Survey

Choking Game INJURY Victim Survey

This survey is intended to gather data regarding persons who have participated in the asphyxiation activity known as the Choking Game and have, as a result, been injured. Injuries may include the following: abrasions, unconsciousness, broken bones, head trauma, brain injury, memory loss, etc.

Your Name (First and Last) *

Your Email Address *

Victim's Name (First and Last) *

Your Relationship to the Victim *

	Parent
	Step-parent
	Sibling
	Guardian
	Grandparent
	Extended Relative
	Other
	Self

Victim's Date of Birth (or age) *

City & State where the incident occurred *

Date (or range of Dates) that the incident occurred *

How many participants were involved in the incident? *

	an individual (solo)
	2 participants
	3 or more
	Not sure

Where did this incident take place? *

	In an individual's home
	Outside the home (backyard, etc)
	Inside a school campus (bathroom, classroom, etc))
	Outside a school campus (school bus, recess,etc)
	Camp or other extracurricular activity location
	Not Sure

What method was used? *

	Chest Constriction
	Neck Constriction
	Not sure

What were the injuries sustained due to participation? *

Please check all that apply

	Abrasions from a fall
	Fractured bones from a fall
	Head trauma from a fall
	Unconciousness
	Hospitalization
	Brain Injury
	Memory loss
	Seizures
	Stroke

Was there an adult /caregiver in the general proximity to the incident? *

Please explain.

	Yes
	No
	Not Sure

What was the motivation of the participants?

Please check all that apply

	To get a 'rush', 'high' or sensation
	Peer pressure
	Curiosity
	Other
	Not Sure

If you answered 'other' in any of the previous questions, please explain here.

May we include this entry into the Database of Choking Game Victims?

	Yes, a full listing (Name, Age, Location, Date)
	Yes, a Partial listing (Anonymous, Age, Location, Date)
	No, please keep all information confidential)

Any further comment you would like to add? Or alternate contact information