Personal Data

Name: ________________________________ Age: ______________________

Civil Status: ____________________________ Education: _________________
Address: ______________________________________________________________
Job: ___________________________ Frequency of violence: __________________

WAIVER

I agree to participate in an interview about the status of crime victims. I understand that
my voice and/or image may be recorded during the session for follow-up analysis and I
have no objection to this. I understand that the recordings of my voice and/or image will
not be publicly broadcast. I release and waive the use of my comments for research
purposes. I acknowledge and agree that I will keep confidential all information
discussed during this session. I affix my signature as evidence of my voluntary
participation.

Respondent:

_____________________________
Signature over Printed Name

Personal Data
Name: ________________________________ Age: ______________________
Civil Status: ____________________________ Education: _________________
Address: ______________________________________________________________
Job: ___________________________ Frequency of violence: __________________

WAIVER

I agree to participate in an interview about the status of crime victims. I understand that
my voice and/or image may be recorded during the session for follow-up analysis and I
have no objection to this. I understand that the recordings of my voice and/or image will
not be publicly broadcast. I release and waive the use of my comments for research
purposes. I acknowledge and agree that I will keep confidential all information
discussed during this session. I affix my signature as evidence of my voluntary
participation.

Respondent:

_____________________________
Signature over Printed Name