Online Report

Report an act of violence INGLES


COGAM trata casos de asalto y violencia hacia población LGTB de cualquier edad. Son cuestiones denunciables los insultos, los ataques y asaltos, también tratamos casos de violencia doméstia y/o sexual. Te pedimos que nos informes, rellenando este cuestionario, de cualquier acto de violencia  en el que has estado implicado. En el caso de que hayas experimentado más actos de violencia en el pasado, por ejemplo, rellena un segundo cuestionario.

Si quieres hablar con nosotros, llámanos por favor al
(+34) 915 230 070 diariamente entre las 18.00 y las 19.00.


Toda la información aportada en este cuestionario será tratada de manera confidencial.

Como has rellenado el cuestionario en nuestra página web, toda la información va a ser enviada a nuestro correo electrónico desde nuestra propia página y no desde tu dirección de correo electrónico. Por tanto recibiremos la información de manera anónima.

COGAM


Instrucciones para rellenar el cuestionario:
Para responder las preguntas tenemos las siguientes alternativas posibles:

a)»selecciona solo una respuesta« significa: solo una respuesta es posible !

b)»puedes seleccionar varias respuestas« más de una respuesta es posible !

c)»(0) - (1) - (2) - (3) - (4)« [valore:(0)=no/para nada/en abasoluto; (4)=Sí/muy parecido/correcto] porfavor seleccione el número que corresponda!

d)»respuesta abierta - ? escriba un breve comentario .


I. 1ª parte del cuestionario.
1. Which form of violence are, in your case, applicable. Where you...
tick as many answers as are applicable
1. harrassed
2. insulted
3. verbally threatened
4. blackmailed
5. mugged or robbed
6. threatened with physical violence
7. slightly injured
8. seriously injured
9. other, please state:


Please explain what happened:
  • When did the attack happened (date, time)?
  • What happened (chronologically)?
  • In which way was the violence inflicted, and you were injured?
  • Where did the attack happen(location)?
  • Who were the attackers (please describe)?


2. From when until when did the attack happen?
Date and time:


3. Did the attackers use weapons (which weapons were used)?
1. No
2. Yes
If yes, which weapons were used?


4. Were you injured?
1. No
2. Yes.
If yes, how were you injured/ which injuries did you sustain?


5. Were any others also affected by the attack? (e.g. friends, people I know etc)?
1. No
2. Yes
If yes, who, and how many people?


6. How long has the attack affected you?
tick only one answer
1. Not at all
2. Only on that day
3. A few days
4. A few weeks
5. A long time
6. It still affects me
7. Other, please state:


7. In which city and which district did the attack take place?
1. Berlin: district:
2. Somewhere else: City/ Federal state/ Country:


8. Where exactly did the attack happen?
e.g. street/ in my appartment/ on the underground etc.


9. In your opinion, did the attack have a gay-related background?
tick as many answers as are applicable
1. I can’t explain the reason
2. There were anti-gay remarks from my attackers
3. My attackers know that I am gay/ bi-/ transsexual
4. My attackers pretended to have a sexual interest in me
5. By the clothing/ gay symbols I was wearing at the time
6. At the time of the attack I happened to be at/ in a place where gay people meet (bar, event, etc.)
7. Other, please state:


10. How many attackers were there? (if not exact, rough guess)
(Number)


11. How old were the attackers? (if not exact, rough guess)
(Age)


12. Were the attackers male or female?
(sext)


13. Did you know your attackers?
1. No, they were strangers.
2. Yes they were:
(e.g. pupils at my school, work colleagues, neighbours etc.)

13a. Description of the attacker(s):


14. Did you report the attack to the police?
tick only one answer
1. Yes
2. No

If no, why:
tick only one answer

1. Because the police won’t find my attackers.
2. I don’t want my name on police files
3. The police can’t deal with it.
4. It would have been too much trouble.
5. Other please state:


15. Did anyone accuse you of provoking the attack?
1. No
2. Yes
If yes, who and what were you accused of


16. Could you talk about your experiences with someone you trust?
tick only one answer
1. No
2. Yes
If yes who was that person?
tick as many answers as are applicable

1. a family member
2. friend
3. Someone from a gay group, organisation, AIDS help group
4. Someone from a non-gay group, organisation
5. Medical staff
6. Psychologist, social worker
7. Other, please state:


17. If your answer is "yes", would you say their support was sufficient?
(0= absolutely no support; 4= very supportive)

0
1
2
3
4


18. Would you say that your behavior/ personality has changed since the attack?
tick only one answer
1. No, because:
2. Yes.
If yes, which answer applies to you?
tick as many answers as are applicable
1. I’m more cautious/ pay more attention
2. I’m not so openly gay anymore
3. I avoid situations in which I could be recognised as
         gay/ bi-/ transsexual
4. I’m more cautious when flirting/ meeting new people
5. I’m more prepared for dangerous situations
6. I’m looking for a new home/ have moved/ would like to move
7. I’ve avoid certain places for a long time
8. I still avoid certain places
9. Other, please explain:


19. Have you already been harrassed, threatened? discriminated against, insulted, harrassed, threatened?
tick only one answer
1. No
If no, please continue with part 2
2. Yes, once before
3. Yes, more than once


Tank you for your answers. Please, continue with part 2.
If you don`t want to give answere to one of our next questions, please, leave the answere empty.

Part 2 of the questionnaire - voluntary information
20. How would you describe yourself?
tick only one answer
I’m gay
I’m homosexual
I’m bisexual
I’m heterosexual
I’m transsexual
I don’t define myself as anything
Other, please state:


21. How old are you?
(Age)


22. Are you in a serious relationship?
tick only one answer
1. I’m not in a serious relationship
2. I’m in a serious relationship with a man
3. I’m in a serious relationship with a woman
4. I’m in a serious relationship with a man and a woman
5. I’m separated/divorced from a man
6. I’m separated/divorced from a woman
7. I’m a widow/-er


23. What school/education grades have you got?
tick only one answer
1. None
2. High school leaving certificate, (exams done at 16 years of age)
3. Advanced high school leaving certificate exams done at 18-19 years of age
4. Certificate from a specialised college (apprenticeship)
5. College or higher technical school certificate
6. University degree


24. What is your current professional position?
tick only one answer
1. employee
2. civil servant
3. trained or unskilled worker
4. skilled worker
5. freelance
6. self-employed
7. Unemployed
8. Pensioner
9. Military, service personel alternative nationale service
10. Student
11. Apprentice
12. school pupil


25. What is the population of your place of residence?
tick only one answer
1. less than 10.000
2. 10.000 - 50.000
3. 50.000 - 100.000
4. 100.000 - 500.000
5. 500.000 - 1 Million
6. 1 Million and over


26. Where do you live?
tick only one answer
1. In Berlin

If in Berlin, in which district of the City?
2. In the federal state Brandenburg
3. Elsewhere, please state:
(district/city/ federal state/ country)


27. What is your nationality?
tick only one answer
1. German
2. Other, please state:



28. Are you curently a member of an organisation or a club?
tick as many answers as are applicable
1. No
2. gay group/ Aids help group
3. Civil action-/ political -group
4. Trade Union
5. Political party
6. Church/ religious group
7. Other, please state:


29. Are you available for further questions? Can we contact you?
1. No
2. Yes

my first name:

my phone:

my eMail:

Do you want to talk to us ?
Please call: 030 -216 33 36.




30. How did you hear of Maneo/ emergency crisis hotline?
open answer - please give a short comment

31. Final comment
open answer - please give a short comment



Many thanks for your time, assistance and your information.
We gruarantee, we will handel all information confidentially.

Click here to print



COGAM © 2014 | Home | webmaster