As we plan for the months ahead, we are conducting this brief survey to assess the needs of our community.  Your responses are confidential and will help guide the development of our support services and programs. The survey will take approximately five minutes to complete.

Please reply by Thursday, March 31.

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* 1. First Name

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* 2. Last Name

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* 3. Contact Information

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* 4. Home Address

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* 5. Age

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* 6. Gender

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* 7. How do you identify your race? ** Check all that apply

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* 8. Have you been impacted by a traumatic event?

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* 9. If yes, which event? (Check all that Apply)

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* 10. How do you identify yourself? *Select all that apply

Please note: If you've lost a loved one, please complete questions 11, 12 and 13. Otherwise proceed to question #14

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* 11. Name of Victim

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* 12. Relationship to Victim

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* 13. Specify Location

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* 14. Have you lost a loved one in the past 3 years?

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* 15. If yes, how?

 
 25% of survey complete.

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