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!

* 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

* 2. YOUR PATH ID NUMBER

* 3. Is this your Pre or Post Evaluation?

* 4. Grade you are in

* 5. Age:

* 6. What is your gender?

* 7. What is your ethnic/racial background?

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

* 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
In my neighborhood
At home
Other places in the community

* 10. POST Curriculum: same question as above

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

* 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
In my neighborhood
At home

* 12. POST CURRICULUM: Same Question as above

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

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

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

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

* 15. POST CURRICULUM: Same Question as Above

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

* 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
In my neighborhood
In my home

* 17. POST CURRICULUM: Same Question as Above

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

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

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

* 19. POST CURRICULUM: Same Question as Above

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

* 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 gender
Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight)
Because of my religion
Because of my physical/mental ability or appearance
Because of my nationality/immigration status
Because of my financial status

* 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 gender
Because of my sexual orientations (i.e. being gay, lesbian, bisexual, or straight)
Because of my religion
Because of my physical/mental ability or appearance
Because of my nationality/immigration status
Because of my financial status

* 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 gender
Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight)
Because of their religion
Because of their physical/ mental ability or stature
Because of their nationality/ immigration status

* 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 gender
Because of their sexual orientation (i.e. being gay, lesbian, bisexual, or straight)
Because of their religion
Because of their physical/ mental ability or stature
Because of their nationality/ immigration status

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

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