SAFE Assessment Tool
This is a self-assessment survey that screens for Intimate Partner Violence.Responses are confidential and have no identifiers.
A score greater than 2 is positive for Intimate Partner Violence.
Survey tool was developed by Elizabeth Ayangunna,MD,MPH & Kingsley Kalu,MD,MPH and questions about the instrument development & copyright permission can be sent to eyayangunna@gmail.com
Submitting the survey authorizes the use of data for research purposes.
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What is your marital status? *
Sexual Abuse -Please check the boxes that apply to you *
2 points
Yes
No
My partner forces me to have sexual intercourse
My partner forces me to perform sexual acts i am not comfortable with
Acts of Physical Abuse- Please check the boxes that apply to you *
4 points
Yes
No
My partner beats/ hits/pushes me
My partner attacks me with weapons or dangerous items like knife and bottles
Financial Restrictions- Please check the boxes that apply to you *
4 points
Yes
No
My partner prevents me from getting a job or having a source of income
My partner does not allow me have access to the family income
My partner constantly ensures i spend all my income
My partner does not suport me pursuing opportunities that will improve my financial state
Emotional Abuse- Please check the boxes that apply to you *
6 points
Yes
No
My partner prevents me from relating with family and friends
My partner constantly threatens me
My partner gets violent in the presence of my kids
My partner insults and/or embarrasses me
My partner constantly monitors my movement
I am afraid of my partner
What sex were you assigned at birth?
Clear selection
How old are you? *
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