Attitudinal Change in Participants of Partner Assault Response (PAR) Programs: A Pilot Project

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APPENDIX B: Research Information Form

Research Information Form

To be completed by Changing Ways Staff

• ID number:
• Date of Birth:
• Program start date:
• Referral:
  • Voluntary
  • Probation
  • Early Intervention Court
  • Other (specify: )
• Past Changing Ways client:
  • Yes
  • No
• History of past assaults? (other than assault related to referral)
  • Yes
  • No

  If yes, how many?

• Police Report Available?
  • Yes
  • No

  If yes, was it a 'serious' assault (i.e., likely to cause lasting damage or be life threatening)?

  • Yes
  • No
  
  
• Client Responsibility (assessed by facilitator):
  • high
  • medium
  • low
  • very low
  • non-existent
• Client Minimization (assessed by facilitator):
  • very high
  • high
  • medium
  • low
  • very low
• Employment status:
  • employed days
  • employed evenings
  • employed shift work
  • unemployed
• Income:
  • under 10, 000
  • 10, 000 - 14, 999
  • 15, 000 - 19, 999
  • 20, 000 - 24, 999
  • 25, 000 - 29, 999
  • 30, 000 - 34, 999
  • 35, 000 - 39, 999
  • 40, 000 - 44, 999
  • 45, 000 - and over
• Do you identify with any particular ethnic group?
  • Yes
  • No

  If yes, please specify. (Check all that apply-for example: French Canadian)

  • Canadian
  • Chinese
  • French
  • Jewish
  • English
  • Polish
  • German
  • Portuguese
  • Scottish
  • Other European (Specify)
  • Irish
  • South Asian
  • Italian
  • Black
  • Ukrainian
  • North American Indian
  • Dutch (Netherlands)
  • Other (Specify )

• **Ratings for the next section are made on the victim of the assault.

  Current relationship status with assaulted partner:

  • single
  • common law
  • dating
  • married
  • divorced
  • planning to divorce
  • separated

• Length of relationship with assaulted partner:

• Length of separation from assaulted partner:

• Plans to reconcile with assaulted partner?
  • Yes
  • No
• Does the man have a current partner that is different from the assaulted partner?
  • Yes
  • No

  If yes, are they:

  • common law
  • dating
  • married
  • other (please specify )
• Pressure to attend program?
  • Yes
  • No

  If yes, from whom?

  • Probation Officer
  • CAS worker
  • Partner
  • Other (who?)

  If yes, how much pressure?

  • Extreme
  • Lots
  • Some
  • A bit
  • Very little
• Alcohol intake:
  • not at all
  • less than one drink/month
  • one drink weekly
  • one drink daily
  • more than 1/day
• Drug intake:
  • not at all
  • occasional
  • regular user

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