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2011
October
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Are you male or female?
Male
Female
How many years have you attended Acadia University?
First year
Second year
Third year
Fourth year
Fifth year and above
Do you consume alcohol?
Yes
No
Which option most accurately describes the frequency of your alcohol consumption?
Daily
4-6 times per week
2-3 times per week
Once per week
Once per every two weeks
1-2 times per month
Other (please state): _____________
Are you sexually active?
Yes
No
Which option most accurately describes the frequency of your sexual activity?
Daily
4-6 times per week
2-3 times per week
Once per week
Once per every two weeks
1-2 times per month
Other (please state): _____________
Do you ever engage in sexual activity while under the influence of alcohol?
Yes
No
How many times were you under the influence of alcohol during your 5 most recent sexual encounters?
5 times
4 times
3 times
2 times
1 time
0 times
Do you engage in sexual activity exclusively with one partner/signifcant other or multiple partners?
One partner
Multiple partners
Have you ever received unwanted sexual attention/aggressive sexual advances while under the influence of alcohol?
Yes
No
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