Cyberstalking Incident Questionnaire Form
Use this form to report and document a cyberstalking incident, including what happened, where it occurred, evidence, impact, and follow-up needs.
Incident Details
Incident date and time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Platform or service where the incident occurred
*
Please Select
Email
Social media
Text messaging
Phone call
Messaging app
Gaming platform
Online forum
Other
Type of cyberstalking behavior observed
*
Repeated messages
Impersonation
Tracking
Unwanted contact
Account compromise
Other
Short incident summary
*
People and Accounts Involved
Reporter's Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
*
Email
Phone
Text Message
Other
Alleged Perpetrator's Name or Handle
Account Identifiers or Profile Links Involved
Evidence and Impact
Evidence attachments
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Description of evidence provided
Impact on you
Emotional distress
Account disruption
Workplace/school impact
Safety concern
Other
Is the behavior ongoing?
*
Yes
No
Safety and Follow-up
Current safety concern level
*
Low
Moderate
High
Immediate danger
Have you contacted law enforcement or a platform moderator?
*
Yes
No
Follow-up request or additional notes
Acknowledgment: The information I submitted may be used to review and respond to this incident report
*
I acknowledge
I do not acknowledge
Submit Incident
Should be Empty: