Survivor Survey

This survey is being administered by Prevention at the Intersections. We are an organization that works to prevent community harm through capacity building efforts and people-centered projects.

The purpose of this project is to give voice to survivors. To gather information to help develop violence prevention strategies and other efforts for community accountability.

Your participation in this project is voluntary. The process involves filling the online form. Your responses will be anonymous and we do not collect identifying information such as your name, email address or IP address. The narratives collected from this project will be used for community organizing, capacity building work for organizations, and advocacy for survivors rights.

If you wish to engage further in this project, you may choose to complete additional information. Completing this information is voluntary and is not required. If you have any questions about the initiative or need to share additional information, please contact preventionagenda@protonmail.com.

ELECTRONIC CONSENT: Please select your choice below.
Clicking on the "agree" button below indicates that: You have read the above information, you voluntarily agree to participate, you re at least 18 years of age.
Sign in to Google to save your progress. Learn more
I agree. *
Required
Zip Code *
Gender *
Required
Race/Ethnicity *
Religion/Faith/Philosophical Beliefs *
From your experience, how do you define violence? *
What happened to you? *
Do you identify as a survivor of violence? Why or why not? Explain your perspective. *
What solutions would you like to see for the type or harm you've experience? What would be the most just response to this type of harm? Explain your response. *
Review the Prevention at the Intersections Survivors Framework (http://www.preventionagenda.org/rights-of-survivors.html) What are your thoughts on the framework? What could be added or changed to strengthen it as a framework for prevention and community accountability? *
Would you like to be in involved in this project in any other way? If so you may choose to include your email address here if you want to be contact confidentially. You can also email preventionagenda@protonmail.com.
Survivor Story Survey
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms