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Age:
   
 
 
 
School/Office:
   
 
 
 
Do you have any background on self defense (martial arts and the likes)?
 
No
 
Yes, I know:
 
 
 
 
Do you regularly commute (ride public transportation)?
 
Yes
 
No
 
 
 
Have you ever been harassed in any way by a stranger?
 
No
 
Yes, and this is what I did:
 
 
 
 
Based from what you know, where do these people usually harass people (what kind of places)?
   
 
 
 
Are you physically fit to protect yourself?
 
Yes
 
No
 
 
 
What will you do if a stranger suddenly harasses you?
 
Run
 
Punch/Kick/Slap
 
Shout
 
Pepper Spray
 
Other
 
 
 
 
Are you willing to learn Self Defense in order to protect yourself in these types of situations? Why or why not?
   
 
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