DIVERSE SITUATIONS REACTION FORM

On a scale of 1 to 10, rate how you feel about this situation. The number 1 means not at all upset or uncomfortable, and the number 10 means extremely upset and highly uncomfortable. Circle the number.

SITUATION 1 1 2 3 4 5 6 7 8 9 10

Circle the letter that matches how you would respond to that situation:

I would:

  1. walk away and ignore it
  2. talk to the abuser to get him to stop
  3. ask someone in the park to help me to get them to stop
  4. look and listen
  5. call the police

In your mind, is the couple young or old?

Describe the people:

On a scale of 1 to 10, rate how you feel about this situation. The number 1 means not at all upset or uncomfortable, and the number 10 means extremely upset and highly uncomfortable. Circle the number.

SITUATION 2 1 2 3 4 5 6 7 8 9 10

Circle the letter that matches how you would respond to that situation:

I would:

  1. walk away and ignore it
  2. talk to the abuser to get him to stop
  3. ask someone in the park to help me to get them to stop
  4. look and listen
  5. call the police

In your mind, is the couple young or old?

Describe the people: