Emily Brown is doing a study on the impact of affairs: one's own affair, a spouse's affair, or the affair of a close friend or relative. To participate, fill in the questions below. Approximate time to answer the questions ranges from two to ten minutes. All responses will remain anonymous.

 

Your age: Your Gender Select Male Female

Have you ever been married? Select Yes No

Your current marital status: Select Married Single Divorced

Of those listed below, please check off any who you believe have had an extramarital affair. Place an "S" next to the one with the most significance for you.

Your Mother	Your Son	Your Sister
Your Father	Yourself	Your Best Friend
Your Spouse	Your Brother	Your Daughter

What was the duration of the affair marked with an "S"?

Is that affair continuing now? Select Yes No

Please describe in as few or as many words as you like, the significance of that affair for you. For longer descriptions, use the return key when you get to the end of the text window. (Because this survey is anonymous, we are not able to answer any questions submitted with the form. If you need a specific answer, please contact us.)

By clicking on "Submit" below, you give permission for this anonymous data to be used in Emily Brown's research. If you do not wish this data to be used, click "Erase Form."