1. What is your age?

2. What is your gender?

3. What is your race / ethnicity?

4. What is your religious affiliation?

5. What is your sexual orientation?

6. How aware are you of the following on campus:

  Very Aware Somewhat Aware Somewhat Unaware Very Unaware
Health Services
Mental Health Services

7. Have you used any of the student health services on campus?

8. Are you aware of on-campus services offered for victims of rape and/or domestic violence?

9. Have you ever sought help on campus for the following:

  Yes No
Immunizations
Basic Healthcare (cold and flu)
Sexual Health
Rape
Domestic Violence

10. Would you use any of the following health services on campus:

  Yes No
Immunizations
Basic Healthcare (cold and flu)
Sexual Health
Rape
Domestic Violence

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