Domestic Violence Survey

An anonymous school survey to help identify whether a student or their family has been exposed to domestic violence.

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Which of the following age ranges includes you?

Under 13 13-15 16-18 Over 18

What is your gender?

Female Male Prefer not to say

Which of the following types of domestic abuse are you aware of?

Physical Emotional Financial Sexual

Have you or someone you know experienced domestic violence?

Yes No

What type of domestic violence have you or someone you know experienced?

Physical Emotional Financial Sexual

What was their relationship to the abuser?

Spouse or partner Parent Other family member Non-family member

Was the abuser male or female?

Male Female

Did you know men can also be victims of domestic violence, not only women and children?

Yes No

Did you know children exposed to domestic violence are more likely to become perpetrators as adults?

Yes No

If you were the victim, where would you go for help?

A family member A school counselor The police A helpline A friend

Add any additional comments if you'd like

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