Transition Home Survey

Table of contents

Section 1 — Facility Profile As Of Noon April 16, 2014
Section 2 — Resident Profile As Of Noon On April 16, 2014
Section 3 — Departures And Turn-aways: Midnight To Noon On April 16, 2014
Section 4 — Services For Non-residents and Ex-residents
Section 5 — Annual Information
Section 6 — Revenues and Expenditures
Section 7 — Issues And Challenges

Please make any corrections to the address label here:

Name of contact person
Name of organization
Postal Address
City
Province/Territory
Postal Code

Authority
Statistics Act, Revised Statutes of Canada, 1985, Chapter S-19. While participation in this survey is voluntary, your cooperation is important to ensure that the information collected in this survey is as accurate and as comprehensive as possible.

Objective
This survey collects data used to produce statistics on facilities in Canada providing residential services for abused women and their children. In aggregated form, the information collected is used by researchers, service providers and policymakers in developing programs, policies and services for abused women and their children. Your information may be also used by Statistics Canada for other statistical and research purposes.

Confidentiality
Statistics Canada is prohibited by law from releasing any information it collects which could identify any person, business, or organization, unless consent has been given by the respondent or as permitted by the Statistics Act. Statistics Canada will use the information from this survey for statistical purposes.

Record linkages
To enhance the data from this survey and to minimize the reporting burden for respondents, Statistics Canada may combine the information you provide with other survey or administrative data sources.

Instructions
Please return this questionnaire by May 16, 2014. Questionnaires may be returned by mail:

Correspondence
Statistics Canada
ATTN: Central Reception, SC 0505
150 Tunney’s Pasture DRWY
Ottawa ON K1A 0T6
Phone: Toll free 1-800-387-0479
Fax: 1-888-883-7999
E-mail: justice@statcan.gc.ca

Fax or e-mail transmission disclosure
Statistics Canada advises you that there could be a risk of disclosure during facsimile or other electronic transmission. However, upon receipt, Statistics Canada will provide the guaranteed level of protection afforded all information collected under the authority of the Statistics Act.

Data sharing agreements
To reduce respondent burden, Statistics Canada has entered into data-sharing agreements under Section 12 of the Statistics Act with the Canada Mortgage and Housing Corporation and the Public Health Agency of Canada, who have agreed to keep the data confidential and use them only for statistical purposes. Statistics Canada will only share data from this survey with those organizations that have demonstrated a requirement to use the data.

Under Section 12, you may refuse to share your information with any of these organizations by writing a letter of objection to the Chief Statistician and returning it with the completed questionnaire. Please specify the organizations with which you do not want to share your data.

PLEASE READ THE ATTACHED GUIDEBOOK FOR INSTRUCTIONS AND DEFINITIONS BEFORE COMPLETING THE QUESTIONNAIRE.

Section 1 — Facility Profile As Of Noon April 16, 2014

Facility:

1. Please indicate which best describes your facility (Check only one. If there is more than one facility, for example a transition house and a second stage house, please complete two questionnaires.)

(Refer to Guidebook for definitions)

• Transition House
• Second Stage Housing
• Safe Home Network
• Satellite
• Women's Emergency Centre
• Emergency Shelter
• Rural Family Violence Prevention Centres (Alberta only)
• Interim Housing (Manitoba only)
• Family Resource Centre (Ontario only, residential)
• Other (please specify)

2. What is the total number of beds within your facility? (Count each bed, child's bed and crib.  Do not count emergency beds [e.g. cots, sofas, sleeping bags, etc.] unless funded or licensed).

• Number of beds:

Area:

3. Please indicate the area(s) your facility serves (Check all that apply).
(Refer to Guidebook for definition)

• Urban/suburban (1,000 or more people)
• Rural/Village (less than 1,000 people)
• Reserve

4. Is your facility owned or operated by a band council? (Band council refers to a group of representatives elected by the on-reserve residents of the community.)

• Owned by a band council?
  • Yes
  • No
• Operated by a band council?
  • Yes
  • No

5. Is your facility located on a reserve?
(Refer to Guidebook for definition)

• Yes
• No

Services:

6. Please indicate all services your facility provides on a regular basis to residents, non-residents and ex-residents. If your facility does not distinguish between non-residents and ex-residents please use the non-resident category. Please indicate all services provided by other agencies to residents of your facility.

(Refer to Guidebook for definitions)

A) Services for Women (Check all services that apply to each: residents, non-residents, ex-residents, and/or provided by other agencies. Select not applicable if none of the other responses are appropriate.)

• Individual short-term counselling
• Individual long-term counselling
• Group counselling
• Family counselling programs (includes mother, child(ren) and partner)
• Safety planning or protection planning
• Addiction counselling (e.g. information or support)
• Crisis telephone line (staffed 24 hour line)
• Medical services (e.g. information or support)
• Mental health services (e.g. information or support)
• Legal services (e.g. information or support, paralegal services)
• Financial assistance or welfare (e.g. information or support)
• Life skills (e.g. banking, groceries, day-to-day management)
• Job training or employment search
• Parenting skills
• Housing referral
• Culturally sensitive services for Aboriginal women
• Culturally sensitive services for ethno-cultural and visible minority women
• Lesbian sensitive services
• Services for women with disabilities
• Recreation services
• Advocacy on behalf of women
• Transportation/accompaniment (e.g., transportation to the shelter, to court)
• Specialized services for older women (55+)
• Other services for women (please specify)

B) Services for Children (Check all services that apply to each: residents, non-residents, ex-residents, and/or provided by other agencies. Select not applicable if none of the other responses are appropriate.)

• Individual counselling
• Group counselling or support
• Programs for child witnesses or victims of abuse (e.g. play therapy)
• Culturally sensitive services for Aboriginal children
• Culturally sensitive services for ethno-cultural and visible minority children
• School classes or tutoring for children
• Child protection or family services
• Supervising visiting for non-resident parent
• Baby-sitting services
• Outdoor recreation spaces for children
• Indoor recreation spaces for children
• Temporary placement of children without parents
• Other services for children (please specify)

C) Services for Abusive Partners (Check all services that apply to each: residents, non-residents, ex-residents, and/or provided by other agencies. Select not applicable if none of the other responses are appropriate.)

• Treatment or counselling services
• Other (please specify)

D) General Services (Check all services that apply to each: residents, non-residents, ex-residents, and/or provided by other agencies. Select not applicable if none of the other responses are appropriate.)

• Information
• Public education or prevention
• Outreach programs
• Advocacy
• Political or social action (e.g. writing letters to politicians, marches, protesting)
• Help with pet accommodation
• Food bank
• Clothing items
• Furniture items
• Other (please specify)

7. Are there any services that are currently needed but not offered or not offered at the level required to meet the needs of the residents, former residents or non-residents your facility serves?  If so, please indicate the most important of these services (up to 3).

Accessibility:

8. In what languages can your facility provide services? Include languages that staff, volunteers or others who can speak to verbally communicate when providing services. (Check all that apply)

(Refer to Guidebook for definitions)

• English
• French
• Arabic
• Chinese (Mandarin, Cantonese, Hakka)
• Cree
• Dutch
• German
• Greek
• Inuktitut
• Italian
• Ojibway
• Polish
• Portuguese
• Punjabi
• Spanish
• Tagalog (Pilipino)
• Ukrainian
• Vietnamese
• Urdu
• Persian (Farsi)
• Russian
• Hindi
• Other languages(s) (please specify):

9. Is at least one of your building entrances wheelchair accessible? (e.g. access ramps, street-level entrances, automatic or easy-to open doors, etc.)

• Yes
• No (Go to Question 12)

10. Are any bedrooms within your facility wheelchair accessible? (e.g. widened doorways, automatic or easy-to-open doors, etc.)

• Yes
• No

11. Are any bathrooms within your facility wheelchair accessible? (e.g. widened doorways, grab bars, automatic or easy-to-open doors, etc.)

• Yes
• No

12. Does your facility have services for people who are deaf or hearing impaired, such as: (answer yes or no for each)

• TTY/TDD? (Teletypewriter, Telephone Device for Deaf)
• Sign language communication or interpretation?
• Other services? (please specify)

13. Does your facility have services for people who are blind or visually impaired, such as: (answer yes or no for each)

• Braille reading materials?
• Large print reading materials?
• Other services? (please specify)

Male Youth:

14. Does your facility admit children and/or youth? (Children and youth are defined as being under 18 and accompanied by a parent or caregiver.)

• Yes
• No (Go to Question 17)

15. How does your facility handle the admission of male youth? (Check only one)

• Male youth are automatically admitted up to an age limit (Go to Question 16)
• Male youth may be admitted up to an age limit, but each case is reviewed individually before deciding whether or not to admit.  (Go to Question 16)
• There is no age limit, but each case is reviewed individually before deciding whether or not to admit. (Go to Question 17)

16. What is the age limit? (years)

17. Does your facility refer male youth elsewhere?

• Yes
• No (Go to Question 19)

18. To whom or to what type of organization does your facility refer male youth? (Check all that apply)

• Youth shelter
• Social services or child protection services
• Family service centre
• Youth centre
• Family or friends
• Other type of organization (please specify)

Section 2 — Resident Profile As Of Noon On April 16, 2014

The purpose of Section 2 is to obtain a one-day snapshot of the clientele being served on a particular day in the year (i.e., April 16, 2014).  Appreciating that a number of residents to whom space has been assigned may be temporarily absent on April 16, 2014, please include all admitted residents when completing the following questions including those who are temporarily absent.

19. For each adult woman residing in your facility as of noon on April 16, 2014, please indicate the reason(s) she came to your facility (number).

Count all the reasons that apply.

For example, a woman suffering physical abuse, financial abuse and threats who is also experiencing mental health problems would be counted once in each of the 4 corresponding categories. Answer with a number for each of the following categories.

Please ensure that only the women are counted.

Do not count the children in this question.

• Physical abuse
• Sexual abuse
• Financial abuse
• Emotional/Psychological abuse
• Threats
• Harassment
• Human trafficking
• Protection of her child(ren):
  • Physical abuse
  • Sexual abuse
  • Threats
  • Psychological abuse
  • Neglect
  • Witnessing abuse of mother
• Other abuse (please specify)
• Housing problems
  • Housing emergency (e.g. had to leave last home because of eviction or damage caused by fire, flood or natural disaster)
  • Unable to find affordable housing
  • Short-term housing problem (e.g. on list for subsidized housing or waiting to move but unable to secure housing in the meantime)
• Mental health problems
• Drug and alcohol addiction
• Other (please specify)
• Reason unknown/Don't know

Number of residents (women, children, total) as of noon on April 16, 2014.

(Count each woman and child only ONCE).

20. Of the total number of residents in your facility as of noon on April 16, 2014, how many women and accompanying children were there primarily because of ABUSE? (Enter "0" if there were none.)

• Women
• Children
• Total

21. Of the total number of residents in your facility as of noon on April 16, 2014, how many women and accompanying children were there primarily for reasons OTHER THAN ABUSE (e.g. housing problem)? (Enter "0" if there were none.)

• Women
• Children
• Total

22. Please indicate the TOTAL number of women and children who were residing in your facility as of noon April 16, 2014. (Enter "0" if there were none.)

• Women
• Children
• Total

23. What were the referral sources for each woman? (Count as many referral sources as apply for each woman)

• Self-referred only
• Family/friend
• Ministry for Children and Families
• Ministry of Human Resources
• Other Ministry
• House resident (current or former)
• Hospital, doctor, nurse, other health care practitioner or hospital social worker
• Clergy, minister of religion
• Police or RCMP
• Other Transition House
• Aboriginal or First Nations organization or reserve
• Other community agency
• Other
• Don't know/no data
• TOTAL

24. Of the women residents in the facility as of noon on April 16, 2014

• a) How many had been there before? (If number of repeat residents equals ZERO, go to Question 25).
• b) How many women have been there:
  • 1 time previously in the last 12 months?
  • 2 to 4 times previously in the last 12 months?
  • 5 times or more previously in the last 12 months?
• How many women have previously stayed in the facility in the last 12 months for an unknown number of times?
• How many women have stayed in the facility before, but it has been more than 12 months since their last stay?
• Total (Should equal number of women in Question 24 a)

Questions 25 to 27 apply only to people who are residing in your facility as of noon April 16, 2014 and came primarily because of abuse (See Question 20)

Characteristics:

25. As of noon on April 16, 2014, indicate the number of residents from abusive situations in each of the following age groups: (Count each woman and child only once)

A) Age categories of women (number of women for each of the following age categories)

• 15-19 years
• 20-24 years
• 25-29 years
• 30-34 years
• 35-44 years
• 45-54 years
• 55-64 years
• 65 years +
• Age unknown
• Total Women (Should equal total number of women in Question 20).

Age categories of accompanying children (For each of the following: Number of female children; Number of male children):

• Under 1 year
• 1-4 years
• 5-9 years
• 10-12 years
• 13-15 years
• 16-18 years
• 19-24 years
• 25-29 years
• Age unknown
• Total Children (Should equal total number of children in Question 20).

B) As of noon on April 16, 2014, indicate the number of women

(Refer to Guidebook for definition)

(Count each woman only once)

• Who were admitted with their children
• Who were admitted without their children
• Who have no children or parenting responsibilities
• Facility doesn't know if they have children or parenting responsibilities
• Total (Should equal total number of women in Question 20)

C) As of noon on April 16, 2014, indicate the number of residents with a disability.

• Women
• Children
• Total residents with a disability  (If total residents with a disability equals ZERO, go to Question 26)
• Don't know (Go to Question 26)

D) As of noon on April 16, 2014, indicate the number of residents with:

(Count each woman and each child as often as applies, if more than one disability. Include residents with permanent and temporary physical disabilities [e.g., someone on crutches due to a broken leg])

(Answer in number for women and children)

• Mobility disabilities
• Visual disabilities
• Hearing disabilities
• Other disabilities (please specify):
• Don't know

Relationship to abuser:

26. As of noon on April 16, 2014, please indicate the number of women residents by the relationship with their abuser. (Count each woman only once. Do not include children)

• Spouse (legally married)
• Common-law partner
• Ex-spouse
• Ex-common-law partner
• Dating relationship (couples who do not live together)
• Ex-dating relationship
• Relative (parent, child, other)
• Friend or acquaintance
• Caregiver (a non-relative responsible for taking care of the victim full or part-time. Caregivers who are also relatives should be categorized as "relative")
• Authority figure (teacher, professor, employer, person in a position of trust)
• Other (please specify)
• Don't know
• Total (Should equal total number of women in Question 20)

Involvement of the criminal justice system in the most recent abusive situation:

This question refers to the most recent abusive situation for which the woman was admitted to your facility. It DOES NOT refer to previous incidents of abuse for which the police may have been involved.

27. As of noon on April 16, 2014, please answer the following questions in relation to the involvement of the criminal justice system for the most recent abusive situation of each woman (Enter "0" if there were none.)

In how many cases: (answer in numbers for: Yes, No, Don't know and Total [Should equal total number of women in Question 20])

• was the incident reported to police?
• were charges laid against the abuser (e.g. by the woman, police or Crown)?
• was an order obtained for the abuser to stay away (peace bond, restraining order, undertaking to keep the peace and have good conduct, conditions of probation,  emergency intervention order, emergency protection order, victim's assistance order, order to abstain from persistently following a person about from place to place, etc.)?

Section 3 – Departures and Turn-aways: Midnight To Noon On April 16, 2014

Questions 28 to 31 apply to Departures and Turnaways that occurred between midnight and noon on April 16, 2014.

Departures (Refer to Guidebook for definitions)

28. How many women and children (number) departed from your facility between midnight and noon on April 16, 2014?

• Women
• Children
• Total Departures (If total departures equal ZERO, Go to Question 30)

29. Upon departure where did the women go? This question refers to departures (number) between midnight and noon on April 16, 2014 (Count each woman only once. Do not count the children in this question).

• Returned to spouse/common-law partner
• Returned home without spouse/common-law partner
• Second stage housing
• Another emergency shelter
• Out of province/territory shelter
• New accommodation without spouse/common-law partner
• Living with friends or relatives
• Hospital
• Residential services (e.g. group home, hostel, detox centre, addictions rehabilitation centre or other adult care facility)
• Other (please specify):
• Unknown
• Total(Should equal number of women in Question 28)

Turn-aways:

30. How many women and children (number) were turned away from your facility between midnight and noon on April 16, 2014?

• Women
• Children
• Total Turn-aways (If total turn-aways equals ZERO, Go to Question 32)

31. Please list the reason(s) women and children were turned away. (Check all that apply)

• Shelter was full
• Alcohol and drug issues
• Mental health issues
• Transportation issue (e.g., no transportation to get to facility)
• Accessibility issues (e.g., not wheelchair accessible)
• Language barrier
• Under age without parent
• Non-admit or caution list
• Other (please specify)

Section 4 — Services for Non-residents and Ex-residents

The purpose of Section 4 is to obtain information on contacts for assistance from non-residents and ex-residents. Question 32 deals with contacts on the day of April 16, 2014 and contacts for an average month.

(For the following categories: Contacts on (date); Contacts for an average month)

32. Please report the number of phone, letter, e-mail, fax, walk-in or other contacts received from non-residents and ex-residents for housing related and non-housing related needs. This includes outreach services. (Enter "0" if there were none. Count each contact for assistance) (Refer to Guidebook for definitions)

(For the following categories: Contacts on (date); Contacts for an average month)

• Housing related (e.g. crisis, needs housing because of abuse; housing problem; non-abuse; etc.)
• Other (non-housing related) (e.g. crisis, needs medical help; general information; emotional support; etc.)
• TOTAL

Outreach work: (Refer To Guidebook For Definitions)

33. How many hours per week are dedicated to doing outreach? (Please note, if there are 3 staff each doing 20 hours of outreach work per week this would equal 60 hours. Include paid staff, volunteers and others.)

• Number of hours per week

Section 5 — Annual Information

The purpose of Section 5 is to obtain annual information on admissions and physical repairs and improvements for your residential facility. This information is to be provided for a 12-month fiscal period, for example, April 1, 2013 to March 31, 2014.

A. Reference Period: Please specify the 12-month period used in providing information for Section 5 (format DD / MM / YYYY).

• From:
• To:

34. Please indicate the total number of admissions during the reference period. 

Please count admissions to residential programs only.

Please count each woman and child each time they were admitted (include repeat admissions).

(Refer to Guidebook for definitions.)

• Number of women
• Number of children
• Total admissions

B. Adult Males:

Questions 35 to 39 refer to adult men, 15 years of age and over, who were admitted to a facility with or without their dependent children.  (DO NOT include adult men who were admitted with a parent.)

35. Does your facility have a policy on admitting adult men (15 years and over) with or without children? (Check only one)

• Policy allows adult men to be admitted
• Policy does not allow adult men to be admitted (Go to Part C- Physical repairs or improvements).
• There is no facility policy on admitting adult men

36. During the reference period (for example, between April 1, 2013 and March 31, 2014), how many adult men were admitted to your facility? (If no men were admitted, enter "0" and go to Part C- Physical repairs or improvements)

• Number of men

37. During the reference period, were any adult men admitted for reasons of abuse?

• Yes
• No (Go to Part C- Physical repairs or improvements)

38. During the reference period, how many adult men (number) were admitted to your facility for reasons of abuse? (If no men were admitted, enter "0" and go to Part C. Physical repairs or improvements)

• Number of men

39. During the reference period, of those adult men admitted for reasons of abuse, how many (number) were victims of spousal violence? (If no men were admitted, enter "0")

• Number of men

C. Physical repairs or improvements:

The purpose of Questions 40 to 43 is to collect information on physical repairs or improvements that have been made to your facility during the reference period (for example, between April 1, 2013 and March 31, 2014 or during your own 12-month fiscal period if March 31, 2014 is not your fiscal year end).

In this section, do not include funds received from Canada Mortgage and Housing Corporation (CMHC) for the construction of new units.

DO NOT INCLUDE REGULAR MAINTENANCE WHEN RESPONDING TO THESE QUESTIONS.

Regular maintenance refers to painting, repairing leaky faucets, furnace cleaning, etc.

40. Have any physical repairs or improvements (e.g., new roof, flooring, windows, floor tiles, plumbing fixtures) been made to your facility during the reference period?

• Yes
• No  (Go to Question 44)

41. What types of physical repairs or improvements have been made to your facility during the reference period? (Check all that apply)

Major physical repairs or improvements refers to defective plumbing or electrical wiring, structural repairs to walls, floors or ceilings, etc. In other words, there is a legal necessity to make these repairs so that your facility is in accordance with municipal building codes.  These repairs are deemed essential for safety reasons and for meeting municipal standards.

Minor physical repairs or improvements refers to missing or loose floor tiles, bricks or shingles, defective steps, railing or siding, etc.

Structural improvements refers to improvements not required for safety reasons or meeting municipal standards, such as making rooms wheelchair accessible, adding a new security system, adding ramps, adding an outside play area for children, creating a ventilated inside smoking area.

• Major
• Minor
• Structural Improvements

42. How were the physical repairs or improvements made during the reference period funded? (Check all that apply)

• Shelter enhancement program (CMHC)
• Other federal department funding
• Provincial or Territorial government funding
• Joint Federal/Provincial/Territorial agreement funding
• Regional/Municipal government funding
• Fundraising
• Donations
• Other (please specify)
• Don't know

43. How much did the physical repairs or improvements made during the reference period cost? (Indicate cost in dollars.)

(If the exact cost is not available please provide an accurate estimate.)

• Exact
• Estimate
• Don't know

44. Within the next five years, do you anticipate necessary physical repairs or improvements to your facility? (Check all that apply)

Major physical repairs or improvements refers to defective plumbing or electrical wiring, structural repairs to walls, floors or ceilings, etc. In other words, there is a legal necessity to make these repairs so that your facility is in accordance with municipal building codes. These repairs are deemed essential for safety reasons and for meeting municipal standards.

Minor physical repairs or improvements refers to missing or loose floor tiles, bricks or shingles, defective steps, railing or siding, etc.

Structural improvements refers to improvements not required for safety reasons or meeting municipal standards, such as making rooms wheelchair accessible, adding a new security system, adding ramps, adding an outside play area for children, creating a ventilated inside smoking area.

• Major
• Minor
• Structural Improvements

45. Within the next five years, from which of the following do you anticipate funding for these necessary physical repairs or improvements? (Check all that apply)

• Shelter enhancement program (CMHC)
• Other federal department funding
• Provincial or Territorial government funding
• Joint Federal/Provincial/Territorial agreement funding
• Regional/Municipal government funding
• Fundraising
• Donations
• Other (please specify)
• Don't know

Section 6 – Revenues and Expenditures

The purpose of Section 6 is to collect information on the revenues and expenditures of your facility for the reference period.

Revenues

46. Please report the dollar amounts received from each of the following sources of funding and the total revenue for your facility. (You can provide either estimated or audited year end figures. Please round figures to the nearest dollar [e.g. $457 rather than $457.25].)

• Ministry of Aboriginal Affairs and Northern Development Canada
• Other federal departments
• Provincial / Territorial government – Housing
• Provincial / Territorial government – Social Services
• Other provincial/territorial departments
• Municipal government
• Regional Authority
• Foundations
• Loans or grants for major repairs or improvements
• United Way
• Indian Bands
• Resident fees
• Provincial / Territorial lotteries (includes the Associated Entities Fund in Saskatchewan, Bingos, Nevada tickets)
• Donations (money only)
• Fundraising
• Other (please specify):
• Total annual facility revenues

Expenditures

47. Please report the total annual expenditures for your facility and the dollar amount of your total annual expenditures spent on the following: (You can provide either estimated or audited year end figures. Please round figures to the nearest dollar [e.g. $457 rather than $457.25].)

• Salary costs (all salary and benefits, includes casuals and fee for service costs)
• Rent (e.g. outreach offices)
• Mortgage and taxes
• Regular maintenance
• Major repairs or improvements
• Other housing costs (house insurance, utilities, furniture, etc.)
• Administrative costs (e.g. staff and board insurance)
• Staff training (includes conferences)
• Office costs (office supplies, postage, etc.)
• Direct client costs (food, supplies, transportation, and disbursements to residents)
• Contributions to reserve fund (as required by CMHC)
• Other (please specify):
• Total annual facility expenditures

48. Are the revenue and expenditure figures that were provided in questions 46 and 47 based on (Check only one):

• Estimated data
• Audited financial data
• Don’t know

Section 7 – Issues and Challenges

• A) What would you identify as the top three issues or challenges facing your facility in the upcoming year? (Refer to Guidebook for definition)
• B) What would you identify as the top three issues or challenges for the women and children using your facility in the upcoming year? (Refer to Guidebook for definition).

Interdepartmental Agreements

In order to reduce response burden and to provide consistent statistics, Statistics Canada has entered into data sharing agreements under Section 12 of the Statistics Act with the Public Health Agency of Canada and the Canada Mortgage and Housing Corporation. The information we provide to these agencies will be kept confidential and used only for statistical purposes. Under Section 12 of the Statistics Act, you may refuse to share your information with the agencies listed above by writing to the Chief Statistician and returning your letter of objection along with the completed questionnaire in the enclosed return envelope.

Questionnaire completed by:

Questionnaire completed by (block letters):
Date:
Telephone number: (please indicate area code)

Comments

Thank you for taking the time to complete this questionnaire. Please keep a copy of the completed questionnaire in the event that Statistics Canada contacts you for clarification of information given. It is hoped that the information will assist us in better understanding the services available within the community to address the needs of victims of abuse. Should you have any comments or questions regarding the questionnaire or the survey itself, please do not hesitate to contact us at 1-800-387-0479. The following space is provided for those of you who would prefer to write down your comments. Please print carefully.