Questions 1 through 11 are designed to acquire demographic information. Please answer by checking the appropriate responses and filling in the blanks as completely as possible.

  1. What is your age?


  2. What is your gender?

    Male
    Female

  3. What is your level of Visual Impairment? (If there is a difference in vision for each eye, please indicate according to the better eye)

    No Visual Impairment = Vision is in need of none or very little correction.
    Low vision =   Vision in need of correction for both near sightedness and farsightedness. 
                                When corrected vision is between 20/40 and 20/100.
    Legally blind = Vision is in need of correction. 
                                 When corrected vision in the best eye is less than 20/100.
    Totally blind = Vision is unable to be corrected. 
                                Cannot make out shapes or figures and may or may not be able to detect light.
     

  4. What is your partner's level of Visual Impairment? 

    No Visual Impairment = Vision is in need of none or very little correction.
    Low vision =   Vision in need of correction for both near sightedness and farsightedness. 
                                When corrected vision is between 20/40 and 20/100.
    Legally blind = Vision is in need of correction. 
                                 When corrected vision in the best eye is less than 20/100.
    Totally blind = Vision is unable to be corrected. 
                                Cannot make out shapes or figures and may or may not be able to detect light.


IF YOU ANSWERED A on Question #3 SKIP TO QUESTION #7

  1. How many years have you been visually impaired?

     

  2. Did you become visually impaired while in your current relationship?

    Yes
    No

  3. Do you have any other disabilities?

    Yes No

    If yes, please specify   


  4. What is your current relationship status?

    Dating
    In a committed relationship
    Living together
    Married

  5. How long have you been in your current relationship?

       Years       Months

  6. What is your highest level of education completed?

    Grade School
    Some High School
    High School
    Some College
    College Degree
    Advanced Degree

  7. What is your annual household income?

    Under $10,000
    $10,000-$30,000
    $30,000-$50,000
    $50,000-$100,00
    Over 100,000

Questions 12 through 18 are intended to find out about various aspects of your current relationship. Please answer all questions as honestly and best as you can?

  1. How well does your partner meet your needs?

    1- Poorly             2               3 - Average         4               5 - Extremely Well

  2. In general, how satisfied are you with your relationship?

    1 - Unsatisfied     2               3 - Average        4               5 - Extremely Satisfied

  3. How good is your relationship compared to most?

    1 - Poor             2                3 - Average        4                 5 - Excellent
     

  4. How often do you wish you hadn't gotten in this relationship?

    1 - Never           2                3 - Sometimes    4                 5 - Very Often
     

  5. To what extent has your relationship met your original expectations?

    1 - Hardly at all   2                3 - Average       4                 5 - Completely
     

  6. How much do you love your partner?

    1 - Not Much     2                 3 - Average       4                 5 - Very Much
     

  7. How many problems are there in your relationship?

    1 - Very Few     2                 3 - Average       4                 5 - Very Many

Please rate statements 19 through 36 as they apply to your current relationship.

  1. When you ask your partner to do something, you have to check if they did it.

    disagree strongly disagree not applicable agree agree strongly

  2. .My partner and I make sure that we meet our responsibilities in the relationship.

    disagree strongly disagree not applicable agree agree strongly

  3. Tasks do not get spread around enough.

    disagree strongly disagree not applicable agree agree strongly

  4. We have trouble meeting the bills.

    disagree strongly disagree not applicable agree agree strongly

  5. There is little time to explore personal interests in our relationship.

    disagree strongly disagree not applicable agree agree strongly

  6. We discuss who is to do household jobs.

    disagree strongly disagree not applicable agree agree strongly

  7. If I ask my partner to do something she/he needs reminding.

    disagree strongly disagree not applicable agree agree strongly

  8. My partner and I are generally dissatisfied with the duties assigned to us in the relationship.

    disagree strongly disagree not applicable agree agree strongly

  9. Planning activities is difficult because we misunderstand each other.

    disagree strongly disagree not applicable agree agree strongly

  10. In times of crisis we can turn to each other for support.

    disagree strongly disagree not applicable agree agree strongly

  11. We cannot talk to each other about the sadness we feel.

    disagree strongly disagree not applicable agree agree strongly

  12. We accept each other for who we are.

    disagree strongly disagree not applicable agree agree strongly

  13. We avoid discussing our fears and concerns.

    disagree strongly disagree not applicable agree agree strongly

  14. We can express feelings to each other.

    disagree strongly disagree not applicable agree agree strongly

  15. There are lots of bad feelings in our relationship.

    disagree strongly disagree not applicable agree agree strongly

  16. We are able to make decisions about how to solve problems.

    disagree strongly disagree not applicable agree agree strongly

  17. We don't get along well together.

    disagree strongly disagree not applicable agree agree strongly

  18. We confide in each other.

    disagree strongly disagree not applicable agree agree strongly

In every relationship somebody has to decide such things as where to live, etc. Many couples talk such things over first but the final decision is often made by one partner or the other. Choose the most appropriate decision category for items 37 through 56.

  1. What car to get?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                  not applicable

  2. What house or apartment to take?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  3. Whether to invest money?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  4. When to invite friends and relatives to dinner?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  5. Whether to save money?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  6. Who tends to be more assertive in stating personal desires?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  7. Who initiates arguments?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  8. Who tends to initiate resolution of arguments?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  9. Who tends to plan leisure time activities (sports, vacations, etc.)?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  10. Who tends to initiate sexual relations?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  11. Who tends to talk about feelings with the other when bothered or upset?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  12. Who kisses the other when you/partner leave or return from someplace?

      man always                    man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  13. Who gets information before you buy big items?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  14. Who makes complaints to salespeople, workers, landlords?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  15. Who tends to give in more when there is a difference in opinion?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  16. Who does the grocery shopping?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  17. Who straightens up the living room when company is coming?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  18. Who keeps track of the money and the bills?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  19. Who cooks the evening meal?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  20. Who cleans the house?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

In addition to your thoughts and feelings about your current relationship, it is also important to look at how you typically feel about romantic partners in general. Please answer questions 57 through 73 as accurately as possible as they pertain to your general feelings towards romantic partners.  

1=Strongly Disagree                    4=Neutral                    7=Strongly Agree

  1. I find it relatively easy to get close to others

    1    2    3    4    5     6    7

  2. I'm not very comfortable having to depend on other people.

    1    2    3    4    5     6    7

  3. I'm comfortable having others depend on me.

    1    2    3    4    5     6    7

  4. I rarely worry about being abandoned by others.

    1    2    3    4    5     6    7

  5. I don't like people getting too close to me.

    1    2    3    4    5     6    7

  6. I'm somewhat uncomfortable being too close to others.

    1    2    3    4    5     6    7

  7. I find it difficult to trust others completely.

    1    2    3    4    5     6    7

  8. I'm nervous whenever anyone gets too close to me.

    1    2    3    4    5     6    7

  9. Others often want me to be more intimate than I feel comfortable being.

    1    2    3    4    5     6    7

  10. Others often are reluctant to get as close as I would like.

    1    2    3    4    5     6    7

  11. I often worry that my partner(s) don't really love me.

    1    2    3    4    5     6    7

  12. I rarely worry about my partner(s) leaving me.

    1    2    3    4    5     6    7

  13. I often want to merge completely with others, and this desire sometimes scares them.

    1    2    3    4    5     6    7

  14. I'm confident that others would not hurt me by suddenly ending our relationship.

    1    2    3    4    5     6    7

  15. I usually want more closeness and intimacy than others do.

    1    2    3    4    5     6    7

  16. The thought of being left by others rarely enters my mind.

    1    2    3    4    5     6    7

  17. I'm confident that my partner loves me just as much as I love them.

    1    2    3    4    5     6    7

     

Thank you for filling out this survey.  

This next section is to be filled out by your partner.

Click HERE to continue  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Questions 1 through 11 are designed to acquire demographic information. Please answer by checking the appropriate responses and filling in the blanks as completely as possible.

  1. What is your age?


  2. What is your gender?

    Male
    Female

  3. What is your level of Visual Impairment? (If there is a difference in vision for each eye, please indicate according to the better eye)

    No Visual Impairment = Vision is in need of none or very little correction.
    Low vision =   Vision in need of correction for both near sightedness and farsightedness. 
                                When corrected vision is between 20/40 and 20/100.
    Legally blind = Vision is in need of correction. 
                                 When corrected vision in the best eye is less than 20/100.
    Totally blind = Vision is unable to be corrected. 
                                Cannot make out shapes or figures and may or may not be able to detect light.
     

  4. What is your partner's level of Visual Impairment? 

    No Visual Impairment = Vision is in need of none or very little correction.
    Low vision =   Vision in need of correction for both near sightedness and farsightedness. 
                                When corrected vision is between 20/40 and 20/100.
    Legally blind = Vision is in need of correction. 
                                 When corrected vision in the best eye is less than 20/100.
    Totally blind = Vision is unable to be corrected. 
                                Cannot make out shapes or figures and may or may not be able to detect light.


IF YOU ANSWERED A on Question #3 SKIP TO QUESTION #7

  1. How many years have you been visually impaired?

     

  2. Did you become visually impaired while in your current relationship?

    Yes
    No

  3. Do you have any other disabilities?

    Yes No

    If yes, please specify   


  4. What is your current relationship status?

    Dating
    In a committed relationship
    Living together
    Married

  5. How long have you been in your current relationship?

       Years       Months

  6. What is your highest level of education completed?

    Grade School
    Some High School
    High School
    Some College
    College Degree
    Advanced Degree

  7. What is your annual household income?

    Under $10,000
    $10,000-$30,000
    $30,000-$50,000
    $50,000-$100,00
    Over 100,000

Questions 12 through 18 are intended to find out about various aspects of your current relationship. Please answer all questions as honestly and best as you can?

  1. How well does your partner meet your needs?

    1- Poorly             2               3 - Average         4               5 - Extremely Well

  2. In general, how satisfied are you with your relationship?

    1 - Unsatisfied     2               3 - Average        4               5 - Extremely Satisfied

  3. How good is your relationship compared to most?

    1 - Poor             2                3 - Average        4                 5 - Excellent
     

  4. How often do you wish you hadn't gotten in this relationship?

    1 - Never           2                3 - Sometimes    4                 5 - Very Often
     

  5. To what extent has your relationship met your original expectations?

    1 - Hardly at all   2                3 - Average       4                 5 - Completely
     

  6. How much do you love your partner?

    1 - Not Much     2                 3 - Average       4                 5 - Very Much
     

  7. How many problems are there in your relationship?

    1 - Very Few     2                 3 - Average       4                 5 - Very Many

Please rate statements 19 through 36 as they apply to your current relationship.

  1. When you ask your partner to do something, you have to check if they did it.

    disagree strongly disagree not applicable agree agree strongly

  2. .My partner and I make sure that we meet our responsibilities in the relationship.

    disagree strongly disagree not applicable agree agree strongly

  3. Tasks do not get spread around enough.

    disagree strongly disagree not applicable agree agree strongly

  4. We have trouble meeting the bills.

    disagree strongly disagree not applicable agree agree strongly

  5. There is little time to explore personal interests in our relationship.

    disagree strongly disagree not applicable agree agree strongly

  6. We discuss who is to do household jobs.

    disagree strongly disagree not applicable agree agree strongly

  7. If I ask my partner to do something she/he needs reminding.

    disagree strongly disagree not applicable agree agree strongly

  8. My partner and I are generally dissatisfied with the duties assigned to us in the relationship.

    disagree strongly disagree not applicable agree agree strongly

  9. Planning activities is difficult because we misunderstand each other.

    disagree strongly disagree not applicable agree agree strongly

  10. In times of crisis we can turn to each other for support.

    disagree strongly disagree not applicable agree agree strongly

  11. We cannot talk to each other about the sadness we feel.

    disagree strongly disagree not applicable agree agree strongly

  12. We accept each other for who we are.

    disagree strongly disagree not applicable agree agree strongly

  13. We avoid discussing our fears and concerns.

    disagree strongly disagree not applicable agree agree strongly

  14. We can express feelings to each other.

    disagree strongly disagree not applicable agree agree strongly

  15. There are lots of bad feelings in our relationship.

    disagree strongly disagree not applicable agree agree strongly

  16. We are able to make decisions about how to solve problems.

    disagree strongly disagree not applicable agree agree strongly

  17. We don't get along well together.

    disagree strongly disagree not applicable agree agree strongly

  18. We confide in each other.

    disagree strongly disagree not applicable agree agree strongly

In every relationship somebody has to decide such things as where to live, etc. Many couples talk such things over first but the final decision is often made by one partner or the other. Choose the most appropriate decision category for items 37 through 56.

  1. What car to get?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                  not applicable

  2. What house or apartment to take?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  3. Whether to invest money?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  4. When to invite friends and relatives to dinner?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  5. Whether to save money?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  6. Who tends to be more assertive in stating personal desires?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  7. Who initiates arguments?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  8. Who tends to initiate resolution of arguments?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  9. Who tends to plan leisure time activities (sports, vacations, etc.)?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  10. Who tends to initiate sexual relations?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  11. Who tends to talk about feelings with the other when bothered or upset?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  12. Who kisses the other when you/partner leave or return from someplace?

      man always                    man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  13. Who gets information before you buy big items?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  14. Who makes complaints to salespeople, workers, landlords?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  15. Who tends to give in more when there is a difference in opinion?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  16. Who does the grocery shopping?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  17. Who straightens up the living room when company is coming?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  18. Who keeps track of the money and the bills?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  19. Who cooks the evening meal?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

  20. Who cleans the house?

    man always                     man more than woman     man same as woman

    woman more than man    woman always                 not applicable

In addition to your thoughts and feelings about your current relationship, it is also important to look at how you typically feel about romantic partners in general. Please answer questions 57 through 73 as accurately as possible as they pertain to your general feelings towards romantic partners.  

1=Strongly Disagree                    4=Neutral                    7=Strongly Agree

  1. I find it relatively easy to get close to others

    1    2    3    4    5     6    7

  2. I'm not very comfortable having to depend on other people.

    1    2    3    4    5     6    7

  3. I'm comfortable having others depend on me.

    1    2    3    4    5     6    7

  4. I rarely worry about being abandoned by others.

    1    2    3    4    5     6    7

  5. I don't like people getting too close to me.

    1    2    3    4    5     6    7

  6. I'm somewhat uncomfortable being too close to others.

    1    2    3    4    5     6    7

  7. I find it difficult to trust others completely.

    1    2    3    4    5     6    7

  8. I'm nervous whenever anyone gets too close to me.

    1    2    3    4    5     6    7

  9. Others often want me to be more intimate than I feel comfortable being.

    1    2    3    4    5     6    7

  10. Others often are reluctant to get as close as I would like.

    1    2    3    4    5     6    7

  11. I often worry that my partner(s) don't really love me.

    1    2    3    4    5     6    7

  12. I rarely worry about my partner(s) leaving me.

    1    2    3    4    5     6    7

  13. I often want to merge completely with others, and this desire sometimes scares them.

    1    2    3    4    5     6    7

  14. I'm confident that others would not hurt me by suddenly ending our relationship.

    1    2    3    4    5     6    7

  15. I usually want more closeness and intimacy than others do.

    1    2    3    4    5     6    7

  16. The thought of being left by others rarely enters my mind.

    1    2    3    4    5     6    7

  17. I'm confident that my partner loves me just as much as I love them.

    1    2    3    4    5     6    7

     

Thank you for filling out this survey.  

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