NYS STOP-DWI Victim Impact Story Collection Form

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Please complete the following form to share your Impaired Driving Victim Story.

We reserve the right to minimally edit content for clarity.

If you have any questions, please visit the NYS STOP-DWI website or contact us at: STOPDWIFoundation@gmail.com.

First Name

Last Name

We can provide you with a set resources (agencies, services, etc.) you can choose to help through your circumstances.

Are you in need of victim services or resources like this?

Yes

Should there be additional questions about your story, and we need to reach you by phone, what is the best phone number to reach you?

What is the best email address to reach you?

Please select your age from the ranges below.
*

Please enter your city of residence.
*

Are there additional individuals who are participating with you to share your Victim Impact Story? Please list their first and last name separately on each line.

What is your relationship to the person injured or killed in the impaired crash?

Spouse

Friend

Partner

Child

Parent/Guardian

Self

Other:

Required

What year did this incident occur?
*

What kind of incident would this be considered?

Alcohol-involved incident

Drug-involved incident

Both alcohol and drug-involved incidents

Required

In what format would you like to share your Victim Impact Story? Please choose all that apply.
*

Written text

Photos/images

Audio recording

Video recording

Required

What county of New York State did this incident take place?
*

Please select your state of residence.
*

Is this incident currently an open investigation or actively in court proceedings?
*

Yes

I'm not sure

Please specify where you feel comfortable with us sharing your story. Check all that apply.
*

Video

Social Media

Audio

Website

Advocacy

Public Speaking

Other:

Required

I, hereby swear that I have completed this Victim Impact Stories Collection form honestly and to the best of my ability.
*

Yes, I acknowledge and agree.

Required

I acknowledge that the provided content becomes the property of NYS STOP-DWI and sharing my victim impact story means that I give NYS STOP-DWI the right to distribute my story and share it as indicated above.
*

Yes, I acknowledge and agree.

Required

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