Attack Victim Feedback Survey

Attack Victim Feedback Survey Victim: Complete this form and present it to your attacker. Or else.

We value your opinion!

Please describe your assailant(s) and their attack on you using the following metrics, either during or immediately after the attack. Your feedback will help us improve our future attacks on others.

The attack on me was, in my opinion, [check all that apply] 

surprising /  frightening /  appalling /  disgusting /



incomprehensible /  malicious /  enlightening

I considered my attackers to be 

fearsome /  skillful /  focused /  amoral /



cunning /  vicious or cruel /  brutish or thuggish

If I could change anything about the attack on me, it would be the 

time /  place /  number of attackers /  weapons used /



language used /  hostility level /  bloodloss

Ratings Rate these aspects of your attack and attackers on a numerical scale from 1 (disagree strongly) to 10 (agree strongly).

My attacker(s) made it clear what he/she/it/they wished to accomplish by attacking me: 1

2

3

4

5

6

7

8

9

10

This attack was effective in securing my cooperation with, or aid to, the attacker(s) goal(s): 1

2

3

4

5

6

7

8

9

10

5

6

7

8

9

10

Make it stop oh please make it stop: 1

2

3

4

Note: If you have no opinion, inform your attacker, who will quickly help you develop an opinion.

True / False

For office use only

Indicate the truth or falsity of the following statements:

True False

Your name __________________________________________ Target(s) ___________________________________________

Location was used creatively





Attack tracking # ____________________________________

Weapon(s) was/were used well





Specified severity of attack: [check all that apply]

Injuries were efficient





Compared well w/ other attacks on me





Witnesses were impressed





 emotional:  passive-aggressive  annoying  poisonous

Witnesses were eliminated





 existential:  troubling  grave  midlife crisis  self-destructive

Saw my life pass before my eyes





Attack left cool-looking scars





Correct number of holes in body





Want my mommy





 building:  vandalism  arson  destruction

Would be attacked this way again





 neighborhood/campus / district/city:  panic  riot  destruction  annihilation

 verbal  physical:  bruises  burns/scars  breakage  mutilation

Associated property damage? [check all that apply]  personal  room:  small items  furnishings  paint/wiring/plumbing

Copyright ©2009 Ninjalistics. Written by Allen Varney. Answer further invasive personal questions on the many forms available free at www.ninjalistics.com