Person Affected Questionnaire

Is your immediate physical and/or emotional safety a concern?* This field is required.This includes physical, and extreme emotional abuse. no matter how minor it may appear to others.

YESNO

Before we begin, we ask a question about timing. Did the reason for you reaching out today happen within the last two months?Don't worry if it's been more than two months. This question helps us find appropriate resources.

YESNO

Would you like us to contact you to follow up with options of relief?You are absolutely NOT obligated to follow up. Sometimes, a story just needs to be told.

YESNO

You indicated you would like us to follow up and contact you.A trained Responder will contact you within two business days of receipt.

Your Full Name

Name(s) of Other Person(s) Involved

Your Email (regularly checked)

Before asking you about specifics please select any options below that could describe the reason for you reaching out today.* This field is required.Your reason does NOT need to be connected to your demographic identity (i.e. race, gender, sexual orientation, religion, physical/mental abilities, etc).

Discrimination

Harassment

Intimidation

Retaliation

None of the Above

Other

You indicated you are experiencing discrimination or other. Please select any that may describe your identity as it related to your visit today.Please feel welcome to use the "Self-Describe" field to share your identity in your own words.

Racial / Ethnic

Sexual Identity Expression

Gender Identity

Age (Youth or Elder)

Religion

Class / Caste

Parental Status

Physical Disability

Neurodivergence

Other

You indicated you are experiencing intimidation, harassment, and/or other. Below are several indicators based on lived experiences. Please select any/all that apply to your experience.This is NOT an exhaustive list of lived experiences. We encourage you to add yours with the "And" option.

Questioning credentials, intellect, expertise, and/or capacity without evidence

Unsolicited comments / conversations regarding one’s identity(ies) and/or culture

Patronizing / consistently over-explaining

Consistent aggression for no discernable reason

Consistently interrupting or not allowing one to speak

Speaking disparagingly about someone to others (marginalization), or in public

Not allowing or interfering with others reasonably socializing

Consistently assigning less favorable tasks

Not giving proper credit to work products

Removal and/or addition of duties and responsibilities without justification

Aggressively not allowing for mistakes or human error

Invading personal space

Unreasonable and/or unfair expectations around time allowances

Violating confidentiality

Involving unnecessary people in conflict

Other

Is the person or persons you identify a supervisor or in a position higher than yours?* This field is required.It is NOT necessary that the person(s) be supervisory. This question helps us understand power dynamics.

YESNO

Now, Your Story.

Help us understand facts and timelines by sharing as many details as you're comfortable. While not required, if your story involves your demographics (race, ethnicity, gender, sexual orientation, physical/mental abilities, etc) please include this information in your own words.

Also we ask, "What do you need for this to feel resolved?" This is NOT required, but helpful.

What brings you here today? What will help understand the situation?We value your confidentiality and do not share your information or contact anyone without your permission.

URGENT

You have indicated that your immediate safety is a factor in contacting us today.

Please hit "REVIEW and SUBMIT" to exit this questionnaire and either call 911 or contact the Executive Director, marc@parkviewservices.org.

Person Affected Questionnaire