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Amherst County Victim/Witness Program
Services Survey
1.
Gender
Male
Female
Other (please specify)
2.
Marital Status
Married
Single
Divorced
Separated
Widowed
3.
Race
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Multiple Races
Native Hawaiian & Other Pacific Islander
Some other race
White Non-Latino/Caucasian
4.
Age
Under 12
13-17
18-24
25-59
60+
5.
Victim of:
Rape/Sexual Assault
Assault/Domestic
Family Member of Homicide Victim
Property Crime (Damage, Fraud, Robbery, Embezzlement, Credit Card Theft, Forgery)
Harassment/Threats
Other (please specify)
6.
Services Received:
Applying for Victim Compensation
Getting Restitution
Travel Reimbursement
Help in Court
Emotional Support
Signing up for Vinelink
Victim Impact Statement
Getting a Protective Order
Talking w/ Police/Lawyers
Did Not Receive Services
Other (please specify)
7.
Which advocate assisted you?
Trinity Alexander
Judy Brooks
Lauren Shelton
Other (please specify)
8.
Were the services helpful?
Yes
Somewhat
No
Why? (please specify)
9.
How can we improve the program?
10.
Is there anything you would like to tell us about the advocate who assisted you?
