Wufoo

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School
Date MM / DD / YYYY
Grade
9th 10th 11th 12th
Class Period
I am
Female Male Other

Evaluate the following statements.
	False	True
1. If you respond to disrespect with disrespect, that creates a cycle of violence.	1	2
2. Once a picture, video, or text is sent electronically via the phone orr internet, the sender loses control of where it ultimately ends up and it is out there forever.	1	2
3. It is illegal and considered child pornography, for ANYONE to send or forward a nude, semi-nude or sexually oriented picture of someoen who is underage.	1	2
4. Your physical identity is separate from your digital identity.	1	2
5. Participating in sexting could lead to being labeled as a sex offender and could affect where a person can live and/or work for the rest of their life.	1	2
6. Both the sender and the receiver of a sext message can be held accountable.	1	2
7. If you receive a sext or an inappropriate email you should send it to everyone you know.	1	2
8. You should tell an adult if you receive an inappropriate or harassing sext or email.	1	2
9. Revenge porn is when a sext message is used against the person who sent it, either for embarrassment or blackmail.	1	2
10. You should stand up for someone who has been the target of a hurtful email or sext.	1	2

Evaluate the following statements.
	Never	Unsure	Maybe	Probably	Always
If you or someone you know is being cyber-bullied, would you seek help?	1	2	3	4	5
Is there ever an appropriate time for you to send, forward, or ask for a nude or semi-nude?	1	2	3	4	5

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