Minnesota Tool
David McCollum. 2001
ابزار مینه سوتا
1. Please read the statements below.
2. Decide which group of statements fits your life best.
3. Then‚ peel off the sticker next to that group and put it on the same colored circle at the bottom of this page.
If you do not wish to answer this survey‚ please return it without moving any of the stickers. If you have any comments‚ please let us know.
If any of the following statements applies to you‚ please attach the blue sticker to the bottom of the page. You do not need to identify your responses in any other way.
• I do not feel safe with my current partner.
• My partner often puts me down‚ yells at me‚ calls me names‚ or tells me I’m worthless.
• My partner is jealous‚ accuses me of being unfaithful‚ is suspicious of my activity.
• My partner does not allow me to see my friends‚ make phone calls‚ or have money without his/her approval.
• My partner has hit me‚ slapped me‚ kicked me‚ pushed me‚ punched me‚ pulled my hair or in some other way hurt me.
• I am here today because of injuries caused by my partner.
• My partner has hurt or threatened to hurt my pet(s).
• I have had sex with my partner when I didn’t want to‚ or performed sex acts that I didn’t want to do.
If the next group of statements apply to you‚ please attach the green sticker to the bottom of the page:
• I am in a healthy relationship.
• I trust my partner to respect me and not to hurt me on purpose.
• I feel safe with my current partner.
Attach the yellow sticker if the following is true:
• None of the statements above applies to me
• I am not now in any close relationship with another person
Please place this survey in the envelope and give to the nurse or doctor when they come back. If you attached the blue sticker‚ one of our staff will give you a chance to talk privately about your answer.
Whether or not you are in a troubled relationship‚ we would like you to know about resources for people who are. If you know of a friend or relative who needs help‚ or feel you might need information in the future‚ please take the card attached to the back of this survey for future use.
Secondary Survey
Face-to-face
This is to be filled out if the patient screens positive for IPV. It should be completed by the nurse or physician caring for the patient‚ but may at times‚ be completed by social services or Family Violence Services Response team.
Introductory statements should be made‚ e.g.:
“I want to review with you your response to the survey that you just completed. I understand that you may be in a relationship that is difficult in one way or another. I am concerned that we provide care for all of your needs. So‚ I’d like to ask you a few more questions. Can you tell me which of the statements are true for you?”
* I do not feel safe with my current partner
* Does your partner frequently put you down‚ yell at you‚ call you names‚ or tell you you’re worthless?
* Is your partner jealous‚ accuse you of being unfaithful‚ is suspicious of your activity?
* Does your partner ever prevent you from seeing your friends‚ making phone calls‚ or having access to money without his/her approval?
* Has your partner ever hit you‚ kicked you‚ pushed you‚ punched you‚ pulled your hair or in some other way hurt you?
* Are you here today because of injuries caused by your partner?
* Has your partner hurt or threatened to hurt your pet(s)?
* Have you had sex with your partner when you didn’t want to‚ or performed sex acts that you didn’t want to do?
* How long have you been in this relationship? _______
* Have you ever tried to leave this relationship? _______
If so‚ what happened? _______________
“I’m sorry those things have happened to you. Nobody deserves to be hurt or treated in that manner. Now I’d like to ask you some other questions that will help us know how best to help you.”
Determine current level of safety for the patient:
Questions should include determining whether there is escalation of the abuse and severity of abuse. One suggested severity ranking scale is as follows:
* Throwing things‚ punching the wall
* Pushing‚ shoving‚ grabbing‚ throwing things at the victim
* Kicking‚ biting
* Hitting with a closed fist
* Attempted strangulation
* Beating up/pinned to wall or floor
* Threatening with a weapon
* Assault with a weapon
Many women who are physically assaulted also feel sexually assaulted. Escalating levels of sexual assault or sexual coercion are risk factors for serious injury and death. Asking questions about this may help determine safety risk.
Survey for past issues of abuse: “Many patients who are experiencing relationships like yours‚ have also had other unpleasant or harmful events happen to them earlier in their lives‚ as teenagers or even as children. Can you tell me if any of the following has happened to you?”
* Have you been in relationships in the past that have been harmful or hurtful‚ either verbally‚ physically or sexually? __________________________________
* Were you hurt physically when you were growing up?
* Were you hurt sexually or made to do things you didn’t want to sexually when you were growing up?
* Did you ever feel that you were raped? If so‚ did you report it? ______________
* Did you ever feel that you were being followed‚ watched‚ or stalked? _________
* Did you grow up with one parent ‚ or both ?
* Were your parents in an abusive relationship/Did your parents fight a lot? ________
* Was either of your parents alcoholic? _______________________
If the patient has been acutely injured or has physical evidence of injury‚ photographic documentation is desirable. Recommended procedure includes:
1. Obtain patient consent - acknowledge that it may be uncomfortable for them to have pictures taken and that if they want to stop at any time‚ they may ask to do so.
2. One photo should show the whole body including face.
3. Subsequent photos are closer in.
4. Take two pictures of each area.
5. Number the pictures for reference (1‚2‚3‚ etc.)
6. Offer the patient one set of pictures.
Referral options:
* Information given (package)
* Called social services
* Called shelter (Southern Valley‚ e.g.)
* Called police
* Called Sexual Violence Center
* Called crisis worker
* 1-800-799-SAFE given
* Supportive statements only
* Other _____________________________________________________
شرح سایت روان سنجی: خشونت جسمی، عاطفی و جنسی شریک زندگی را می سنجد. پس از آن که مراجع به بخش نخست پاسخ می دهد، درصورت نیاز بررسی دوم انجام می شود.
اعتبار: یافت نشد.
نمره گذاری
If the patient places the “blue” sticker on the circle at the bottom of the page‚ this is considered positive for IPV.
If a patient screens positive for IPV‚ the following survey is generally completed by a physician‚ but could be completed by nursing‚ social service or an in-house advocate if the physician is delayed.
چگونگی دستیابی
منبع و ماخذ
Family Violence Prevention Fund (2003). Interpersonal Violence New Tool for Identification in Health Care Settings‚ Health Alert‚ 9‚ 8-9.