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Abuse Assessment Screen
This tool may be used to quickly screen for domestic violence. Prior to use the
agency should have record-keeping and confidentiality standards that ensure
against disclosure of participant information and maximize participant safety.
Instructions: Circle Yes or No for each question.
1.    Have you ever been emotionally or physically abused by your partner or someone
important to you?   YES          NO

2.   Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by
someone?    YES             NO
If YES, by whom? (Circle all that apply)
Husband         Ex-Husband          Boyfriend          Stranger    Other     Multiple
Total no. of times ___________

3.     (If applicable): Since you’ve been pregnant, have you been slapped, kicked or otherwise
physically hurt by someone? YES              NO
If YES, by whom? (Circle all that apply)
Husband         Ex-Husband          Boyfriend          Stranger    Other     Multiple
Total no. of times ___________

4. Within the last year, has anyone forced you to have sexual activities?
If YES, by whom? (Circle all that apply)
Husband         Ex-Husband          Boyfriend          Stranger    Other     Multiple
Total no. of times ___________

5. Are you afraid of your partner or anyone you listed above?
YES            NO             Multiple (please list)

Developer: Judith McFarlane, Barbara Parker, Karen Soeken, and Linda Bulloc
Copyright (c) 1992, American Medical Association. All rights reserved. Journal of the American
Medical Association, 1992, 267, 3176-78.
Administration method: Provide a private and confidential setting. Inform each woman
that all women attending this service are being assessed for abuse. Read the Abuse Assessment
Screen (AAS) questions to the woman.
Scoring procedures: If any questions on the screen are answered affirmatively, the AAS is
considered positive for abuse (Weiss, Ernst, Cham, & Nick, 2003).
Follow-up procedures: At a minimum, all agencies should offer women with positive
screens referral sources and legal options (Soeken et al. 1998).

SHARE Study Handout                                                         January 2012

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1.3 Abuse Assessment Screen

  • 1. Abuse Assessment Screen This tool may be used to quickly screen for domestic violence. Prior to use the agency should have record-keeping and confidentiality standards that ensure against disclosure of participant information and maximize participant safety. Instructions: Circle Yes or No for each question. 1. Have you ever been emotionally or physically abused by your partner or someone important to you? YES NO 2. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? YES NO If YES, by whom? (Circle all that apply) Husband Ex-Husband Boyfriend Stranger Other Multiple Total no. of times ___________ 3. (If applicable): Since you’ve been pregnant, have you been slapped, kicked or otherwise physically hurt by someone? YES NO If YES, by whom? (Circle all that apply) Husband Ex-Husband Boyfriend Stranger Other Multiple Total no. of times ___________ 4. Within the last year, has anyone forced you to have sexual activities? If YES, by whom? (Circle all that apply) Husband Ex-Husband Boyfriend Stranger Other Multiple Total no. of times ___________ 5. Are you afraid of your partner or anyone you listed above? YES NO Multiple (please list) Developer: Judith McFarlane, Barbara Parker, Karen Soeken, and Linda Bulloc Copyright (c) 1992, American Medical Association. All rights reserved. Journal of the American Medical Association, 1992, 267, 3176-78. Administration method: Provide a private and confidential setting. Inform each woman that all women attending this service are being assessed for abuse. Read the Abuse Assessment Screen (AAS) questions to the woman. Scoring procedures: If any questions on the screen are answered affirmatively, the AAS is considered positive for abuse (Weiss, Ernst, Cham, & Nick, 2003). Follow-up procedures: At a minimum, all agencies should offer women with positive screens referral sources and legal options (Soeken et al. 1998). SHARE Study Handout January 2012