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* 1. Name (optional):

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* 2. Age:

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* 3. Gender:

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* 4. Ethnicity:

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* 5. Have you ever been sexually assaulted?

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* 6. Did you confide in anyone?
If so, what was their response?

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* 7. How old were you whe you were assaulted?

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* 8. Did you know the perpetrator?

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* 9. Did you file a police report?
If yes, was the perpetrator prosecuted?

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* 10. Since the assault, have you noticed any behavioral changes?

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* 11. Do you think raising awareness will reduce the chances of assaults with future generations?

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* 12. Are you willing to share your story?

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