Have you been forced to do something sexual that you find degrading or humiliating?

1. Yes

2. No

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2.3. Psychological violence

Have you been insulted or made to feel bad about yourself?

1. Yes

2. No

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Have you been humiliated or made to feel bad in front of others?

1. Yes

2. No

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Have you been intimidated or scared on purpose (for example by a partner yelling and smashing things)

1. Yes

2. No

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Have you been threatened with harm (directly or indirectly in the form of a threat to hurt someone the respondent cares about).

1. Yes

2. No

3. Assessing Risk factors

Who carries out the violence

1. Intimate partner

2. Non-partner

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Age of partner

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Educational level of partner

1. uneducated

2. primary education

3. secondary education

4. university

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Does your partner smoke

1. Yes

2. No

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Is your partner an alcoholic?

1. Yes

2. No

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Did you experience sexual assault as a child? Example

a) When you were a child, before you were 15 years of age, did a man ever touch you sexually or force you to touch him sexually when you didn’t want to?

1. Yes

2. No

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b) When you were a child, before you were 15 years of age, did anyone ever persuade or force you to have sex when you did not want to?

Total

1. Yes

2. No

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Is your mother being violated by your father//or did your mother experience gender-based violence

1. Yes

2. No

3. I don’t know

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