Do you agree to participate? *

I HAVE READ AND UNDERSTOOD THE PARTICIPATION CONSENT AGREEMENT AND APPROVE TO BE BOUND BY IT AS INDICATED BY MY INITIALS BELOW.

Yes

No

Gender *

Female

Male

Non-Binary

Have you been a victim or survivor of gender-based violence? *

Yes

No

I don't know

Where did the abuse take place? *

You may select more than one answer.

Indoors (home, hideout, private or closed space)

Outdoors (public space, market, gatherings/parties)

Identify the person committing the crime. *

You may select more than one answer.

Domestic partner

Parent/Step-parent

Sibling(s)

Children

Parent-in-Law

Teacher

Relative(s)

Friend(s)

Friend(s) of friend(s)

Other

Are you financially dependent on the abuser? *

Yes

No

Are you emotionally or psychologically dependent on the abuser? *

Yes

No

Identify the type of violence that you have experienced the most. *

You may select more than one answer.

Physical (push, hit, slap, arm-twist, hair pull, punch, kick, drag, beaten up, choked, burnt, attacked with a knife or weapon)

Sexual (forced to have sexual intercourse, forced to perform sexual acts)

Emotional (humiliate or insult in front of others, threaten to hurt or harm, made you feel worthless)

Psychological (threats of violence, intimidation, controlling behavior)

Economic (preventing or forbidding from working, forcing to work, controlling income and other financial resources)

Violence during pregnancy

Frequency of abuse *

Just once

Multiple times

Have you reported or asked for help from anyone to stop this injustice for you? *

Yes

No

Have you faced any consequence(s) in seeking help? *

Yes

No

Do you feel embarrassed to talk about your experience? Is it hurting or humiliating? *

Yes

No