Victims Survey Form Step 1 of 5 20% Section 1: Background Information1. Age Group(Required) 18-25 26-35 36-45 46-55 56-65 66+ 2. Gender identity (optional): Female Male Non-binary Prefer not to answer 3. Region or country (optional):4. Employment or living situation at the time of suspected poisoning: Living alone With family/partner Shared housing Institutional housing (e.g., dorm, shelter, care facility) Other Section 2: Suspected Poisoning Event1. How many times have you suspected you were poisoned? Once 2–3 times More than 3 times 2. When did the most recent incident occur? Within past 6 months 6–12 months ago 1–3 years ago Over 3 years ago 3. What type of poisoning did you suspect? (Check all that apply) Select All Food or drink contamination Medication tampering Environmental or air exposure Chemical contact (skin, fumes, etc.) Unknown source 4. What symptoms or reactions did you experience?5. Did you seek medical or emergency help at that time? Yes No 6. If yes, where did you first seek help? Emergency room Primary care doctor Poison Control Law enforcement Other Section 3: Response and Credibility Experience1. When you reported your concern, how seriously did the following people take you?(1 = Not taken seriously at all, 5 = Taken very seriously)12345N/ADoctor / ER staffPoison Control centerPolice / Law enforcementFamily or friends2. Did you feel your concerns were dismissed or minimized? Yes No Unsure 3. Did anyone imply that your symptoms were psychological or stress-related instead of toxic exposure? Yes No 4. What kind of response would you have wanted but didn’t receive?5. Were any tests (toxicology, environmental, etc.) performed? Yes No Unknown 6. If yes, were you given the results in writing? Yes No Partial or unclear results 7. Did you ever feel intimidated or discouraged from pursuing further testing or reporting? Yes No Please explain Section 4: Emotional and Psychological Impact1. On a scale of 1–5, how stressful has this experience been for you?(1 = Not stressful, 5 = Extremely stressful) 1 2 3 4 5 2. Have you experienced any of the following as a result? Anxiety Depression Sleep disturbance Distrust of authorities Isolation Other 3. Do you currently feel safe in your environment? Yes No Unsure Section 5: Perceptions and Recommendations1. What do you think prevented doctors, police, or poison control from believing you?2. If a Poison Response Social Worker (PRSW) had been available to help coordinate testing and communication, how helpful do you think that would have been?(1 = Not helpful, 5 = Extremely helpful) 1 2 3 4 5 3. What kind of support would you have wanted most? Someone to advocate to doctors or labs Better access to toxicology testing Legal or documentation assistance Emotional or mental health support Education on toxins or symptoms Other 4. What advice would you give to others in your situation?5. What changes do you think are needed in how poison cases are handled?
