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What is your gender?
 
Male
 
Female
 
 
 
What year of school are you in?
 
Freshman
 
Sophomore
 
Junior
 
Senior
 
Graduate student
 
 
 
Have you ever been in a relationship where any of the following behaviors occured? Choose all that apply
 
The other person was constantly jealous
 
You felt isolated or pushed away from your friends
 
You were being checked up on via phone or internet constantly
 
The other person used guilt tactics to get you to do things
 
The other person made your problems seem insignificant
 
Lots of verbal fighting ie. name calling, blaming, accusatons

 
 
 
Do you know anyone who has been in a PHYSICALLY abusive relationship?
 
Yes
 
No
 
 
 
Do you know anyone who has been in a NON-PHYSICALLY abusive relationship?
 
Yes
 
No
 
 
 
Have you ever been harassed after breaking up with someone by that person or their friends?
 
Yes
 
No
 
 
 
Have you ever turned to any of the following habits because of a relationship or after a breakup? If yes, choose all that apply
 
Drinking
 
Physical fights
 
Sex
 
Drugs
 
Suicidal Thoughts

 
 
 
Who would you most likely tell if you felt unsafe or uncomfortable in a relationship? Choose all that apply
 
A close friend
 
A parent
 
A teacher
 
A school counseler
 
Other

 
 
 
Is it the school's business what goes on in the students' relationships? Why or why not?
   
 
 
 
What's the definition of an abusive relationship? Do you have an example in your life?
   
 
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