* 1. I am a:

* 2. What grade are you in?

* 3. What school do you go to?

* 6. Please answer the following questions about your own experiences.

  Never 1-2 times 3-5 times 6 or more times
How many times have you been physically abused (kicked, shoved, hit, strangled etc.) on a date?
How many times have you been verbally abused (such as using threatened or putdown) on a date?
How many times has your date abused you by trying to control you (for example, by trying to choose your friends, what you do with your time or what you wear?)
How many times have you been sexually abused on a date (for example forced to be involved in sexual activity that you have said you are not comfortable with?)

* 7. Whom have you asked for help about the dating abuse for yourself

* 8. Please answer the following question regarding your own experiences.

  None 1-2 3-5 6
How many of your friends have been victims of any kind of dating violence?
How many times have you helped a friend who is having problems with dating abuse?