Middle School Primary Prevention Pre/Post Survey

2014- 2015

Center Name: ______

Curriculum: ______

Facilitator: ______

Location: ______

Age/Grade: ______

Date: ____/____/______

Middle School Survey

Instructions

The purpose of this survey is to help us better understand your opinion. This is NOT a test, so there are no right or wrong answers. Please read the directions and questions carefully and answer them honestly. If there is a question that you do not want to answer, skip it and move on to the next question.

Please do not put your name on this form. Your cooperation in completing this survey is greatly appreciated!

Part 1: About you

1. Student number: ______2. Age: ___ 3. Gender: M or F 4. Grade: _____

Part 2: Your opinion
Read each statement and decide how much you agree or disagree with it.
Then for each statement, please check þ or “X” ý ONE of the four boxes that best reflect your opinion.
STRONGLY AGREE / AGREE / DISAGREE / STRONGLY DISAGREE
1.  Abuse in relationships is preventable. / £ / £ / £ / £
2.  Abuse between couples is their business; other people should not get involved. / £ / £ / £ / £
3.  It is only abuse if you physically hurt someone. / £ / £ / £ / £
4.  In a dating relationship, people have the right to know where their partner is at all times. / £ / £ / £ / £
5.  Acting jealous in a relationship shows that you care. / £ / £ / £ / £
6.  It bothers me when someone is interested in a girl only because she looks good. / £ / £ / £ / £
7.  It is okay for someone to decide who their dating partner is allowed to hang out with. / £ / £ / £ / £
8.  It bothers me when a guy acts like a girl. / £ / £ / £ / £
9.  I know a trusted adult that helps me when I have a problem. / £ / £ / £ / £
10.  There are rules in my school to help me if I am being abused. / £ / £ / £ / £

J Thank you very much for filling out this survey! J