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PARTNER RAPE
IS
REAL RAPE

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JOURNALIST/WRITER REQUESTS INPUT FORM

If you are a journalist/writer seeking input from survivors of intimate partner sexual assault, rape, domestic violence or other related area, please place your request in the form below. Please give as much information as relevant.

 
Name
Media feature is for: Television Program
Print Publication
Radio
Website
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:
Can interviewee/s be anonymous? Yes No Up to Interviewee
Does interviewee need to be photographed? Yes No Up to Interviewee
Do you need interviewees from a specific geographical location (please elaborate):
How will interviews be conducted? Face-to-Face
Telephone
Email Correspondence
Combination of ways
What type of questions will interviewee/s be asked (general elaboration):
Specific instructions for Interviewees?
What is the latest date you need interviewees by?
E-mail address that Interveiwees should contact you at:
Other contact details you would like interviewees to have?
Any final relevant information?

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