Appendix E Office of the Ombudsman/National Human Rights Institution National Public Inquiry on Family Violence in Samoa Survey The results of this questionnaire will be kept completely anonymous and confidential. Your answers will not be shared with anyone. Please answer truthfully and to the best of your ability. 1. DEMOGRAPHIC DETAILS What is your gender? □ Male □ Female □ Other Do you identify as a person with disabilities? □ Yes □ No What is your age? □ Younger than 18 □ 18-24 □ 25-34 □ 35-44 □ 45-54 □ 55-64 □ Older than 65 What is your marital status? □ Never married □ Married/de facto/living together □ Widowed, divorced or separated What village do you live in? ________________________ What is your highest level of education? □ Primary School □ Secondary School/College □ University or higher □ None of the above What is your religion? □ Congregational Christian Church □ Roman Catholic □ Methodist □ Assembly of God □ Seventh-Day Adventist □ Mormon □ Baha’i □ Other ________________ What is your occupation? 2. AWARENESS LEVEL Do you think family violence is a problem in Samoa? □ Strongly disagree □ Disagree □ Neither agree nor disagree □ Agree □ Strongly agree Have you ever participated in an awareness/community outreach program about family violence? □ Yes, more than one □ Yes, one □ No, never