Items:

Instructions: Listed below are a number of stressful events that people sometimes experience. Please read over this list carefully, and mark only those events that describe a significant event you have experienced. By significant event, we are referring to events which resulted in considerable emotional distress at the time andor continue to result in ongoing distress.

Ask the following questions for: Sexual Assault, Molestation, andor Rape

1. Personally experienced (i.e., this happened to me)?

Response Options:
Yes
No

2. If yes . . .
At what age(s) did this occur?

Response Options:
Enter age for each occurrence

3. If occurring more than once, at what age did the most serioussevere episode occur?

Response Options:
Enter age for this occurrence

4. For the most serious episode, were you or anyone involved seriously injured?

Response Options:
Yes
No

For the most serious episode, rate on a 0 –100 scale with 0 being not at all and 100 being the most ever in my life:
5. How fearful were you?
6. How helpless did you feel?
7. How certain were you that you might die?

Response Options:
__ [value between 0-100]

8. To what degree does this experience continue to bother you in your day-to-day life?

Response Options:
None - 1
A little - 2
Moderately - 3
Quite a bit - 4
Extremely - 5

9. Of those events indicated above, which continues to be the most upsetting (event number)? __