1. Were you ever raped (or experienced such an attempt), fondled, touched, or forced to perform sexual acts?
2. Has this happened to you without you freely giving consent?
3. Has this happened with your initial freely given consent and desire to refuse later?
4. Has this happened with your freely given consent about one thing (e.g., a kiss) and then desire to refuse when asked about another (e.g., sex)?
5. Were you forced with objects, weapons, or physical force to consent?
6. Were you threatened psychologically or verbally to consent?
7. Do you feel unsafe or nervous as a result of such a situation?
8. Do you have periods of difficulties falling or staying asleep or nightmares after a similar situation?
9. Do you have difficulty thinking and talking about a similar situation or have memory blanks?
10. Do you feel confused, scared, ashamed, angry, or sad about a similar situation?
11. Were you intoxicated at the time of the act?
12. Did you feel pressured to give your consent for the act?
13. Did you feel safe with the other party?
14. During the experience, were you forced to do any act?
15. Did you ask the other person to stop or show signs you were uncomfortable?
