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.
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Citizenship:
Select an option Italian Other European country Non-European country
Please specify the name of the country:
Select an option Austria Belgium Bulgaria Croatia Cyprus Cechia Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden
Please specify:
Select an option Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bahamas Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Cuba Curaçao Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Ghana Gibraltar Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Iceland India Indonesia Iran, Islamic Republic of Iraq Isle of Man Israel Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Puerto Rico Qatar Réunion Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
The Italian region you usually live in:
Select an option Abruzzo Basilicata Calabria Campania Emilia Romagna Friuli Venezia Giulia Lazio Liguria Lombardia Marche Molise Piemonte Puglia Sardegna Sicilia Toscana Trentino Alto Adige Umbria Valle d’Aosta Veneto
Marital status
Select an option Unmarried Married Legally separated Divorced Widowed
Educational level
Select an option No diploma Primary School Diploma Middle School Diploma High School Diploma or Professional Qualification Graduate Degree PhD or Post-Graduate Degree
Employment Status
Select an option Full time worker Part-time worker Occasional worker Seeking Emplyment Housewife Student Pensioner In other situation
Health condition (you can choose multiple options)
Select an option Certified Disability or Impairment Uncertified Disability or Impairment Chronic 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 option Sensory Disability or Impairment Motor Disability or Impairment Cognitive/Intellectual Disability or Impairment Psychological Disability or Impairment Other
Are you currently living with this person?
Select an option Yes No
At what moment of your relationship did your current or former partner’s violent behaviour begin?
Select an option Since the beginning After a few months After a few years After having moved in together After we got married During pregnancy After I expressed the possibility I might leave him Other
Please indicate the gender and the age of the children:
Have you ever reported your current or former partner’s violent behaviour to law enforcement?
Select an option Yes, once Yes, more than once No
If you have reported your current or former partner’s violent behaviour to law enforcement, did you later withdraw the complaint?
Select an option Yes, always Yes, but no always No, never
Have you previously contacted some kind of service in order to get help? Please specify which one(s):
Select an option Anti-Violence Centres and/or Shelters Social Services Law Enforcement Health care providers Lawyer Other No, I have never contacted any service
