Is Dating Fun or Deadly?

Please indicate your gender

Male

Female

Please indicate your grade

09

10

11

12

Check all the ones you consider to be a part of dating violence

If the abuse is not physical, is it still considered a part of dating violence?

Yes

No

In your opinion, do drugs and alcohol influence dating violence?

Have you ever been a victim of dating violence?

Yes

No

If the answer to question 4 was yes, were drugs and alcohol involved?

Yes

No

Not Applicable

Has a boyfriend/girlfriend ever limited your activities in any way?

Never

Rarely

Occasionally

Frequently

What types of credit cards do you have (Select all that apply)?

How often do you conduct surveys?

Weekly

Monthly

Quarterly

Annually