Sexual Assault Experience Survey

General Information

Please complete this survey regarding your experience with sexual assault.

Question Title

1. Age:

Question Title

2. Gender

Female

Male

Other (please specify)

Question Title

3. Race (Choose all that apply)

American Indian, Alaskan Native

Asian

Black, African American

Native Hawaiian, Pacific Islander

White

Other (please specify)

Question Title

4. Ethnicity

Hispanic, Latina

Not Hispanic,Latina

Question Title

5. Location (City/State):

Question Title

6. Relationship to the offender

Current or former dating partner or spouse

Stranger

Family Member

Acquaintance

Other (please specify)

Question Title

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+

Question Title

8. Did the offender strangle or attempt to strangle you during the assault?

Yes

I'm unsure

Question Title

9. If so, did you seek medical attention?

Yes

I'm unsure

Sexual Assault Experience Survey

General Information

Question Title

* 1. Age:

Question Title

* 2. Gender

Question Title

* 3. Race (Choose all that apply)

Question Title

* 4. Ethnicity

Question Title

* 5. Location (City/State):

Question Title

* 6. Relationship to the offender

Question Title

* 7. How old were you when you were assaulted (choose all that apply)

Question Title

* 8. Did the offender strangle or attempt to strangle you during the assault?

Question Title

* 9. If so, did you seek medical attention?

1. Age:

2. Gender

3. Race (Choose all that apply)

4. Ethnicity

5. Location (City/State):

6. Relationship to the offender

7. How old were you when you were assaulted (choose all that apply)

8. Did the offender strangle or attempt to strangle you during the assault?

9. If so, did you seek medical attention?