Following is a sample questionnaire you could use or adapt when surveying domestic violence-related programs and services within your community. 

Instructions: Distribute this form and collect it from any and all organizations and professionals who in some way address the issues of domestic violence response and prevention in your area. Alternatively, you could call each organization and ask these questions over the phone, filling in the form as you go. Once these forms are collected, tabulate and summarize the responses. This will “map” all that is being done to address domestic violence prevention and response in your community. It will allow you to look at what is being done at what levels of prevention (with response being at the secondary and tertiary levels of prevention), and to have an overall picture of your community’s approach to domestic violence.

1. Organization Name and Contact Information

 

2. Is your organization:

• Public  -- specify a) county or b) city

• Non-profit

• Private

• Other  -- explain

 

3. DO YOU VIEW YOUR ORGANIZATION’S WORK AS DOMESTIC    VIOLENCE PREVENTION OR RESPONSE OR BOTH?

• Prevention of domestic violence

• Response to domestic violence

• Both prevention of and response to domestic violence

 

4. IF YOUR REPLY TO QUESTION #3 IMMEDIATELY ABOVE INCLUDES PREVENTION AND OR PREVENTION AND RESPONSE, PLEASE INDICATE WHAT FORMS OF PREVENTION YOUR ORGANIZATION IS INVOLVED IN:

Efforts to stop the violence before it occurs:

• Public information (use of media in)

• Education in the schools

• Education of adults

• Other efforst to stop the violence before it occurs (please describe)

Efforts to stop the violence from reoccurring:

• Shelter programs

• Rehabilitation programs

• Education for persons who have survived domestic violence

• Programs for persons who have been violent

• Educational programs for persons who have been violent

• Other efforts to prevent further violence (please describe)

  

5. General Population Served by Your Organization

Individuals Served:

• Particular ethnic groups (list)

• Particular age groups (list)

• Particular gender groups (list)

• Homeless

• Other characteristics

Agencies Served:

• Public (list)

• Private (list)

• Other (list)

 

Other Populations Served:

 

6. Domestic violence population served by your organization

Victims of violence

• Women

• Men

• Teens

• Children

Perpetrators of violence

• Women

• Men

• Teens

• Children

 

Witnesses

• Women

• Men

• Teens

• Children

 

7. METHODS OF REFERRAL TO YOU

Referrals of individuals to you:

• Direct by individual client

• Hotline (list number/s)

• Call-ins (list number/s)

• Family

• Other

• Indirect referral of client by agency

• Law enforcement

• Court

• Social services

• Employer

• Other (list)

 

Referrals of agencies to you:

• Agencies contact us

• We are informed of agencies to contact

• Other (explain)

 

8. HOW DO INDIVIDUALS AND AGENCIES KNOW ABOUT YOU?

• Advertisement in media

• If yes, specify who arranges and pays for advertisement:

• Mailings

• Other means of letting community know what you do (list)

 

9. DO YOU HAVE WRITTEN PROCEDURES FOR DEALING WITH DOMESTIC VIOLENCE VICTIMS?

• Yes, our organization wrote these procedures

• Yes, these procedures were given to us by (specify):

• No, we are in the process of developing written procedures

• No, there is not a need for written procedures

• Informal procedures are used

 

10. TO WHOM/WHAT AGENCIES IF ANY DO YOU REFER DOMESTIC VIOLENCE VICTIMS?

 

11. TO WHOM/WHAT AGENCIES IF ANY DO YOU REFER CHILDREN OF DOMESTIC VIOLENCE VICTIMS?

 

12. TO WHOM/WHAT AGENCIES IF ANY DO YOU REFER PERPETRATORS OF DOMESTIC VIOLENCE?

 

13. DO YOU HAVE WRITTEN PROCEDURES FOR DEALING WITH CHILDREN OF DOMESTIC VIOLENCE VICTIMS?

• Yes, these procedures were given to us by (specify):

• No, we are in the process of developing written procedures

• No, there is not a need for written procedures

• Informal procedures are used

 

14. DO YOU HAVE WRITTEN PROCEDURES FOR DEALING WITH PERPETRATORS OF DOMESTIC VIOLENCE?

• Yes, these procedures were given to us by (specify):

• No, we are in the process of developing written procedures

• No, there is not a need for written procedures

• Informal procedures are used

 

15. OTHER THAN REFERRAL, WHAT DOES YOUR AGENCY DO TO ASSIST DOMESTIC VIOLENCE VICTIMS?

• Reporting of victims to (list):

• Counseling of victims

• Education of victims

• Sheltering of victims

 

16. DO YOU HAVE:

• Domestic violence screening tools

• Safety guidelines

• Lethality assessments

 

17. IS YOUR AGENCY GOVERNED BY DOMESTIC VIOLENCE REGULATIONS OR POLICIES? IF SO, WHICH ONES? (PLEASE LIST):