Social Harm Report Visit Month Screening ID: Participant ID: Visit Date: Site Study Screening Number Site Study Couple I/P Chk dd mm yy The following questions are not interviewer-administered. Please collect the following information in a culturally appropriate way in the context of a counseling session. 1 Was the participant verbally abused by his or her yes no If no, go to item 2. partner? How often? 1a 2 Was the participant physically abused by his or her yes no If no, go to item 3. partner? 2a How often? 3 Was the participant economically abused by his or her study yes no partner? 4 Was the participant abused by his or her study partner in If yes, go to item 6. any other way (not fitting into the categories of verbal, physical, or economic abuse)? 5 What were the consequences of the abuse? Mark all that apply. i relationship break-up ii loss of income or economic support iii loss of employment iv change of residence v loss of custody of children vi Other : vii None 6 Concisely describe the social harm: Completed by: (initials/date) _________________________________________ Forms Instruction The CRF is not interviewer-administered. The questions should be asked Social Harm Report in a culturally appropriate way in the context of a counseling session.
Social Harm Report Visit Month Screening ID: Site Study Screening Number Participant ID: Site Study Couple I/P Chk Visit Date: dd mm yy The following questions are not interviewer-administered. Please collect the following information in a culturally appropriate way in the context of a counseling session. 1 Was the participant verbally abused by his or her partner? yes no If no, go to item 2. 1a How often? 2 Was the participant physically abused by his or her partner? yes no If no, go to item 3. 2a How often? 3 Was the participant economically abused by his or her study partner? yes no 4 Was the participant abused by his or her study partner in any other way (not fitting into the categories of verbal, physical, or economic abuse)? If yes, go to item 6. 5 What were the consequences of the abuse? Mark all that apply. i relationship break-up ii loss of income or economic support iii loss of employment iv change of residence v loss of custody of children vi Other : vii None 6 Concisely describe the social harm: Completed by: (initials/date) _________________________________________ Forms Instruction The Social Harm Report CRF is not interviewer-administered. The questions should be asked in a culturally appropriate way in the context of a counseling session.
CRF2_Social_Harm-_Report.docx