetration.

Physician administered Male patients in health care

settings.

Relationship Chart, The 4-item word and picture tool 

assesses frequency of physical and 

psychological IPV in the past 

4 weeks. 

Self report Women in obstetrics and gynecology 

clinics and domestic violence

support groups.

Screening Tools -

Domestic Violence

3 items; 2 assess 

physical and sexual 

violence by anyone; 1 

assesses physical IPV.

Clinician administered Female patients in health

care settings.

STaT 3 items; 2 assess physical

IPV; 1 assesses threats.

Clinician administered Female patients in non-acute section

of hospital emergency department.

Suggested Screening

Questions

3 framing items and 

8 direct items to assess

physical, sexual, and

emotional IPV.

Clinician administered Female and male patients

in health care settings.

Two-Question

Screening Tool 

2 items; 1 assesses 

physical IPV; 1 assesses

sexual violence (SV).

Clinician administered African-American, Hispanic, and 

white women in public and

private emergency departments.

Universal Violence

Prevention Screening

Protocol

7 items assess physical violence 

and SV by anyone and fear of 

harm by an intimate partner in 

the last year and

last month.

Nurse administered Women and men in 

emergency departments.

Universal Violence

Prevention Screening

Protocol - Adapted 

6 items; 1 screener and 5 

items assessing physical,

sexual, and emotional

IPV in the last year.

Clinician administered or

self report

Low income African-American 

women in emergency departments.

Victimization 

Assessment Tool 

5 items assess physical 

IPV, SV, suicidal ideation,

and risk of hurting others.

Clinician administered Women and men in primary 

care settings.

Women Abuse

Screening Tool 

(WAST)

7 items assess physical,

and emotional IPV.

Self report Abused and non-abused 

English-speaking women in clinical

health care settings and 

women’s shelters.
19

Reliability/Validity Sensitivity/Specificity Developer Articles

Unavailable Unavailable Alpert, 2004 Alpert, 1995

Unavailable Unavailable Jaeger, 2004 Unavailable

Test/retest reliability

is 0.60; Evidence of face and 

criterion validity.

Unavailable Wasson, Jette, 

Anderson, Johnson, 

Nelson, & Kilo, 2000

Unavailable

Unavailable Unavailable American College

of Obstetricians

and Gynecologists,

2003

Unavailable

Unavailable Sensitivity: 96% for STaT 

score of 1, 89% for score of 2, 

64% for score of 3; 

Specificity: 75% for score of 

1, 100% for 2 or 3 (Using 

lifetime IPV from semistructured interview as 

reference standard).

Paranjape & 

Liebschutz, 2003

Unavailable

Unavailable Unavailable Family Violence

Prevention Fund,

2002

Unavailable

Unavailable Unavailable McFarlane, 

Greenberg, Weltge, &

Watson, 1995

Unavailable

Unavailable Unavailable Dutton, Mitchell, & 

Haywood, 1996

Unavailable

Unavailable Sensitivity: 31%-95%

(Using the ISA physical and 

nonphysical scale as the gold 

standard). 

Heron, Thompson, 

Jackson, & Kaslow, 2003

Unavailable

Inter-rater agreement:

61.7%-86.7% for

female patients.

Unavailable Hoff & Rosenbaum, 

1994

Unavailable

Cronbach’s alpha: 0.75;

construct validity: 

correlation with Abuse 

Risk Inventory (ARI) of 

0.69; Discriminant 

validity: significant

differences between

abused and non-abused

women for each item. 

Unavailable Brown, Lent, Schmidt, 

& Sas, 2000 

Punukollu, 2003; 

Valente, 2002;

Brown, Lent, Brett, Sas, &

Pederson, 1996
20

DESCRIPTION OF IPV MEASURES

Scale/Assessment Characteristics Administration Method Populations Studied* 

*This list is not exhaustive.

WAST - Short 2 items assess tension in

relationship and how respondent 

and partner work out arguments.

Self report Abused and non-abused 

English-speaking women in clinical

health care settings and 

women’s shelters.

WAST - Spanish Version 8 items assess physical, sexual, 

and emotional IPV.

Self report Abused and non-abused 

Spanish-speaking women in clinical

health care settings and 

women’s shelters.

Women’s Experience

with Battering

Scale (WEB)

10 items assess

emotional IPV or battering.

Self report African-American and white women

in family practice settings.

Work/School Abuse

Scale

12 items assess physical

and nonphysical tactics

used by intimate partners

to prevent partner from or 

interfere with going to work 

or school.

Self report African-American and white women 

in domestic violence shelters.
21

Reliability/Validity Sensitivity/Specificity Developer Articles

Construct validity: 

correlation with 7-item

WAST of 0.86 and with 

ARI of 0.90.

Sensitivity: 91.7%;

Specificity: 100%

(Using a criterion cut-off 

score of 1).

Brown, Lent, Brett, 

Sas, & Pederson, 

1996

Punukollu, 2003; 

Valente, 2002;

Brown, Lent, Schmidt, &

Sas, 2000

Cronbach’s alpha: 0.91. Sensitivity: 89%;

Specificity: 94%

(Using only items 5 and 7 

and comparing to 8-item 

WAST as the gold standard).

Fogarty & Brown, 

2002

Unavailable

Cronbach’s alpha: 0.95. Sensitivity: 86.0%;

Specificity: 91.0%

(Using ISA as the gold 

standard).

Smith, Tessaro, & 

Earp, 1995

Smith, Thorton, DeVellis,

Earp, & Coker, 2002;

Coker, Bethea, Smith,

Fadden, & Brandt, 2002;

Punukollu, 2003

Full scale, Cronbach’s 

alpha: 0.82; restraint 

subscale: 0.73; interference 

subscale: 0.77; Convergent 

validity: full scale correlation 

with CTS physical assault 

subscale: 0.43; correlation 

with Psychological Abuse 

Index: 0.39.

Unavailable Riger, Ahrens, &

Blickenstaff, 2001

Unavailable
22

Abuse Assessment Screen

Instructions: Circle Yes or No for each question

1. Have you ever been emotionally or physically abused by your partner or someone important 

 to you? YES NO

2. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by 

 someone? YES NO 

 If YES, who? (Circle all that apply)

Husband Ex-Husband Boyfriend Stranger Other Multiple

 Total no. of times ___________

3. Since you’ve been pregnant, have you been slapped, kicked or otherwise physically hurt by 

 someone? YES NO

 If YES, who? (Circle all that apply)

 Husband Ex-Husband Boyfriend Stranger Other Multiple

 Total no. of times ___________

Mark the area of injury on the body map. Score each incident according to the following scale:

 SCORE

1 = Threats of abuse including use of weapon _______

2 = Slapping, pushing; no injuries and/or 

 lasting pain _______

3 = Punching, kicking, bruises, cuts, and/or

 continuing pain _______

4 = Beating up, severe contusions, burns,

 broken bones _______

5 = Head injury, internal injury, permanent 

 injury _______

6 = Use of weapon; wound from weapon _______

4. Within the last year, has anyone forced you to have sexual activities? YES NO

 If YES, who? (Circle all that apply)

 Husband Ex-Husband Boyfriend Stranger Other Multiple

 Total no. of times ___________

5. Are you afraid of your partner or anyone you listed above? YES NO

Copyright (c) 1992, American Medical Association. All rights reserved. 

Journal of the American Medical Association, 1992, 267, 3176-78.
23

Developer: Judith McFarlane, Barbara Parker, Karen Soeken, and Linda Bullock

Publication Year: 1992

Administration method: Provide a private and confidential setting. Inform each woman that all 

women attending this clinic are being assessed for abuse. Read the Abuse Assessment Screen 

(AAS) question to the woman.

Scoring procedures: If any questions on the screen are answered affirmatively, the AAS is considered 

positive for abuse (Weiss, Ernst, Cham, & Nick, 2003).

Follow-up procedures: Document the abuse and respect the woman’s response to the questions. If 

a woman reports physical abuse, give her a pencil and have her mark the areas of abuse on the body 

map (Soeken, McFarlane, Parker, & Lominack, 1998). At a minimum, all agencies should offer 

patients referral sources and legal options (Soeken et al. 1998). 

Index Reference:

McFarlane J, Parker B, Soeken K, Bullock L. (1992). Assessing for abuse during pregnancy: 

 Severity and frequency of injuries and associated entry into prenatal care. 

 Journal of the American Medical Association, 267, 3176-78.

Additional References:

Norton LB, Peipert JF, Zierler S, Lima B, Hume L. (1995). Battering in pregnancy: 

 An assessment of two screening methods. Obstetrics & Gynecology, 85, 321-25.

Soeken KL, McFarlane J, Parker B, Lominack MC. (1998). The Abuse Assessment Screen:

 A clinical instrument to measure frequency, severity, and perpetrator of abuse against 

 women. In JC Campbell (Ed.), Empowering survivors of abuse: Health care for battered 

 women and their children (pp. 195-203). Thousand Oaks, CA: Sage Publications. 

Weiss SJ, Ernst AA, Cham E, Nick TG. (2003). Development of a screen for ongoing

 intimate partner violence. Violence and Victims, 18, 131-41.
24

Encuesta Sobre El Maltrato

(Abuse Assessment Screen, Spanish Version)

1. Durante el ultimo ano, fue golpeada, bofeteada, pateada, o lasatimada fisicamente de alguna 

 otra manera por alguien? SI NO

 Si la respuesta es “si” por quien(es) ___________________________________

2. Desde que salio embarazado, ha sido golpeada, bofeteada, pateada, o lastimada fisicamente de 

 alguna otra manera por alguien? SI NO

 Si la respuesta es “si” por quien(es) ___________________________________

En el diagrama anatomico marque las partes de su cuerpo que han sido lastimadas. Valore cada 

incidente usando las siguinete escala:

 GRADO

1 = Amenazas de maltrato que incluyen el use de un arma ________

2 = Bofeteadas, empujones sin lesiones fisicas o 

 dolor permanente ________

3 = Moquestas, patadas, moretones, heridas, y/o

 dolor continuo ________

4 = Molida a palos, contusiones several, quemaduras

 fracturas de huesos ________

5 = Heridas en las cabeza, lesiones internal, lesiones

 permanentes ________

6 = Uso de armas; herida por arma ________

Si cualquiera de las situaciones valora un numero alto en la escala. 

3. Durante el ultimo ano, fue forzada a tener relaciones sexuales? SI NO

 Si la respuesta es “si” por quien(es) ___________________________________

 Cuantas veces? ___________________
25

American Medical Association Screening Questions

1. Are you in a relationship in which you have been physically hurt or threatened by 

 your partner? 

2. Are you in a relationship in which you felt you were treated badly? In what ways?

3. Has your partner ever destroyed things that you cared about?

4. Has your partner ever threatened or abused your children?

5. Has your partner ever forced you to have sex when you didn’t want to? Does he force you to 

 engage in sex that makes you feel uncomfortable?

6. We all fight at home. What happens when you and your partner fight or disagree?

7. Do you ever feel afraid of your partner?

8. Has your partner ever prevented you from leaving the house, seeing friends, getting a job, or 

 continuing your education?

9. You mentioned that your partner uses drugs/alcohol. How does he act when he is drinking 

 or on drugs? Is he ever verbally or physically abusive?

10. Do you have guns in your home? Has your partner ever threatened to use them when

 he was angry?

Reprinted with permission from the American Medical Association.

Developer: American Medical Association

Publication year: 1992

Administration method: Interview the patient alone. Begin with an opening statement such as, 

“Because abuse and violence are so common in women’s lives, I’ve begun to ask about it routinely.” 

These items are sample questions that should be asked in the physician’s own words.

Scoring procedures: This information is not available. 

Follow-up procedures: Document the abuse. Assess the patient’s safety before she leaves the medical 

setting. Provide her with written information about legal options, crisis intervention services, local 

counseling, shelters, and the National Domestic Violence Hotline (1-800-799-SAFE or www.

ndvh.org). See the website ( www.ama-assn.org/ama/pub/category/3548.html)

for more detailed information. 

Index Reference: 

American Medical Association. Diagnosis and treatment guidelines on domestic violence. (1992) 

 Chicago, IL: American Medical Association. 
26

Assessment of Immediate Safety Screening Questions

1. Are you in immediate danger?

2. Is your partner at the health facility now?

3. Do you want to (or have to) go home with your partner?

4. Do you have somewhere safe to go?

5. Have there been threats of direct abuse of the children (if s/he has children)?

6. Are you afraid your life may be in danger?

7. Has the violence gotten worse or is it getting scarier? Is it happening more often?

8. Has your partner used weapons, alcohol, or drugs?

9. Has your partner ever held you or your children against your will?

10 Does your partner ever watch you closely, follow you or stalk you?

11. Has your partner ever threatened to kill you, him/herself or your children?

Reprinted with permission from Family Violence Prevention Fund.

Produced by

The Family Violence Prevention Fund

383 Rhode Island Street, Suite 304

San Francisco, CA 94103-5133

(415) 252-8900

TTY (800) 595-4889

First Printing: September, 2002

Updated: February, 2004

Developer: Family Violence Prevention Fund

Publication year: 2002

Administration method: Clinician administered.

Scoring procedures: This information is not available. 

Follow-up Procedures: Clinicians should assess the impact of the abuse on the patient’s health 

and the pattern and history of the abuse. Clinicians also need to provide validation, information 

about domestic violence, referrals to local resources, and information about safety planning. See 

the National Consensus Guidelines (2002) for more detailed information. 

Index Reference:

Family Violence Prevention Fund. National consensus guidelines on identifying and responding to 

 domestic violence victimization in health care settings. San Francisco, CA: Author. 

 www. endabuse.org/programs/healthcare/files/Consensus.pdf
27

Bartlett Regional Hospital Domestic Violence Assessment

DOMESTIC VIOLENCE ASSESSMENT

Date _______________ Patient ID # _________________

Patient Name ____________________________________

Patient pregnant _____ yes _____ no

R= Routinely Screen

"Because violence is so common in peoples' lives, I've

begun to ask about it routinely."

A=Ask Direct Questions

_____ yes _____ no Are you afraid at home?

_____ yes _____ no Are you in a relationship in which

you have been hurt or threatened?

_____ yes _____ no Have you ever been hit, kicked, or

punched by someone close to you?

_____ # of times in the past year.

_____ yes _____ no I notice you have a number of

bruises; did someone do this to

you?

D=Document Your Findings

Patient report: Patient's description of assault (use

patient's own words)

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_____ yes _____ no Domestic Violence confirmed by

patient.

If yes, name and relationship of perpetrator:

_______________________________________________

_______________________________________________

_____ yes _____ no Domestic Violence suspected.

State reasons:

_______________________________________________

_______________________________________________

_______________________________________________

______________________________________________

A=Assess Patient Safety

_____ yes _____ no Is client afraid to go home?

_____ yes _____ no Increase in severity/frequency of

abuse?

_____ yes _____ no Threats of homicide or suicide?

_____ yes _____ no Weapon present?

_____ yes _____ no Do you want police intervention?

R=Review Options and Referrals

_____ yes _____ no Need immediate shelter?

_____ yes _____ no Hotline number/community

resources given?

_____ yes _____ no Referred to AWARE staff?

_____ yes _____ no Referred to outside source?

_____ yes _____ no Follow-up appointment made?

Date ___________________

_____ yes _____ no Can patient be called at home?

If no, is there a safe number where

patient can be reached?

_________________________

Provider Evaluation

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Provider Signature ______________________________

Check Physical Findings Indicate Where Injury Was Observed

Contusion Abrasion Laceration Bleeding Tenderness

Head

Ears

Nose

Cheeks

Mouth

Neck

Shoulder

Arms

Hands

Chest

Back

Abdomen

Genitals

Buttocks

Legs

Feet `

_____ yes _____ no Photographs taken? Addressograph
28

Developer: Bartlett Regional Hospital

Publication year: This information is not available

Administration method: Clinician administered. Begin with saying “Because domestic violence is 

so common among many peoples’ lives, I’ve begun to ask all my patients about it routinely.”

Scoring procedures: This information is not available

Follow-up procedures: Assess immediate safety, notify the medical doctor, notify security if 

necessary, and document the patient’s report. Discuss a safety plan and offer referrals for shelters 

and legal assistance. See the website listed below for more detailed information. 

Index Reference: 

Bartlett Regional Hospital Domestic Violence Assessment 

www.hospitalsoup.com/public/dvassess.pdf

Additional Reference:

Bartlett Regional Hospital Domestic Violence Protocol, from

www.hospitalsoup.com/public/brhdvprotocol.pdf
29

Computer-Based IPV Questionnaire

Intimate Partner Violence Questions

Possible emotional abuse

- Do you have a partner or spouse who gets very jealous or

 tries to control your life? YES NO

- Does your partner or spouse try to keep you away from 

 your family or friends? YES NO

- Does someone close to you sometimes say insulting 

 things or threaten you? YES NO

 (Yes to at least one of the above emotional abuse questions?) YES NO

Perception of safety

- Is there someone you are afraid to disagree with because

 they might hurt you or other family members? YES NO

Physical abuse in a current relationship

- Are you in a relationship with someone who has pushed,

 hit, kicked, or otherwise physically hurt you? YES NO

 (Possible current intimate partner abuse?) YES NO

 (Yes to any of the above domestic violence questions?) YES NO

Other violence-related questions

- Have you ever physically hurt someone close to you? YES NO

- Are you worried that you might physically hurt 

 someone close to you? YES NO

- In the past 12 months, have you ever felt so low that you 

 thought about harming yourself or committing suicide? YES NO

- Have you ever been made to have sex when you didn’t want to? YES NO

- Is there a handgun in your home or car? YES NO

- Have you ever witnessed or taken part in any argument or fight 

 where someone had a gun or knife? YES NO
30

Reprinted from Annals of Emergency Medicine, 40, Rhodes K V, Lauderdale D S, He T, Howes D 

S, Levinson W, “Between me and the computer”: Increased detection of intimate partner violence 

using a computer questionnaire, 476-84, Copyright 2002, with permission from American College 

of Emergency Physicians. 

Developer: Karin Rhodes, Diane Lauderdale, Theresa He, David Howes, and Wendy Levinson

Publication year: 2002

Administration method: Self-report via computer located in the emergency department (ED). 

Note that phrases in parentheses are intended for the individual reviewing the print out (e.g., 

nurse) and not the patient. 

Scoring procedures: Patients answer each question “yes” or “no.” If a patient responds affirmatively 

to questions about either emotional or physical abuse by a current partner, this is considered 

positive for IPV (Rhodes et al. 2002). 

Follow-up procedures: After completing the computer-based questionnaire, patients are offered a 

printout to take with them, which lists their individualized health recommendations. The results 

of the patient survey are shared with the treating physician in the ED and the summary includes 

a physician prompt to assess for domestic violence if the patient has answered one or more of 

the IPV questions affirmatively. Community service, hotline numbers, and hospital-based social 

service resources are also provided to the patient (Rhodes et al. 2002). 

Index Reference:

Rhodes KV, Lauderdale DS, He T, Howes DS, Levinson W (2002). “Between me and the

 computer”: Increased detection of intimate partner violence using a computer 

 questionnaire. Annals of Emergency Medicine, 40, 476-84. 

Additional Reference:

Heron SL, Kellermann AL (2002). Screening for intimate partner violence in the 

 emergency department: Where do we go from here? Annals of Emergency

 Medicine, 40, 493-95.
31

Danger Assessment

Several risk factors have been associated with homicides (murders) of both batterers and battered 

women in research conducted after the murders have taken place. We cannot predict what will 

happen in your case, but we would like you to be aware of the danger of homicide in situations of 

severe battering and for you to see how many of the risk factors apply to your situation. 

On the calendar, please mark the approximate dates during the past year when you were beaten by 

your husband or partner. Write on that date how long each incident lasted in approximate hours 

and rate the incident according to the following scale:

 1. Slapping, pushing; no injuries and/or lasting pain

 2. Punching, kicking; bruises, cuts, and/or continuing pain

 3. “Beating up”; severe contusions, burns, broken bones

 4. Threat to use weapon; head injury, internal injury, permanent injury

 5. Use of weapon; wounds from weapon

(If any of the descriptions for the higher number apply, use the higher number.)

Answer these questions Yes or No. The “he” in the questions refers to your husband, partner, exhusband, or whoever is currently physically hurting you. 

___1. Has the physical violence increased in frequency over the past year?

___2. Has the physical violence increased in severity over the past year and/or has a

 weapon or threat from a weapon ever been used?

___3. Does he ever try to choke you?

___4. Is there a gun in the house?

___5. Has he ever forced you to have sex when you did not wish to do so?

___6. Does he use drugs? By drugs, I mean “uppers” or amphetamines, speed, angel dust,

 cocaine, “crack”, street drugs or mixtures.

___7. Does he threaten to kill you and/or do you believe he is capable of killing you?

___8. Is he drunk every day or almost every day? (In terms of quantity of alcohol.)

___9. Does he control most or all of the your daily activities? For instance: does he tell

 you who you can be friends with, how much money you can take with you

 shopping, or when you can take the car? (If he tries, but you do not let him,

 check here: ____)

___10. Have you ever been beaten by him while you were pregnant? (If you have never

 been pregnant by him, check here: ____

___11. Is he violently and constantly jealous of you? (For instance, does he say “If I 

 can’t have you, no one can.”)

___12. Have you ever threatened or tried to commit suicide?

___13. Has he ever threatened or tried to commit suicide?

___14. Is he violent toward your children?

___15. Is he violent outside of the home?

___ Total “Yes” Answers
32

Reprinted with permission from

Jacquelyn Campbell, PhD

Johns Hopkins Bloomberg School of Public Health

Johns Hopkins University

525 N. Wolfe St. Rm 436

Baltimore, MD 21205

Developer: Jacquelyn Campbell

Publication year: 1986

Administration method: Self report.

Scoring procedures: Sum the number of total positive (i.e., “yes”) responses. 

Follow-up procedures: This measure is to be used as the basis for discussion with battered women, 

to help women assess their danger of homicide, and to help them make decisions about what to do 

in their situation.

Index Reference:

Campbell JC (1986). Nursing assessment for risk of homicide with battered women. 

 Advances in Nursing Science, 8, 36-51.

Additional References:

Campbell JC (1989). Women’s responses to sexual abuse in intimate relationships. 

 Health Care for Women International, 10, 335-46.

Campbell JC (1995). Prediction of homicide of and by battered women. In JC Campbell (Ed.), 

 Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers 

 (pp. 96 - 113). Thousand Oaks: Sage Publications. 

Goodman LA, Dutton MA, Bennett L (2000). Predicting repeat abuse among arrested

 batterers. Journal of Interpersonal Violence, 15, 63-74. 

McFarlane J, Greenberg L, Weltge A, Watson M (1995). Identification of abuse in emergency

 departments: Effectiveness of a two-question screening tool. 

 Journal of Emergency Nursing, 21, 391-94. 
33

Domestic Violence Initiative Screening Questions

Health worker to explain the following in own words:

• In this health service, we are concerned about your health and safety, so we ask all 

 women the same questions about violence at home;

• This is because violence is very common and we want to improve our response to

 families experiencing violence. 

Health worker to ask the following questions of ALL female patients on their own:

1. Are you ever afraid of your partner? YES NO

2. In the last year, has your partner hit, kicked, punched

 or otherwise hurt you? YES NO

3. In the last year, has your partner put you down, humiliated

 you or tried to control what you can do? YES NO

4. In the last year, has your partner threatened to hurt you? YES NO

If domestic violence has been identified in any of the above questions, continue to questions 5 and 6. 

5. Would you like help with any of this now? YES NO

6. Would you like us to send a copy of this form to your doctor? YES NO

 Name of Doctor:

 Address: ______________________

 ______________________

 ______________________

 ______________________

 _______________________

 Signature of Client

 _______________________

 Date

IF THIS FORM WAS NOT COMPLETED PLEASE SCREEN ON NEXT VISIT

DV Risk Status:

Domestic Violence not identified 

Domestic Violence identified, refused help 

Domestic Violence identified, help provided 

Provided With:

Contact phone numbers for DV ` 

Written information for DV 

Referral to hospital-based service 

Referral to community DV service 

Referral to GP 

Other: ____________________________

Screening Not Completed Due to: 

Presence of partner 

Presence of family member/friend 

Absence of interpreter 

Woman refused to answer the questions 

Additional Comments:

Signature of Health Professional:

______________________________

Date: 
34

Reprinted with permission from

Joan Webster, RN

Nursing Director, Research

Centre for Clinical Nursing

Royal Brisbane and Women’s Hospital

Herston 4029

Australia

Developer: Joan Webster, RN , Susan M. Stratigos, MA, and Kerry M. Grimes, BA

Publication year: 1998

Administration method: Clinician administered.

Scoring procedures: There are no scoring procedures for this tool. These questions are used as a 

guide for nurses when questioning women about their experience of violence.

Follow-up procedures: Educational materials on domestic violence are provided to women who are 

positive for partner abuse, and they are offered referral to a support agency. 

Index Reference: 

Queensland Government (1998). Domestic violence initiative screening tool, from 

 http://www.health.qld.gov.au/violence/domestic/dvi/publications.asp)

Additional Reference:

Webster J, Stratigos SM, Grimes KM (2001). Women’s responses to screening for 

 domestic violence in a health-care setting. Midwifery, 17, 289-294.

Webster J, Holt, V. (2004). Screening for partner violence: direct questioning or self-report? 

 Obstetrics & Gynecology, 103, 299-303.
35

Domestic Violence Screen for Pediatric Settings

1 Are you in a relationship now or have you ever been in a relationship in which you have been 

 harmed or felt afraid of your partner?

2. Has your partner ever hurt any of your children?

3. Are you afraid of your current partner?

4. Do you have any pets in the house?

5. Has your partner or child ever threatened or hurt any of the pets?

6. Are there any guns in your house?

Reprinted with permission from Robert M. Siegel, MD.

Developer: Robert M. Siegel, Teresa Hill, Vicki Henderson, Heather Ernst, and Barbara Boat

Publication year: 1999

Administration method: Clinician administered.

Scoring procedures: This information is not available. 

Follow-up procedures: If a woman responds affirmatively to any of the first three questions, she is 

referred to an in-house social worker. The patient is then referred to a domestic violence program, 

local women’s center, legal services, and/or family counseling (Siegel et al. 1999).

Index Reference:

Siegel RM, Hill TD, Henderson VA, Ernst HM, Boat BW (1999). Screening for domestic 

 violence in the community pediatric setting. Pediatrics 104, 874-77.
36

Domestic Violence Screening/Documentation Form

Date _____________ Patient ID# __________

Patient Name___________________________

Provider Name _________________________

Patient Pregnant? YES NO

ASSESS PATIENT SAFETY

YES NO Is abuser here now?

YES NO Is patient afraid of their partner?

YES NO Is patient afraid to go home?

YES NO Has physical violence increased in severity?

YES NO Has partner physically abused children?

YES NO Threats of homicide? 

 By whom: ______________________

YES NO Threats of suicide? 

 By whom: _____________________

YES NO Is there a gun in the home?

YES NO Alcohol or substance abuse?

YES NO Was safety plan discussed?

PHOTOGRAPHS

YES NO Consent to be photographed?

YES  NO Photographs taken?

Attach photographs and consent form

REFERRALS

Hotline number given

Legal referral made

Shelter number given

In house referral made

Describe: ___________________

Other referral made

Describe: ___________________

REPORTING

Law enforcement report made

Child Protective Services report made

Adult Protective Services report made

Developed by the Family Violence Prevention Fund and Educational Programs Associates, Inc.

Reprinted from Home Healthcare Nurse, 17, Cassidy K, How to assess and intervene in domestic 

violence situations, 664-72, Copyright 1999, with permission from Lippincott Williams & 

Wilkins.
37

Developer: Family Violence Prevention Fund and Educational Programs Associates, Inc. 

Publication year: 1996

Administration method: Home care nurse administered.

Scoring procedures: This information is not available. 

Follow-up procedures: Provide information about local resources, shelters, and legal assistance. 

Help the person plan for future safety (Cassidy 1999). See the Family Violence Prevention Fund 

guidelines for more detailed information. 

Index Reference:

Family Violence Prevention Fund (1996). Health alert: Strengthening the health care system’s

 response to domestic violence. San Francisco, CA: Author. 

Additional References: 

Cassidy K (1999). How to assess and intervene in domestic violence situations. 

 Home Healthcare Nurse, 17, 664-72. 

Family Violence Prevention Fund (2002). National consensus guidelines on identifying 

 and responding to domestic violence victimization in health care settings.

 San Francisco, CA: Author. 
38

Emergency Department Domestic Violence Screening Questions

1. Does anyone in your family have a violent temper?

2. During an argument at home have you ever worried about your safety or the safety of 

 your children?

3. Many women who present to the Emergency Department with similar injuries or complaints 

 are victims of violence at home. Could this be what happened to you?

4. Would you like to speak to someone about this?

5. Were any of the previous visits to the Emergency Department prompted by an injury or 

 symptom suffered as a victim of violence at home?

Reprinted from The Journal of Emergency Medicine, 19, Morrison LJ, Allan R, Grunfeld A, 

Improving the emergency department detection rate of domestic violence using direct questioning, 

117-24, Copyright 2000, with permission from Elsevier.

Developer: Laurie Morrison, Rebecca Allan, and Anton Grunfeld

Publication year: 2000

Administration method: Self report. 

Scoring procedures: Based on the patient’s response, individuals are grouped into the following 

categories:

Acute domestic violence = Yes to question 3, or yes to question 1 or 2 and 4

Probable acute domestic violence = Yes to question 1 or Yes to question 2, or both

Past domestic violence = Yes to question 5

Follow-up procedures: Morrison , Allan, and Grunfeld (2000) report the following:

 If the patient responded positively to question 4, the patient was offered all of the following

 options: 1) to notify the Emergency Physician, 2) immediate assistance with respect to 

 shelters, victim advocacy, police involvement or protective admission to hospital, 3) a 

 follow-up appointment the next day with the ED social worker, and 4) printed matter on 

 shelters, legal aid, social services, and community support groups, etc. (p. 119). 

Index Reference:

Morrison LJ, Allan R, Grunfeld A (2000). Improving the emergency department detection 

 rate of domestic violence using direct questioning. The Journal of Emergency 

 Medicine, 19, 117-24. 
39

Falmouth Pediatric Associates Violence Handout

Today’s Date _______

Child’s Name (optional) ______________________ Child’s Date of Birth ___/___/___

Mother’s Name (optional) _____________________ Mother’s Date of Birth ___/___/___

Please confirm that the person filling out this form is the child’s mother

 Y N

In your current relationship, have you ever been harmed or felt afraid of your partner?

 Y N No current relationship

In a previous relationship, have you ever been harmed or felt afraid of your partner?

 Y N

Has your current or past partner harmed any of your children? 

 Y N

Are there any guns in your home?

 Y N

Has any health professional ever asked you about domestic violence before?

 Y N

Note: The original handout also includes several questions about demographic characteristics 

(e.g., type of medical insurance, number of children). See Parkinson, Adams, & Emerling, 2001 

for further details. 

Reproduced with permission from Parkinson GW, Adams RC, Emerling FG (2001). Maternal 

domestic violence screening in an office-based pediatric practice. Pediatrics, 108, 1-9. 

Copyright (c) 2001 by the American Academy of Pediatrics.

Developer: Gregory Parkinson, Richard Adams, and Frank Emerling

Publication year: 2001

Administration method: Self report.

Scoring procedures: This information is not available. 

Follow-up procedures: All participants are given the Falmouth Pediatric Associates Violence 

Handout, a personalized safety plan: 

FALMOUTH PEDIATRIC ASSOCIATES VIOLENCE HANDOUT
40

Here is a PERSONALIZED SAFETY PLAN that you may find useful:

Suggestions for increasing safety in the relationship

 • I will have important phone numbers available to my children and myself.

 o Police: 911

 o National Domestic Violence Hotline: (800) 797-SAFE

 o INSERT OTHER LOCAL RESOURCES

 o SafeLink: (877) 785-2020 (toll free)

 (877) 561-2601 (hearing impaired)

 o Parents Anonymous: (800) 882-1250 (for parents with trouble coping)

I can tell _______________ and ______________ about the violence and ask them to call 

the police if they hear suspicious noises coming from my home.

 • If I leave my home, I can go (list places):

 1._______________________________

 2.________________________________

 3.________________________________

 • I can leave extra money, car keys, clothes, and documents with _____________.

 • If I leave, I will bring:

  Identification

  Birth certificates for me and my children

  Social Security cards

  School and medical records

  Money, bankbooks, credit cards

  Keys-house/car/office

  Driver’s license and registration

  Medications

  Change of clothes

  Welfare identification

  Passports

  Divorce papers

  Lease/rental agreement, house deed

  Mortgage payment book, current unpaid bills

  Insurance papers

  Address book

  Pictures, jewelry, items of sentimental value

  Children’s favorite toys and/or blankets

• To ensure safety and independence, I can: keep change for phone calls with me at all times; 

 open my own savings account; practice my escape route with a support person; and review 

 safety plan on _________________ (date).
41

Suggestions for increasing safety when relationship is over:

• I can: change the locks; install steel/metal doors, a security system, smoke detectors and an 

 outside lighting system.

• I will inform ________________ and ________________ that my partner no longer

 lives with me and ask them to call the police if s/he is observed near my home or 

 my children.

• I will tell people who take care of my children the names of those who have permission to 

 pick them up. The people who have permission are:

 1. ______________________

 2. ______________________

 3. ______________________

• I can tell ____________________ at work about my situation and ask 

 ________________ to screen my calls.

• I can avoid stores, banks, and __________________ that I used when 

 living with my battering partner.

• I can obtain a protective order form the local court house. I can keep it on 

 or near me at all times as well as leave a copy with __________________.

• If I feel down and ready to return to a potentially abusive situation, I can call

 ________________________ for support or attend workshops and support

 groups to gain support and strengthen my relationships with other people.

Index Reference: 

Parkinson GW, Adams RC, Emerling FG (2001). Maternal domestic violence screening in an 

 office-based pediatric practice. Pediatrics, 108, 1-9. 
42

HITS

Hurt, Insult, Threaten, and Scream

How often does your partner physically Hurt you?

How often does your partner Insult or talk down to you?

How often does your partner Threaten you with physical harm?

How often does you partner Scream or curse at you?

Copyright (c) 2003 by Kevin Sherin, MD, MPH. There is a $25 fee for copyright.

Reproduced with permission from

Kevin Sherin MD, MPH

Orange County Health Department

6101 Lake Ellenor Drive

Orlando, FL 32809

Kevin_Sherin@doh.state.fl.us

Developer: Kevin Sherin, James Sinacore, Xiao-Qiang Li, Robert Zitter, and Amer Shakil

Publication year: 1998

Administration method: Self report or clinician administered. 

Scoring procedures: Each question is answered on a 5-point scale: 

1 = never, 2 = rarely, 3 = sometimes, 4 = fairly often, 5 = frequently

The scores range from 4 to a maximum of 20. For female patients, A HITS cut off score 10 or 

greater was used to classify participants as victimized; for male patients, A HITS cut off score 

of 11 or greater was used to classify participants as victimized (Sherin et al 1998; Shakil et al. 

2005). 

Follow-up procedures: This information is not available. 

Index Reference:

Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. (1998). HITS: A short domestic 

 violence screening tool for use in a family practice setting. Family Medicine, 30, 508-12. 

Additional References:

Punukollu M (2003). Domestic violence: Screening made practical. The Journal of Family 

 Practice, 52, 537-43.
43

Shakil A, Donald S, Sinacore JM, Krepcho M. (2005). Validation of the HITS domestic 

 violence screening tool with males. Family Medicine, 37, 193-98.

Chen PH, Rovi S, Vega M, Jacobs A, Johnson MS. (2005). Screening for domestic violence in 

 predominantly Hispanic clinical settings, Family Practice, 22, 617-23.
44

Minnesota Tool

To our patients:

The staff at *Anyplace* Health Center know that many things happen in our lives that affect our 

physical and mental health. We have started a new program to find and help people who are now, 

or have been, in difficult or harmful relationships. Your response to this survey will help us make 

that program better. It’s easy.

1. Please read the statements below. 

2. Decide which group of statements fits your life best. 

3. Then, peel off the sticker next to that group and put it on the same colored circle at the 

 bottom of this page. 

Your answers will be kept confidential.

If you do not wish to answer this survey, please return it without moving any of the stickers. If you 

have any comments, please let us know. 

If any of the following statements applies to you, please attach the blue sticker to the bottom of the 

page. You do not need to identify your responses in any other way.

• I do not feel safe with my current partner.

• My partner often puts me down, yells at me, calls me names, or tells me I’m worthless.

• My partner is jealous, accuses me of being unfaithful, is suspicious of my activity.

• My partner does not allow me to see my friends, make phone calls, or have money without 

 his/her approval.

• My partner has hit me, slapped me, kicked me, pushed me, punched me, pulled my hair or in 

 some other way hurt me.

• I am here today because of injuries caused by my partner.

• My partner has hurt or threatened to hurt my pet(s).

• I have had sex with my partner when I didn’t want to, or performed sex acts that I didn’t 

 want to do.

If the next group of statements apply to you, please attach the green sticker to the bottom of the 

page:

• I am in a healthy relationship.

• I trust my partner to respect me and not to hurt me on purpose.

• I feel safe with my current partner.
45

Attach the yellow sticker if the following is true:

• None of the statements above applies to me

• I am not now in any close relationship with another person

Please place this survey in the envelope and give to the nurse or doctor when they come back. If 

you attached the blue sticker, one of our staff will give you a chance to talk privately about your 

answer.

Whether or not you are in a troubled relationship, we would like you to know about resources 

for people who are. If you know of a friend or relative who needs help, or feel you might need 

information in the future, please take the card attached to the back of this survey for future use.

Reproduced with permission from David McCollum, MD.

Developer: David McCollum

Publication year: 2001

Administration method: The form is Z-folded and inserted into a brown envelope (to help ensure 

privacy). The patient completes the form which is collected by the nurse or physician. If the “blue” 

sticker has been placed on the circle at the bottom of the page, the patient is moved to a private 

room and a face-to-face interview is conducted using a scripted form (see below). This is generally 

done by the physician, but could be done by nursing, social service or an advocate.

Scoring procedures: If the patient places the “blue” sticker on the circle at the bottom of the page, 

this is considered positive for IPV.

Follow-up procedures: If a patient screens positive for IPV, the following survey is generally 

completed by a physician, but could be completed by nursing, social service or an in-house advocate 

if the physician is delayed. 
46

Secondary Survey

Face-to-face

This is to be filled out if the patient screens positive for IPV. It should be completed by the nurse 

or physician caring for the patient, but may at times, be completed by social services or Family 

Violence Services Response team.

Introductory statements should be made, e.g.:

“I want to review with you your response to the survey that you just completed. I understand 

that you may be in a relationship that is difficult in one way or another. I am concerned that 

we provide care for all of your needs. So, I’d like to ask you a few more questions. Can you 

tell me which of the statements are true for you?”

  I do not feel safe with my current partner

  Does your partner frequently put you down, yell at you, call you names, or tell you 

 you’re worthless?

  Is your partner jealous, accuse you of being unfaithful, is suspicious of your activity?

  Does your partner ever prevent you from seeing your friends, making phone calls, or 

 having access to money without his/her approval?

  Has your partner ever hit you, kicked you, pushed you, punched you, pulled your hair or 

 in some other way hurt you?

  Are you here today because of injuries caused by your partner?

  Has your partner hurt or threatened to hurt your pet(s)?

  Have you had sex with your partner when you didn’t want to, or performed sex acts that 

 you didn’t want to do?

  How long have you been in this relationship? _______

  Have you ever tried to leave this relationship? _______ 

 If so, what happened? _______________

“I’m sorry those things have happened to you. Nobody deserves to be hurt or treated in 

that manner. Now I’d like to ask you some other questions that will help us know how best 

to help you.”

Determine current level of safety for the patient:

Questions should include determining whether there is escalation of the abuse and severity of 

abuse. One suggested severity ranking scale is as follows:

  Throwing things, punching the wall

  Pushing, shoving, grabbing, throwing things at the victim

  Kicking, biting

  Hitting with a closed fist

  Attempted strangulation

  Beating up/pinned to wall or floor

  Threatening with a weapon

  Assault with a weapon

Filled out by:

MD 

RN 

SW 

FVSA 

Filled out by:

MD 

RN 

SW 

FVSA 
47

Many women who are physically assaulted also feel sexually assaulted. Escalating levels of sexual 

assault or sexual coercion are risk factors for serious injury and death. Asking questions about this 

may help determine safety risk.

Survey for past issues of abuse: “Many patients who are experiencing relationships like yours, 

have also had other unpleasant or harmful events happen to them earlier in their lives, as 

teenagers or even as children. Can you tell me if any of the following has happened to you?”

  Have you been in relationships in the past that have been harmful or hurtful, either

 verbally, physically or sexually? _____________________________________

  Were you hurt physically when you were growing up? 

  Were you hurt sexually or made to do things you didn’t want to sexually when you 

 were growing up?

  Did you ever feel that you were raped? If so, did you report it?_________________

  Did you ever feel that you were being followed, watched, or stalked?_____________

  Did you grow up with one parent  , or both ?

  Were your parents in an abusive relationship/Did your parents fight a lot?________

  Was either of your parents alcoholic? _______________________

If the patient has been acutely injured or has physical evidence of injury, photographic documentation 

is desirable. Recommended procedure includes:

 1. Obtain patient consent - acknowledge that it may be uncomfortable for them to have

 pictures taken and that if they want to stop at any time, they may ask to do so.

 2. One photo should show the whole body including face.

 3. Subsequent photos are closer in.

 4. Take two pictures of each area.

 5. Number the pictures for reference (1,2,3, etc.)

 6. Offer the patient one set of pictures.

Referral options:

  Information given (package)

  Called social services

  Called shelter (Southern Valley, e.g.)

  Called police

  Called Sexual Violence Center

  Called crisis worker

  1-800-799-SAFE given

  Supportive statements only

  Other _____________________________________________________

Filled out by:

MD 

RN 

SW 

FVSA 

Filled out by:

MD 

RN 

SW 

FVSA 

Filled out by:

MD 

RN 

SW 

FVSA 
48

Index Reference:

Contact Dr. David McCollum at md4peace@earthlink.net

Additional Reference:

Family Violence Prevention Fund (2003). Interpersonal Violence New Tool for Identification in 

 Health Care Settings, Health Alert, 9, 8-9. 
49

New South Wales Department of Health Survey

In this Health Survey we have begun a new project to routinely ask all women the same questions 

about violence. This is because violence in the home is very common and can be serious and we 

want to improve our responses to women experiencing domestic violence. You don’t have to answer 

these questions if you don’t want to. This information will remain confidential to the Health Service 

except where you give us information that indicates that you or your children are at immediate risk 

of serious harm.

1. Within the last 12 months, have you been hit, slapped or hurt in other ways by your partner 

 or ex-partner?

2. Are you frightened of your partner or ex-partner?

3. Are you safe to go home when you leave here?

Reprinted from Accident and Emergency Nursing, 10, Ramsden C, Bonner M, A realistic view of 

domestic violence screening in an emergency department, 31-9, Copyright 2002, with permission 

from Elsevier. 

Developer: Clair Ramsden and Michelle Bonner

Publication year: 2002

Administration method: Clinician administered.

Scoring procedures: This information is not available. 

Follow-up procedures: If IPV was identified in any of the first three questions, a fourth question 

is asked: “Would you like some assistance with this?” Any further action taken is documented 

on the form. All women, regardless of whether domestic violence was disclosed, were still given 

an information resource card and told “here is some information that we are giving to all women 

about domestic violence” (Ramsden & Bonner 2002 p. 33).

Index Reference:

Ramsden C, Bonner M. (2002). A realistic view of domestic violence screening in an 

 emergency department. Accident and Emergency Nursing, 10, 31-9. 
50

Ongoing Abuse Screen (OAS) 

1. Are you presently emotionally or physically abused by your partner or someone 

 important to you? (Yes/No) 

2. Are you presently being hit, slapped, kicked, or otherwise physically hurt by your

 partner or someone important to you? (Yes/No) 

3. Are you presently forced to have sexual activities? (Yes/No) 

4. Are you afraid of your partner or anyone of the following (circle if appropriate): husband/ 

 wife, ex-husband/ex-wife, boyfriend/girlfriend, stranger 

5. (If pregnant) Have you ever been hit, slapped, kicked, or otherwise physically hurt by your 

 partner or someone important to you during pregnancy? (Yes/No)

Reprinted with permission from Medical Science Monitor.

Developer: Steve Weiss, Amy Ernst, Elaine Cham, and Todd Nick

Publication year: 2003

Administration method: Self report.

Scoring procedures: If any questions on the screen are answered affirmatively, the OAS is 

considered positive for ongoing abuse. 

Follow-up procedures: Referrals to social services are offered. 

Index Reference: 

Weiss SJ, Ernst AA, Cham E, Nick TG. (2003). Development of a screen for ongoing intimate 

 partner violence. Violence and Victims, 18, 131 -41.

Additional Reference:

Ernst AA, Weiss SJ, Cham E, Marquez M. (2002). Comparison of three instruments for 

 assessing ongoing intimate partner violence. Medical Science Monitor, 8, 197-201.
51

Ongoing Violence Assessment Tool (OVAT)

1. At the present time does your partner threaten you with a weapon? (Yes/No)

2. At the present time does your partner beat you up so badly that you must seek medical help? 

 (Yes/No)

3. At the present time does your partner act like he/she would like to kill you? (Yes/No)

4. My partner has no respect for my feelings. (Never, Rarely, Occasionally, Often, Always)

Reprinted with permission from Medical Science Monitor.

Developer: Steve Weiss, Amy Ernst, Elaine Cham, and Todd Nick

Publication year: 2003

Administration method: Self report.

Scoring procedures: This information is not available. 

Follow-up procedures: Referrals to social services are offered. 

Index Reference:

Weiss SJ, Ernst AA, Cham E, Nick TG. (2003). Development of a screen for ongoing intimate 

 partner violence. Violence and Victims, 18, 131-41.

Additional Reference:

Ernst AA, Weiss SJ, Cham E, Hall L, Nick TG. (2004). Detecting ongoing intimate partner 

 violence in the emergency department using a simple 4-question screen: the OVAT. 

 Violence and Victims, 19, 375-84.
52

Partner Violence Screen (PVS)

1. Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If 

 so, by whom?

2. Do you feel safe in your current relationship?

3. Is there a partner from a previous relationship who is making you feel unsafe now?

Reprinted with permission from Davis JW, Parks SN, Kaups KL, Bennink LD, Bilello JF. 

(2003). Victims of domestic violence on the trauma service: Unrecognized and underreported. 

Journal of Trauma, 54, 352-55. 

Developer: Kim Feldhaus, Jane Koziol-McLain, Holly Amsbury, Ilena Norton, Steven 

Lowenstein, and Jean Abbott

Publication year: 1997

Administration method: Clinician administered.

Scoring procedures: Feldhaus et al. (1997) report the following:

 A “yes” response to the physical violence question was considered positive for partner

 violence if the perpetrator was a current or former spouse or other intimate partner. 

 For the safety questions, women who reported feeling unsafe because of a current or past

 partner and those who were unsure about their safety were considered positive for partner

 violence...A positive response to any 1 of the 3 questions constitutes a positive screen for

 partner violence. 

Follow-up procedures: All positive screens should be documented in the medical record, and 

the patient should be offered support, counseling, and referrals to safe shelters. A plan to ensure 

their future safety should be created (Feldhaus et al. 1997). 

Index Reference:

Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR., Abbot JT.

 (1997). Accuracy of 3 brief screening questions for detecting partner violence in the 

 emergency department. Journal of the American Medical Association, 277, 1357-61.

Additional References: 

Davis JW, Parks SN, Kaups KL, Bennink LD, Bilello JF. (2003). Victims of domestic 

 violence on the trauma service: Unrecognized and underreported. 

 Journal of Trauma, 54, 352-55. 

Morrison LJ, Allan R, Grunfeld A. (2000). Improving the emergency department detection rate

 of domestic violence using direct questioning. The Journal of Emergency 

 Medicine, 19, 117-24. 
53

Patient Satisfaction and Safety Survey (PSSS)

1. Did you come to the emergency department today because you were hurt by your current or 

 former husband, boyfriend, or partner?

2. Within the past year, have you been pushed, shoved, hit, slapped, kicked, or otherwise hurt

 by a current or former husband, boyfriend, or partner?

3. Within the past year, has your current or former husband, boyfriend, or partner forced you 

 to have sexual activities?

4. Have you ever been emotionally or physically abused by your current or former husband, 

 boyfriend, or partner?

Note. The original PSSS also contained 14 other items about demographics, whether patients 

were screened for IPV, mandatory reporting, and their perception of the medical care received 

from the ED staff. 

Reprinted from Journal of Emergency Nursing, 27, Glass N, Dearwater S, Campbell J., Intimate 

partner violence screening and intervention: Data from eleven Pennsylvania and California 

community hospital emergency departments, 141-9, Copyright 2001, with permission from 

Emergency Nurses Association. 

Developer: Nancy Glass, Stephen Dearwater, and Jacquelyn Campbell

Publication year: 2001

Administration method: Self report.

Scoring procedures: This information is not available. 

Follow-up procedures: Best practice interventions are recommended. These include legal 

interventions, assessment of physical and psychological consequences of abuse, and referral to 

appropriate community resources (Glass, Dearwater & Campbell 2001). 

Index Reference: 

Glass N, Dearwater S, Campbell J. (2001). Intimate partner violence screening and intervention: 

 Data from eleven Pennsylvania and California community hospital emergency

 departments. Journal of Emergency Nursing, 27, 141-9.
54

RADAR

The acronym “RADAR” summarizes action steps physicians should take in recognizing and 

treating victims of partner violence. 

Remember to ask routinely about partner violence in your own practice.

Ask directly about violence with such questions as, “At any time, has a partner hit, kicked, or 

otherwise hurt or frightened you?” Interview your patient in private at all times.

Document information about “suspected domestic violence” or “partner violence” in the patient’s 

office.

Assess your patient’s safety. Is it safe for her to return home? Find out if any weapons are kept in 

the house, if the children are in danger, and if the violence is escalating.

Review options with your patient. Know about the types of referral options (e.g., shelters, support 

groups, legal advocates). 

Note. There is another version of the RADAR screening tool (called RADAR/SA) that also 

assesses for sexual assault with the following question: “Have you ever been sexually assaulted or 

involved in sexual acts against your will?”

Reprinted from Annals of Internal Medicine, 123, Alpert EJ. Violence in intimate relationships and 

the practicing internist: New “disease” or new agenda? 774-81 Copyright 1995, with permission 

from American College of Physicians. 

Developer: RADAR was developed by the Massachusetts Medical Society. The sexual assault 

question was developed by Dr. Wanda Filer. 

Publication year: 1992, 1996, 1999, 2004

Administration method: Physician administered.

Scoring procedures: This information is not available.

Follow-up procedures: This information is included in the screening tool. 

Index Reference:

Alpert EJ. (Ed.) (2004). Partner violence: How to recognize and treat victims of abuse, 

 Fourth Edition. Waltham, MA: Massachusetts Medical Society.

Additional Reference:

Alpert EJ. (1995). Violence in intimate relationships and the practicing internist: New “disease” 

 or new agenda? Annals of Internal Medicine, 123, 774-81.
55

RADAR for Men: A Domestic Violence Intervention 

R=Routine inquiry

A=Always ask

D=Document findings

A=Assess safety and lethality

R=Respond

Domestic violence (DV) remains a common problem encountered by clinicians in the practice of 

medicine. Traditionally, screening for DV has focused on female victims. This approach ignores 

the reality that men are commonly involved in DV, both as perpetrators and victims. 

DV is a risk to your patient’s health. A lack of provider interest in a patient’s health risks 

communicates to the patient that the status quo is acceptable. Screening for DV must provoke a 

helpful, positive response which does not humiliate or punish, but which focuses on improving the 

health, well-being and safety of all our patients. Asking men about DV is a way to protect women, 

children and men from the consequences of DV.

R= Routine inquiry of all male patients 14 and older 

Some patients will not volunteer information concerning the presence of DV, but will talk freely 

about it when asked. Asking your male patients about domestic violence should be a routine part 

of medical care, whether the patient appears to be involved in DV or not. We expect health care 

providers to ask their male patients at a first visit and on a yearly basis. 

In addition to routine inquiry, providers should ask about DV whenever patients present with 

risk factors such as substance abuse; PTSD; financial stressors such as job loss or foreclosure; 

unexplained bruises or injuries; or depression. Abuse may increase during pregnancy; partners of 

pregnant women should be asked about DV.

A=Always ask 

Below are several questions you might ask your patient to assess his involvement in a violent 

relationship. You may also want to notify the patient of exceptions to confidentiality. Specifically, if 

children are being harmed, you will have to involve the appropriate authority in your municipality; 

and if your questions discover an imminent risk to your patient or someone else, you will have to 

involve the police.

Providers have their own personal style, and this will affect how you ask your patients. The exact 

wording is not that important; what is important is that you ask. Patients report being more 

comfortable with health care providers who ask in a non-judgmental fashion and who appear to be 

genuinely interested in their well-being. 

 “Are you in a relationship in which you are being hurt or threatened?”
56

 “Have you ever used any kind of physical force against your partner?”

 “Has your partner ever pushed, grabbed, slapped, choked, or hit you?”

 “Have you ever done that to her/him?”

 “Has your partner ever forced you to have sex or perform sexual acts which you did 

 not want to do?” 

 “Have you done that to her/him?”

Some providers and patients are more comfortable with questions that assess the nature of the 

relationship first.

 “How would you characterize your relationship with your partner?”

 “All people argue. How do you and your partner handle disagreements or fights?”

 “Do your fights ever become physical?”

If a patient admits to DV, it may be difficult to determine whether the patient is primarily the 

victim or the perpetrator. Your response and advice are based to a great extent on the balance 

of power and control in the relationship. The following questions may help to further define the 

patient’s role in the relationship.

 

 “Does your partner put you down or make you feel bad about yourself?”

 “Do you do that to her/him?”

 “Are you afraid of your partner?” “Is he/she afraid of you?”

 “Has your partner stopped you from going places or seeing people?”

 “Have you done that to her/him?”

 “Who controls financial decisions in your relationship?” 

 “Do you share decisions over financial matters?” 

 “Has your partner threatened to call immigration and have you deported?”

 “Have you done that to her/him?”

If the patient answers “Yes” to either being a perpetrator or victim of DV, see what to do under the 

“Respond” section below, and then continue with the following steps. 

D=Document findings

Document in the chart that you asked about DV, and what the patient said. If the patient denies 

DV, it is important to document that you asked, as this is widely becoming a standard of care. If 

the patient admits to being involved in DV, document his story. Use quotation marks to document 

exact words. Note what injuries, if any, you observed. State your assessment of the potential for 

future violence including threats made. Describe safety and follow-up plans including your next 

scheduled appointment. Document that you asked about safety of children in the home.
57

A=Assess for safety and lethality

We can never totally predict who will do harm to their partner, but there are some questions you 

can ask to help asses the current situation.

 If your patient acknowledges being a victim of domestic violence:

 Is it safe for him to go home today?

 Is he being stalked?

 Has there been an increase in the frequency or severity of violence? 

 Are there weapons easily accessible to the perpetrator?

 Have there been threats of homicide or suicide to him, the children, and/or pets?

 If your patient admits to being a perpetrator:

 Has there been an increase in the frequency or severity of violence? 

 Is your patient tracking his partner’s behavior without his/her knowledge?

 Are there weapons easily accessible to him?

 Has there been prior contact with the police? Is there a Protection From Abuse Order?

 Are issues such as substance abuse, depression, or mental illness exacerbating his behavior?

 Should you consider contacting the victim?

It is important to identify whether there are children in the home and whether or not the children 

are being harmed. If you have evidence that the children are being harmed, you have a moral and 

legal obligation to involve the appropriate agency in your municipality.

If your patient discloses intent to imminently harm a named victim, you may have a duty to warn 

that person. Case law in California established that the provider who has reason to believe that 

someone may be at risk for injury from his/her client has a duty to initiate contact with that person 

to warn the victim. It is important for sites to develop and implement policies that reflect existing 

statutes, protect victims of DV, and protect patient confidentiality. 

R=Respond 

A general statement should first be made: “Being in a violent relationship affects the health and 

well-being, of you, your partner, your children and your community. This kind of stress can 

worsen illness, and depression, and increase substance abuse and absence from work. This is hard, 

complicated and will take time to work out.”

 If your patient is a victim of DV, you can respond as follows:

 Encourage him to talk about it: 

 “Would you like to talk about what has happened to you? Would you like some help?” 

 Validate his experience and emphasize the risk of violence to his and his families’ health

 and well-being.

 “Many people feel that only women are victims of domestic violence, but we know that 

 it can happen to anyone, including men. No one deserves to be treated this way.”

 “If you’re being hurt, your kids are being hurt, too.”
58

 If the patient does not need immediate assistance, offer information about resources in

 the community. 

 “I can put you in touch with someone who can help you.”

 Acknowledge that change is a process, and follow the situation over time:

 “I am glad you told me about this, and I want to help you to stay healthy and safe. Let’s make 

 sure we bring this up at the next visit.”

If your patient acknowledges being a perpetrator of DV, you can respond as follows:

 Positively reinforce the patient’s telling you about this, and reframe the issue as a health issue. 

 “I am glad you told me about this. I’d like to spend some time talking about this because 

 I am concerned about your health and safety. Do you feel that this behavior is affecting your 

 health in any way?”

 Make it clear that you do not condone this behavior. 

 “I strongly believe that violence is not an acceptable way to resolve disputes. The behavior 

 you describe is dangerous and illegal.”

 Remind the patient of the consequences of his abusive behavior.

 “This situation puts at risk everything you care about - your health, the health of your 

 partner and children, your freedom, your job. You must stop the violence and stay away from 

 your family if you have an urge to use force. You could be arrested and convicted for hurting 

 your partner. Also, your kids are learning from your behavior.”

 Offer hope that the patient can change his behavior and offer appropriate referrals.

 “You can do something about this. Are you interested in help to change your behavior? 

 Do you have friends or family you can turn to for help with this? Can your faith help 

 you? I know some community programs for men that can help.”

 Recognize that change is a process, and follow the pattern of behavior over time.

 “Again, I am glad you told me about this. I want to help you to stay healthy and safe. 

 Let’s make sure we bring this up at the next visit.”

Make referrals and schedule a follow-up appointment.

Reprinted with permission from Institute for Safe Families.

RADAR for Men (c) 2004 Jeffrey R. Jaeger, MD and The Family Violence Clinical Network, c/o 

The Institute for Safe Families, Philadelphia, PA 19129. 

info@instituteforsafefamilies.org www.instituteforsafefamilies.org
59

Developer: RADAR for Men was developed by Jeffrey R. Jaeger, MD and The Family Violence 

Clinical Network.

Publication year: 2004

Administration method: Physician administered.

Scoring procedures: This information is not available.

Follow-up procedures: This information is included in the screening tool. 

Index Reference:

Jaeger JR. (2004). RADAR for Men [teaching protocol]. Philadelphia, PA: Institute for 

 Safe Families.
60

The Relationship Chart

DURING THE PAST 4 WEEKS, HOW OFTEN HAVE PROBLEMS IN YOUR

HOUSHOLD LED TO:

 • INSULTING OR SWEARING?

 • YELLING?

 • THREATENING?

 • HITTING OR PUSHING?

None of the Time

A Little of the Time

Some of the Time

Most of the Time

All of the Time

Copyright: Trustees of Dartmouth College 1999. All rights reserved. Used by permission.
61

Reprinted with permission from 

John Wasson, MD

Research Director

Dartmouth Medical School

Hanover, NH 03755

Developer: John Wasson, Anne Jette, Jessica Anderson, Deborah Johnson, Eugene Nelson, and 

Charles Kilo

Publication year: 2000 

Administration method: Self report. 

Scoring procedures: Items are scored on a 5-point scale:

1 = None of the time

2 = A little of the time

3 = Some of the time

4 = Most of the time

5 = All of the time

Follow-up procedures: If a woman indicates that she has experienced an abusive relationship at 

least some of the time in the past 4 weeks, more direct inquiry about the nature of the abuse is 

indicated (Wasson et al. 2000). 

Index Reference: 

Wasson JH, Jette AM, Anderson J, Johnson DJ, Nelson EC, Kilo CM. (2000). Routine, 

 single-item screening to identify abusive relationships in women. The Journal of 

 Family Practice, 49, 1017-22. 
62

Screening Tools-Domestic Violence

American College of Obstetricians and Gynecologists

Because violence is so common in many women’s lives and because there is help available for women 

being abused, I now ask every patient about domestic violence:

1. Within the past year - or since you have become pregnant - have you been hit, slapped, 

 kicked, or otherwise physically hurt by someone?

2. Are you in a relationship with a person who threatens or physically hurts you?

3. Has anyone forced you to have sexual activities that made you feel uncomfortable?

Reprinted with permission from American College of Obstetricians and Gynecologists.

Developer: American College of Obstetricians and Gynecologists

Publication year: 2003

Administration method: Clinician administered.

Scoring procedures: This information is not available.

Follow-up procedures: Please see the ACOG website for more information. 

www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585

Index Reference: 

American College of Obstetricians and Gynecologists (2003). Screening tools-domestic violence. 

 Available at: 

 http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585

 Retrieved August 8, 2006.
63

STaT 

(Slapped, Things, and Threaten)

NOTE: This scale is available for purchase from Mary Ann Liebert, Inc. 

Developer: Anuradha Paranjape and Jane Liebschutz

Publication year: 2003

Administration method: Clinician administered.

Scoring procedures: A positive response to each item scores 1 point.

Follow-up procedures: This information is not available.

Index Reference: 

Paranjape A. Liebschutz J. (2003). STaT: A three-question screen for intimate partner violence. 

 Journal of Women’s Health, 12, 233-9.
64

Suggested Screening Questions

Framing Questions

1. Because violence is so common in many people’s lives, I’ve begun to ask all my 

 patients about it. 

2. I am concerned that your symptoms may have been caused by someone hurting you.

3. I don’t know if this is (or ever has been) a problem for you, but many of the patients I see 

 are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up 

 themselves, so I’ve started asking about it routinely.

Direct Verbal Questions

1. Are you in a relationship with a person who physically hurts you or threatens you?

2. Did someone cause these injuries? Was it your partner/husband?

3. Has your partner or ex-partner ever hit you or physically hurt you? Has he ever threatened to 

 hurt you or someone close to you?

4. Do you feel controlled or isolated by your partner?

5. Do you ever feel afraid of your partner? Do you feel you are in danger?

6. Is it safe for you to go home?

7. Has your partner ever forced you to have sex when you didn’t want to? Has your partner ever 

 refused to practice safe sex?

8. Has any of this happened to you in a previous relationship?

Reprinted with permission from Family Violence Prevention Fund.

Produced by

The Family Violence Prevention Fund

383 Rhode Island Street, Suite 304

San Francisco, CA 94103-5133

(415) 252-8900

TTY (800) 595-4889

First Printing: September, 2002

Updated: February, 2004

Developer: Family Violence Prevention Fund

Publication year: 2002

Administration method: Clinician administered.

Scoring procedures: This information is not available. 

Follow-up procedures: Clinicians should assess 1) the impact of the abuse on the patient’s health, 

and 2) the pattern and history of the abuse. Clinicians also need to provide 1) validation, 2) 

information about domestic violence, 3) referrals to local resources, and 4) information about 

safety planning. See the National Consensus Guidelines (2002) for more detailed information. 
65

Index Reference:

Family Violence Prevention Fund (2002, September). National consensus guidelines on identifying 

 and responding to domestic violence victimization in health care settings. San Francisco, CA: 

 Author. www.endabuse.org/programs/healthcare/files/Consensus.pdf
66

Two-Question Screening Tool

1. Have you ever been hit, slapped, kicked, or otherwise physically hurt by your male partner?

 (If yes, ask date of last episode)

2. Have you ever been forced to have sexual activities?

 (If yes, ask date of last episode)

Reprinted from Journal of Emergency Nursing, 21, McFarlane J, Greenberg L, Weltge A, Watson 

M, Identification of abuse in emergency departments: Effectiveness of a two-question screening 

tool, 391-4, Copyright (1995), with permission from The Emergency Nurses Association.

Developer: Judith McFarlane, Lyn Greenberg, Arlo Weltge, and Mary Watson

Publication year: 1995

Administration method: Nurse administered.

Scoring procedures: A woman is considered abused if she gives a positive response to either 

question. 

Follow-up procedures: All women who participated were offered an informational brochure on 

abuse. Women who are identified as abused need to be further assessed for level of personal danger. 

A safety plan should be discussed with them, and they should receive information regarding abuse 

and community resources (McFarlane et al. 1995). 

Index Reference:

McFarlane J, Greenberg L, Weltge A, Watson M. (1995). Identification of abuse in emergency

 departments: Effectiveness of a two-question screening tool. Journal of Emergency 

 Nursing, 21, 391-4. 
67

Universal Violence Prevention Screening Protocol

Introduction:

 1. These days many people are exposed to violence in some form.

 2. Violence is a health risk and can result in physical and emotional problems.

 3. It is our routine procedure to ask adult patients about their exposure to violence.

 4. If you are a violence victim, we can better help you if we know it.

Last

12 months

If “yes”

to 12 Months,

Last 1 Month?

1. In the past 12 months...has anyone 

threatened you with or actually used a knife or 

gun to scare or hurt you? Yes No Yes No

2. ...choked, kicked, bit, or punched you? Yes No Yes No

3. ...slapped, pushed, grabbed, or shoved you? Yes No Yes No

4. ...forced or coerced you to have sex? Yes No Yes No

5. ...have you been afraid that a current or former 

intimate partner would hurt you physically? Yes No Yes No

6. What is your relationship with the person who has hurt you?

 ___ Current or former intimate partner

 ___ Other family member

 ___ Acquaintance or friend

 ___ Coworker

 ___ Stranger

 ___ Other (specify)

7. Have the police been notified within the last month about any of these experiences? 

 YES NO

Reprinted with permission from American Medical Women’s Association.

Developer: Mary Ann Dutton, Barbara Mitchell, and Yolanda Haywood

Publication year: 1996

Administration method: Nurse administered.
68

Scoring procedures: This information is not available.

Follow-up procedures: A positive score for any of the items signals the need for further risk 

assessment.

Index Reference: 

Dutton MA, Mitchell B, Haywood Y. (1996). The emergency department as a violence

 prevention center. Journal of American Medical Women’s Association, 51, 92-6.
69

Universal Violence Prevention Screening Protocol - Adapted

Have you been in a relationship with a partner in the past year? (Yes/No)

If yes, within the past year has a partner:

(a) Slapped, kicked, pushed, choked, or punched you? (Yes/No)

(b) Forced or coerced you to have sex? (Yes/No)

(c) Threatened you with a knife or gun to scare or hurt you? (Yes/No)

(d) Made you afraid that you could be physically hurt? (Yes/No)

(e) Repeatedly used words, yelled, or screamed in a way that frightened you, threatened you, put 

you down, or made you feel rejected? (Yes/No)

Reprinted from Annals of Emergency Medicine, 42, Heron SL, Thompson MP, Jackson E, Kaslow 

NJ, Do responses to an intimate partner violence screen predict scores on a comprehensive 

measure of intimate partner violence in low-income black women? 483-91, Copyright (2003), with 

permission from American College of Emergency Physicians.

Developer: Sheryl Heron, Martie P. Thompson, Emily Jackson, and Nadine Kaslow

Publication year: 2003

Administration method: Clinician administered or self report.

Scoring procedures: This information is not available. 

Follow-up procedures: This information is not available. 

Index Reference: 

Heron SL, Thompson MP, Jackson E, Kaslow NJ. (2003). Do responses to an intimate partner 

 violence screen predict scores on a comprehensive measure of intimate partner violence 

 in low-income black women? Annals of Emergency Medicine, 42, 483-91.
70

Victimization Assessment Tool

1. Have you been troubled or injured by any kind of abuse or violence (e.g., hit by partner, 

 forced sex)?

 Yes _____ No _____ Not sure ______ Refused ______

 If yes, check one: 

 By someone in your family ______

 By an acquaintance or stranger ______

 Describe: 

2. If yes, has something like this ever happened before?

 Yes _____ No _____ If yes, when? ___________

 Describe:

3. Do you have anyone you can turn to or rely on now to protect you from possible 

 further injury?

 Yes _____ No _____ If yes, who? ____________ 

4. Do you feel so badly now that you have thought of hurting yourself/suicide?

 Yes _____ No _____

 If yes, what have you thought about doing? 

 _____________________________________________________________

5. Are you so angry about what’s happened that you have considered hurting someone else?

 Yes _____ No _____

 If yes, describe briefly: _____________________________

Reprinted from Journal of Advanced Nursing, 20, Hoff LA, Rosenbaum L, A victimization 

assessment tool: Instrument development and clinical implications, 627-34, Copyright (1994) 

with permission from Blackwell Publishing. 
71

Developer: Lee Ann Hoff and Linda Rosenbaum

Publication year: 1994

Administration method: Clinician administered. 

Scoring procedures: According to Hoff and Rosenbaum (1994), individuals are classified into one 

of the following risk groups based on the degree of victimization:

 1 = No experience of physical violence or abuse.

 2 = Experience of abuse/violence with minor physical and/or emotional trauma (e.g., 

 verbal arguments that occasionally escalate to pushing and shoving or mild slapping. 

 History may include past victimization that is no longer problematic.)

 3 = Experience of abuse/violence with moderate physical and/or emotional trauma 

 (e.g., abused several times a month in recent years resulting in moderate trauma or 

 emotional distress. No threat to life, no weapons available. History may include past 

 victimization that is still somewhat problematic.)

 4 = Experience of abuse/violence with severe physical and/or emotional trauma (e.g., 

 violently attacked or physically abused in recent years, resulting in physical injury 

 requiring medical treatment. Threats to kill, no guns available. History may include 

 serious victimization requiring medical and/or physical treatment.)

 5 = Life-threatening or prolonged abuse/violence with very severe physical and/or 

 emotional trauma (e.g., recent or current life-threatening physical abuse, potentially 

 lethal assault or threats with available deadly weapons. History may include severe 

 abuse requiring medical treatment, frequent or ongoing sexual abuse, recent rape, 

 other physical attack requiring extensive medical treatment.)

Follow-up procedures: If rating is Level 2 or above on the assessment scale, clinician should discuss 

with client and recommend referral to victim care specialist for full assessment and follow-up 

care.

Index Reference:

Hoff LA, Rosenbaum L. (1994). A victimization assessment tool: Instrument development and 

 clinical implications. Journal of Advanced Nursing, 20, 627-34.
72

Woman Abuse Screening Tool (WAST)

1. In general, how would you describe your relationship?

  A lot of tension

  Some tension

  No tension

2. Do you and your partner work out arguments with:

  Great difficulty?

  Some difficulty?

  No difficulty?

3. Do arguments ever result in you feeling down or bad about yourse1f?

  Often

  Sometimes

  Never

4. Do arguments ever result in hitting, kicking or pushing?

  Often

  Sometimes

  Never

5. Do you ever feel frightened by what your partner says or does?

  Often

  Sometimes

  Never

6. Has your partner ever abused you physically?

  Often

  Sometimes

  Never

7. Has your partner ever abused you emotionally?

  Often

  Sometimes

  Never

8. Has your partner ever abused you sexually?

  Often

  Sometimes

  Never
73

Reprinted from Family Medicine, 28, Brown JB, Lent B, Brett PJ, Sas G, Pederson LL, Development 

of the Woman Abuse Screening Tool for use in family practice, 422-28, Copyright (1996) with 

permission from the Society of Teachers of Family Medicine, www.stfm.org. 

Developer: Judith Belle Brown, Barbara Lent, Gail Schmidt, and George Sas

Publication year: 2000 

Administration method: Self report.

Scoring procedures: Recode responses to reflect a higher score for higher reported frequency of 

experiences and sum the WAST scores for individuals who answered all 8 items. 

Follow-up procedures: This information is not available.

Index Reference: 

Brown JB, Lent B, Schmidt G, Sas G. (2000). Application of the woman abuse screening tool

 (WAST) and WAST-short in the family practice setting. 

 The Journal of Family Practice, 49, 896-903. 

Additional References:

Brown JB, Lent B, Brett PJ, Sas G, Pederson LL. (1996). Development of the Woman Abuse 

 Screening Tool for use in family practice. Family Medicine, 28, 422-28.

Punukollu M. (2003). Domestic violence: Screening made practical. 

 The Journal of Family Practice, 52, 537-43.

Valente SM. (2002). Evaluating intimate partner violence. Journal of the American Academy of 

 Nurse Practitioners, 14, 505-13. 
74

Woman Abuse Screening Tool (WAST) - Short

1. In general, how would you describe your relationship?

  A lot of tension

  Some tension

  No tension

2. Do you and your partner work out arguments with:

  Great difficulty?

  Some difficulty?

  No difficulty?

Reprinted from Family Medicine, 28, Brown JB,Lent B, Brett PJ, Sas G, Pederson LL, Development 

of the Woman Abuse Screening Tool for use in family practice, 422-28, Copyright (1996) with 

permission from the Society of Teachers of Family Medicine, www.stfm.org. 

Developer: Judith Belle Brown, Barbara Lent, Pamela J. Brett, George Sas,

and Linda L. Pederson

Publication year: 1996 

Administration method: Self report.

Scoring procedures: Assign a score of 1 to the most extreme positive response (“a lot of tension”) 

and a score of 0 to other response options. Scores range from 0 to 2 and criterion cut-off score is 1. 

Follow-up procedures: According to the authors, if a woman answers affirmatively to these two 

questions, the physician can then use the remaining WAST questions or other appropriate 

questions to elicit more information about the patient’s experience of abuse. This can ultimately 

lead to an assessment of additional factors such as history of prior abuse, extent and severity of 

abuse, sources of support, need for legal assistance, and information about available community 

resources (Brown, et al., 1996).

Index Reference: 

Brown JB, Lent B, Brett PJ, Sas G, Pederson LL. (1996). Development of the Woman Abuse 

 Screening Tool for use in family practice. Family Medicine, 28, 422 -28.

Additional References:

Brown JB, Lent B, Schmidt G, Sas G. (2000). Application of the woman abuse screening tool

 (WAST) and WAST-short in the family practice setting. 

 The Journal of Family Practice, 49, 896-903. 

Punukollu M. (2003). Domestic violence: Screening made practical. The Journal of Family 

 Practice, 52, 537-43.

Valente SM. (2002). Evaluating intimate partner violence. Journal of the American Academy of 

 Nurse Practitioners, 14, 505-13. 
75

Pruebas De La Violencia Contra La Mujer

(Women Abuse Screening Tool (WAST), Spanish Version)

1. En general, como describiría usted su relación con su pareja?

  Mucha tension 

  Alguna tension 

  Sin tension

2. Usted y su pareja resuelven sus discusiones (argumentos) con...

  Mucha dificultad

  Alguna dificultad

  Sin dificultad

3. Al terminar las discusiones usted se siente decalda o mal con usted misma?

  Muchas veces

  A veces

  Nunca

4. Las discusiones terminan en golpes, patadas, o empujones?

  Muchas veces

  A veces

  Nunca

5. Siente miedo de lo que su pareja diga o haga?

  Muchas veces

  A veces

  Nunca

6. Su pareja ha abusado de usted fisicamente?

  Muchas veces

  A veces

  Nunca

7. Su pareja ha abusado de usted emocionalmente?

  Muchas veces

  A veces

  Nunca

8. Su pareja ha abusado de usted sexualmente?

  Muchas veces

  A veces

  Nunca
76

Reprinted with permission from American Board of Family Medicine.

Developer: Colleen T. Fogerty and Judith Belle Brown

Publication year: 2002

Administration method: Self report.

Scoring procedures: This information is not available. 

Follow-up procedures: This information is not available.

Index Reference: 

Fogarty CT, Brown JB. (2002). Screening for abuse in Spanish-speaking women. Journal of the 

 American Board of Family Practitioners, 15, 101-11.
77

Description of how your 

partner makes you feel:

Agree 

strongly

Agree

somewhat

Agree

a little

Disagree

a little

Disagree

somewhat

Disagree

strongly

1. He makes me feel unsafe

 even in my own home

6 5 4 3 2 1

2. I feel ashamed of the 

 things he does to me

6 5 4 3 2 1

3. I try not to rock the boat

 because I am afraid of

 what he might do

6 5 4 3 2 1

4. I feel like I am

 programmed to react in a

 certain way to him

6 5 4 3 2 1

5. I feel like he keeps me

 prisoner

6 5 4 3 2 1

6. He makes me feel like

 I have no control over my 

 life, no power, no protection

6 5 4 3 2 1

7. I hide the truth from others 

 because I am afraid not to

6 5 4 3 2 1

8. I feel owned and

 controlled by him

6 5 4 3 2 1

9. He can scare me without

 laying a hand on me

6 5 4 3 2 1

10. He has a look that goes

 straight through me and

 terrifies me

6 5 4 3 2 1

Reprinted from Violence Against Women, 8(10), Smith PH, Thornton GE, DeVellis R, Earp JA, 

Coker AI. A population-based study of prevalence and distinctiveness of battering, physical assault, 

and sexual assault in intimate partner relationships, 1208-32, Copyright 2002, with premission 

from Sage Publications.

Women’s Experience with Battering Scale (WEB)

Following are a number of statements that women have used to describe their relationships with 

their “male partners.” Please read each statement and then circle the answer that best describes 

how much you agree or disagree in general with each one as a description of your relationship with 

your “partner.” If you do not now have a partner, think about your last one. There are no right or 

wrong answers; just circle the number that seems to best describe how much you agree or disagree 

with it. 
78

Developer: Paige Hall Smith, Irene Tessaro, and Jo Anne Earp

Publication year: 1995

Administration method: Self report.

Scoring procedures: Reverse score and then add the responses for all items. Range of scores is 

10 to 60. A score of 20 or higher is a positive screening test for battering (Coker et al. 2002; 

Punukollu 2003).

Follow-up procedures: This information is not available. 

Index Reference:

Smith PH, Tessaro I, Earp JA. (1995). Women’s experiences with battering: A conceptualization

 from qualitative research. Women’s Health Issues, 5, 173-82.

Additional References: 

Smith PH, Thornton GE, DeVellis R, Earp JA, Coker AI. (2002). A population-based study of

 the prevalence and distinctiveness of battering, physical assault, and sexual assault in 

 intimate partner relationships. Violence Against Women, 8, 1208-32.

Coker AL, Bethea L, Smith PH, Fadden MK, Brandt HM. (2002). Missed opportunities: 

 Intimate partner violence in family practice settings. Preventive Medicine, 34, 445-54.

Punukollu, M. (2003). Domestic violence: Screening made practical. The Journal of Family 

 Practice, 52, 537-43.
79

Work/School Abuse Scale

The following questions are about things that _________ (ABUSER’S NAME) may have 

done to bother you at work or to keep you from going to work. During your relationship with 

________ did he ever....

-----------------------------------------------------------------------------------------------------------

1. Come to your work to harass you? YES NO N/A

2. Bother your coworkers? YES NO N/A

3. Lie to your coworkers about you? YES NO N/A

4. Sabotage the car so you couldn’t go to work? YES NO N/A

5. Not show up for childcare so you couldn’t go to work? YES NO N/A

6. Steal your keys or money so you couldn’t go to work? YES NO N/A

7. Refuse to give you a ride to work? YES NO N/A

8. Physically restrain you from going to work? YES NO N/A

9. Threaten you to prevent your going to work? YES NO N/A

10. Physically force you to leave work? YES NO N/A

11. Lie about your children’s health or safety to make you YES NO N/A

 leave work? 

12. Threaten you to make you leave work? YES NO N/A

The following questions are about things that _________ (ABUSER’S NAME) may have 

done to bother you at school or to keep you from going to school. During your relationship with 

________ did he ever....

-----------------------------------------------------------------------------------------------------------

1. Come to school to harass you? YES NO N/A

2. Bother your school friends or teachers? YES NO N/A

3. Lie to your friends/teachers about you? YES NO N/A

4. Sabotage the car so you couldn’t go to school? YES NO N/A 

5. Not show up for childcare so you couldn’t go to school? YES NO N/A

6. Steal your keys or money so you couldn’t go to school? YES NO N/A

7. Refuse to give you a ride to school? YES NO N/A

8. Physically restrain you from going to school? YES NO N/A

9. Threaten you to prevent your going to school? YES NO N/A

10. Physically force you to leave school? YES NO N/A

11. Lie about your children’s health or safety to make you YES NO N/A

 leave school?

12. Threaten you to make you leave school? YES NO N/A
80

Developer: Stephanie Riger, Courtney Ahrens, and Amy Blickenstaff

Publication year: 2001 

Administration method: Self-report. 

Scoring procedures: There are two subscales. The Restraint Tactics Subscale contains 6 items 

that assess the use of tactics that prevent the respondent from going to work or school and 

includes items 4-9. The Interference Tactics Subscale contains 6 items that assess the use of 

tactics aimed at making the respondent leave work or school and includes items 1-3 and 10-12. 

Items are scored as yes = 1, no = 0.

Follow-up procedures: This information is not available.

Index Reference:

Riger S, Ahrens C, Blickenstaff A. (2001). Measuring interference with employment and 

 education reported by women with abusive partners: Preliminary data. In D. O’Leary 

 and R. Maiuro (Eds.), Psychological abuse in violent domestic relations (pp. 119 -33). 

 New York, NY: Springer Publishing Co.

Reprinted from Psychological Abuse in Violence Domestic Relations, O’Leary D, Maiuro R, 

(Eds.), Copyright 2001, Springer Publishing Company, Inc., New York 10036. Used with 

permission.


SECTION B.

SEXUAL VIOLENCE (SV)
84

DESCRIPTION OF SV MEASURES

Scale/Assessment Characteristics Administration Method Populations Studied* 

*This list is not exhaustive. 

Abuse Assessment

Screen (AAS)

5 items assess frequency and perpetrator of physical, sexual, and 

emotional abuse by anyone. 

Body map to document 

area of injury. 

Clinician administered Abused pregnant and nonpregnant

African-American, Hispanic, and 

white women in health and prenatal 

clinics and emergency departments.

AAS - Spanish Version 5 items assess frequency and 

perpetrator of physical, sexual, 

and emotional abuse by anyone. 

Body map to document 

area of injury. 

Clinician administered Abused pregnant and nonpregnant

African-American, Hispanic, and 

white women in health and prenatal 

clinics and emergency departments.

Computer Based Intimate 

Partner Violence (IPV)

Questionnaire

14 items assess physical

and emotional IPV, 

suicidal ideation, 

perpetration, sexual violence

victimization, and access 

to handguns.

Self report via a computer

in emergency department

African-American and white men and 

women in emergency departments. 

Minnesota Tool 13 items and color-coded

stickers assess physical, 

emotional, and sexual IPV.

Self report Women and men in a community 

hospital setting.

RADAR 5 areas to help physicians

recognize and discuss

physical IPV and safety. 

One added item on SV by 

any perpetrator.

Physician administered Female and male patients in 

health care settings.

SAVE: A Tool for Screening for 

Sexual Assault

4 areas assist health

care workers in Screening

Asking, Validating, and

Evaluating patients for

sexual assault.

Clinician administered English-speaking women and men in 

health care settings. 

SAVE - Spanish Version 4 areas assist health

care workers in Screening

Asking, Validating, and

Evaluating patients for

sexual assault. 

Clinician administered Spanish-speaking women and men in 

health care settings. 

Screening ToolsDomestic Violence3 items; 2 assess 

physical and sexual 

violence by anyone; 1

assesses physical IPV.

Clinician administered Female patients in health care settings. 

Screening Tools-Sexual Assault 5 items assess sexual assault and 

knowledge of ways to 

reduce risk of assault.

Clinician administered Teenage and adult women in 

primary care clinics.

Sexual and Physical

Abuse History Questionnaire

6 items assess child or

adult sexual abuse;

4 items assess child or

adult physical abuse. 

Self report African-American and white women 

in a gastroenterology clinic.
85

Reliability/Validity Sensitivity/Specificity Developer Articles

Test/retest reliability across 

the same trimester for 

pregnant women: 83%.

Sensitivity: 93%;

Specificity: 55%.

(The Index of Spouse Abuse [ISA] is 

used as the gold standard.) 

McFarlane, Parker,

Soeken, & Bullock, 

1992

Norton, Peipert, Zierler, 

Lima, & Hume, 1995; 

Soeken, McFarlane, 

Parker, & Lominack,1998; 

Weiss, Ernst, Cham, &

Nick, 2003

Unavailable Unavailable Unavailable Unavailable

Unavailable Unavailable Rhodes, Lauderdale, 

He, Howes, &

Levinson, 2002 

Heron & Kellermann, 2002

Unavailable Unavailable md4peace@earthlink.net Family Violence Prevention 

Fund, 2003

Unavailable Unavailable Alpert, 2004 Alpert, 1995

Unavailable Unavailable Stevens & New

York State Coalition

Against Sexual

Assault, 2003

Unavailable

Unavailable Unavailable Stevens & New

York State Coalition

Against Sexual

Assault, 2003

Unavailable

Unavailable Unavailable American College

of Obstetricians

and Gynecologists, 2003

Unavailable

Unavailable Unavailable American College

of Obstetricians

and Gynecologists, 2003

Unavailable

Test/retest reliability for

sexual abuse items: 81%.

Sensitivity for sexual abuse was

71% at time 1; 88% at time 2;

Specificity for sexual abuse was

91% at time 1; 85% at time 2.

(The structured abuse interview is used as the gold standard.)

Leserman, Drossman, 

& Li, 1995

Unavailable
86

DESCRIPTION OF SV MEASURES

Scale/Assessment Characteristics Administration Method Populations Studied* 

*This list is not exhaustive. 

Two-Question 

Screening Tool 

2 items; 1 assesses 

physical IPV; 1 assesses SV.

Clinician administered African-American, Hispanic, and 

white women in public and private

emergency departments.

Universal Violence

Prevention Screening

Protocol

7 items assess physical 

violence and SV by anyone 

and fear of harm by an intimate 

partner in the last year and

last month.

Nurse administered Women and men in 

emergency departments.

Universal Violence

Prevention Screening

Protocol - Adapted 

6 items; 1 screener and 5 

items assess physical,

sexual, and emotional

IPV in the last year.

Clinician administered or

self report

Low income African-American 

women in emergency departments.

Victimization 

Assessment Tool 

5 items assess physical 

IPV, SV, suicidal ideation,

and risk of hurting others.

Clinician administered Women and men

in primary care settings. 
87

Reliability/Validity Sensitivity/Specificity Developer Articles

Unavailable Unavailable McFarlane, 

Greenberg, Weltge, &

Watson, 1995

Unavailable

Unavailable Unavailable Dutton, Mitchell, & 

Haywood, 1996

Unavailable

Unavailable Sensitivity: 31%-95%

(The ISA physical and nonphysical 

scale is used as the gold standard.) 

Heron, Thompson, 

Jackson, & Kaslow, 2003

Unavailable

Inter-rater agreement:

61.7%-86.7% for

women patients.

Unavailable Hoff & Rosenbaum, 1994 Unavailable
88

Abuse Assessment Screen 

Instructions: Circle Yes or No for each question

1. Have you ever been emotionally or physically abused by your partner or someone

 important to you? YES NO 

2. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by

 someone? YES NO 

 If YES, who? (Circle all that apply)

 Husband Ex-Husband Boyfriend Stranger Other Multiple

 Total no. of times ___________

3. Since you’ve been pregnant, have you been slapped, kicked or otherwise physically hurt by 

 someone? YES NO

 If YES, who? (Circle all that apply)

 Husband Ex-Husband Boyfriend Stranger Other Multiple

 Total no. of times ___________

Mark the area of injury on the body map. Score each incident according to the following scale:

 SCORE

1 = Threats of abuse including use of weapon _______

2 = Slapping, pushing; no injuries and/or 

 lasting pain _______

3 = Punching, kicking, bruises, cuts, and/or

 continuing pain _______

4 = Beating up, severe contusions, burns,

 broken bones _______

5 = Head injury, internal injury, permanent 

 injury _______

6 = Use of weapon; wound from weapon _______

4. Within the last year, has anyone forced you to have sexual activities? YES NO

 If YES, who? (Circle all that apply)

 Husband Ex-Husband Boyfriend Stranger Other Multiple

 Total no. of times ___________

5. Are you afraid of your partner or anyone you listed above? YES NO

Copyright (c) 1992, American Medical Association. All rights reserved. 

Journal of the American Medical Association, 1992, 267, 3176-78.

Developer: Judith McFarlane, Barbara Parker, Karen Soeken, & Linda Bullock
89

Publication year: 1992

Administration method: Provide a private and confidential setting. Inform each woman that all 

women attending this clinic are assessed for abuse. Read the Abuse Assessment Screen (AAS) 

question to the woman. 

Scoring procedures: If any questions on the screen are answered affirmatively, the AAS is considered 

positive for abuse (Weiss et al. 2003).

Follow-up procedures: Document the abuse and respect the woman’s response to the questions. If 

a woman reports physical abuse, give her a pencil and have her mark the areas of abuse on the body 

map (Soeken et al. 1998). At a minimum, all agencies should offer patient’s referral sources, and 

legal options (Soeken et al. 1998). 

Index Reference:

McFarlane J, Parker B, Soeken K, Bullock L. (1992). Assessing for abuse during pregnancy: 

 Severity and frequency of injuries and associated entry into prenatal care. Journal of the 

 American Medical Association, 267, 3176 -78.

Additional References:

Norton LB, Peipert JF, Zierler S, Lima B, Hume L. (1995). Battering in pregnancy: An 

 assessment of two screening methods. Obstetrics & Gynecology, 85, 321 -25.

Soeken KL, McFarlane J, Parker B, Lominack MC. (1998). The Abuse Assessment Screen:

 A clinical instrument to measure frequency, severity, and perpetrator of abuse against 

 women. In JC Campbell (Ed.), Empowering survivors of abuse: Health care for battered 

 women and their children (pp. 195 - 203). Thousand Oaks, CA: Sage Publications. 

Weiss SJ, Ernst AA, Cham E, Nick TG. (2003). Development of a screen for ongoing intimate 

 partner violence. Violence and Victims, 18, 131 -41.
90

Encuesta Sobre El Maltrato

(Abuse Assessment Screen, Spanish Version)

1. Durante el ultimo ano, fue golpeada, bofeteada, pateada, o lasatimada fisicamente de alguna 

 otra manera por alguien? SI NO

 Si la respuesta es “si” por quien(es) ___________________________________

2. Desde que salio embarazado, ha sido golpeada, bofeteada, pateada, o lastimada fisicamente 

 de alguna otra manera por alguien? SI NO

 Si la respuesta es “si” por quien(es) ___________________________________

En el diagrama anatomico marque las partes de su cuerpo que han sido lastimadas. Valore cada 

incidente usando las siguinete escala:

 GRADO

1 = Amenazas de maltrato que incluyen el use de un arma ________

2 = Bofeteadas, empujones sin lesiones fisicas o 

 dolor permanente ________

3 = Moquestas, patadas, moretones, heridas, y/o

 dolor continuo ________

4 = Molida a palos, contusiones several, quemaduras

 fracturas de huesos ________

5 = Heridas en las cabeza, lesiones internal, lesiones

 permanentes ________

6 = Uso de armas; herida por arma ________

Si cualquiera de las situaciones valora un numero alto en la escala. 

3. Durante el ultimo ano, fue forzada a tener relaciones sexuales? SI NO

 Si la respuesta es “si” por quien(es) ___________________________________

 Cuantas veces? ___________________
91

Computer-Based IPV Questionnaire

Intimate Partner Violence Questions

Possible emotional abuse

- Do you have a partner or spouse who gets very jealous or 

 tries to control your life? YES NO

- Does your partner or spouse try to keep you away from 

 your family or friends? YES NO

- Does someone close to you sometimes say insulting 

 things or threaten you? YES NO

 (Yes to at least one of the above emotional abuse questions?) YES NO

Perception of safety

 Is there someone you are afraid to disagree with because 

 they might hurt you or other family members? YES NO

Physical abuse in a current relationship

- Are you in a relationship with someone who has pushed, 

 hit, kicked, or otherwise physically hurt you? YES NO

 (Possible current intimate partner abuse?) YES NO

 (Yes to any of the above domestic violence questions?) YES NO

Other violence-related questions

- Have you ever physically hurt someone close to you? YES NO

- Are you worried that you might physically hurt 

 someone close to you? YES NO

- In the past 12 months, have you ever felt so low that you 

 thought about harming yourself or committing suicide? YES NO

- Have you ever been made to have sex when you didn’t want to? YES NO

- Is there a handgun in your home or car? YES NO

- Have you ever witnessed or taken part in any argument or fight 

 where someone had a gun or knife? ` YES NO
92

Reprinted from Annals of Emergency Medicine, 40, Rhodes K V, Lauderdale D S, He T, Howes 

D S, Levinson W, “Between me and the computer”: Increased detection of intimate partner 

violence using a computer questionnaire, 476-84, Copyright 2002, with permission from 

American College of Emergency Physicians. 

Developer: Karin Rhodes, Diane Lauderdale, Theresa He, David Howes, and Wendy Levinson

Publication year: 2002

Administration method: Self-report via computer located in the emergency department (ED). 

Note that phrases in parentheses are intended for the individual reviewing the print out (e.g., 

nurse) and not the patient. 

Scoring procedures: Patients answer each question “yes” or “no.” If a patient responds 

affirmatively to questions about either emotional or physical abuse by a current partner, this is 

considered positive for IPV (Rhodes et al. 2002). 

Follow-up procedures: After completing the computer-based questionnaire, patients are offered a 

printout to take with them, which lists their individualized health recommendations. The results 

of the patient survey are shared with the treating physician in the ED and the summary includes 

a physician prompt to assess for domestic violence if the patient has answered one or more of 

the IPV questions affirmatively. Community service, hotline numbers, and hospital-based social 

service resources are also provided to the patient (Rhodes et al. 2002). 

Index Reference:

Rhodes KV, Lauderdale DS, He T, Howes DS, Levinson W (2002). “Between me and 

 the computer”: Increased detection of intimate partner violence using a computer 

 questionnaire. Annals of Emergency Medicine, 40, 476-84. 

Additional Reference:

Heron SL, Kellermann AL (2002). Screening for intimate partner violence in the emergency 

 department: Where do we go from here? Annals of Emergency Medicine, 40, 493-95.
93

Minnesota Tool

To our patients:

The staff at *Anyplace* Health Center know that many things happen in our lives that affect our 

physical and mental health. We have started a new program to find and help people who are now, 

or have been, in difficult or harmful relationships. Your response to this survey will help us make 

that program better. It’s easy.

1. Please read the statements below. 

2. Decide which group of statements fits your life best. 

3. Then, peel off the sticker next to that group and put it on the same colored circle at the

 bottom of this page. 

Your answers will be kept confidential.

If you do not wish to answer this survey, please return it without moving any of the stickers.

If you have any comments, please let us know. 

If any of the following statements applies to you, please attach the blue sticker to the bottom of the 

page. You do not need to identify your responses in any other way.

 • I do not feel safe with my current partner.

 • My partner often puts me down, yells at me, calls me names, or tells me I’m worthless.

 • My partner is jealous, accuses me of being unfaithful, is suspicious of my activity.

 • My partner does not allow me to see my friends, make phone calls, or have money 

 without his/her approval.

 • My partner has hit me, slapped me, kicked me, pushed me, punched me, pulled my hair 

 or in some other way hurt me.

 • I am here today because of injuries caused by my partner.

 • My partner has hurt or threatened to hurt my pet(s).

 • I have had sex with my partner when I didn’t want to, or performed sex acts that I didn’t 

 want to do.

If the next group of statements apply to you, please attach the green sticker to the bottom

of the page:

 • I am in a healthy relationship.

 • I trust my partner to respect me and not to hurt me on purpose.

 • I feel safe with my current partner.
94

Attach the yellow sticker if the following is true:

 • None of the statements above applies to me

 • I am not now in any close relationship with another person

Please place this survey in the envelope and give to the nurse or doctor when they come back. 

If you attached the blue sticker, one of our staff will give you a chance to talk privately about your 

answer.

Whether or not you are in a troubled relationship, we would like you to know about resources 

for people who are. If you know of a friend or relative who needs help, or feel you might need 

information in the future, please take the card attached to the back of this survey for future use.

Reproduced with permission from David McCollum, MD.

Developer: David McCollum

Publication year: 2001

Administration method: The form is Z-folded and inserted into a brown envelope (to help ensure 

privacy). The patient completes the form and the nurse or physician collects it. If the “blue” sticker 

has been placed on the circle at the bottom of the page, the patient is moved to a private room and 

a face-to-face interview is carried out using a scripted form (see below). This is generally done by 

the physician, but could be done by nursing, social service or an advocate.

Scoring procedures: If the patient places the “blue” sticker on the circle at the bottom of the page, 

this is considered positive for intimate partner violence (IPV).

Follow-up procedures: If a patient screens positive for IPV, the following survey is completed. It 

is generally completed by a physician, but could be completed by nursing, social service or an inhouse advocate if the physician is delayed. 
95

Filled out by:

MD 

RN 

SW 

FVSA 

Filled out by:

MD 

RN 

SW 

FVSA 

Secondary Survey

Face-to-face

This is to be filled out if the patient screens positive for IPV. It should be completed by the nurse 

or physician caring for the patient, but may at times, be completed by social services or Family 

Violence Services Response team.

Introductory statements should be made, e.g.:

“I want to review with you your response to the survey that you just completed. I understand 

that you may be in a relationship that is difficult in one way or another. I am concerned that 

we provide care for all of your needs. So, I’d like to ask you a few more questions. Can you 

tell me which of the statements are true for you?”

  I do not feel safe with my current partner

  Does your partner frequently put you down, yell at you, call you names, or 

 tell you you’re worthless?

  Is your partner jealous, accuse you of being unfaithful, is suspicious of 

 your activity?

  Does your partner ever prevent you from seeing your friends, making

 phone calls, or having access to money without his/her approval?

  Has your partner ever hit you, kicked you, pushed you, punched you, pulled 

 your hair or in some other way hurt you?

  Are you here today because of injuries caused by your partner?

  Has your partner hurt or threatened to hurt your pet(s)?

  Have you had sex with your partner when you didn’t want to, or performed 

 sex acts that you didn’t want to do?

  How long have you been in this relationship? _______

  Have you ever tried to leave this relationship? _______ 

 If so, what happened?__________

“ I’m sorry those things have happened to you. Nobody deserves to be hurt or treated in that 

manner. Now I’d like to ask you some other questions that will help us know how best to 

help you.”

Determine current level of safety for the patient:

Questions should include determining whether there is escalation of the abuse and severity of 

abuse. One suggested severity ranking scale is as follows:

  Throwing things, punching the wall

  Pushing, shoving, grabbing, throwing things at the victim

  Kicking, biting

  Hitting with a closed fist

  Attempted strangulation

  Beating up/pinned to wall or floor

  Threatening with a weapon

  Assault with a weapon
96

Filled out by:

MD 

RN 

SW 

FVSA 

Filled out by:

MD 

RN 

SW 

FVSA 

Many women who are physically assaulted also feel sexually assaulted. Escalating levels of sexual 

assault or sexual coercion are risk factors for serious injury and death. Asking questions about this 

may help determine safety risk.

Survey for past issues of abuse: “Many patients who are experiencing relationships like yours, 

have also had other unpleasant or harmful events happen to them earlier in their lives, as 

teenagers or even as children. Can you tell me if any of the following has happened to you?”

 Have you been in relationships in the past that have been harmful or hurtful,

 either verbally, physically or sexually? ____________________________

 Were you hurt physically when you were growing up? 

 Were you hurt sexually or made to do things you didn’t want to sexually when 

 you were growing up?

 Did you ever feel that you were raped? If so, did you report it?__________________

 Did you ever feel that you were being followed, watched, or stalked?______________

 Did you grow up with one parent , or both ?

 Were your parents in an abusive relationship/Did your parents fight a lot?________

 Was either of your parents alcoholic? _______________________

If the patient has been acutely injured or has physical evidence of injury, photographic 

documentation is desirable. Recommended procedure includes:

 1. Obtain patient consent - acknowledge that it may be uncomfortable for them to 

 have pictures taken and that if they want to stop at any time, they may ask to do so.

 2. One photo should show the whole body including face.

 3. Subsequent photos are closer in.

 4. Take two pictures of each area.

 5. Number the pictures for reference (1,2,3, etc.)

 6. Offer the patient one set of pictures.

Referral options:

  Information given (package)

  Called social services

  Called shelter (Southern Valley, e.g.)

  Called police

  Called Sexual Violence Center

  Called crisis worker

  1-800-799-SAFE given

  Supportive statements only

  Other _____________________________________________________
97

Index Reference:

Contact Dr. David McCollum at md4peace@earthlink.net

Additional Reference:

Family Violence Prevention Fund (2003). Interpersonal Violence New Tool for 

 Identification in Health Care Settings, Health Alert, 9, 8-9. 
98

RADAR

The acronym “RADAR” summarizes action steps physicians should take in recognizing and 

treating victims of partner violence. 

Remember to ask routinely about partner violence in your own practice.

Ask directly about violence with such questions as, “At any time, has a partner hit, kicked, or 

otherwise hurt or frightened you?” Interview your patient in private at all times.

Document information about “suspected domestic violence” or “partner violence” in the

patient’s office.

Assess your patient’s safety. Is it safe for her to return home? Find out if any weapons are kept in 

the house, if the children are in danger, and if the violence is escalating.

Review options with your patient. Know about the types of referral options (e.g., shelters, support 

groups, legal advocates). 

Note. There is another version of the RADAR screening tool (called RADAR/SA) that also 

assesses for sexual assault with the following question: “Have you ever been sexually assaulted or 

involved in sexual acts against your will?”

Reprinted from Annals of Internal Medicine, 123, Alpert EJ. Violence in intimate relationships and 

the practicing internist: New “disease” or new agenda? 774-81 Copyright 1995, with permission 

from American College of Physicians. 

Developer: RADAR was developed by the Massachusetts Medical Society. The sexual assault 

question was developed by Dr. Wanda Filer. 

Publication year: 1992, 1996, 1999, 2004

Administration method: Physician administered.

Scoring procedures: This information is not available.
99

Follow-up procedures: This information is included in the screening tool. 

Index Reference:

Alpert EJ. (Ed.) (2004). Partner violence: How to recognize and treat victims of abuse, 

 Fourth Edition. Waltham, MA: Massachusetts Medical Society.

Additional Reference:

Alpert EJ. (1995). Violence in intimate relationships and the practicing internist: New

 “disease” or new agenda? Annals of Internal Medicine, 123, 774-81.
100

SAVE: A Tool for Screening for Sexual Assault

S = Screen all your patients for sexual assault.

Anyone could be the victim of sexual assault. Healthcare providers are the people who most 

patients prefer to tell about these experiences, but they need to be asked about it by you. Interview 

the patient alone. 

A = Ask direct questions in a non-judgmental way. 

Do not use formal, technical, or medical jargon. 

“If I am to be your doctor, we need to have the best sort of working partnership. It would help if 

you could answer my questions about your sexual history.” 

“I ask all of my patients these questions because it is important to me to know what has gone on 

and what is going on in their lives. For instance, someone can be traumatized by witnessing or 

experiencing violence.”

“Have you ever been touched sexually against your will or without your consent?”

“Have you ever been forced or pressured to have sex?”

“Do you feel that you have control over your sexual relationships and will be listened to if you say 

‘no’ to having sex?”

V = Validate the patient’s response.

If a patient answers “yes” to your questions asked above, offer support. Do not minimize the 

patient’s response even if she does. Be sure to document your physical and psychological findings 

of the sexual assault. If a patient answers “no,” but you suspect by her symptoms and behaviors that 

she is a sexual assault survivor, make a note in the patient’s chart and be sure to follow up in the 

future and ask her again.

E = Evaluate, educate and refer.

If the patient answers “yes,” ask what you can do to help. Offer the patient empathy, education, 

and referrals. If the patient is hesitant to take the referral now, inform them that they can change 

their mind and receive the information at some later time. Let your patients know that you will not 

judge them if they do not follow up with the referral immediately. Mention the disclosure of the 

sexual assault again during another visit. 
101

Reprinted with permission from the New York State Coalition Against Sexual Assault.

Developer: Lynne Stevens, New York State Coalition Against Sexual Assault 

Publication year: 2003

Administration method: Clinician or staff administered.

Scoring procedures: This information is not available. 

Follow-up procedures: This information is included in the screening tool. 

Index Reference:

Stevens L. (2003). New York State Coalition Against Sexual Assault. 

 See the Library at the following website: www.nsvrc.org 
102

PUDE: Un instrumento para la identificacion sobre casos de asalto 

sexual

(SAVE: A Tool for Screening for Sexual Assault, Spanish Version)

P = Porvea la oportunidad a todas sus pacientes de hablar sobre el asalto sexual.

Cualquier persona puede ser victima de asalto sexual. La mayoria de los pacientes prefieren 

comunicar estas experiencias a los provedores de atencion medica, pero no muchos no lo hacen a 

menos que le pregunten. Entreviste a la/el paciente sola/o.

U = Utilize preguntas directas sin emitir juicio.

No use lenguaje formal, tecnico, o medico.

“Si voy a ser su medico, necesitamos establecer una buena relacion para trabajar. Me ayudaria 

hacerle varias preguntas sobre su historial sexual.”

“Le hago esta pregunta a todas mis pacientes porque es importante que yo sepa lo que haya pasado 

y este pasado en su vida. Por ejemplo, una persona pude estar traumatizada si ha observado o ha 

experimentado actos de violencia en su vida.”

“Alguna vez alguien le ha tocado en contra de su voluntad o sin su consentimiento?”

“Se ha sentido alguna vez forzada o presionada a tener relaciones sexuales?”

“Usted cree que tiene control sobre sus relaciones sexuales y que le haran caso si dice que no desea 

tener relaciones?”

D = Darle validez a las repuestas obetnidas por el paciente.

Si la/el paciente responde “si” a su pregunta, ofrezcale apoyo. No minimice o le reste importancia 

a una respuesta aun cuando ella/el lo haga. Asegurese de documentar la informacion fisica 

y psicologica obetnida con respecto al asalto sexual. Si la/el paciente responde “no,” pero usted 

sospecha que, por sus sintomas y conducta, ha sobrevivido un asalto sexual, anotelo en el expediente 

de la paciente y asegurese preguntarle de nuevo en el futuro.

E = Evalue, eduque, y refiera.

Si la/el paciente responde “si” preguntele lo que puede hacer para ayudarla/lo. Ofrezcale su apoyo, 

comprension, informacion, y una referencia a una fuente de ayuda. Si ella/el se muestra insegura/o 

en aceptar la referencia, dejele saber que puede cambiar de opinion en el futureo y recibirlo despues. 

Digale que usted no lo/la juzgara si no sigue la referencia. Durante la proxima visita mencione su 

revelacion del asalto sexual. 

Reprinted with permission from the New York State Coalition Against Sexual Assault.
103

Developer: Lynne Stevens, New York State Coalition Against Sexual Assault 

Publication year: 2003

Administration method: Clinician or staff administered.

Scoring procedures: This information is not available. 

Follow-up procedures: This information is included in the screening tool. 

Index Reference:

Stevens L. (2003). New York State Coalition Against Sexual Assault. 

 See the Library at the following website: http://www.nsvrc.org 
104

Screening Tools-Domestic Violence

American College of Obstetricians and Gynecologists

Because violence is so common in many women’s lives and because there is help available for women 

being abused, I now ask every patient about domestic violence:

1. Within the past year - or since you have become pregnant - have you been hit,

 slapped, kicked, or otherwise physically hurt by someone?

2. Are you in a relationship with a person who threatens or physically hurts you?

3. Has anyone forced you to have sexual activities that made you feel uncomfortable?

Reprinted with permission from American College of Obstetricians and Gynecologists. 

Developer: American College of Obstetrics and Gynecologists

Publication year: 2003

Administration method: Clinician administered.

Scoring procedures: This information is not available.

Follow-up procedures: Please see the ACOG website for more information. 

www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585

Index Reference: 

American College of Obstetricians and Gynecologist (2003). Screening tools-domestic violence. 

 Available at: http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=5 

 85 Retrieved August 8, 2006.
105

Screening Tools-Sexual Assault

American College of Obstetricians and Gynecologists

Because sexual violence is an enormous problem for women in this country and can affect a 

woman’s health and well being, I now ask all my patients about exposure to violence and about 

sexual assault.

1. Do you have someone special in your life? Someone you’re going out with?

2. Are you now-or have you been-sexually active?

3. Think about your earliest sexual experience. Did you want this experience?

4. Has a friend, a date, or an acquaintance ever pressured or forced you into sexual activities 

 when you did not want them? Touched you in a way that made you uncomfortable? 

 Anyone at home? Anyone at school? Any other adult?

5. Although women are never responsible for rape, there are things they can do that may reduce 

 their risk of sexual assault. Do you know how to reduce your risk of sexual assault?

Reprinted with permission from American College of Obstetricians and Gynecologists. 

Developer: American College of Obstetricians and Gynecologists

Publication year: 2003

Administration method: Clinician administered.

Scoring procedures: This information is not available.

Follow-up procedures: Please see the ACOG website for more information: 

www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=1477

Index Reference: 

American College of Obstetricians and Gynecologist (2003). Screening tools-sexual assault.

 Available at: http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=1 

 477 Retrieved August 6, 2006.
106

Sexual and Physical Abuse History Questionnaire

We now know that many people have unwanted “sexual” or violent experiences as children or 

adults. Some of these are with playmates or friends and some with relatives or acquaintances. 

These experiences may be so upsetting that they may not be discussed with anyone. Sometimes 

they are forgotten for long periods of time, and sometimes they are frequently brought to mind. 

We would like you to help us understand these experiences that people may have. Please try to 

remember whether any of the following occurred to you:

Sexual Abuse Items on the Questionnaire 

Circle for both as child and as adult.

 As a child As an adult

 (13 and younger) (14 and over)

1a. Has anyone ever exposed the sex organs of

 their body to you when you did not want it? Yes No Yes No

 lb. Has anyone ever threatened to have sex with

 you when you did not want it? Yes No Yes No

1c. Has anyone ever touched the sex organs of

 your body when you did not want this? Yes No Yes No 

1d. Has anyone ever made you touch the sex organs

 of their body when you did not want this? Yes No Yes No 

1e. Has anyone ever forced you to have sex when

 you did not want this? Yes No Yes No

1f. Have you had any other unwanted sexual 

 experiences not mentioned above? Yes No Yes No

 If yes, please specify:________________________________________________

Physical Abuse Items on the Questionnaire 

2. When you were a child (13 or younger), did an older person do the following:

 a. Hit, kick, or beat you? 0. Never 1. Seldom 2. Occasionally 3. Often

 b. Seriously threaten your life 0. Never 1. Seldom 2. Occasionally 3. Often

3. Now that you are an adult (14 or older), has any other adult done the following:

 a. Hit, kick, or beat you? 0. Never 1. Seldom 2. Occasionally 3. Often

 b. Seriously threaten your life 0. Never 1. Seldom 2. Occasionally 3. Often
107

Reprinted with permission from

Jane Leserman, PhD

University of North Carolina

Chapel Hill, NC 27599-7160

Developer: Jane Leserman, Douglas Drossman, and Zhiming Li

Publication year: 1995

Administration method: Self report.

Scoring procedures: Respondents indicating “yes” to any of the items 1a through 1f are given a 

score of 1 for abuse and the rest are scored 0 for no abuse. 

Follow-up procedures: This information is not available. 

Index Reference:

Leserman J, Drossman DA, Zhiming L. (1995). The reliability and validity of a sexual

 and physical abuse history questionnaire in female patients with gastrointestinal

 disorders. Behavioral Medicine, 21, 141-50.
108

Two-Question Screening Tool

1. Have you ever been hit, slapped, kicked, or otherwise physically hurt by your male partner?

 (If yes, ask date of last episode)

2. Have you ever been forced to have sexual activities?

 (If yes, ask date of last episode)

Reprinted from Journal of Emergency Nursing, 21, McFarlane J, Greenberg L, Weltge A, Watson 

M, Identification of abuse in emergency departments: Effectiveness of a two-question screening 

tool, 391-4, Copyright (1995), with permission from The Emergency Nurses Association.

Developer: Judith McFarlane, Lyn Greenberg, Arlo Weltge, and Mary Watson

Publication year: 1995

Administration method: Nurse administered.

Scoring procedures: A woman is considered abused if she gives a positive response to either 

question. 

Follow-up procedures: All women who participated were offered an informational brochure 

about abuse. Women who are identified as abused need to be further assessed for level of 

personal danger. A safety plan should be discussed with them, and they should receive 

information regarding abuse and community resources (McFarlane et al. 1995). 

Index Reference:

McFarlane J, Greenberg L, Weltge A, Watson M. (1995). Identification of abuse in emergency

 departments: Effectiveness of a two-question screening tool. Journal of Emergency 

 Nursing, 21, 391-94. 
109

Universal Violence Prevention Screening Protocol

Introduction:

 1. These days many people are exposed to violence in some form.

 2. Violence is a health risk and can result in physical and emotional problems.

 3. It is our routine procedure to ask adult patients about their exposure to violence.

 4. If you are a violence victim, we can better help you if we know it.

Last

12 months

If “yes”

to 12 M onths,

Last 1 Month?

1. In the past 12 months...has anyone 

threatened you with or actually used a knife or 

gun to scare or hurt you?

Yes No Yes No

2. ...choked, kicked, bit, or punched you? Yes No Yes No

3. ...slapped, pushed, grabbed, or shoved you? Yes No Yes No

4. ...forced or coerced you to have sex? Yes No Yes No

5. ...have you been afraid that a current or former 

intimate partner would hurt you physically?

Yes No Yes No

6. What is your relationship with the person who has hurt you?

 ___ Current or former intimate partner

 ___ Other family member

 ___ Acquaintance or friend

 ___ Coworker

 ___ Stranger

 ___ Other (specify)

7. Have the police been notified within the last month about any of these experiences?

 YES NO

Reprinted with permission from American Medical Women’s Association.

Developer: Mary Ann Dutton, Barbara Mitchell, and Yolanda Haywood

Publication year: 1996

Administration method: Nurse administered.

Scoring procedures: This information is not available.

Follow-up Procedures: A positive score for any of the items signals the need for further risk 

assessment.

Index Reference: 

Dutton MA, Mitchell B, Haywood Y. (1996). The emergency department as a violence 

 prevention center. Journal of American Medical Women’s Association, 51, 92-6.
110

Universal Violence Prevention Screening Protocol - Adapted

Have you been in a relationship with a partner in the past year? (Yes/No)

If yes, within the past year has a partner:

(a) Slapped, kicked, pushed, choked, or punched you? (Yes/No)

(b) Forced or coerced you to have sex? (Yes/No)

(c) Threatened you with a knife or gun to scare or hurt you? (Yes/No)

(d) Made you afraid that you could be physically hurt? (Yes/No)

(e) Repeatedly used words, yelled, or screamed in a way that frightened you, threatened you, put 

you down, or made you feel rejected? (Yes/No)

Reprinted from Annals of Emergency Medicine, 42, Heron SL, Thompson MP, Jackson E, Kaslow 

NJ, Do responses to an intimate partner violence screen predict scores on a comprehensive 

measure of intimate partner violence in low-income black women? 483-91, Copyright (2003), with 

permission from American College of Emergency Physicians.

Developer: Sheryl Heron, Martie P. Thompson, Emily Jackson, and Nadine Kaslow

Publication year: 2003

Administration method: Clinician administered or self report.

Scoring procedures: This information is not available. 

Follow-up procedures: This information is not available. 

Index Reference: 

Heron SL, Thompson MP, Jackson E, Kaslow NJ. (2003). Do responses to an intimate partner 

 violence screen predict scores on a comprehensive measure of intimate partner violence in 

 low-income black women? Annals of Emergency Medicine, 42, 483-91.
111

Victimization Assessment Tool

1. Have you been troubled or injured by any kind of abuse or violence (e.g., hit by 

 partner, forced sex)?

 Yes _____ No _____ Not sure ______ Refused ______

 If yes, check one: 

 By someone in your family ______

 By an acquaintance or stranger ______

 Describe: 

2. If yes, has something like this ever happened before?

 Yes _____ No _____ If yes, when? ___________

 Describe:

3. Do you have anyone you can turn to or rely on now to protect you from 

 possible further injury?

 Yes _____ No _____ If yes, who? ____________ 

4. Do you feel so badly now that you have thought of hurting yourself/suicide?

 Yes _____ No _____

 If yes, what have you thought about doing? 

 _____________________________________________________________

5. Are you so angry about what’s happened that you have considered hurting someone else?

 Yes _____ No _____

 If yes, describe briefly: _____________________________

Reprinted from Journal of Advanced Nursing, 20, Hoff LA, Rosenbaum L, A victimization 

assessment tool: Instrument development and clinical implications, 627-34, Copyright (1994) 

with permission from Blackwell Publishing. 
Developer: Lee Ann Hoff and Linda Rosenbaum

Publication year: 1994

Administration method: Clinician administered. 

Scoring procedures: According to Hoff and Rosenbaum (1994), individuals are classified into one 

of the following risk groups based on the degree of victimization:

1 = No experience of physical violence or abuse.

2 = Experience of abuse/violence with minor physical and/or emotional trauma (e.g., verbal 

 arguments that occasionally escalate to pushing and shoving or mild slapping. History may 

 include past victimization that is no longer problematic.)

3 = Experience of abuse/violence with moderate physical and/or emotional trauma (e.g., abused 

 several times a month in recent years resulting in moderate trauma or emotional distress. No

 threat to life, no weapons available. History may include past victimization that is still

 somewhat problematic.)

4 = Experience of abuse/violence with severe physical and/or emotional trauma (e.g., violently

 attacked or physically abused in recent years, resulting in physical injury requiring medical

 treatment. Threats to kill, no guns available. History may include serious victimization

 requiring medical and/or physical treatment.)

5 = Life-threatening or prolonged abuse/violence with very severe physical and/or emotional

 trauma (e.g., recent or current life-threatening physical abuse, potentially lethal assault or

 threats with available deadly weapons. History may include severe abuse requiring medical 

 treatment, frequent or ongoing sexual abuse, recent rape, other physical attack requiring 

 extensive medical treatment.)

 (p. 630) 

Follow-up procedures: If rating is Level 2 or above on the assessment scale, clinician should 

discuss with client and recommend referral to victim care specialist for full assessment and 

follow-up care.

Index Reference:

Hoff LA, Rosenbaum L. (1994). A victimization assessment tool: Instrument development and 

 clinical implications. Journal of Advanced Nursing, 20, 627-34.

For More Information:

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

www.cdc.gov/injury

1-800-CDC-INFO

cdcinfo@cdc.gov

CS105344