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REP 1 Student Eval

Instructions: This survey is about relationships. The information you give will be used to evaluate the Relationship Education Project and to improve dating violence programs for other students. The answers you give will be confidential. No one will know what you write. Answer the questions based on your HONEST opinions. Your feedback is used to create better programs for students!

  • (or what community organization)
  • Demographics

  • 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.
    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
  • The following statements describe how safe your relationship felt. Please indicate how often you...
  • 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...
  • Evaluation Questions

    You’re almost finished! Instructions: Read the categories and circle the number for your answer.
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