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* 1. Today's Date

Date
Time

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* 2. School

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* 3. Chosen Gender Identification

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* 4. Class Period

Please rate the following by circling words that best show your answer regarding the class you have just completed.

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* 5. Have you ever taken a self-defense or safety skills class?

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* 6. Since starting middle school, have you experienced any incidents of sexual harassment?

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* 7. Did you feel you could diffuse and respond effectively to these incidents of sexual harassment?

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* 8. Have you experienced any incidents of bullying since starting middle school?

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* 9. Did you feel you could diffuse and respond to these incidents of bullying?

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* 10. I am confident that I could use my voice forcefully in an uncomfortable situation like sexual harassment, assault or bullying.

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* 11. How important is your body language for helping you avoid trouble and staying safe?

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* 12. How important is using your voice is in avoiding trouble and staying safe?

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