FACSAFoundation.org Shattering The Silence Tour Documentary Project February 2015 Volume 3 | Page 98
13) I was at what age when I was sexually assaulted. Circle All That Apply.
0-2
3-5
6-10
11-15 15-18 18-25
25-35 35-50 50-75 75-100
Does Not Apply
14) I have been sexually assaulted more than once. Circle One
Strongly
Agree
Doesn’t
Disagree Strongly
Agree
Disagree
Apply
15) Were you sexually assaulted by? Circle All That
Apply
Father
Mother
Sibling
Neighbor
Step-Father Uncle
Stranger
Cousin
Does Not
Apply
16) I told
Circle one or all that apply
Father Mother Relative Police Teacher Clergy Friend
Anyone
No one
17) I was believed by the person I told? Circle One
Strongly
Agree
Agree
Disagree Strongly
Disagree
Doesn’t
Apply