Sexual Assault Victim Survey Please enable JavaScript in your browser to complete this form.Who did you first tell about the assault? *Medical Services (Sexual Assault Nurse Examiner (SANE), Emergency Dept. Nurse, or physician, clinic, personal doctor, etc.)Crisis Center/ CASA Shelter AdvocateLaw EnforcementCounseling/Mental Health ServicesFamily or FriendNot ApplicableOTHERIf you answered OTHER, please explain:If you did not tell someone immediately following the assault, why not? (Check all that apply) *Fear of not being believedAshamed/EmbarrassedFear of being blamedDidn't want others to find outFear of retaliation from the person who did itDidn't want that person to get in troubleDidn't think it was serious enoughI thought it was my faultNot applicableOTHERIf OTHER please explainHow soon after the assault did you tell the person identified above? *Within 5 daysLess than 1 month3-6 Months6 months - 1 year1-2 yearsMore than 2 yearsNot applicableIf you sought services from additional sources, please check ALL that apply: *Medical Services (Hospital, Doctors office, clinic, etc.)Crisis Center/ShelterLaw EnforcementCounseling/Mental Health ServicesNot applicableOTHERIf OTHER please ExplainDid you receive medical services as a result of the assault? *YesNo Select OneHow much time passed before you sought medical attention? *ImmediatelyHoursDaysA week or moreNot ApplicableSelect OneIf you were examined by any medical provider, what services did you receive? Check ALL that apply. *Physical ExamEvidence Collection Kit ("Rape Kit")Tested for PregnancyInformationReferrals to other resourcesNot ApplicableIf you were examined by a SANE nurse or another medical provider, how do you feel you were treated? *ExcellentGoodPoorNot ApplicableSelect OneAt the conclusion of the exam, how did you feel? Check ALL that apply. *RelievedBelievedSupportedInformed of options/resourcesListened toGuilty or blamedDepressedNervous/AnxiousViolatedDisappointedReluctant to seek further helpNot ApplicableDid you receive support through a crisis center/shelter after the sexual assault? *YesNoSelect OneHow long before you sought help through a crisis center/shelter? *ImmediatelyDaysWeeksA year or moreNot ApplicableSelect OneIf you worked with a crisis center/shelter, what services did you receive? Check ALL that apply. *Called the hotlineConfidential emotional supportHospital accompanimentExplanation of medical optionsExplanation of legal optionsReferrals to other resourcesAn advocate went with me to courtSupport groupNot ApplicableIf you had contact with a Crisis Center/Shelter how do you feel you were treated? *ExcellentGoodPoorNot ApplicableSelect OneDid you report the assault to law enforcement? *YesNoSelect OneHow long before you reported the assault to law enforcement? *ImmediatelyDaysWeeksA year or moreNot ApplicableSelect OneOftentimes, survivors come in to contact with more than one law enforcement officer. How many officers have been involved in your case to date? (if none, answer 0) *Was there a report filed by law enforcement on your behalf? *YesNoNot SureNot ApplicableSelect OneDid anyone from law enforcement provide you with referrals to other available resources? *YesNoNot ApplicableSelect OneIf you had contact with Law Enforcement how do you feel you were treated? *ExcellentGoodPoorNot ApplicableSelect OneAt the conclusion of your contact with Law Enforcement, how did you feel? Check ALL that apply. *RelievedBelievedSupportedBetter informed on steps of reporting/ProsecutionListened toGuilty and/or blamedDepressedNervous and/or anxiousViolatedDisappointedReluctant to seek further helpNot ApplicableIf you chose not to be involved with the criminal justice system, please explain why. (type Not Applicable in the space below if this does not apply) *At the time of the assault, what was your age? *under the age of 1818-2526-4041-6061 or olderSelect OneWas the person who assaulted you: (Check ALL that apply) *A strangerNot a friend or family member, but someone you knowFamily MemberIntimate partnerIn general, how do you feel you were treated by the community agencies or individuals that you encountered regarding your sexual assault? Please explain below referencing what agency it is in reference to. *If you did not interact with any community agencies type Not Applicable in the space provided.Submit
