Consent and Safe Sex Questionnaire Pre-Test

​ California State University, San Bernardino

Name: _________________________

The purpose of this survey is to study the knowledge, attitude, and practice of consent and safe
sex practices. By filling out the questionnaire, you are voluntarily agreeing to participate. Be
aware that this survey requests the discussion of personal sexual practices and may be
uncomfortable. If for any reason you feel uncomfortable, please let the survey administrator
know and you will be excused without penalty.

This survey will take approximately 5 minutes to complete.

INSTRUCTIONS:
Please read each question or statement carefully, circle and print responses legibly.

1. What is your biological sex?

1. Male
2. Female

2. What is your age?

1. 18-24 years old
2. 25-29 years old
3. 30 years old and older

3. What is your race?

1. Latino/Hispanic
2. Asian/Pacific Islander
3. African American
4. Caucasian
5. Other: __________________

4. What year of schooling are you currently in?

1. First year
2. Second year
3. Third year
4. Fourth year
5. Fifth year +

5. What is your relationship status?

1. Single
2. Married
3. In a relationship

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6. How confident are you in your ability to define sexual consent?
1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

7. Do you know what stealthing is?

1. Yes
2. No
3. Not sure

8. Can you identify two or more forms of contraceptive methods?

1. Yes
2. No

9. I am aware of the available resources on campus to receive STI testing,

free condoms, and/or contraceptives, etc.
1. Yes
2. No

10. I understand the emotional distress that results from stealthing.

1. Yes
2. No
3. Not sure

11. Is the way a person dresses, smiles, looks, or acts an indication of the desire to have
sex?
1. Yes
2. No

12. How important is it for both parties to understand sexual consent before any
sexual activity?
1. Very important
2. Fairly important
3. Important
4. Slightly important
5. Not important

13. It is embarrassing to purchase condoms.

1. Yes
2. No

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14. Having sex without a condom is not important.
1. Strongly agree
2. Fairly agree
3. Agree
4. Slightly agree
5. Do not agree

15. You do not need a condom if you do not have a lot of sexual partners.
1. True
2. False

16. I am fully confident on how to properly use a condom.

1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

17. Do you always check the expiration date of a condom prior to usage?
1. Yes
2. No
3. Not applicable

18. During sexual activity I always use a condom.

1. Yes
2. No
3. Not applicable

19. Consent is always communicated between me and my sexual partner(s) prior

to any sexual activity.
1. Yes
2. No

20. Have you ever been tested for a sexually transmitted infection?
1. Yes
2. No

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 Consent and Safe Sex Questionnaire Post-Test
California State University, San Bernardino

INSTRUCTIONS:
Please read each question or statement carefully, circle and print responses legibly.

1. After viewing the PSA, how confident are you in your ability to define sexual consent?
1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

2. After watching the PSA, do you understand what stealthing is?

1. Yes
2. No

3. After watching the PSA, I understand the emotional distress that results from
stealthing.
1. Yes
2. No

4. After watching the PSA, how important is it for both parties to understand
sexual consent before any sexual activity?
1. Very important
2. Fairly important
3. Important
4. Slightly important
5. Not important

5. After watching the PSA, I am fully confident on how to properly use a condom.
1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

6. What were the most impactful takeaways from the PSA?

____________________________________________________________________________
____________________________________________________________________________

Thank you for your participation & have a great day!