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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.
Were the services helpful?
Yes
Somewhat
No
Why? (please specify)
8.
How can we improve the program?