* 1. I am a survivor of

* 2. Someone else I know is a survivor of:

* 3. This incident took place:

* 4. What action did you (or another survivor) take after this incident?

* 5. I know the following about my perpetrator that may help identify them

* 6. If there were other victims, how comfortable would you be speaking with them?

* 7. Would you be more likely to take action and report the incident if you knew there were others with similar experiences with the same perpetrator?

* 8. If you had a way to reach other survivors, without having to identify the perpetrator, would you be willing to try this?

* 9. Would you be willing to make a post on social media in order to reach other survivors, if the post did not identify the perpetrator?

* 10. Please provide any further comments about your experiences, or suggestions on how to help survivors and prevent recurring incidents.

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