Harassment surveyUpdated at Apr 20, 2021, 10:47
HARASSMENT SURVEY
Full Name:...................................................
WhatsApp no:.........................................
Twitter Handle:.......................................
Phone No:...............................................
Residential Address:...............................
Location:................................................
DOB:.......................................................
(1) Which city do you live?
..............................................
(2) How old are you?
...............................................
(3) What faith group would you say you belong?
(I) Atheist (ii) Christian (iii) Buddist
(iv) Islam
Other (please specify)
..................................................
(4) Have you ever experienced
sexual harassment before?
..................................................
(5) How often has this happen to you?
(i) Daily (ii) Weekly (iii) Monthly
(iv) Only Once
(6) What type of Harassment did you Experience?
(I) Unwanted physical contact
(ii) Suggestive remark
(iii) Unwanted comment on dress or Appearance.
(iv) Steering or leering (v) Intimidating Presence following at close proximity.
(7) How did it make you feel?
(I) Afraid (ii) Embarrassed and angry (iii) Degrading and intimidating
(iv) Neutral (Use to the behavior or
it is expected).
(8) Where did it happen?
(I) Work (ii) School (iii)Public transport
(iv) Street (v) Shop (vi) Public building
Others (please specify)........................
(9) Did you feel you needed support or help with this?
(I) Yes (ii) No (iii) Maybe
(10) Did you get the support you needed?
............................................
(11) Who supported you?
(I) Friend (ii) Family
(iii) Counseling service
(iv) Public Service
(v) Advocacy agency (vi)No one.
(12) Fo you think you have been pushed
Or forced to do anything differently
Because of experience from Harassment (e.g You stop
Walking through certain route,
Change your dress etc).
(I) Yes (ii) No (iii) Maybe.
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