The 2023 ISA Questionnaire Increasing Self-Awareness (Risk self-assessment) 2023 ISAManual Leave the website 1PART 1 2PART 2 3PART 3 4PART 4 The questions concern your current or former partner, who is or was violent towards you. The expression “current or former partner” refers to the person you are or have been in an intimate relationship with (husband, boyfriend, domestic partner, occasional partner, or someone with whom you are or were having an extramarital relationship). The first question is whether you fear your current or former partner may continue being violent towards you. Do you experience this fear: A lotQuite a lotNot muchNot at all Next Now read the following statements and mark an “X” on “Yes” if you agree, or “No” if you disagree. Focus on statements and at the end, when you have answered all the questions, read the indications in the last line. My current or former partner has sometimes restricted my decisions, my plans or the choice of people I want to meet 1 Yes0 No My current or former partner has sometimes undermined my role as a woman or as a mother 1 Yes0 No My current or former partner has sometimes controlled or followed me (i.e., he checks my phone, he calls me repeatedly, he gets angry if I don’t reply, he follows me on foot or by car, he tracks me through apps or video surveillance devices, he checks my social media profiles and my online interactions) 1 Yes0 No My current or former partner has sometimes threatened to harm or kill me 1 Yes0 No My current or former partner has sometimes prevented me from running away or leaving the house 2 Yes0 No My current or former partner has sometimes been physically aggressive towards me (i.e., by slapping, pushing, punching, kicking, choking, etc.) 2 Yes0 No My current or former partner has sometimes forced me to have sexual intercourse when I didn’t feel like it (i.e., because he insisted, he coerced me or because I was afraid of the consequences of refusing) 2 Yes0 No My current or former partner’s requests or behaviours during sex have sometimes made me feel humiliated (i.e., due to the way he touched me, what he asked me to do, his comments) 2 Yes0 No My current or former partner has caused me to leave my job 2 Yes0 No My current or former partner has restricted my ability to make necessary household or personal purchases (i.e., preventing me from freely accessing the bank account) 2 Yes0 No My current or former partner has sometimes exhibited violent behaviour towards me in front of the children (mark “No” if you don’t have children) 2 Yes0 No My current or former partner has sometimes been physically violent towards the children (mark “No” if you don’t have children 2 Yes0 No Part 1PreviousNext Now read the following statements and mark an “X” on “Yes” if you agree, or “No” if you disagree. I am not free to move about or connect with society (i.e., I do not have access to a cell phone or a means of transport) 2 Yes0 No I have never told anybody about my current or former partner’s violent behaviour (i.e., because I prefer dealing with it on my own, because I feel shame, because I wouldn’t want my inner circle to worry, because I don’t think anybody would believe me) 1 Yes0 No I spoke to someone or I addressed the services or the law enforcement about what happened to me but I was not believed, or I was told to leave it behind. 1 Yes0 No I am aware of the fact that my current or former partner has a gun license and/or owns a weapon 2 Yes0 No I am aware of the fact that my current or former partner uses alcohol, drugs and/or is addicted to gambling 1 Yes0 No I am aware of the fact that my current or former partner also exhibited violent behaviour towards other partners or other people 1 Yes0 No I am aware of the fact that my current or former partner has violated the judge’s orders in civil or criminal proceedings 1 Yes0 No I am aware of the fact that my current or former partner has a criminal record (involving domestic violence and/or other criminal charges 1 Yes0 No I sometimes resort to alcohol or drugs to cope with what has happened to me (i.e., take medication to be able to sleep, drink a lot to not think about what happened) 1 Yes0 No I sometimes have difficulty focusing and/or fixed thoughts, unpleasant thoughts, memories or dreams involving what has happened to me 1 Yes0 No I often feel hypervigilant, my heartbeat at times is rapid or irregular, I sweat excessively, I breathe heavily 1 Yes0 No I sometimes have trouble falling and/or staying asleep due to what happened to me 1 Yes0 No Part 1PreviousNext We will now proceed to ask you some information about you and your current or former partner which we assure will remain entirely confidential. This information is extremely helpful for us to better support you or other women in your situation. However, feel free to refrain from responding if you would prefer not to. CONTINUE TO FILL IN, OR GO DIRECTLY TO THE RESULT BY PRESSING THE BUTTON AT THE BOTTOM Age Place of birth: Select an optionAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua e BarbudaArabia SauditaArgentinaArmeniaAustraliaAustriaAzerbaigianBahamasBahreinBangladeshBarbadosBelgioBelizeBeninBhutanBielorussiaBirmaniaBoliviaBosnia ErzegovinaBotswanaBrasileBruneiBulgariaBurkina FasoBurundiCambogiaCamerunCanadaCapo VerdeCiadCileCinaCiproCittà del VaticanoColombiaCongoCorea del NordCorea del SudCosta d’AvorioCosta RicaCroaziaCubaCechiaDanimarcaDominicaEcuadorEgittoEl SalvadorEmirati Arabi UnitiEritreaEstoniaEtiopiaFigiFilippineFinlandiaFranciaGabonGambiaGeorgiaGermaniaGhanaGiamaicaGiapponeGibutiGiordaniaGreciaGrenadaGuatemalaGuineaGuinea EquatorialeGuyanaHaitiHondurasIndiaIndonesiaIranIraqIrlandaIslandaIsole ComoreIsole MarshallIsole SalomoneIsraeleItaliaKazakistanKenyaKirghizistanKiribatiKosovoKuwaitLaosLesothoLettoniaLibanoLiberiaLibiaLiechtensteinLituaniaLussemburgoMacedoniaMadagascarMalawiMaldiveMalesiaMaliMaltaMaroccoMauritaniaMauritiusMessicoMicronesiaMoldovaMonacoMongoliaMontenegroMozambicoNamibiaNauruNepalNicaraguaNigerNigeriaNorvegiaNuova ZelandaOmanPaesi BassiPakistanPalauPalestinaPanamaPapua Nuova GuineaParaguayPerùPoloniaPortogalloQatarRegno UnitoRepubblica CentrafricanaRepubblica Democratica del CongoRepubblica DominicanaRuandaRussiaSahara OccidentaleSaint Kitts e NevisSaint Vincent e GrenadineSamoaSan MarinoSanta LuciaSão Tomé e PríncipeSenegalSerbiaSeychellesSierra LeoneSingaporeSiriaSlovacchiaSloveniaSomaliaSpagnaSri LankaStati UnitiSud SudanSudafricaSudanSurinameSvizzeraSwazilandTagikistanTaiwanTanzaniaThailandiaTimor LesteTogoTongaTrinidad e TobagoTunisiaTurchiaTurkmenistanTuvaluUcrainaUgandaUngheriaUruguayUzbekistanVanuatuVenezuelaVietnamYemenZambiaZimbabwe Citizenship: Select an optionItalianOther European countryNon-European country Please specify the name of the country: Select an optionAustriaBelgiumBulgariaCroatiaCyprusCechiaDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSweden Please specify: Select an optionAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBahamasBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCubaCuraçaoDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGhanaGibraltarGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIsle of ManIsraelJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPuerto RicoQatarRéunionRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)Solomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe If you have a residence/stay permit ("permesso di soggiorno"), please specify the type: The Italian region you usually live in: Select an optionAbruzzoBasilicataCalabriaCampaniaEmilia RomagnaFriuli Venezia GiuliaLazioLiguriaLombardiaMarcheMolisePiemontePugliaSardegnaSiciliaToscanaTrentino Alto AdigeUmbriaValle d’AostaVeneto Marital status Select an optionUnmarriedMarriedLegally separatedDivorcedWidowed Educational level Select an optionNo diplomaPrimary School DiplomaMiddle School DiplomaHigh School Diploma or Professional QualificationGraduate DegreePhD or Post-Graduate Degree Employment Status Select an optionFull time workerPart-time workerOccasional workerSeeking EmplymentHousewifeStudentPensionerIn other situation Indicate your working condition: Due to any health problems and/or conditions, please indicate whether and to what extent you have limitations that last, or may last, for at least six months in tasks people ordinarily carry out: Select an optionSevere limitationsMild limitationsNo limitations Health condition (you can choose multiple options) Select an optionCertified Disability or ImpairmentUncertified Disability or ImpairmentChronic illness or long-term health issues (which have lasted or will last more than 6 months)None of the above Indicate the type of disability or impairment (you can choose more answers) Select an optionSensory Disability or ImpairmentMotor Disability or ImpairmentCognitive/Intellectual Disability or ImpairmentPsychological Disability or ImpairmentOther Indicate the type of disability or impaiment If you have selected “Disability or Impairment” (certified or uncertified), “Chronic illness or long-term health issues”, please specify whether it is (you can choose more options): Select an optionPresent from birthAcquired or worsened following illnesses or accidentsAcquired or worsened following violence perpetrated against you The person who was or is violent towards you is: Select an optionYour husband (with whom you have an ongoing relationship)Your former husband (from whom you are divorced or separated, legally or physically)Your boyfriend (with whom you have an ongoing relationship)Your former boyfriendOther Indicate the person who is, or was, violent towards you: Are you currently living with this person? Select an optionYesNo At what moment of your relationship did your current or former partner’s violent behaviour begin? Select an optionSince the beginningAfter a few monthsAfter a few yearsAfter having moved in togetherAfter we got marriedDuring pregnancyAfter I expressed the possibility I might leave himOther Please, specify the beginning of the violence: Have you children? YesNo Please indicate the gender and the age of the children: Gender MF Age Add Remove Have you ever reported your current or former partner’s violent behaviour to law enforcement? Select an optionYes, onceYes, more than onceNo If you have reported your current or former partner’s violent behaviour to law enforcement, did you later withdraw the complaint? Select an optionYes, alwaysYes, but no alwaysNo, never Have you previously contacted some kind of service in order to get help? Please specify which one(s): Select an optionAnti-Violence Centres and/or SheltersSocial ServicesLaw EnforcementHealth care providersLawyerOtherNo, I have never contacted any service Please indicate which service you contacted: Part 1Previous
