I am a survivor of

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* 1. I am a survivor of

Someone else I know is a survivor of:

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

This incident took place:

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* 3. This incident took place:

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

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

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

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

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

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

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?

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* 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?

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

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

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?

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* 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?

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

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

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