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appendix twelve

PDF symbol Prospective Victim Speaker Questionnaire

prospective victim speaker questionnaire

 

Name __________________________________________________________   Date ______________________

 

1. How frequently in the last seven (7) days did you consciously avoid letting yourself get emotional when you thought about or were reminded of your victimization?

check box  not at all    check box  once or twice    check box  once every day or two    check box  once or twice daily    check box  a few times daily    check box  several times daily    check box  much of each day

 

2. How angry are you at the person who committed the crime?

check box  never was angry    check box  no longer angry    check box  mildly angry    check box  moderately angry    check box  still very angry

 

3. How frequently in the last seven (7) days did you have bad dreams related to your victimization?

check box  not at all    check box  once or twice    check box  once every day or two    check box  once or twice daily    check box  a few times daily    check box  several times daily    check box  much of each day

 

4. Not counting medication you take to help you sleep, on how many days out of the last thirty (30) did you take prescription or non-prescription medication to help you feel more relaxed and calm?

____________ days     check box  None

 

5. How much discomfort have you experienced in the past seven (7) days from thoughts of ending your life?

check box  not at all    check box  a little bit    check box  moderate amount    check box  quite a bit    check box  an extreme amount

 

6. When you consider all aspects of your life, how happy would you say you are these days?

check box  very happy    check box  pretty happy    check box  not very happy    check box  very unhappy

 

7. How often in the last seven (7) days were you distressed about blaming yourself for things in general?

check box  not at all    check box  a little bit    check box  moderate amount    check box  quite a bit    check box  an extreme amount

 

List any concerns you may have about speaking on a Victim Impact Panel.

 

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