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SA Victim Survey
"
*
" indicates required fields
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 Advocate
Law Enforcement
Counseling/Mental Health Services
Family or Friend
Not Applicable
Other
If 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 believed
Ashamed/Embarrassed
Fear of being blamed
Didn't want others to find out
Fear of retaliation from the person who did it
Didn't want that person to get in trouble
Didn't think it was serious enough
I thought it was my fault
Not applicable
Other
If OTHER, please explain:
How soon after the assault did you tell the person identified above?
*
Within 5 days
Less than 1 month
3-6 Months
6 months - 1 year
1-2 years
More than 2 years
Not applicable
If you sought services from additional sources, please check ALL that apply:
*
Medical Services (Hospital, Doctors office, clinic, etc.)
Crisis Center/Shelter
Law Enforcement
Counseling/Mental Health Services
Not applicable
Other
If OTHER, please explain:
Did you receive medical services as a result of the assault?
*
Yes
No
How much time passed before you sought medical attention?
*
Immediately
Hours
Days
A week or more
Not Applicable
How much time passed before you sought medical attention?
*
Immediately
Hours
Days
A week or more
Not Applicable
If you were examined by any medical provider, what services did you receive? Check ALL that apply.
*
Physical Exam
Evidence Collection Kit ("Rape Kit")
Tested for Pregnancy
Information
Referrals to other resources
Not Applicable
If you were examined by a SANE nurse or another medical provider, how do you feel you were treated?
*
Excellent
Good
Poor
Not Applicable
At the conclusion of the exam, how did you feel? Check ALL that apply.
*
Relieved
Believed
Supported
Informed of options/resources
Listened to
Guilty or blamed
Depressed
Nervous/Anxious
Violated
Disappointed
Reluctant to seek further help
Not Applicable
Did you receive support through a crisis center/shelter after the sexual assault?
*
Yes
No
How long before you sought help through a crisis center/shelter?
*
Immediately
Hours
Days
A week or more
Not Applicable
If you worked with a crisis center/shelter, what services did you receive? Check ALL that apply.
*
Called the hotline
Confidential emotional support
Hospital accompaniment
Explanation of medical options
Explanation of legal options
Referrals to other resources
An advocate went with me to court
Support group
Not Applicable
If you had contact with a Crisis Center/Shelter how do you feel you were treated?
*
Excellent
Good
Poor
Not Applicable
Did you report the assault to law enforcement?
*
Yes
No
How long before you reported the assault to law enforcement?
*
Immediately
Hours
Days
A week or more
Not Applicable
Oftentimes, 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?
*
Yes
No
Not Sure
Not Applicable
Did anyone from law enforcement provide you with referrals to other available resources?
*
Yes
No
Not Applicable
If you had contact with Law Enforcement how do you feel you were treated?
*
Excellent
Good
Poor
Not Applicable
At the conclusion of your contact with Law Enforcement, how did you feel? Check ALL that apply.
*
Relieved
Believed
Supported
Better informed on steps of reporting/Prosecution
Listened to
Guilty and/or blamed
Depressed
Nervous and/or anxious
Violated
Disappointed
Reluctant to seek further help
Not Applicable
If 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 18
18 - 25
26 - 40
41 - 60
61 or older
Was the person who assaulted you: (Check ALL that apply)
*
A stranger
Not a friend or family member, but someone you know
Family Member
Intimate partner
In 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.
*
Δ
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Safety & Shelter
Client Outreach
Court Advocacy
Sexual Assault Response Team
Children and Youth
Language Access
Counseling
Hispanic/Latina Outreach
Education
Education and Awareness
What Is Sexual Violence?
What is Domestice Violence?
Get Involved
Volunteer Opportunities
Monetary Donations
In-Kind Donations
Stay Up To Date
Contact Us
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