VICTIM IMPACT STATEMENT *Victims have the right to submit a Victim Impact Statement. The Victim Impact Statement is a written, detailed account of the emotional, physical, psychological, and financial impact the crime hashed on the victims and family members. This document can be used to explain your feelings of loss, frustration, and fear. Only you can provide this vital information. The Victim Impact Statement has become a significant tool in the criminal justice process.VICTIM IMPACT INFORMATION *To be completed by the victim, parent/guardian or close relative of the victim. Please give any other information you believe is important about the effect of this crime on you and your family. Please do not relate any information about the crime itself; those facts are available already in other reports.Victim Name *FirstLastPhone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeIndiaAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States of AmericaUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweCountryDate of Birth *Date EMOTIONAL/PSYCHOLOGICAL IMPACT. *Use this section to discuss your feelings about what has happened to you as a result of the crime and how it has affected your general well-being. Please checkPlease check all the reactions you have experienced.Loss of SleepAnxietyWant to be aloneLoss of security/controlSchool stressNo trust in anyoneDepressionMarital problemsSerious change in appetiteLack of concentrationCry more easily Fear of strangersThoughts of suicideFear of leaving homeAngerFamily not as closeNightmaresFeelings of helplessnessFear of being aloneJob stressPHYSICAL INJURY.Use this section to discuss what physical injuries or symptoms were suffered as a result of this crime. You may want to write about the extent of the injuries, how long your injuries lasted, and if you received and/or where you received medical treatment for your injuries.Indicate medical treatment received. Attach a doctor’s statement if you wish.Treated at the scene onlyTreated at medical centerHospitalized for days1 day2 days 3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days VICTIM IMPACT STATEMENT *VICTIM IMPACT INFORMATION. To be completed by the victim, parent/guardian or close relative of the victim. Please give any other information you believe is important about the effect of this crime on you and your family. Please do not relate any information about the crime itself; those facts are available already in other reportsRequest for appropriate actionTo be completed by the victim, parent/guardian or close relative of the victim.Incident Information / Date or Time DateTimeLocation of IncidentBrief Description of Incident *Information submitted by:VictimsParent/GuardianClose Relativeothers Name *FirstLastDECLARATION I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. In case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences. I also declare that if any information provided by me is found false, my candidature may be rejected at any point in time. I/ We have not concealed or misrepresented any fact stated in aforesaid columns and the documents submitted herewith.PhoneSubmit