7 - 12 Grade TDV Pre Program Survey

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* 1. I am a:

Male

Female

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* 2. What grade are you in?

7

8

9

10

11

12

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* 3. What school do you go to?

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* 4. Do you date?

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* 5. Have you ever been afraid on a date?

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* 6. Please answer the following questions about your own experiences.

	Never	1-2 times	3-5 times	6 or more times
How many times have you been physically abused (kicked, shoved, hit, strangled etc.) on a date?	How many times have you been physically abused (kicked, shoved, hit, strangled etc.) on a date? Never	How many times have you been physically abused (kicked, shoved, hit, strangled etc.) on a date? 1-2 times	How many times have you been physically abused (kicked, shoved, hit, strangled etc.) on a date? 3-5 times	How many times have you been physically abused (kicked, shoved, hit, strangled etc.) on a date? 6 or more times
How many times have you been verbally abused (such as using threatened or putdown) on a date?	How many times have you been verbally abused (such as using threatened or putdown) on a date? Never	How many times have you been verbally abused (such as using threatened or putdown) on a date? 1-2 times	How many times have you been verbally abused (such as using threatened or putdown) on a date? 3-5 times	How many times have you been verbally abused (such as using threatened or putdown) on a date? 6 or more times
How many times has your date abused you by trying to control you (for example, by trying to choose your friends, what you do with your time or what you wear?)	How many times has your date abused you by trying to control you (for example, by trying to choose your friends, what you do with your time or what you wear?) Never	How many times has your date abused you by trying to control you (for example, by trying to choose your friends, what you do with your time or what you wear?) 1-2 times	How many times has your date abused you by trying to control you (for example, by trying to choose your friends, what you do with your time or what you wear?) 3-5 times	How many times has your date abused you by trying to control you (for example, by trying to choose your friends, what you do with your time or what you wear?) 6 or more times
How many times have you been sexually abused on a date (for example forced to be involved in sexual activity that you have said you are not comfortable with?)	How many times have you been sexually abused on a date (for example forced to be involved in sexual activity that you have said you are not comfortable with?) Never	How many times have you been sexually abused on a date (for example forced to be involved in sexual activity that you have said you are not comfortable with?) 1-2 times	How many times have you been sexually abused on a date (for example forced to be involved in sexual activity that you have said you are not comfortable with?) 3-5 times	How many times have you been sexually abused on a date (for example forced to be involved in sexual activity that you have said you are not comfortable with?) 6 or more times

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* 7. Whom have you asked for help about the dating abuse for yourself

Nobody

Parent

Friend

Teacher

Counselor

Other

Doesn’t Apply

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* 8. Please answer the following question regarding your own experiences.

	None	1-2	3-5	6
How many of your friends have been victims of any kind of dating violence?	How many of your friends have been victims of any kind of dating violence? None	How many of your friends have been victims of any kind of dating violence? 1-2	How many of your friends have been victims of any kind of dating violence? 3-5	How many of your friends have been victims of any kind of dating violence? 6
How many times have you helped a friend who is having problems with dating abuse?	How many times have you helped a friend who is having problems with dating abuse? None	How many times have you helped a friend who is having problems with dating abuse? 1-2	How many times have you helped a friend who is having problems with dating abuse? 3-5	How many times have you helped a friend who is having problems with dating abuse? 6

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* 9. Do you receive information about Teen Dating Violence at School?

If yes, where do you receive this information?