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National Census Sheet on Male Sexual Abuse.
(Census to be completed by Men of 17 years and over who have experienced, at some time in their life, sexual abuse and/or rape).



Which county do you reside in?:

Town/City:

What is your age now?

What is your sexuality?

Were you sexually abused as a child?	Yes No

If it were a single event, how old were you?

If the abuse occurred over a period of time, how old were you when the abuse:	started: ended:

Was your abuser:	Male Female Both

Was your abuser a:

Where did the abuse occur:

Is there anything you would like to add?

Were you sexually assaulted as an adult (17 or over):	Yes No

Your age at time of assault:

How many assailants were involved?

Was your assailant:	Male Female Both

Was the assailant?

Have you experienced more than one event of sexual assault, if so how many times:

Where did the assault occur?

Is there anything you would like to add?

Have you been raped?	Yes No

Your age at time of rape?:

How many rapists were involved?

Was your rapist:	Male Female Both

Was your rapist?

Have you been raped more than once, if so how many times?

Where did the rape occur?

Is there anything you would like to add?

Have you had any contact with a Helpline specifically dealing with male abuse?

Have you received any form of Counselling for your abuse?	Yes No

Was the abuse/rape reported to the police?	Yes No

Is there anything you would like to add?

Thank you for helping us by completing this census.