A. Age:

B.Year in school (check one):
Freshman
Sophomore
Junior
Senior
Gradate Student
Other

C. What is your PRIMARY ethnic heritage? Please state (for example: Latina, other):

D. What is your country of birth?

E. How religious or spiritual are you? (check one)
Not at all Religious/Spiritual
Somewhat Religious/Spiritual
Moderately Religious/Spiritual
Very Religious/Spiritual

F. Is your residence status? (check one):
Documented Resident - Legal resident(not U.S. citizen)
Undocumented Resident - Illegal resident
U.S. Citizen - Born in U.S. or its' territories; or became a citizen
Student Visa/Work Permit

G. What was your FAMILY'S annual income in 2006? (check one):
Less than $10,000
$10,000 to $14,999
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more

H. What was your annual STUDENT income in 2006? (check one):
Less than $10,000
$10,000 to $14,999
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more

I 1. Have you ever seen your parents/legal guardians fight physically (e.g., fight, hit, choke, kick, slap, burn, slam, bite, push, force sex, throw things and/or use weapon) while living with them? (check one)
Yes No

I 2. Have you ever seen your parents/legal guardians fight verbally (e.g., yell, scream, call names, humiliate, insult and/or curse one another) while living with them? (check one):
Yes No

I 3. Have you ever seen your parents/legal guardians fight emotionally (pull away, ignore, not talk to one another) while living with them? (check one):
Yes No


_____________________________________________________________________

Look at the following behaviors for items J 1 and J 2: insulting, yelling, throwing something that could hurt, slapping, hitting, punching, choking, burning, stabbing, and/or using a gun

J 1. Have you ever seen any of the above behaviors between the following: (check ALL that apply):
MALE GUARDIAN against FEMALE GUARDIAN
FEMALE GUARDIAN against MALE GUARDIAN
both FEMALE GUARDIAN and MALE GUARDIAN against each other
none

J 2. Have you ever experienced any of the above behaviors from the following? (check all that apply)
from MALE guardian
from FEMALE guardian
from both MALE guardian and FEMALE guardian
none


______________________________________________________________________

K. Who do you live with? (Check one only):
Alone
Family
Roommate (s) (nonpartner)
Romantic partner

L. What is your current relationship status? (Check one only):
Single
Dating
Cohabiting
Married
Divorced/Separated

M. Have you been in your current or most recent romantic/intimate relationship? (check one):
more than 1 year
1 year
6 months
30 days
less than 30 days

Please check your answers. When you are done, push the button below.