12.03.04

Danger assessment questionnaire

Targeted at assessing the degree of Risk for the life & well being of a Woman who live together with her spouse

N	Questions	Score	Answer
1.	Are there firearms on the premises	0 – There aren't 1 – There are
2.	Are there two or more such firearms?	0 – No 1 - Yes
3.	Are the firearms kept in a safe?	0 – Yes 1 - No
4.	Does the woman have equal access to the safe key as well as to the safe itself (or any other place where the weapons kept stored)?	0 – Yes 11 – No
5.	Is the ammunition stored separately from the weapons, inside a sealed box which is placed in a locked drawer?	0 – Yes 5 - No
6.	Is the ammunition left outside the house or apartment?	0 – Yes 1 - No
7.	Does you partner view women as men's property in general & and you as his property in particular?	0 – No 1 - Yes
8.	Does you partner forbid you to go out by yourself in the evenings?	0 – No 1 - Yes
9.	Does your partner forbid you to go out in the evening with your friends?	0 – No 3 - Yes
10.	Does your partner express hostility or hatred towards women? Does he make utterances such as "All women are whores", stupid "broads", etc?	0 – No 1 – Only when we have a fight 3 - Yes
11.	Does your partner believe that women are worth less than men?	0 – He thinks women are equal to men 1 – He thinks women are worth less than men
12.	Does your partner become extremely hostile when you eye other men? (He won't talk to you for days, become aggressive & offensive?)	0 – No 1 – Happened once or twice 3 – It as happened more than twice since we met
13.	Is you partner jealous & suspicious of you for no apparent reason?	0 – No 3 – Usually/Always
14.	Does you partner stalk you or spy on you by himself or by the help of others?	0 – No 3 – Sometimes 5 – Usually/Always
15.	Does a male friend/relative of yours or of your partner, have a key to your house or easy access to this key?	0 – No 3 - Yes
16.	Was your partner a victim of domestic violence?	0 – No 3 – Once 7 – twice 11 – Three time or more
17.	Was your partner involved in domestic violence as an offender before being your spouse?	0 – No 3 – Once 7 – twice 11 – Three time or more
18.	Has your partner violently attacked other people (outside his family) as an adult?	0 – No 3 – Once 7 – twice 11 – Three time or more
19.	Were charges filed against your partner when he was a minor? (If your partner scored 0 in Q.17 and 5 in this question, deduct 2 pts.	0 – No 1 – Once 3 – twice 5 – Three time or more
20.	Does your partner often get drunk?	0 – Never 3 – Once every few months 7 – Once a month 11 – At least once a week
21.	Does your partner abuse drags?	0 – Never 3 – Once every few months 11 – At least once a week
22.	Is your partner a drug addict?	0 – No 3 – Used to be 11 - Yes
23.	During argument, does your partner threaten you physically, nudged you with his finger or shake his fists at you?	0 – No 1 – Once or twice 7 – three times or more 11 – Always
24.	During argument, does your partner hold you tightly without letting you go? Does your partner drag your body while you resist him?	0 – Never 1 – Once 5 – twice 11 – Three time or more
25.	Has your partner ever slapped your face during an argument?	0 – Never 1 – Once 5 – twice 11 – Three time or more
26.	Has your partner pinched or bitten you (without risking your life and without your consent)	0 – No 1 – Once or twice 5 – three times or more 11 – Always
27.	Has your partner kicked you or punched you with his fists?	0 – Never 33 – Once 99 – more then once
28.	Has your partner bruised you or caused any harm your health?	0 – Never 33 – Once or more
29.	Has your partner ever raped you?	0 – Never 11 – Once 22 – Twice 33 – Three times or more
30.	Has your partner ever broken any objects/furniture during an argument?	0 – Never 1 – Once 3 – Twice 7 – Three times or more
31.	Has your partner ever tossed objects at your direction during an argument?	0 – Never 5 – Once 9 – Twice 11 – Three times or more
32.	Has your partner ever attacked you with a stick or a rod?	0 – Never 9 – Once 11 – Twice or more
33.	Has your partner ever threatened you with a knife or a broken bottle?	0 – Never 11 – Once 33 – Twice or more
34.	Has your partner ever threatened to commit suicide in case you leave him?	0 – Never 1 – Once or Twice 5 – Three times or more
35.	Has your partner ever threatened to kill you?	0 – Never 11 – Once 23 – Twice 99 – Three times or more
36.	Has your partner ever threatened to kill the children or any other family members?	0 – Never 11 – Once 23 – Twice 99 – Three times or more
37.	Do you often get drunk?	0 – Never or rarely 1 – Once a month 3 – At least once a week
38.	Are you a drag addict?	0 – No 1 – I used to be 3 - Yes
39.	Do you tend to raise your voice or shout during an argument	0 – Never or rarely 1 - Often
40.	Have you ever done one of the following during an argument: · Broken or tossed objects at people · Forced a change or action that was un accepted by your partner · Threatened to attack your spouse or other family members?	0 – Never 1 – Rarely 3 - Often
41.	Have you ever humiliated your partner, hurt his pride, derogated him sexually or threatened to divulge his secrets?	0 – Never 1 – Once or twice 3 – three times or more
42.	Have you ever been physically violent towards your spouse or other family members (not as self-defense)	0 – Never 1 – Once or twice 3 – three times or more
1-42	Total Score =

Score	Explanation & recommendation
0	No evidence of danger
1-6	No sufficient evidence of danger. Reassessing the level of danger is recommended within 2 year.
7-10	In most cases there is no immediate danger, but there are signs that indicate a possibility of physical violence in the future. You should be alert and check at least annually whether the level of danger has risen.
11-21	Medium to high risk (high if the score for one of the questions is 11) At least one trusted friend or relative should be informed. Steps should be taken to reduce risk (Seeking consulting, mediation, changing behavior patterns at home, taking up a self defense course, etc)
22-32	A very high risk. The largest number possible of friends & relatives should be informed. Filing charges should be considered. Immediate steps for risk reduction should be taken.
33 and up	There is clear and immediate risk for your life!

We invite social organizations or agencies that act for the welfare of women and for achieving a non violent atmosphere in the community to use this questionnaire freely.

We would be happy to have your comments or questions, and we would love to know that the Danger assessment questionnaire has actually helped to prevent violence against women and by that assist them to achieve better and violence-free life.

Best regards

Ofer Cohen

The author of Danger assessment questionnaire,

CEO of the Blue Cliff - applied thinking consulting and publishing company

Martial Arts Teacher, 8Dan, Shidoshi - From the Bujinkan Dojo: Dr Hatsumi Sensei, Atago - Japan.

Tel-fax: 972-3-6731288

info@think-kadima.com