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Conversion Institution Survivor Questionnaire

Privacy notice: Personal basic information entered in this questionnaire, such as birth year and sex/gender, will be kept strictly confidential. Related experiences and institution exposure information may be publicly displayed in the future. Please do not enter ID numbers, private phone numbers, home addresses, or other personal sensitive information in fields that may become public. You may stop at any time if you feel uncomfortable while filling it out.

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Basic information

What identity are you using to fill out this form?
Birth year
Sex / gender

Experience

Province before entering the institution
City before entering the institution
First admission date

If there were multiple admissions, describe them in the experience field.

End date

Leave blank if the person is still there.

Why did the guardian choose the correction institution?
Before you were sent there, had you heard of this kind of school or any news about it?
On-campus experience description

If describing someone else, add context in Other notes.

Report or legal aid status

Institution exposure

Institution name
Province
Institution city / district
County / district
Institution address
Coordinates (latitude, longitude)

Coordinate format is "latitude, longitude". Map selection or geolocation will fill it automatically, and you can edit it manually.

Institution contact information
Headmaster / lead staff
Known abusers / instructors
Scandals and violent acts
Scandal and violence
Other notes

National mental health support: 12356; youth mental health counseling and legal aid: 12355; Hope Hotline (national 24-hour psychological crisis intervention): 400-161-9995.