Questionnaire for Influence of Socioeconomic Status on Domestic Violence
Background
1. What is your age group?
___________________
2. Do you live with your partner?
Yes
No 3. Do you have children with your partner?
o Yes
o No
4. What is your gender?
o Male
o Female
5. What is your occupation?
____________________
6. What is your current level of education? ( background)
o
o
o
o
o Secondary or high school level
College level
University level
PhD
None 7. What is the current level of education of your significant other?
o
o
o
o Secondary or high school level
College level
University level
PhD o None
8. Choose the socioeconomic status that best describes your current social class.
o Lower Middle Class
o Middle Class
o Upper Middle Class
o Upper Class
9. Choose the socioeconomic status that best describes your partner’s current social
class.
o Lower class
o Lower middle class
o Middle class
o Upper middle class
o Upper class
10. Which of the following best describes your current relationship?
o Married
o Common-law relationship
o Single
o In a relationship (unmarried)
o Other (please specify)
11. How long have you been in the relationship outlined in question 10?
o Less than three months
o Three-Six months
o Six months to a year
o One year plus
Domestic Violence
12. Have you ever been physically assaulted by your significant other?
o Yes
o No
13. Have you ever been emotionally assaulted by your significant other? (e.g. verbal
abuse, threats)
o Yes
o No 14. How frequently did the assault take place? If no, do not answer.
o Never
o Less than three times
o More than 5 times
o All the time Gender
15. To what extent do you believe that gender norms and roles play a part in your
relationship? (add definition) Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
Level of Income
16. Who is the breadwinner of the household?
o
o
o
o Yourself
Your significant other
Both you and your significant other
We do not live together 17. To what extent do you agree with the notion that income plays a role in the dynamic
of a relationship? Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly agree

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