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Sexual Assault Experience Survey
General Information
Please complete this survey regarding your experience with sexual assault.
1.
Age:
2.
Gender
Female
Male
Other (please specify)
3.
Race (Choose all that apply)
American Indian, Alaskan Native
Asian
Black, African American
Native Hawaiian, Pacific Islander
White
Other (please specify)
4.
Ethnicity
Hispanic, Latina
Not Hispanic,Latina
5.
Location (City/State):
6.
Relationship to the offender
Current or former dating partner or spouse
Stranger
Family Member
Acquaintance
Other (please specify)
7.
How old were you when you were assaulted (choose all that apply)
birth - 9 years old
10-17 years old
18-24 years old
25-39 years old
40-59 years old
60+
8.
Did the offender strangle or attempt to strangle you during the assault?
Yes
No
I'm unsure
9.
If so, did you seek medical attention?
Yes
No
I'm unsure
