Safe States is collecting stories highlighting the real-world impact of injury and violence prevention (IVP) efforts to demonstrate and defend the essential, life-saving work our field carries out daily.

*Stories can be short anecdotes, in-depth articles, powerful images, or even a single quote or data point.

If you have any questions about the questionnaire, contact comms@safestates.org.

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* 1. Do you agree to participate in this survey and allow your story to be used (with or without your name) to raise awareness or improve programs?

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* 2. First Name

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* 3. Last Name

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* 4. Email Address

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* 5. Organization

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* 6. Position/Role

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* 7. In what setting do you practice?

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* 8. State

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* 9. Related to this story, what geographic location is the primary focus of your work?

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* 10. Related to this story, I primarily with

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* 11. What program or service are you sharing a story about?

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* 12. What is the goal of the program?

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* 13. Which of the following topic(s) areas does your story address? (select all that apply)

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* 14. Do you receive direct funding from the CDC National Center for Injury Prevention and Control?

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* 15. Has the CDC National Center for Injury Prevention and Control contributed to the success of this program in any way? If yes, how?

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* 16. Can you describe a specific story or example that demonstrates how your program has made a difference in someone's life or in the broader community?

Please focus on one story that stands out. If possible, include details such as the person's background (no names), the issue they faced, what support they received, and what changed as a result.

Example: A youth who avoided retaliation violence after a hospital-based intervention; a family who accessed safe housing after domestic violence; a senior who reduced fall risk thanks to a home safety check.

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* 17. What outcomes or changes were most meaningful in this story?
(Examples: improved safety, reduced risk, restored relationships, increased stability, new confidence, etc.)

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* 18. If applicable, share quotation(s) from community members impacted by your program?

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* 19. Why does this story matter to you—and what does it say about the value of prevention in your community?

Thank you for taking the time to complete this survey and for your commitment to reducing the burden of injuries and violence and for keeping America safe.

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