Formulario de denuncia
I. 1st part of the questionnaire
1. Which form of violence are, in your case, applicable. Where you...tick as many answers as are applicable







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?
If yes, which weapons were used?
4. Were you injured?
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)
If yes, who, and how many people?
6. How long has the attack affected you?





7. In which city and which district did the attack take place?
If it happened in Madrid, ¿In which district of Madrid?
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?characters entered





10. How many attackers were there? (if not exact, rough guess)
11. How old were the attackers?(if not exact, rough guess)
12. Were the attackers male or female?(attackers sex)
13. Did you know your attackers?
Description of the attacker(s):
14. Did you report the attack to the police?selecciona una única respuesta
If no, why:tick only one answer



15. Did anyone accuse you of provoking the attack?
If yes, who and what were you accused of
16. Could you talk about your experiences with someone you trust?tick only one answer
If yes who was that person?tick as many answers as are applicable





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



18. Would you say that your behavior/ personality has changed since the attack?tick only one answer
If yes, which answer applies to you?tick as many answers as are applicable







19. Have you already been harrassed, threatened? discriminated against, insulted, harrassed, threatened?tick only one answer

Part 2 of the questionnaire
20. How would you describe yourself?





21. How old are you?
22. Are you in a serious relationship?





23. What school/education grades have you got?




24. What is your current professional position?










25. What is the population of your place of residence?




26. Where do you live?

(district/city/ federal state/ country)
If in Madrid, in which district of the City?
27. What is your nationality?
28. Are you curently a member of an organisation or a club?





30. How did you hear of COGAM/ emergency crisis hotline?open answer - please give a short comment
30. Final commentopen answer - please give a short comment
In observance of the Organic law 15/1999 of 13 December on the Protection of Personal Data, we communicate you that your personal data will be included in a file owned by COGAM, in order to carry out the necessary actions for the correct performance of the service.

You will be able to exercise the rights of access, correction, cancellation and opposition, by sending a writing request, accompanied by photocopy of your D. N. I. directed to:

COGAM
C/ de La Puebla, 9
28004 Madrid

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