Create a Student ID
To maintain anonymity and track individual student progress, please create a student ID.
Enter the first three letters of your middle name. *
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.
Enter the first 3 numbers of your street address. *
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.
Enter your numerical birth month. *
Your birth month. For example, March would be 03.
Please enter demographic data based on how YOU identify yourself.
What county are you in? * Anderson Greenville Oconee Pickens Other What school do you attend? *
(or community organization)
What grade are you in? * What is your gender? * What is your race? * Do you qualify for free and reduced lunch? * Relationships
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.
1. Your partner tells you how special you are and how much they care about you. * 2. If you have a disagreement, your partner uses the silent treatment and won’t talk to you for days. * 3. Your partner controls your social media accounts (facebook, instagram, snapchat, twitter). * 4. Your partner says you don’t really love them because you want to go to a movie with a friend instead of spending time alone with them. * 5. You always feel like your partner’s wishes and goals come first. * 6. Your partner threatens to tell other people about your sex life or share private pics or texts. * 7. You had a really good day and can’t wait to tell your partner because you know they will be excited to hear about it. * 8. Your partner gives you gifts but demands something in return, like money or sexual acts. * 9. Your partner texts you more than you want them to and gets angry if you don’t respond. * 10. You and your partner feel like you can share things with each other, but you also feel like you can keep some things private. * 11. Your partner uses physical force during an argument to stop you from leaving. * 12. Your partner tries to change the way you dress or express yourself. * 13. You’re more likely to trust your partner if you have access to their cell phone and social media accounts. * 14. You feel safe to voice your opinion in a disagreement. * 15. You and your partner disagree and argue often, but you are usually able to reach a compromise. * 16. Your partner becomes suspicious or jealous if you are hanging out with certain people. * 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.
17. Are you currently dating someone? * 18. Have you dated someone in the past year? *
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
19. He/she sometimes wants to control what you do. 20. You sometimes try to control what he/she does. 21. You did something to make him/her feel jealous. 22. He/she did something to make you feel jealous. 23. He/she insulted you with put-downs. 24. You insulted him/her with put-downs. 25. You touched him/her sexually when he/she didn’t want you to.You touched him/her sexually when he/she didn’t want you to. 26. He/she touched you sexually when you didn’t want him/her to. 27. He/she harassed or stalked you through social media. 28. You harassed or stalked him/her through social media.
The following statements describe how safe your relationship felt. Please indicate how often you...
29. ...felt afraid of being seriously hurt by him/her? 30. ...think that he/she felt afraid of being seriously hurt by 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...
31. ...you have been physically hurt by him/her? 32. ....you yourself physically hurt him/her? Evaluation Questions
You’re almost finished!
Instructions: Read the categories and circle the number for your answer.
33. Do you know a friend or peer who has been physically, emotionally, or sexually harmed by a dating partner? (If “yes,” go to Question 34. If “no,” SKIP to Question 35.) * 34. (SKIP if you did not answer “yes” to Question 33) Have you told a trusted adult about your friend or peer’s experiences? 35. Have you ever personally witnessed dating and/or domestic violence in your family/household? * 36. Did this program increase your knowledge about the issue of dating violence? * 37. Did you learn any useful information or tools to keep your relationships healthy? * 38. What was your favorite activity, topic, class? 39. What was your least favorite topic OR where did you find yourself falling asleep? 40. Did you talk to anyone (friend, parent, teacher, mentor, etc.) as a result of your REP classes? Tell us more…who and what did you talk about? 41. Did this program change your views about healthy, unhealthy, or abusive relationship behaviors? Can you give us an example? 42. 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!