Confidential Survey
Disclaimer: if at anytime you feel uncomfortable answering
any of the following questions, simply refrain from answering
Are you: Female Male
I. Have you experienced any of the following: (circle as many that apply):
a)unwanted verbal advances
b)unwanted touching (i.e. rubbing up against)
c)unwanted fondling of breasts
d)unwanted touching of genitals
e)being forced to touch someone genitals
f)being forced to have oral sex
g)being forced to remove one's clothing
h)any form of penetration
I) OTHER (explain)__________________
If so, what was your relation to the person who did it? relative (please specify), friend, teacher, fellow employee, boyfriend/girlfriend, stranger, spouse
Why do you think this person did this?
What did you do about it?
II. Have you experienced any of the following (circle all that apply):
a)forced oral sex
b)forced anal sex (with penis or other object)
c)forced vaginal sex (with penis or other object)
d)OTHER (please explain)
What was your relationship with the perpetrator? relative (please specify), friend, teacher, fellow employee, boyfriend/girlfriend, stranger, spouse
Why do you think this person did this?
What did you do about it?
III. Have you ever made unwanted advances towards someone? Yes No
If so, what did you do and how was this person related to you?
Have you ever forced someone into a sexual act? Yes No
If so, what did you do and how was this person related to you?
If so, why do you think you did this?
IV. In general, why do you think people sometimes behave in this way?
-The End- Thank you for sharing this information with us and thank you for your time.
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