Choking Game Victims Registration
We appreciate all Choking Game Victim's family's co operation in showing the true numbers of how many youth are injured and killed due to participating in the Choking Game.
The Incident Information is extremely important for research to promote education and prevention.
We thank you for taking the time to complete this survey.
If you are filling out a printed form, please mail it to The DB Foundation, PO BOX 351787, Palm Coast, FL 32135
Privacy Policy
The security and confidentiality of your information is very important to The DB Foundation. The data collected through this survey will be kept private. Respondent identities will not be revealed in any publication or presentation of the results of this survey, and results will only be presented in an aggregated form. The DB Foundation will not disclose or use the names of respondents for non-research purposes unless the respondent grants us permission to do so. Information that you share with us — by sending us e-mails, participating in the survey, or otherwise — will not be sold or provided to outside third parties. We report data obtained through surveys and other means only in aggregate form; for example, by combining your data with other victims data. We will not publish data in any way in which the confidentiality of the survey responses is not absolutely guaranteed. Access to raw data will be tightly restricted to only those individuals directly involved in data analysis. Our staff will not grant access to third parties or otherwise disseminate your data. If you have any questions about these policies, please email us at support@TheDBFoundation.com
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| Please Check the Appropriate box
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INITIAL REGISTRATION UPDATE
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| Victim's First Name
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| Victim's Last Name
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| Your Name
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| Prefix
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| First
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| Last
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| Suffix
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| Your Email Address
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| Confirm
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| Address
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| Street Address
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| Address Line 2
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| City
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| State / Province / Region
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| Postal / Zip Code
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| Country
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| Your Relation to the Victim
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Parent Step-parent Guardian Sibling Relative Friend Other No Relation
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| Victims Gender
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M F
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| Victims Age
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| Victims Date of Birth
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| Year the Incident Occur
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| Month the incident occurred
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| Day of the Month the incident occurred
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Zip Code / Province
where this incident occurred
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STATE
where the incident occurred
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| Please share with us a few adjectives that paint a picture of this person. For example: Athletic, Artistic, Studious, Curious
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About the Incident
We know how painful it can be recounting some of the details and we wish there was no need to do so. The more we understand the details of the children falling victim to this, the better equipped we are to prevent future death and injury.
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| Was this a group activity or a solo practice?
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Group Solo
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| What type of Ligature was used?
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Belt Scarf Cord Rope Other Not Sure
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| Please briefly describe the location and details of the incident.
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| What time of day did the incident occur?
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6AM-12PM 12PM-6PM 6PM-12AM 12AM-6AM
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| Was there an adult in proximity when the incident occurred?
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No Yes Not sure
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| Prior to the incident: Did anyone notice any warning signs or symptoms indicating they were participating ?
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Yes No
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| In hindsight, were there any signs or symptoms indicative of the victim participating? (check all that apply)
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No Headaches Bloodshot Eyes Marks on the Neck Disorientation Increase in Privacy Locked Doors Marks on Furniture/Ligatures found Computer History Other (please describe in Comments)
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| Do you believe this was the Victims first time participating?
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Yes No Not Sure
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| Any additional comments you would like to share about noticing signs or symptoms prior to the incident.
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| Did you know about the Choking Game prior to this incident?
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No No, I learned about it from the investigator of this case No, I learned about it from the Medical Examiner of this case Yes, there was prevention education by their school, camp, church etc. Yes, But I had not spoken with this child about it Yes and we had discussed it Other
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| Where do you think the victim learned of the Choking Game? (check all that apply)
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At School From Friends Camp Internet News/Media YouTube Older Sibling Not sure Other
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| Would you like this victim included in the Choking Game Victims Database?
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Yes, full listing (Name, Date) Yes but keep name confidential No, please keep all information confidential
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| Would you like to be contact by any media outlet requesting information or interviews? Please leave the best way to contact you below.
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The DB Foundation will only use this contact info to contact you directly and relay the requesting media's contact information to you. We never sell or share you contact info with anyone.
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| Additional Comments
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