What school do you attend? * Demographics
What is your age range? What is your gender? * What is your race? * Dating violence prevalence
Instructions: The next questions are about dating relationships. By dating, we mean a relationship with a boy or a girl who you are "going out with," "dating," or
have had that kind of relationship with. This includes anyone who is or was your boyfriend or girlfriend, where you liked someone and they liked you back.
1. Are you currently dating someone? * 2. Have you dated someone in the past year? *
If you answered “yes” to QUESTION 1 OR 2, please continue answering the following questions, 3-16.
If you did not answer “yes” to QUESTION 1 OR 2, SKIP to QUESTION 17/Evaluation questions at the end of the survey.
Instructions: The next 8 questions ask you about how often things may have happened with the person you are currently dating, or with the person you dated in the past year. As a guide, use the following scale:
NEVER means this has never happened in your relationship
SELDOM means this has happened only 1-2 times in your relationship
SOMETIMES means this has happened about 3-5 times in your relationship
OFTEN means this has happened 6 times or more in your relationship
3. He/she sometimes wants to control what you do. 4. You sometimes try to control what he/she does. 5. You did something to make him/her feel jealous. 6. He/she did something to make you feel jealous. 7. He/she insulted you with put-downs. 8. You insulted him/her with put-downs. 9. You touched him/her sexually when he/she didn’t want you to. 10. He/she touched you sexually when you didn’t want him/her to. 11. He/she harassed or stalked you through social media. 12. You harassed or stalked him/her through social media.
The following statements describe how safe your relationship felt. Please indicate how often you...
13. ...felt afraid of being seriously hurt by him/her? 14. ...think that he/she felt afraid of being seriously hurt by him/her?
The following questions ask about the times you have been physically hurt in your relationship. “Hurt” means you could still feel pain in your body the next day. You are also hurt when you have a bruise, a cut that bleeds, or a broken bone. Please indicate how often...
15. ....you have been physically hurt by him/her? 16. ....you yourself physically hurt him/her? Evaluation Questions
You’re almost finished!
Instructions: Read the categories and circle the number for your answer.
17. Do you know a friend or peer who has been physically, emotionally, or sexually harmed by a dating partner? (If “yes,” go to Question 18. If “no,” SKIP to Question 19) * 18. (SKIP if you did not answer “yes” to Question 17) Have you told a trusted adult about your friend or peer’s experiences? 19. Have you ever personally witnessed dating and/or domestic violence in your family/household? * 20. Did this program increase your knowledge about the issue of dating violence? * 21. Did you learn any useful information or tools to keep your relationships healthy? * 22. Did this program change your views about healthy, unhealthy, or abusive relationship behaviors? Can you give us an example? 23. Is there anything else you want to tell us? We want to hear from you! Tell us what you think or let us know if you need any follow up resources by leaving your contact info!