Rape Survivor Survey (Part 2 of 2)

Rape Survivor Survey (Part 2 of 2)

Please complete this survey based on the provided form structure and attachment. Organize answers as shown and use the reference PDF for field accuracy.
Survivor Information
First Name
Last Name Initial
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Country
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Country of Origin
Nationality
Race / Ethnicity
Gender
Sexual Preference
Willing to Participate in a Noninvasive Research Study Including Traditional Talk Therapy
Do You Have Any Siblings?
How Many Girls?
How Many Boys?
Have You Ever Experienced Domestic Violence, Sexual Assault, or Rape?
Do You Have Support to Help with Your Recovery?
Do You Have a Support System?
Who Will Help and Listen?
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Identification Number
Current Educational Level
Mental Health & Feelings
27. I have felt scared.
28. I have had trouble sleeping.
29. I have felt sad.
30. I have felt angry.
31. I have felt anxious.
32. I have had nightmares.
33. I have felt guilty.
34. I have had trouble concentrating.
35. I have felt ashamed.
36. I have felt alone.
37. I have felt afraid of people.
38. I have felt afraid to go out.
39. I have had flashbacks.
40. I have felt numb.
41. I have felt upset.
42. I have felt depressed.
43. I have felt hopeless.
44. I have had panic attacks.
45. I have felt nervous.
46. I have felt restless.
47. I have felt irritable.
48. I have felt helpless.
49. I have had thoughts of self-harm.
50. I have felt disconnected from others.
51. I have had difficulty trusting others.
52. I have felt unsafe.
53. I have felt overwhelmed.
54. I have felt embarrassed.
55. I have had difficulty working or studying.
56. I have avoided reminders of what happened.
57. I have felt withdrawn.
58. I have had crying spells.
59. I have felt worthless.
60. I have had difficulty enjoying things.
61. I have had other emotional difficulties.
Assault / Rape Details
I’m sorry this happened to you. You may skip any question you do not want to answer.
Did the assault involve force or threat of force?
Were you physically injured?
What type(s) of physical force were used?

Other
What type(s) of injuries did you experience?

Other
Did you seek medical care after the assault?
Where did you receive medical care?
Date you first received medical care

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Were forensic samples collected?
Who collected the forensic samples?
Which samples were collected?

Other
Did you report the assault to police?
Date reported to police

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How was the assault reported?
Was a police report filed?
Police report number
Did you speak with an investigator?
Was the assault reported to a campus or workplace authority?
Which campus or workplace authority?
Did you obtain a restraining or protection order?
Date protection order was obtained

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was the assault committed by one person or multiple people?
How many people were involved?
Did the person use a weapon?
What type of weapon was used?
Was alcohol involved?
Was drug use involved?
How was alcohol involved?
How was drug use involved?
Were you incapacitated?
What contributed to incapacitation?

Other
Did the assault occur in a home or residence?
Location type
Did the assault occur indoors or outdoors?
Specific location description
Were you able to leave the location safely?
Did you know the location beforehand?
Did the assault involve sexual contact?
What type(s) of sexual contact occurred?

Other
Was there attempted but not completed penetration?
Did the assault involve oral contact?
Did the assault involve vaginal contact?
Did the assault involve anal contact?
Was a condom used?
Did ejaculation occur?
Did you believe pregnancy was possible?
Did you receive emergency contraception?
Date emergency contraception was received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did you receive treatment for sexually transmitted infections?
Did you receive HIV prevention medication?
Did the assault involve strangulation or choking?
Did you lose consciousness?
Did you have memory loss or blackouts?
Did you experience bleeding?
Did you experience pain?
Where was the pain located?
Did you have trouble walking or standing afterward?
Did you miss work, school, or usual activities because of the assault?
How many days did you miss?
Did you tell anyone about the assault?
Who did you tell?

Other
Did anyone witness the assault?
Was there any property damage or theft during the assault?
Property damaged or taken
Did the assailant make threats?
Describe the threats
Did the assailant use coercion or manipulation?
Describe coercion or manipulation
Did the assault happen once or multiple times?
Number of times
Are there any other details about the assault you would like to share?
Other details
Perpetrator Information
Upload a picture of the perpetrator.

Cancelof
How was the perpetrator identified?

Other
Police / Legal Response
Was the incident reported to the police?
If reported, please describe the police response or actions taken.
Was any legal action taken?
Please describe any investigation, court proceedings, or other official response.
Recovery Services & Outcomes
Recovery services received

Other
Did you receive any follow-up care?
Describe the support or services received
Overall outcome of recovery support
Additional follow-up notes
Should be Empty:

Rape Survivor Survey (Part 2 of 2)

Survivor Information

Mental Health & Feelings

Assault / Rape Details

Perpetrator Information

Police / Legal Response

Recovery Services & Outcomes