Sexual Assault Experience Questionnaire
This confidential survey aims to understand experiences and the impact of sexual assault. Your responses are anonymous and will help improve support services. Please answer as you feel comfortable.
What is your age range?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55 or older
Prefer not to say
What is your gender?
*
Female
Male
Non-binary / Third gender
Prefer not to say
Prefer to self-describe
When did the experience(s) occur?
*
Please Select
Within the past year
1-3 years ago
More than 3 years ago
Prefer not to say
What was your relationship to the person(s) responsible?
*
Stranger
Acquaintance
Friend
Family member
Colleague/classmate
Partner/ex-partner
Other
Where did the incident(s) occur?
*
Home
Workplace
School/University
Public space
Other private location
Prefer not to say
Other
Please indicate the impact(s) of the experience(s) on you.
*
Rows
Not at all
A little
Somewhat
Very much
Emotional distress
1
2
3
4
Difficulty trusting others
5
6
7
8
Physical health issues
9
10
11
12
Academic/work performance
13
14
15
16
Social withdrawal
17
18
19
20
Did you seek any support after the experience(s)?
*
Yes
No
Prefer not to say
If you sought support, which of the following resources did you use? (Select all that apply)
Family or friends
Counselor/therapist
Support group
Medical professional
Police/legal services
Other
How would you rate the helpfulness of the support you received?
1
2
3
4
5
Please share anything else you would like us to know about your experience or needs for support.
Submit
Should be Empty: