Residential School Survivor Questionnaire

1.   Name 

2.   Address 

3.   Phone Number 

4.   Email address

5.   Date of Birth 

6.   Place of Birth 

7.   Residential School(s) attended

8.   Dates of Attendance 

9.   Did brothers and sisters also attend?    YES NO

10.   If yes, list their names and dates of attendances: 

NAMES

DATE OF ATTENDANCE

11. What grade did you complete at the Residential School?  

12. What education have you obtained since leaving the Residential School?

13. Describe the jobs you have held since leaving the Residential School including locations and dates:
 

14. While attending at the Residential School, were you abused: 

(a)            sexually?      YES NO

(b)            physically?     YES NO

15.  Please describe the abuse(s) you suffered

16. Names of the Residential School supervisor, priest, student or other official who committed the abuses.  If you don’t know their name, please indicate their job at the school: 

NAME

 TITLE

17. Have you as a result of attending the Residential School experienced: 

(a)        alcohol problems?   YES NO

(b)        drug problems?   YES NO

(c)        employment problems?    YES NO

(d)        personal relationship problems?      YES NO

(e)        other problems?  

18.  Please describe your experiences: