For each of the items in the following list, identify your level of concern about the possibility of this happening:

Having your residence burglarized

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Having your car or other vehicle broken into or vandalized

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Theft from your yard, garden/grounds, shed, garage or farm

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Having your car or other vehicle stolen

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Vandalism or damage to your property

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Drug related incident or crime happening to you

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Gang related incident or crime happening to you

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Street robbery (mugging)

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Drunk people causing a problem near your residence

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Another type of violent attack happening to you or your family

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Being insulted or bothered by people who live close to you

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Being sexually assaulted

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Being sexually harassed (unwanted sexual advances such as "cat calls" or unsolicited sexual propositions)

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Being bullied in school / college / workplace

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Being harassed because of your race, ethnicity, religion, or sexual orientation

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

Being assaulted because of your race, ethnicity, religion, or sexual orientation

Not at all worried
Not very worried
Fairly worried
Very worried
Not applicable

This form was created by RiddleMeThis Runtime, ©2002-4 Tonio Loewald.