Control group survey
(This survey is for individuals who have NOT experienced sexual assault or rape)
First name
Last name
Phone
Phone country code (If outside of U.S.)
Email
Address
Zip code/postal code
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Country
United States of America
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Austrian Empire
Azerbaijan
Baden
Bahamas
Bahrain
Bangladesh
Barbados
Bavaria
Belarus
Belgium
Belize
Benin (Dahomey)
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Brunswick and Lüneburg
Bulgaria
Burkina Faso (Upper Volta)
Burma
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
The Central African Republic
Central American Federation*
Chad
Chile
China
Colombia
Comoros
Congo Free State
The Costa Rica
Cote d’Ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czechia
Czechoslovakia
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Duchy of Parma,
Germany
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Federal Government of Germany
Fiji
Finland
France
Gabon
Gambia
The Georgia
Germany
Ghana
Grand Duchy of Tuscany
The Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Hanover
Hanseatic Republics
Hawaii*
Hesse*
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kingdom of Serbia
Yugoslavia*
Kiribati
Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Lew Chew
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mecklenburg-Schwerin*
Mecklenburg-Strelitz*
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nassau*
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Germany
Norway
Oldenburg*
Oman
Orange Free State
Pakistan
Palau
Panama
Papal States*
Papua New Guinea
Paraguay
Peru
Philippines
Piedmont-Sardinia*
Poland
Portugal
Qatar
Republic of Genoa*
Republic of Korea (South Korea)
Republic of the Congo
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Schaumburg-Lippe*
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands, The
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Texas*
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Two Sicilies*
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Württemberg*
Yemen
Zambia
Zimbabwe
Date of birthdate (mm-dd-yyyy)
Country of origin
United States of America
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Austrian Empire
Azerbaijan
Baden
Bahamas
Bahrain
Bangladesh
Barbados
Bavaria
Belarus
Belgium
Belize
Benin (Dahomey)
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Brunswick and Lüneburg
Bulgaria
Burkina Faso (Upper Volta)
Burma
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
The Central African Republic
Central American Federation*
Chad
Chile
China
Colombia
Comoros
Congo Free State
The Costa Rica
Cote d’Ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czechia
Czechoslovakia
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Duchy of Parma,
Germany
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Federal Government of Germany
Fiji
Finland
France
Gabon
Gambia
The Georgia
Germany
Ghana
Grand Duchy of Tuscany
The Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Hanover
Hanseatic Republics
Hawaii*
Hesse*
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kingdom of Serbia
Yugoslavia*
Kiribati
Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Lew Chew
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mecklenburg-Schwerin*
Mecklenburg-Strelitz*
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nassau*
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Germany
Norway
Oldenburg*
Oman
Orange Free State
Pakistan
Palau
Panama
Papal States*
Papua New Guinea
Paraguay
Peru
Philippines
Piedmont-Sardinia*
Poland
Portugal
Qatar
Republic of Genoa*
Republic of Korea (South Korea)
Republic of the Congo
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Schaumburg-Lippe*
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands, The
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Texas*
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Two Sicilies*
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Württemberg*
Yemen
Zambia
Zimbabwe
Nationality
Race / Ethnicity
Gender
Female
Male
Transgender
Sexual preference
Female
Male
Sexually fluid
Bisexual
Are you willing to participate in a noninvasive research study that includes traditional talk therapy?
yes
no
Do you have any siblings?
Yes
No
How many Girls?
How many Boys?
Who should we contact in the event of an emergency? Name
Emergency contact’s number
What is your current educational level
Elementary school
middle school
high school
college
university
masters
professional degree
doctorate
Note: You are a part of the control group for rape research at the Jeanine Horowitz Research Center (JHRC). Which means your answers will be compared to rape survivors. You should only complete this part of survey IF you have never experienced sexual assault or rape? Remember:
Did you remember to email your Patient Identification Number to yourself:
Yes
No
Share your feelings
Please share how you feel by choosing one statement that closely matches how you’ve been feeling in the past week. Don’t take too long over your replies, as your immediate answers are most accurate.
How Do you feel right Now?
I do not feel sad.
I feel sad.
I am sad all the time and I can't snap out of it.
I am so sad and unhappy that I can't stand it.
I am not particularly discouraged about the future.
I feel discouraged about the future.
I feel I have nothing to look forward to.
I feel the future is hopeless and that things cannot improve.
I do not feel like a failure.
I feel I have failed more than the average person.
As I look back on my life, all I can see is a lot of failures.
I feel I am a complete failure as a person.
I get as much satisfaction out of things as I used to.
I don't enjoy things the way I used to.
I don't get real satisfaction out of anything anymore.
I am dissatisfied or bored with everything.
I don't feel particularly guilty
I feel guilty a good part of the time.
I feel quite guilty most of the time.
I feel guilty all of the time.
I don't feel I am being punished.
I feel I may be punished.
I expect to be punished.
I feel I am being punished.
I don't feel disappointed in myself.
I am disappointed in myself.
I am disgusted with myself.
I hate myself.
I don't feel I am any worse than anybody else.
I am critical of myself for my weaknesses or mistakes.
I blame myself all the time for my faults.
I blame myself for everything bad that happens.
I don't have any thoughts of killing myself.
I have thoughts of killing myself, but I would not carry them out.
I would like to kill myself.
I would kill myself if I had the chance.
I don't cry any more than usual.
I cry more now than I used to.
I cry all the time now.
I used to be able to cry, but now I can't cry even though I want to.
I am no more irritated by things than I ever was.
I am slightly more irritated now than usual.
I am quite annoyed or irritated a good deal of the time.
I feel irritated all the time.
I have not lost interest in other people.
I am less interested in other people than I used to be.
I have lost most of my interest in other people.
I have lost all of my interest in other people.
I make decisions about as well as I ever could.
I put off making decisions more than I used to.
I have greater difficulty in making decisions more than I used to.
I can't make decisions at all anymore.
I don't feel that I look any worse than I used to.
I am worried that I am looking old or unattractive.
I feel there are permanent changes in my appearance that make me look unattractive
I believe that I look ugly.
I can work about as well as before.
It takes an extra effort to get started at doing something.
I have to push myself very hard to do anything.
I can't do any work at all.
I can sleep as well as usual.
I don't sleep as well as I used to.
I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
I wake up several hours earlier than I used to and cannot get back to sleep.
I don't get more tired than usual.
I get tired more easily than I used to.
I get tired from doing almost anything.
I am too tired to do anything.
My appetite is no worse than usual.
My appetite is not as good as it used to be.
My appetite is much worse now.
I have no appetite at all anymore.
I haven't lost much weight, if any, lately.
I have lost more than five pounds.
I have lost more than ten pounds.
I have lost more than fifteen pounds.
I am no more worried about my health than usual.
I am worried about physical problems like aches, pains, upset stomach, or constipation
I am very worried about physical problems and it's hard to think of much else.
I am so worried about my physical problems that I cannot think of anything else.
I have not noticed any recent change in my interest in sex.
I am less interested in sex than I used to be.
I have almost no interest in sex.
I have lost interest in sex completely.
I feel tense or wound up
Most of the time
A lot of the time
From time to time, occasionally
Not at all
I still enjoy the things I used to enjoy:
Definitely as much
Not quite so much
Only a little
Hardly at all
I get a sort of frightened feeling as if something awful is about to happen:
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn't worry me
Not at all
I can laugh and see the funny side of things
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
Worrying thoughts go through my mind:
A great deal of the time
A lot of the time
From time to time, but not too often
Only occasionally
I feel cheerful:
Not at all
Not often
Sometimes
Most of the time
I can sit at ease and feel relaxed:
Definitely
Usually
Not Often
Not at all
I feel as if I am slowed down:
Nearly all the time
Very often
Sometimes
Not at all
I get a sort of frightened feeling like 'butterflies' in the stomach:
Not at all
Occasionally
Quite Often
Very Often
I have lost interest in my appearance:
Definitely
I don't take as much care as I should
I may not take quite as much care
I take just as much care as ever
I feel restless as I have to be on the move:
Very much indeed
Quite a lot
Not very much
Not at all
I look forward with enjoyment to things:
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
I get sudden feelings of panic:
Very often indeed
Quite often
Not very often
Not at all
I can enjoy a good book or radio or TV program:
Often
Sometimes
Not often
Very seldom
Have you ever reported a non sexual related crime to the police?
Yes
No
What was the crime you reported to law enforcement?
Did the police investigate the crime and follow up with you after the police report was taken?
Yes
No
When you reported the non sexual crime was an official police report made, and were you provided the officer car or contact information for follow up?
Yes
No
Did a detective from the police department meet with you to investigate the matter after you filed the police report?
Yes
No
In what time frame did you report the incident?
Immediately
One week
One month
Six months to a year
A year or more later
In what city and state and/or country did the non-sexual related crime occur?
In what city and state and country did you report the non-sexual related crime?
Was the local police department quick to respond?
Yes
No
How long did it take for the police to arrive to take police report?
Did you drive to the station or was a police report taken over the phone?
Yes
No
Did the police department conduct a thorough investigation?
Yes
No
Was the accused taken in for questioning regarding your police report?
Yes
No
Was the accused arrested for the crime committed against you?
Yes
No
Was the suspect arrested, charged, and convicted?
Yes
No
Criminal/Victim of Crime Resources
Did the convicted criminal serve anytime for the non-sexual related crime that was committed against you?
Yes
No
Were you notified when the suspect was released from jail or prison?
Yes
No
Were you notified when about the criminal prosecution process related to the non-sexual crime you reported and resulted in prosecution?
Yes
No
When your case was over and/or the suspect was released was there a protective order established and again, were you notified of the outcome of court proceedings?
Yes
No
Outside of investigation and/or prosecuting were you offered any restitution from your local government or law enforcement agency?
Yes
No
On a scale of 1 to 10 (1 being the lowest and 10 being the greatest) how would you rate your overall experience with making a police report for a non-sexual related crime and the response of the local government’s agency?
On a scale of 1 to 10 (1 being the lowest and 10 being the greatest) how would you rate your overall experience with receiving restitution for a non-sexual related crime and the response of the local government’s advocate?
How many months did it take for you receive any recovery or restitution from law enforcement agencies?
What services were you provided from filing a non-sexual criminal report (if any)?
Do you know a person that has experienced rape?
Yes
No
Do you know the first name of the person that committed the alleged rape or sexual assault?
What is the last name of the person that committed the alleged rape or sexual assault?
What did you say when to the person when they shared their trauma from rape or sexual assault?
Did they tell you in a private place?
Yes
No
Did you tell anyone else?
Did you encourage the sexual assault or rape survivor to report the incident to the police?
Yes
No
Did you notice any behavior changes in your friend that was sexually assaulted or rape?
Yes
No
Do you know the difference between sexual assault and rape?
Yes
No
Explain in your own words what does it mean to be sexually assaulted?
Explain in your own words what does it mean to be rape?
Have you ever had a close encounter that you feared rape or sexual assault?
Yes
No
What are some precautions you specially implement to protect yourself from experiencing an sexual assault and/or rape?
Did you know that the FBI states that only 2 percent of women falsely report sexual assault and rape to the police?
Yes
No
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