WHOA Cyberstalking Questionnaire Copy the contents of this file to a new email in your email software. Fill in the answers to all of the questions. After answering all of the questions, please send the email to cases@haltabuse.org Please make your answers as complete as possible. We realize that we are asking many questions, but the information is necessary in order for us to properly assist you. What is your full name?_______________________________ What is your email address?____________________________ Do you certify that you are over 18 years of age, or over the age of majority in you country of residence?_______ 1. What do you know about the person who is harassing you? Please provide as much information as possible. If you don't know something, then skip that field. Name: Email address(es): Age: Physical or Mailing Address: Address: City: State: Zip or Postal Code: Country: Telephone number: Web site(s): Instant Messaging IDs (please specify messaging system - AOL, ICQ, etc.): Please add any other information you have, such as aliases, nicknames, etc. 2. Did you have any relationship or contact with the harasser, online or offline, before the harassment began? __None - absolutely no contact prior to the beginning of the harassment __Online acquaintance __Offline acquaintance __Family member __Romantic relationship (marriage, dating, online romance, etc.) __Coworker __Other - please explain 3. Do you know why you are being harassed by this person or persons? Please explain this in as much detail as possible. 4. Date of first known interaction with the harasser: ______________ Type of first known interaction: __Email (not on a mailing list) __Mailing list __AOL Instant Messages, ICQ, Yahoo Messenger, etc. __IRC/chat rooms __Usenet (newsgroups) __Message board (other than newsgroups) __Web site __Telephone calls __Letters or other physical items delivered via postal mail, UPS, Federal Express or other means __Offline (face-to-face) __Other - please describe: 5. Date of first harassing communication: _________________ Type of first harassing communication: __Email (not on a mailing list) __Mailing list __AOL Instant Messages, ICQ, MSN or Yahoo Messenger, etc. __IRC/chat rooms __Usenet (newsgroups) __Message board (other than newsgroups) __Web site __Telephone calls __Letters or other physical items delivered via postal mail, UPS, Federal Express or other means __Offline (face-to-face) __Other - please describe: Other information regarding how the harassment began. Please describe fully and give specific dates. 6. On what date did you receive the most recent harassing communication? _____________ Type of most recent harassing communication: __Email (not on a mailing list) __Mailing list __AOL Instant Messages, ICQ, MSN or Yahoo Messenger, etc. __IRC/chat rooms __Usenet (newsgroups) __Message board (other than newsgroups) __Web site __Telephone calls __Letters or other physical items delivered via postal mail, UPS, Federal Express or other means __Offline (face-to-face) __Other - please describe: 7. What forms has the harassment taken? (You may select multiple answers) __Email messages (not on a mailing list) __IRC/chat rooms __Usenet (newsgroups) __Mailing list messages __Message board (other than newsgroups) __AOL Instant Messages, ICQ, Yahoo Messenger, etc. __Web site __Telephone calls __Letters or other physical items delivered via postal mail, UPS, Federal Express or other means __Offline (face-to-face) __Other (please describe) 8. Has the harassment escalated since it began? For instance, have the communications become more frequent, or has the content of those communications become more overtly threatening or defamatory? __No __Yes 9. Have you been threatened with physical offline harm, e.g. violence, kidnapping, rape, death? Include threats made against members of your family or household or your significant others: __No __Yes If yes, how were these particular threats communicated to you? __Email messages (not on a mailing list) __IRC/chat rooms __Usenet (newsgroups) __Mailing list __Message board (other than newsgroups) __AOL Instant Messages, ICQ, Yahoo Messenger, etc. __Web site __Telephone calls __Letters or other physical items delivered via postal mail, UPS, Federal Express or other means __Offline (face-to-face) __Other - please describe: Please give any other details regarding the threats: 10. Have you (or a member of your family/household or someone who is a significant other to you) been physically attacked by this person? This does NOT include damage to property: __No __Yes If yes, please give details: Person attacked: __Self __Other __Both Date of attack: ___________ Other details: Was the attack reported to the police or other authorities? __No __Yes If it was reported, what was the outcome of that report and/or prosecution: If it was not reported, why not? 11. Has your reputation been attacked, e.g. have lies been spread about you to others? __No __Yes 12. Please describe the defamatory statements, including where, how, when and to whom they were made: 13. Has someone been impersonating you online (forging your name on posts, emails, etc)? __No __Yes If yes, how? 14. What material evidence do you have of this harassment? Check off one or more of the following categories below. Remember to keep anything you may receive or know about, on disk and/or hard copy (printed out): __Email messages (not on a mailing list) __Mailing list messages __IRC/live chat logs __Logs of AOL Instant Messages, ICQ, Yahoo Messenger, etc. __Logs of various types of electronic attacks (i.e. Nukes, ICMPs etc) __Usenet (Newsgroup) posts __Message board messages __Hostile web pages __Recorded telephone conversations or messages __Letters/correspondence or other items delivered via postal mail, UPS, Federal Express, etc. __Witnesses who would be prepared to make statements under oath __Other - please explain: 15. Have you reported this harassment to anyone before coming to WHOA for help? __No __Yes If so, who? __Harasser's ISP __Harasser's email provider __Forum/Board Moderator __Web Hosting Firm __Law Enforcement __Other - please explain: Please give full details of everyone to whom you have complained or reported, and the outcome of those reports. 16. Have you sent any communication to the harasser yourself, or made statements about the harasser in a public place? __No __Yes If yes, please describe. Give dates, type of communication, etc. Consider any email messages, chat or IM exchanges, usenet or forum/board messages directed to or about the harasser, web sites published, etc. 17. Do you use the following: Hardware firewall: __No __Yes __Don't Know If you have a hardware firewall, does it support Network Address Translation (NAT)? __No __Yes __Don't Know Software firewall: __No __Yes __Don't Know If yes, what software and version: ________________ How often do you update it? __________ Antivirus software: __No __Yes __Don't Know If yes, what software and version: ____________ How often do you update it? ____________ 18. What steps have you taken so far to protect yourself online? 19. What steps have you taken to protect yourself offline? 20. How long have you been using the Internet? 21. What level of internet user are you: __Consumer - You can check your email, surf the web and chat, but that's about it. You might have a web site, but you don't really know HTML. If you don't understand anything else we're asking about, pick this one. __Power User - You can also install and configure different programs so that they work with your internet access. You know HTML. You know how to get the full headers of messages in your email program(s). __Expert - You can accurately trace email and usenet messages to their origin, get registration information for domains and find out who owns IP addresses. __Guru - You are a sysadmin, or you train other to be advanced users. You know all about firewalls, proxies, anonymizers, daemons, etc. 22. Please state where you live (state and/or country) - there may be a law on the books to help you. 23. Providing the following information is completely optional, but will help us greatly when compiling statistics for law enforcement. This information does not in any way affect how your case is handled. If you don't want to provide the information, simply choose "not saying": Gender: __Female __Male __Not saying Age: __18-30 __31-40 __41 or over __Not saying Marital status: __Single __Married __Life Partner __Divorced __Separated __Widowed __Not Saying Race/Nationality: __African-American __Asian __Caucasian __Hispanic __Native American __Other __Not Saying WHOA does not practice or support any kind of gender, race, age or other discrimination. By submitting this report to us, you certify that all of the information you have provided is true to the best of your knowledge, and that you will be completely truthful in your interactions with any and all WHOA personnel. Please be patient - we work with many victims and will get back to you as soon as we can. We are all volunteers and we are not online 24 hours a day, 7 days a week. We need time to assess your questionnaire and what to do next - you will not get results overnight. We understand you want something done right now, but please understand that we cannot realistically make that kind of commitment. We'll do everything we can to help you, but you must be patient. Do NOT submit the questionnaire multiple times - it will not speed up the response.