Identifying Interpersonal Violence in Health Care Settings

David McCollum, MD, a Minnesota-based emergency physician and a member of the American Medical Association's National Advisory Council on Violence and Abuse developed a low-cost, comprehensive survey to screen patients for interpersonal violence.

Dr. McCollum developed this tool based on his hypothesis that a written format would do a better job of identifying abuse than the face-to-face screening method because it:

  • Doesn’t require verbal conversation that can be overheard
  • Allows the ER nurses to hand the form to the patient without struggling over asking the questions
  • Is a uniform method of screening
The tool

The survey form is Z-folded, inserted into a brown envelope, and handed to patients when they are brought back alone from triage. The patient completes the form and the nurse or physician picks it up when he or she returns.

The survey is divided into three, color-coded sections (identified by a blue, green, and yellow sticker). The forms are laminated and reused, and the stickers are replaced as needed, keeping costs to a minimum.

The survey directs the patient to:

  1. Read the statements in each section.
  2. Decide which group of statements best fits his/her life.
  3. Peel off the sticker next to the group of statements and place it on the same colored circle at the bottom of the survey.
The color code

Blue = Unhealthy Relationship

A blue sticker indicates an unhealthy relationship and a face-to-face interview should be conducted.

The statements in this section are as follows:

  • “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.”

Green = Healthy Relationship

A green sticker indicates a healthy relationship and includes the following statements:

  • “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.”

Yellow = N/A

A yellow sticker indicates the survey is not applicable because:

  • “None of the statements above applies to me.”
  • “I am not now in any close relationship with another person.”

Face-to-face interview

If the blue sticker has been placed on the circle at the bottom of the page, the patient should be moved to a private room for a face-to-face interview using the secondary survey for interpersonal violence below.

This generally should be done by the physician but could be done by nursing staff, social services, or an inhouse advocate if the physician will be delayed.

The scripted form walks the interviewer through the steps of:

  • Providing responses
  • Assessing safety
  • Offering various forms of help

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Last Updated: 4/8/2009
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