Create a Student ID
To maintain anonymity and track individual student progress, please create a student ID.
If you don’t have a middle name, use the first three letters of your mother’s first name. For example, if your middle name is Apple, you would write APP.
If you don’t have three numbers, put zero first. For example, if your street address is 1 Apple Lane, write 001. If your street address is 12 Apple Lane, write 012.
Your birth month. For example, March would be 03.
Please enter demographic data based on how YOU identify yourself.
(or community organization)
Instructions: The next 16 questions ask you to think about various things that might happen in a relationship, and to rate them on a scale from healthy to abusive. We are asking you for YOUR OPINIONS about relationships IN GENERAL, not about your ACTUAL experiences.
Please read each statement carefully before answering.
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 17 OR 18, please continue answering the following questions, 19-32.
If you did not answer “yes” to QUESTION 17 OR 18, SKIP to QUESTION 33/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...
You’re almost finished!
Instructions: Read the categories and circle the number for your answer.