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  1. Surveys
  2. 2016
  3. March
  4. D
  5. Domestic 2
0%
Exit Survey
 
 
Who was the perpetrator of the abusee (Select all that apply)?
 
Father
 
Mother
 
Boyfriend
 
Common law spouse
 
Husband /wife
 
Former spouse
 
Brother
 
Sister
 
Girlfriend
 
Uncle
 
Aunt
 
Cousin
 
Other

 
 
 
Were you able to leave?
 
Yes
 
No
 
 
 
If you were unable, why?
 
Financial dependant
 
They promised to change
 
Promised to attend counciling
 
Fear if you left they would be retaliation
 
Fear of what family and community members would think
 
Other_________________________________
 
 
 
Was the violator under the influence of intoxicant at the time?
 
Yes
 
No
 
 
 
How did you stop the violence?
 
Fight back
 
Leave the premises
 
Call authorities
 
Call someone to help
 
Nothing
 
Other_____________________________________________
 
 
 
If you did not go to the authorities why?
 
Do not trust the police
 
Afraid CAS would become involved
 
To avoid court process
 
Cause police, had attended prior and did nothing
 
Fear of the police attitudes
 
Hope to work things out
 
Perpetrator left
 
You left
 
Incident was not serious
 
Fear retaliation via the perpetrator or their friends/family
 
Other_______________
 
 
 
If you do not trust the police why?
 
Corruption of police
 
In the past they have recommended to tolerate it for the sake of the family
 
Attitude of indiffrence
 
Past police encounters have been negative
 
Other_____________________
 
 
 
Even if you believe your child(ren) did not witness the violence. Please fill out the below questions

Since the incident have you noticed a change in your children ?

 
Eating
 
Behaviours
 
Sleeping
 
Mood
 
Anxiety
 
Depression
 
Acting out violently
 
Temper-tantrums
 
Attention seeking behaviours
 
Use of substances
 
 
 
Has the child(ren) teachers seen a change in behavior in school ?
 
Yes
 
No
 
 
 
What changes has the teacher noticed ?
 
Attention Span
 
Aggressive Behaviour
 
Attention Speaking
 
Mood
 
Withdrawing from classmates and friends
 
Other ______________________________________________