1004) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner. 4A) (Does/did) your last husband/partner ever: a) say or do something to humiliate you in front of others? YES 1 NO 2 (GO TO B) b) threaten you or someone close to you with harm? YES 1 NO 2 (GO TO 1005) 4B) How many times did this happen during the last 12 months? a) say or do something to humiliate you in front of others? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) threaten you or someone close to you with harm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1004) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner. 4A) (Does/did) your last husband/partner ever: a) say or do something to humiliate you in front of others? YES 1 NO 2 (GO TO B) b) threaten you or someone close to you with harm? YES 1 NO 2 (GO TO 1005) 4B) How many times did this happen during the last 12 months? a) say or do something to humiliate you in front of others? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) threaten you or someone close to you with harm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1004) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner. 4A) (Does/did) your last husband/partner ever: a) say or do something to humiliate you in front of others? YES 1 NO 2 (GO TO B) b) threaten you or someone close to you with harm? YES 1 NO 2 (GO TO 1005) 4B) How many times did this happen during the last 12 months? a) say or do something to humiliate you in front of others? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) threaten you or someone close to you with harm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever: a) Push you, shake you, or throw something at you? YES 1 NO 2 (GO TO B) b) slap you or twist your arm? YES 1 NO 2 (GO TO C) c) punch you with his fist or with something that could hurt you? YES 1 NO 2 (GO TO D) d) kick you or drag you? YES 1 NO 2 (GO TO E) e) try to strangle you or burn you? YES 1 NO 2 (GO TO F) f) threaten you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO G) g) attack you with a knife, gun, or other type of weapon? YES 1 NO 2 (GO TO H) h) physically force you to have sexual intercourse with him even when you did not want to? YES 1 NO 2 (GO TO I) i) force you to perform other sexual acts you did not want to? YES 1 NO 2 (GO TO 1006) 5B) How many times did this happen during the last 12 months? a) Push you, shake you, or throw something at you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 b) slap you or twist your arm? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 c) punch you with his fist or with something that could hurt you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 d) kick you or drag you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 e) try to strangle you or burn you? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 f) threaten you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 g) attack you with a knife, gun, or other type of weapon? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 h) physically force you to have sexual intercourse with him even when you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95 i) force you to perform other sexual acts you did not want to? NUMBER OF TIMES ___ IF WIDOWED, DIVORCED OR SEPARATED 95