Black Girlhood Survey

What is your year of birth? *

Geographic Location *

Do you have any children? *

No Yes

If yes, what was your age when your first child was born?

Relationship Staus *

Divorced/Widowed Cohabitation/Domestic Partnership Single Married

What is the highest level of education you have completed? *

High School Some College College Graduate (BA, BS) Graduate School (MA, MS) Professional Degree (MD) Doctorate (PhD)

What is your occupation? *

What is your ethnic background? You can choose more than one. *

West Indian/Caribbean Black/African American Latina/Hispanic Asian/Pacific Islander Native American

What was the age of first sexual activity? *

Younger than 8 8-12 13-18 19+ Not Applicable

If you are currently sexually active, how often do you practice safer sex? *

What is your sexual orientation? *

Heterosexual (straight) Homosexual (gay/lesbian) Bisexual Transgender

If you are gay, bisexual or transgender, at what age were you aware of this?

Have you ever terminated a pregnancy? *

Yes No

If yes, how old were you?

If you are heterosexual, have you ever had sexual contact with someone of the same sex? *

Yes No

If you answered yes to the above, how old were you?

Do either of your biological parents identify as gay/lesbian/bisexual/transgender? *

Yes No

Have you ever been a victim of sexual assault? And by this we mean: molestation, date rape or forcible rape. *

No Yes

If yes, how old were you when the incident occurred?

If you answered yes to the above, was the incident reported?

Yes No

At what age was your first alcohol/drug use? *

8-12 13-18 19+ Not applicable

How often do you currently use alcohol or drugs? *

Have you now or ever had an alcohol or drug problem? *

No Yes

If the answer to the above is yes, have you ever sought help for your problem?

No Yes

Does anyone in your immediate family have an alcohol or drug problem? *

No Yes

How often do you exercise? And by exercise, we mean vigorous, sustained movement for 25 minutes or more. *

Would you consider yourself overweight? *

No Yes

If so, how much weight, in pounds, do you need to loose?

Have youe ever had a problem with" *

Anorexia Bulemia Binge Eating Compulsive Exercise None of the Above

How do you manage stress? *

Yoga/Tai Chi Prayer/Meditation Raiding the Refrigerator Retail Therapy Other

Have you ever seen a therapist or counselor? *

Yes No

If you have never seen a therapist, would you ever consider seeing one?

Yes No

Why or why not?

Have you ever seriously considered committing suicide? *

No Yes

If so, how old were you?

Have you ever attempted suicide? *

Yes No

If your answer is yes, how old were you?

Do you believe in a higher power? *

Yes No

What is your faith system? *

If you chose other, please clarify.

How often do you attend religious or spiritual services? *

Weekly Never Monthly When Your Mama Comes to Visit More Than Once A Week

What type of school did you attend? You can choose more than one. *

Public Private Religious Homeschool/Unschool

Growing up, would you have been considered: *

Middle class. We were comfortable. Poor. Received Gov't Aid. Upper Middle Class/Wealthy. Working Class. The ends were met.

Were you a good student? And by good we mean 80 (or 3.0) and above? *

Yes No

Where you involved in any of the following? *

Sports Clubs (Science Club, Model UN, etc.) Volunteer Work Part Time Job

Were you popular in school? *

Have you ever lived in the following. Check all that apply. *

Group Home/Foster Home Homeless Shelter Youth Detention Facility None of the Above

Did you grow up under the threat of violence? And by violence, we mean domestic violence, beatings or whippings. *

No Yes

Were either you or any of your immediate family members of a gang? *

No Yes

Please add any information you feel might help with this survey.

Super Hussy Media, LLC