AbuseAssessmentScreenThis too lmaybeusedtoquicklyscreenfordomesticviolence.Priortousetheagencyshouldhaverecordkeepingandconfidentialitystandardsthatensureagainstdisclosureofparticipantinformationandma ximizeparticipantsafety.Instructions:CircleYesorNoforeachquestion .1.Haveyoueverbeenemotionallyorphysicallyabusedbyyourpartnerorsomeoneimportanttoyou? YESNO 2.Withinthelastyear,haveyoubeenhit,slapped,kickedorotherwisephysicallyhurtbysomeone? YESNOIfYES,bywhom?(Circleallthatapply)HusbandExHusbandBoyfriendStrangerOtherMultipleTotalno.oftimes___________ 3. (Ifapplicable):Sinceyouvebeenpregnant,haveyoubeenslapped,kickedorotherwisephysicallyhur tbysomeone?YESNOIfYES,bywhom?(Circleallthatapply)HusbandExHusbandBoyfriendStrangerOtherMultipleTotalno.oftimes___________ 4.Withinthelastyear,hasanyoneforcedyoutohavesexualactivities?IfYES,bywhom? (Circleallthatapply)HusbandExHusbandBoyfriendStrangerOtherMultipleTotalno.oftimes___________ 5.Areyouafraidofyourpartneroranyoneyoulistedabove?YESNOMultiple(pleaselist) Developer:JudithMcFarlane,BarbaraParker,KarenSoeken,andLindaBullocCopyright(c)1992,A mericanMedicalAssociation.Allrightsreserved.

JournaloftheAmericanMedicalAssociation,199 2,267,317678.Administrationmethod:Provideaprivateandconfidentialsetting.Informeachwomanthatallwo menattendingthisservicearebeingassessedforabuse.ReadtheAbuseAssessmentScreen(AAS)que stionstothewoman.Scoringprocedures:Ifanyquestionsonthescreenareansweredaffirmatively,the AASisconsideredpositiveforabuse(Weiss,Ernst,Cham,&Nick,2003).Followupprocedures:Ataminimum,allagenciesshouldofferwomenwithpositivescreensreferralsourcesa ndlegaloptions(Soekenetal.1998). Abuse Assessment Screen Many women with disabilities are at risk for abuse, however standard screening tools may not unveil abuse common to women with disabilites such as with holding assistance or treatment. Abuse Assessment Screen-Disability (AAS-D) 1. Within the last year, have you been hit, slapped, kicked, pushed shoved or otherwise physically hurt by someone? YES NO If YES, who? (circle all that apply) Intimate Care Health Family Other (e.g., Partner Provider Professional Member stranger, clergy) Please describe __________________________________________________ 2. Within the last year, has anyone forced you to have sexual activities? YES NO If yes, who? (circle all that apply) Intimate Care Health Family Other (e.g., Partner Provider Professional Member stranger, clergy) Please describe __________________________________________________

3. Within the last year, has anyone prevented you from using a wheelchair, cane, respirator, or other assistive devices? YES NO If yes, who? (circle all that apply) Intimate Care Health Family Other (e.g., Partner Provider Professional Member stranger, clergy) Please describe __________________________________________________ 4. Within the last year, has anyone you depend on refused to help you with an important personal need, such as taking your medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting food or drink? YES NO If yes, who? (circle all that apply) Intimate Care Health Family Other (e.g., Partner Provider Professional Member stranger, clergy) Please describe __________________________________________________

McFarlane, J, et al. Abuse Assessment Screen-Disability (AAS-D): Measuring frequency, type, and perpetrator of abuse toward women with physical disabilities. J of Women's Health and Gender-Based Medicine 2001;10(9):861-866.