Intimate Partner Violence Risk Assessment Survey

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This is a self-assessment survey that can help you determine if you're at risk of being a victim of Intimate Partner Violence.Responses are confidential and have no identifiers.
A score greater than 5 suggests you have a high risk of being a victim of Intimate Partner Violence. Please note that being identified as a low/ high risk respondent does not necessarily mean you would/would not be a victim of intimate partner violence.
Survey tool was developed by Kingsley Kalu,MD,MPH & Elizabeth Ayangunna,MD,MPH. Questions about the instrument development & copyright permission can be sent to eyayangunna@gmail.com
Submitting the survey authorizes the use of data for research purpose.

What is your marital status? *

Single

Married

Living Together

Widowed

Separated

Please check the boxes that apply to you *

24 points

Yes

I am less than 18 years of age

I don't like relating with people

I don't have a job/source of income

I don't believe Intimate Partner Violence exists

I did not complete secondary school education

I have been in a relationship with an abusive partner

I am carrying an unplanned pregnancy

I have a child from a previous relationship

I witnessed my parents fight a lot

I argue a lot with my partner

I have family and friends i can reach out to if i need help

I believe my partner can hit me as an expression of his/her love for me

I have friends involved in relationship with violent partners

My partner gets violent when drunk

My partner has other sexual partners

My partner is controlling

My partner is possessive

My partner is currently unemployed

My partner is insecure

My partner is excessively jealous

My partner witnessed his parents fight a lot of times

I or my partner have been previously separated or divorced

My family doesn't believe in Intimate Partner Violence

Intimate Partner Violence is culturally accepted in my community

Yes

I am less than 18 years of age

I don't like relating with people

I don't have a job/source of income

I don't believe Intimate Partner Violence exists

I did not complete secondary school education

I have been in a relationship with an abusive partner

I am carrying an unplanned pregnancy

I have a child from a previous relationship

I witnessed my parents fight a lot

I argue a lot with my partner

I have family and friends i can reach out to if i need help

I believe my partner can hit me as an expression of his/her love for me

I have friends involved in relationship with violent partners

My partner gets violent when drunk

My partner has other sexual partners

My partner is controlling

My partner is possessive

My partner is currently unemployed

My partner is insecure

My partner is excessively jealous

My partner witnessed his parents fight a lot of times

I or my partner have been previously separated or divorced

My family doesn't believe in Intimate Partner Violence

Intimate Partner Violence is culturally accepted in my community

What sex were you assigned at birth? *

Female

Male

Other:

How old are you? *

< or = 20 years

21 - 30 years

31- 40 years

41- 50 years

51- 60 years

>61 years

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