To better serve our web site users, we would like to get a better idea about who our users are. This will also help us get specific information to the people who are most likely to find it useful. We would appreciate it if you would help us by answering the following questions.
Last Name:     First Name:      M.I.
Organization:  

Address:

City State Zip

Phone Fax
E-Mail

Current Position

Highest Degree Earned

Concentration Of Study

1. Which of the following statements apply to you?
      (Check all that apply)

I provide direct services to victims of violence
I am a victim advocate
I am a researcher
I am a teacher
I am in the media
I want to learn more about violence against women to help someone who is a victim or survivor
I just want to know more about the topic

2. Select the category that best describes the type of organization you work for, then make one selection within that category:

A. Community/Nonprofit-based:
Sexual Assault Domestic Violence
Child Abuse

All victims Other

B. Criminal Justice-Based:
Police/Sheriff-based Prosecution-based
Court-based Probation-based
Corrections-based Parole-based
Juvenile Justice-based
Other

C. Academic-Based
University
Medical School or Academic Health Care Insitution
High School
Middle School
Elementary School
Other

D. Additional Agencies:

News Media State Government Agency
s Local Government Agency VOCA Assistance Staff State Victim Compensation Staff
Other



3. If you provide direct services or advocacy, please indicate the types of victims that you primarily serve.
Domestic Violence Sexual Assault Child Abuse Elderly Victims Native Americans Special Needs/ Victims with Disabilities
Other


4. If you responded to the previous question, please indicate the types of services you primarily provide for victims in your current position.
Crisis Intervention 24-hour Hotline Emergency Medical Shelter Counseling

Criminal Justice System Advocacy Court Accompaniment Restitution Assistance

Notification Victim Impact Statement Assistance Compensation Claim Assistance

Legal Advocacy Information/Referral
Training and Technical Assistance

Transportation Child Care
Other:
5. If you conduct research in the area of violence against women, please check the types of victims your area of study is concentrated in:

Domestic Violence Sexual Assault Child Abuse
Elderly Victims Native Americans
Special Needs/ Victims with Disabilities
Other

6. Additional Comments:


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