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Questions marked with a * are required Exit Survey
 
 
* Are you ?
 
Female
 
Male
 
Other

 
 
 
Age Range
 
15-20
 
21-30
 
31-40
 
41-50
 
51-60
 
60 plus
 
 
 
Where do you reside?
 
Town
 
City
 
Rural
 
Reserve
 
 
 
Do you have children
 
Yes
 
No
 
 
 
Have you ever experienced Domestic Violence
 
Yes
 
No
 
 
 
How many Children do you have
 
one
 
two
 
three
 
four
 
five
 
6 or more
 
 
 
What ages are your children (Select all that apply)?
 
Infant 0-2
 
Toddler 2-4
 
School aged 4-12
 
Teen 13-19

 
 
 
are you aware if the child(ren) were witness to the domestic violence
 
yes
 
no
 
maybe
 
 
 
How often do you conduct surveys?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
 
 
What types of abuse have you experienced (Select all that apply)?
 
Physical
 
Sexual
 
Emotional /psychological
 
verbal
 
financial
 
spiritual