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"When bad men combine, the good must associate; else they will fall one by one, an unpitied sacrifice in a contemptible struggle"
~ Edmund Burke ~

JOURNALIST/WRITER REQUESTS INPUT FORM


If you are a journalist/writer seeking input from survivors of intimate partner sexual violence, rape, domestic violence or other related area, please place your request in the form below. You may leave irrelevant fields blank, but please give as much information as possible.

Name:
Media feature is for:
  • Television Program
  • Film
  • Print
  • Publication
  • Radio
  • Website/Blog
  • Book
Focus of media item (to be elaborated below):
Name of Program/Publication/Website
Link to Program/Publication/Website
Tell us about the media item:
Slant media item will take:
What type of questions will interviewees be asked (general elaboration):
Can interviewee/s be anonymous?
  • Yes
  • No
  • Up to Interviewee
Does interviewee need to be photographed?
  • Yes
  • No
  • Up to Interviewee
Do you need interviewee/s from a specific geographical location (If yes, please elaborate):
Are you looking for a specific age group? (specify age group or just say "any")
How are interviews to be conducted?
  • Questionnaire / Survey
  • Face-to-Face Interview
  • Telephone Interview
  • Email Correspondence
  • Skype
  • Combination of Ways
  • Will discuss preference with respondent
Specific instructions for Interviewees?
What is the latest date you need interviewees by?
E-mail address that interviewee/s should contact you at:
Other Contact Details you'd like interviewee/s to have?
Any final relevant information?