Path evaluation

1. Regional Crime Victim Crisis Center Primary Prevention Violence Survey for Youth

If you are under the age of 24,please participate in this short, simple youth survey on Youth Violence. This is an anonymous survey that the RCVCC Primary Prevention Program is conducting to hear about what is really happening from the voices that matter--yours!

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* 1. IMPORTANT 24 hour Crisis Lines if you are a victim of abuse:
* Regional Crime Victim Crisis Center: 325-677-7895 www.regionalcrime.org
* Department Family Protective Services: 1-800-252-5400 www.txabusehotline.org
* Rape Abuse Incest National Network: 1-800-656-HOPE www.rainn.org
* MHMR: 1-800-758-3344
* OR 211 Help in Texas www.211texas.org

PATH GROUP LOCATION

Austin Elementary

Bassetti Elementary

Bonham Elementary

Bowie Elementary

College Hts Elementary

Dyess Elementary

Fannin Elementary

Jackson Elementary

Johnston Elementary

Lee Elementary

Long Elementary

Martinez Elementary

Ortiz Elementary

Reagan Elementary

Taylor Elementary

Thomas Elementary

Ward Elementary

Clack Middle School

Craig Middle School

Madison Middle School

Mann Middle School

Abilene High School

Cooper High School

A.T.E.M.S.

Jefferson Center

Ash Street Center

Sherry Lane Center

Vine Street Center

Cedar Street Center

Kids Kampus

Alliance for Women and Children

DiCipher

Carver Youth Council

PEACE group

Abilene Christian University

Hardin Simmons University

McMurry University

Other (please specify)

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* 2. YOUR PATH ID NUMBER

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* 3. Is this your Pre or Post Evaluation?

Pre (first day of group)

Post (end of group)

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* 4. Grade you are in

Pre K - 5th grade

6th - 8th grade

9th- college

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* 5. Age:

3-4 yrs

5-6 yrs

7-8 yrs

9-10 yrs

11-12 yrs

13-14 yrs

15 yrs

16 yrs

17 yrs

18 yrs

19 yrs

20 yrs

21 -24 yrs

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* 6. What is your gender?

Male

Female

Transgender

Other

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* 7. What is your ethnic/racial background?

Asian/Pacific Islander

Black/African American

Hispanic/Latino

Middle Eastern/South Asian

Multiracial

Native American Indian

White/Caucasian

Identity not listed

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* 8. Choose which of the below statements apply to you.

I personally know another youth that has been a victim of violence.(which may include sexual violence)

I have been a victim of violence. (Which may include sexual violence)

I personally know a youth who has died from an act of violence.

These statements do not apply to me.

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* 9. In the past 30 days, I have excluded or ignored others from my clique of friends

	Never	1-3 times	4-6 times	7-10 times	More than 10 times
At school	At school Never	At school 1-3 times	At school 4-6 times	At school 7-10 times	At school More than 10 times
In my neighborhood	In my neighborhood Never	In my neighborhood 1-3 times	In my neighborhood 4-6 times	In my neighborhood 7-10 times	In my neighborhood More than 10 times
At home	At home Never	At home 1-3 times	At home 4-6 times	At home 7-10 times	At home More than 10 times
Other places in the community	Other places in the community Never	Other places in the community 1-3 times	Other places in the community 4-6 times	Other places in the community 7-10 times	Other places in the community More than 10 times

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* 10. POST Curriculum: same question as above

	Never	1-3 times	4-6 times	7-10 times	More than 10 times
At School	At School Never	At School 1-3 times	At School 4-6 times	At School 7-10 times	At School More than 10 times
In My Neighborhood	In My Neighborhood Never	In My Neighborhood 1-3 times	In My Neighborhood 4-6 times	In My Neighborhood 7-10 times	In My Neighborhood More than 10 times
At Home	At Home Never	At Home 1-3 times	At Home 4-6 times	At Home 7-10 times	At Home More than 10 times
Other places in community	Other places in community Never	Other places in community 1-3 times	Other places in community 4-6 times	Other places in community 7-10 times	Other places in community More than 10 times

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* 11. On average, how often do you witness violence each week?

	Never	1-3 times	4-6 times	7-10 times	more than 10 times
At school	At school Never	At school 1-3 times	At school 4-6 times	At school 7-10 times	At school more than 10 times
In my neighborhood	In my neighborhood Never	In my neighborhood 1-3 times	In my neighborhood 4-6 times	In my neighborhood 7-10 times	In my neighborhood more than 10 times
At home	At home Never	At home 1-3 times	At home 4-6 times	At home 7-10 times	At home more than 10 times

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* 12. POST CURRICULUM: Same Question as above

	Never	1-3 times	4-6 times	7-10 times	more than 10 times
At School	At School Never	At School 1-3 times	At School 4-6 times	At School 7-10 times	At School more than 10 times
In my neighborhood	In my neighborhood Never	In my neighborhood 1-3 times	In my neighborhood 4-6 times	In my neighborhood 7-10 times	In my neighborhood more than 10 times
At Home	At Home Never	At Home 1-3 times	At Home 4-6 times	At Home 7-10 times	At Home more than 10 times

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* 13. Choose which of the below apply to you.

I could get a weapon easily.

I already have a weapon

My older brother/ sister or parent has a weapon.

I don't know how to get a weapon.

N/A

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* 14. Within the last 30 days, have been a victim of:

	At school	In my neighborhood	In my home	Elsewhere
Been hit	Been hit At school	Been hit In my neighborhood	Been hit In my home	Been hit Elsewhere
Been shoved	Been shoved At school	Been shoved In my neighborhood	Been shoved In my home	Been shoved Elsewhere
Been kicked or tripped	Been kicked or tripped At school	Been kicked or tripped In my neighborhood	Been kicked or tripped In my home	Been kicked or tripped Elsewhere
Been attacked with a weapon	Been attacked with a weapon At school	Been attacked with a weapon In my neighborhood	Been attacked with a weapon In my home	Been attacked with a weapon Elsewhere
Been cyber-bullied	Been cyber-bullied At school	Been cyber-bullied In my neighborhood	Been cyber-bullied In my home	Been cyber-bullied Elsewhere
Been threatened	Been threatened At school	Been threatened In my neighborhood	Been threatened In my home	Been threatened Elsewhere
Been forced to do unwanted sexual things	Been forced to do unwanted sexual things At school	Been forced to do unwanted sexual things In my neighborhood	Been forced to do unwanted sexual things In my home	Been forced to do unwanted sexual things Elsewhere

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* 15. POST CURRICULUM: Same Question as Above

	At School	In my Neighborhood	In my Home	Elsewhere
Been hit	Been hit At School	Been hit In my Neighborhood	Been hit In my Home	Been hit Elsewhere
Been shoved	Been shoved At School	Been shoved In my Neighborhood	Been shoved In my Home	Been shoved Elsewhere
Been kicked or tripped	Been kicked or tripped At School	Been kicked or tripped In my Neighborhood	Been kicked or tripped In my Home	Been kicked or tripped Elsewhere
Been attacked with a weapon	Been attacked with a weapon At School	Been attacked with a weapon In my Neighborhood	Been attacked with a weapon In my Home	Been attacked with a weapon Elsewhere
Been cyber-bullied	Been cyber-bullied At School	Been cyber-bullied In my Neighborhood	Been cyber-bullied In my Home	Been cyber-bullied Elsewhere
Been threatened	Been threatened At School	Been threatened In my Neighborhood	Been threatened In my Home	Been threatened Elsewhere
Been forced to do unwanted sexual things	Been forced to do unwanted sexual things At School	Been forced to do unwanted sexual things In my Neighborhood	Been forced to do unwanted sexual things In my Home	Been forced to do unwanted sexual things Elsewhere

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* 16. How much do you worry about your safety and about violence? (including sexual violence)

	I don't worry	I worry a little bit	I worry a lot
At school	At school I don't worry	At school I worry a little bit	At school I worry a lot
In my neighborhood	In my neighborhood I don't worry	In my neighborhood I worry a little bit	In my neighborhood I worry a lot
In my home	In my home I don't worry	In my home I worry a little bit	In my home I worry a lot

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* 17. POST CURRICULUM: Same Question as Above

	I don't worry	I worry a little bit	I worry a lot
At school	At school I don't worry	At school I worry a little bit	At school I worry a lot
In my neighborhood	In my neighborhood I don't worry	In my neighborhood I worry a little bit	In my neighborhood I worry a lot
In my home	In my home I don't worry	In my home I worry a little bit	In my home I worry a lot

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* 18. Within the last 30 day, I have or helped someone else:

	At School	In my neighborhood	In my home	Elsewhere
Hit someone	Hit someone At School	Hit someone In my neighborhood	Hit someone In my home	Hit someone Elsewhere
Shove Someone	Shove Someone At School	Shove Someone In my neighborhood	Shove Someone In my home	Shove Someone Elsewhere
Kick or Trip someone	Kick or Trip someone At School	Kick or Trip someone In my neighborhood	Kick or Trip someone In my home	Kick or Trip someone Elsewhere
Attack someone with a weapon	Attack someone with a weapon At School	Attack someone with a weapon In my neighborhood	Attack someone with a weapon In my home	Attack someone with a weapon Elsewhere
Cyber-Bullied or Sexted someone	Cyber-Bullied or Sexted someone At School	Cyber-Bullied or Sexted someone In my neighborhood	Cyber-Bullied or Sexted someone In my home	Cyber-Bullied or Sexted someone Elsewhere
Threaten someone	Threaten someone At School	Threaten someone In my neighborhood	Threaten someone In my home	Threaten someone Elsewhere
Force someone to do sexual things they did not want to do	Force someone to do sexual things they did not want to do At School	Force someone to do sexual things they did not want to do In my neighborhood	Force someone to do sexual things they did not want to do In my home	Force someone to do sexual things they did not want to do Elsewhere

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* 19. POST CURRICULUM: Same Question as Above

	At School	In my neighborhood	In my home	Elsewhere
Hit someone	Hit someone At School	Hit someone In my neighborhood	Hit someone In my home	Hit someone Elsewhere
Shove Someone	Shove Someone At School	Shove Someone In my neighborhood	Shove Someone In my home	Shove Someone Elsewhere
Kick or Trip someone	Kick or Trip someone At School	Kick or Trip someone In my neighborhood	Kick or Trip someone In my home	Kick or Trip someone Elsewhere
Attack someone with a weapon	Attack someone with a weapon At School	Attack someone with a weapon In my neighborhood	Attack someone with a weapon In my home	Attack someone with a weapon Elsewhere
Cyber-Bullied or Sexted someone	Cyber-Bullied or Sexted someone At School	Cyber-Bullied or Sexted someone In my neighborhood	Cyber-Bullied or Sexted someone In my home	Cyber-Bullied or Sexted someone Elsewhere
Threaten someone	Threaten someone At School	Threaten someone In my neighborhood	Threaten someone In my home	Threaten someone Elsewhere
Force someone to do sexual things they did not want to do	Force someone to do sexual things they did not want to do At School	Force someone to do sexual things they did not want to do In my neighborhood	Force someone to do sexual things they did not want to do In my home	Force someone to do sexual things they did not want to do Elsewhere

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* 20. During the last 30 days, have you been teased, gossiped about, sexually harassed and/or bullied by peers?

	Not at all	A little bit	It happens sometimes	It happens a lot
Because of my race/ethnicity	Because of my race/ethnicity Not at all	Because of my race/ethnicity A little bit	Because of my race/ethnicity It happens sometimes	Because of my race/ethnicity It happens a lot
Because of my gender	Because of my gender Not at all	Because of my gender A little bit	Because of my gender It happens sometimes	Because of my gender It happens a lot
Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight)	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) Not at all	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) A little bit	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) It happens sometimes	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) It happens a lot
Because of my religion	Because of my religion Not at all	Because of my religion A little bit	Because of my religion It happens sometimes	Because of my religion It happens a lot
Because of my physical/mental ability or appearance	Because of my physical/mental ability or appearance Not at all	Because of my physical/mental ability or appearance A little bit	Because of my physical/mental ability or appearance It happens sometimes	Because of my physical/mental ability or appearance It happens a lot
Because of my nationality/immigration status	Because of my nationality/immigration status Not at all	Because of my nationality/immigration status A little bit	Because of my nationality/immigration status It happens sometimes	Because of my nationality/immigration status It happens a lot
Because of my financial status	Because of my financial status Not at all	Because of my financial status A little bit	Because of my financial status It happens sometimes	Because of my financial status It happens a lot

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* 21. POST CURRICULUM: Same Question as Above

	Not at all	A little bit	It happens sometimes	It happens a lot
Because of my race/ethnicity	Because of my race/ethnicity Not at all	Because of my race/ethnicity A little bit	Because of my race/ethnicity It happens sometimes	Because of my race/ethnicity It happens a lot
Because of my gender	Because of my gender Not at all	Because of my gender A little bit	Because of my gender It happens sometimes	Because of my gender It happens a lot
Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight)	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) Not at all	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) A little bit	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) It happens sometimes	Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight) It happens a lot
Because of my religion	Because of my religion Not at all	Because of my religion A little bit	Because of my religion It happens sometimes	Because of my religion It happens a lot
Because of my physical/mental ability or appearance	Because of my physical/mental ability or appearance Not at all	Because of my physical/mental ability or appearance A little bit	Because of my physical/mental ability or appearance It happens sometimes	Because of my physical/mental ability or appearance It happens a lot
Because of my nationality/immigration status	Because of my nationality/immigration status Not at all	Because of my nationality/immigration status A little bit	Because of my nationality/immigration status It happens sometimes	Because of my nationality/immigration status It happens a lot
Because of my financial status	Because of my financial status Not at all	Because of my financial status A little bit	Because of my financial status It happens sometimes	Because of my financial status It happens a lot

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* 22. During the last 30 days, have you teased, gossiped about, sexually harassed and/or bullied others or participated with others in these acts of violence?

	Not at all	A little bit	It happens sometimes	It happens a lot
Because of their race/ethnicity	Because of their race/ethnicity Not at all	Because of their race/ethnicity A little bit	Because of their race/ethnicity It happens sometimes	Because of their race/ethnicity It happens a lot
Because of their gender	Because of their gender Not at all	Because of their gender A little bit	Because of their gender It happens sometimes	Because of their gender It happens a lot
Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight)	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) Not at all	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) A little bit	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) It happens sometimes	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) It happens a lot
Because of their religion	Because of their religion Not at all	Because of their religion A little bit	Because of their religion It happens sometimes	Because of their religion It happens a lot
Because of their physical/ mental ability or stature	Because of their physical/ mental ability or stature Not at all	Because of their physical/ mental ability or stature A little bit	Because of their physical/ mental ability or stature It happens sometimes	Because of their physical/ mental ability or stature It happens a lot
Because of their nationality/ immigration status	Because of their nationality/ immigration status Not at all	Because of their nationality/ immigration status A little bit	Because of their nationality/ immigration status It happens sometimes	Because of their nationality/ immigration status It happens a lot

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* 23. POST CURRICULUM: Same Question as Above

	Not at all	A little bit	It happens sometimes	It happens a lot
Because of their race/ethnicity	Because of their race/ethnicity Not at all	Because of their race/ethnicity A little bit	Because of their race/ethnicity It happens sometimes	Because of their race/ethnicity It happens a lot
Because of their gender	Because of their gender Not at all	Because of their gender A little bit	Because of their gender It happens sometimes	Because of their gender It happens a lot
Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight)	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) Not at all	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) A little bit	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) It happens sometimes	Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight) It happens a lot
Because of their religion	Because of their religion Not at all	Because of their religion A little bit	Because of their religion It happens sometimes	Because of their religion It happens a lot
Because of their physical/ mental ability or stature	Because of their physical/ mental ability or stature Not at all	Because of their physical/ mental ability or stature A little bit	Because of their physical/ mental ability or stature It happens sometimes	Because of their physical/ mental ability or stature It happens a lot
Because of their nationality/ immigration status	Because of their nationality/ immigration status Not at all	Because of their nationality/ immigration status A little bit	Because of their nationality/ immigration status It happens sometimes	Because of their nationality/ immigration status It happens a lot

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* 2. YOUR PATH ID NUMBER

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* 3. Is this your Pre or Post Evaluation?

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* 4. Grade you are in

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* 5. Age:

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* 6. What is your gender?

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* 7. What is your ethnic/racial background?

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* 8. Choose which of the below statements apply to you.

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* 9. In the past 30 days, I have excluded or ignored others from my clique of friends

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* 10. POST Curriculum: same question as above

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* 11. On average, how often do you witness violence each week?

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* 12. POST CURRICULUM: Same Question as above

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* 13. Choose which of the below apply to you.

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* 14. Within the last 30 days, have been a victim of:

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* 15. POST CURRICULUM: Same Question as Above

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* 16. How much do you worry about your safety and about violence? (including sexual violence)

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* 17. POST CURRICULUM: Same Question as Above

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* 18. Within the last 30 day, I have or helped someone else:

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* 19. POST CURRICULUM: Same Question as Above

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* 20. During the last 30 days, have you been teased, gossiped about, sexually harassed and/or bullied by peers?

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* 21. POST CURRICULUM: Same Question as Above

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* 22. During the last 30 days, have you teased, gossiped about, sexually harassed and/or bullied others or participated with others in these acts of violence?

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* 23. POST CURRICULUM: Same Question as Above

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* 24. If you could make ONE change that would help stop the violence that young people experience today, what would that change be?