You are on page 1of 12

Targeted Individual Report of Abuse - May,

2014
Page 1 Untitled Page 1 of 1
1. Please enter your contact information

First Name
Last Name
City
Country
Home Phone
Email Address
2. If you in live in the United States, what state do you live in?

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 1 / 12
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, DC
West Virginia
Wisconsin
Wyoming
3. What part of the state do you live in?

Northeast
Northwest
Southeast
Southwest
Central
4. If you live outside of the US, in which region do you live? (US residents leave blank)

Africa
Asia
Australia
Europe
Middle East
North America
South America
5. Gender

Male
Female
6. Are you a twin?

Yes
No
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 2 / 12
7. Are you left or right-handed? or ambidextrous?

Left-handed
Right-handed
Ambidextrous
8. Ethnic Heritage

African
Asian
Caucasian
Other
9. Sexual Orientation

Straight
Gay
Bisexual
Transgender
10. Year of Birth

1900-1905
1906-1910
1911-1915
1916-1920
1921-1925
1926-1930
1931-1935
1936-1940
1941-1945
1946-1950
1951-1955
1956-1960
1961-1965
1966-1970
1971-1975
1976-1980
1981-1985
1986-1990
1991-1995
1996-2000
After 2000
11. Employment Status

unemployed
underemployed
employed
12. Do you receive Social Security payments?
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 3 / 12

Yes
No
13. If yes, what type?
Please Select
14. Highest level of education attained:

did not graduate high school
GED
high school graduate
some college
college graduate
Master's Degree
Doctorate
If other, please specify
15. With What religion are you affiliated?

Christianity
Judaism
Islam
Hindu
Buddhism
None
Other
16. Year you became targeted as best you can remember:

Before 1950
1950 - 1955
1956 - 1960
1961 - 1965
1965 - 1970
1971 - 1975
1976 - 1980
1981 - 1985
1986 - 1990
1991 - 1995
1996 - 2000
2001 - 2005
2006 - 2010
2011 - present
17. Marital Status
Please Select
18. If married, do you believe that the harassment is related to your spouse whether directly or indirectly?
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 4 / 12

Yes No
19. Is your harassment all or partly sexual in nature?

Yes No
20. If yes, are you...

Please Select
21. Are you a parent or guardian?

Yes
No
22. If yes, do you feel one or more of your children are also targeted?

Yes
No
23. Are you reporting...

a single incident
a series of incidents
that your attacks are continuous either all day or all night or both
24. Type of Harassment you are reporting (One or more boxes):

Organized Stalking
Remote Electronic Assaults
Synthetic Telepathy (Voice-to-Skull)
Chemical/Biological Attacks
Cloaking
Other
25. What type of targeting do you receive? Please check all that apply.

Organized Stalking
Remote Electronic Assaults
Synthetic Telepathy (Voice-to-Skull)
Chemical/Biological Attacks
Cloaking
Other
26. Date of Incident(s) that you're reporting: May, 2014
1
2
3
4
5
6
7
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 5 / 12

8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
27. Time of Day Incident(s) occurred:

AM
PM
N/A
28. Closest Time of Incident(s). (Select N/A if not applicable.)
12:00
12:15
12:30
12:45
1:00
1:15
1:30
1:45
2:00
2:15
2:30
2:45
3:00
3:15
3:30
3:45
4:00
4:15
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 6 / 12

4:30
4:45
5:00
5:15
5:30
5:45
6:00
6:15
6:30
6:45
7:00
7:15
7:30
7:45
8:00
8:15
8:30
8:45
9:00
9:15
9:30
9:45
10:00
10:15
10:30
10:45
11:00
11:15
11:30
11:45
N/A
29. Time Zone:

EST
CST
MST
PST
AKST
HST
GMT
OTHER
30. How long did the attack last? Please select one.

a few minutes
a few hours
all morning
all day
all evening
continuous
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 7 / 12
31. Severity of the attack(s):

1
2
3
4
5
6
7
8
9
10
N/A
32. Description of what's happening. Check all that apply.

organized stalking by police
organized stalking by federal government
organized stalking by neighbors
organized stalking by friends
organized stalking by family
all of the above
organized stalking is related to money issues
organized stalking is related to a run-in with someone
organized stalking is related to drugs
organized stalking is related to a sexual situation
electronic torture occurs only at home
electronic torture occurs only at workplace
electronic torture occurs everywhere
the above followed you after you moved within your city
the above followed you after you moved within your state
the above followed you after you moved to another state
the above followed you while you were outside of the country
33. Who do you feel is targeting you? Please read all the choices and select one.

federal agency
state or local government
police
current employer
former employer
one or more neighbors
current or former spouse
current or former boyfriend
current or former girlfriend
family member
drug dealer
crime syndicate
secret society
satanic cult
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 8 / 12
don't know
other
If other, please specify
34. Why do you feel you became targeted? Please select the response that most accurately reflects your targeting experience.

Political or Social Activism
Religion
Race or Ethnicity
Sexual Orientation
Incident or argument with someone
Refused to cooperate with Harassers
Randomly Chosen
Don't Know
If other, please specify
35. Do you feel you have been implanted with a microchip?

Yes
No
Not sure
36. Location of Harassment:

Home
Place of Employment
Church
Hotel
Restaurant
School
Store
Other public place
37. For statistical purposes only. Have you ever been involuntarily detained in a mental facility?

Yes
No
38. Check one or more boxes. If the abuse is organized stalking, the complaint is in regards to:

appliance tampering
auto accident
aeriel stalking (plane, helicopter,drone, etc.)
computer tampering
difficulties at place of employment
home entry
attacks on pet(s)
interference with friend or family relationships
involuntary commitment to a mental facility
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 9 / 12
finances
street theater
surveillance in home
surveillance on foot
taunting
unemployment
vandalism
vehicle tampering
food tampering
39. If your complaint is Voice-to-Skull activity, also known as Synthetic Telepathy, check one or more boxes:

Threats
Taunting
Endless Idle Chatter
Criticism
Interrogation
Other
40. If your complaint is regarding directed energy weapons abuse, what part of the body is being affected? You may select one or more.

Head
Eyes
Nose
Face
Abdomen
Stomach
Genitals
Bowels
Arms
Legs
Feet
Hands
Heart
Jaw
Kidneys
Lungs
Liver
Teeth
Throat
If other, please specify
41. If your complaint is directed energy assaults, what effects are you experiencing? Check one or more boxes.

Burning
Extreme Fatigue
Feeling of Electricity running through body
Electronic Rape
Remote Body Manipulation
Holographics
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 10 / 12
Ringing in Ears
Itching
Migraines
Sleep Deprivation
Stinging
42. Pain Level you're experiencing.

1
2
3
4
5
6
7
8
9
10
N/A
43. Your emotional state:

Frightened
Angry
Calm
Concerned
Enraged
Depressed
Despondent
44. You've reported or plan to report this to (check one or more boxes):

Local Representatives
State Representatives
Congressional Representatives
Newspaper
Radio Station
TV Station
Other
45. Number of Times you've reported this month:

1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 11 / 12
46-50
more than 50
46. Comments

Remaining Characters: 500
Submit
This survey is powered by www.surveymethods.com
Targeted Individual Report of Abuse - May, 2014 17.05.2014
http://www.surveymethods.com/Preview.aspx?D7C9DDD08399809296DDDBD0DB968A87DD948B9294EDD689D79D808CD69D8284&DO_NOT_COPY_THIS_LINK# 12 / 12