Drunk and / or Distracted Driving Survivor Survey

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* 1. Have you ever been in an accident caused by a drunk driver?

Yes

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* 2. Have you ever been involved in an accident caused by a distracted driver?

Yes

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* 3. If Yes, were you

Driving

A passenger in a car

Struck while Walking / Running/ Riding a Bike

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* 4. When was the approximate date of the accident?

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* 5. Was anyone arrested or charged because of the accident?

Yes, I was ticketed, arrested, or charged

Yes, the other driver was

No, It was a hit and run

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* 6. If yes, were you able to speak in court and give a victim impact statement?

Yes

No, the sentencing has not occurred yet

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* 7. Immediately following the accident did you receive medical attention?

Yes, I was transported by ambulance to the hospital

Yes, I was treated at the scene or drove myself to the doctor / hospital

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* 8. Did you seek treatment for new medical issues following the accident?

Yes

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* 9. Have you ever been treated for or diagnosed with a head injury?

Yes, I had a head injury before the accident

Yes, I received a head injury because of the accident

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* 10. Have you ever been treated for or diagnosed with whiplash?

Yes, I had whiplash before the accident

Yes, I received whiplash because of the accident

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* 11. How did this accident impact your life immediately following the accident? (Check all that apply.)

I had mild anxiety about driving / walking / riding my bike

I had trouble concentrating at work / school

I had difficulty expressing my thoughts and feelings

I felt depressed and isolated

I had physical injuries (such as broken bones)

I suffered from PTSD, headaches, migraines, or dizziness

Other (please specify)

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* 12. How did this accident impact your life in the months or years following the accident? (Check all that apply)

I had mild anxiety about driving / walking / riding my bike

I had trouble concentrating at work / school

I had difficulty expressing my thoughts and feelings

I felt depressed and isolated

I had physical injuries (such as broken bones)

I suffered from PTSD, headaches, migraines, or dizziness

I had financial difficulties due to medical debt or health problems

Other (please specify)

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* 13. Since the accident, have you had to make changes at work, school, or home?

Yes

If yes, please explain.

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* 14. Since the accident have you been able to enjoy the hobbies, sports, and activities that you did before?

Yes

If no, please explain.

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* 15. Since the accident, have you ever sought services for related issues?

Yes

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* 16. What kind of supports do you feel would be helpful to you following the accident you had with a distracted and/or drunk driver?

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* 17. Is there anything else you would like us to know?

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* 18. Please leave your contact information if you would like someone to reach out to you.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

This survey was conducted by the United States Brain Injury Alliance.

This publication was made possible by grant number 1H79TI085739-01 from SAMHSA. The views, opinions and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS