Secondary Survey for Interpersonal Violence
This is to be filled out if the patient screens positive for IPV. It should be completed by the physician (MD) or nurse (RN) caring for the patient but may, at times, be completed by social services (SW) or an inhouse abuse/interpersonal violence advocate (IPVA).
Introductory statements
“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. |
| Filled out by: |
| MD |
∠ |
| RN |
∠ |
| SW |
∠ |
| IPVA |
∠ | |
| ∠ |
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, 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 hurt you in some other way? |
| ∠ |
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?
___________________________________
___________________________________
___________________________________ |
Determine current level of safety
“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.”
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. 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 |
| Filled out by: |
| MD |
∠ |
| RN |
∠ |
| SW |
∠ |
| IPVA |
∠ | |
| ∠ |
Pushing, shoving, grabbing, throwing things at the victim |
| ∠ |
Kicking, biting |
| ∠ |
Hitting with a closed fist |
| ∠ |
Attempted strangulation |
| ∠ |
Beating up/pinning to wall or floor |
| ∠ |
Threatening with a weapon |
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? |
| Filled out by: |
| MD |
∠ |
| RN |
∠ |
| SW |
∠ |
| IPVA |
∠ | |
| ∠ |
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 parents? |
| ∠ |
Were your parents in an abusive relationship/Did your parents fight a lot? |
| Were your parents alcoholics? |
|
∠
∠ |
Both parents
One parent _________________ |
Documentation
If the patient has been acutely injured or has physical evidence of injury, photographic documentation is desirable.
Recommended procedure includes:
1. Obtain patient consent.
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.
6. Offer the patient one set of pictures.
Referral options
| ∠ |
Information given (package) |
| Filled out by: |
| MD |
∠ |
| RN |
∠ |
| SW |
∠ |
| IPVA |
∠ | |
| ∠ |
Called social services |
| ∠ |
Called local shelter |
| ∠ |
Called police |
| ∠ |
Called Sexual Violence Center |
| ∠ |
Called crisis worker |
| ∠ |
Gave National Domestic Violence Hotline number (800) 799-SAFE |
| ∠ |
Supportive statements only |
| ∠ |
Other:
___________________________________
___________________________________
___________________________________ |
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Last Updated: 8/14/2008