EmailMe Form - Choking Game Victim's Registration

Please Check the Appropriate box *

INITIAL REGISTRATION

UPDATING EXISTING REGISTRATION

Victim's First Name *

Victim's Last Name *

Your Name *

Prefix First Last Suffix

Your Email Address *

Confirm

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Your Relation to the Victim *

Victims Gender *

M

F

Victims Date of Birth *

MM / DD / YYYY

Month when the incident occurred *

Day of the Month the incident occurred

Year the Incident Occur *

If different than the incident date - Victims Date of Death

MM / DD / YYYY

Zip Code / Province
where this incident occurred *

STATE
where the incident occurred *

Please share with us a few adjectives that paint a picture of this person. For example: Athletic, Artistic, Studious, Curious

We know how painful it can be recounting some of the details and we wish there was no need to do so. However, the more we understand the details of the children falling victim to this, the better equipped we are to prevent future death and injury.

(F) Was this a group activity or a solo practice? *

Group

Solo

(F) What type of Ligature was used? *

Please briefly describe the location and position of the Victim when found. *

(F) What time of day did the incident occur? *

6AM-12PM

12PM-6PM

6PM-12AM

12AM-6AM

(F) Was there an adult in proximity when the incident occurred? *

No

Yes

Not sure

(F) How much time elapsed before the victim was discovered? *

(F) Prior to the incident: Did you notice any warning signs or symptoms indicating they were participating ?

Yes

No

(F) In hindsight, were there any signs or symptoms of the victim participating? (check all that apply) *

(F) Do you believe this was the Victims first time participating? *

Yes

No

Not Sure

(F) Any additional comments you would like to share about noticing signs or symptoms prior to the incident

(F) Had the victim been diagnosed with a mental health issues, a learning disorder or other handicap or medical issues?
If yes, please elaborate. If no, skip to the next question.

(F) Was the victim currently taking any medication on a daily basis?
If yes, please elaborate. If no, skip to the next question.

(F) Was AeA evident at the scene?
See below for definition *

Yes

No

Not Sure

Definition of AEA: Where oxygen flow to the brain is reduced, as by controlled strangulation or suffocation to achieve a heightened climax. Signs of AeA: full or partial clothing removed, arousing paraphernalia near the scene.

(F) The original Death Certificate states _________ as the cause of death. *

(F) Was this Certificate amended?

No

Yes, from Suicide to Undetermined

Yes, from Suicide to Accidental

Yes, from Undetermined to Accidental

(F) If the certificate was amended, what do you feel were contributing factors?

(F) Did you know about the Choking Game prior to this incident? *

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

(F) Were there any reports in the media referring to Choking Game as a cause for this incident? *

Yes

No

(F) Where do you think the victim learned of the Choking Game? (check all that apply) *

Sharing the Story

When people look at all of children, of different ages, creed, color and religion being effected by the Choking Game it sends home a powerful message. We encourage, but never require, you to share your child's story.

Would you like this victim included in the Choking Game Victims Database? *

Yes, full listing (Name, Date)

Yes but keep name confidential

No, please keep all information confidential

Include a short tribute biography on the database? (optional)

Include a Photo of the Victim on the Database? (optional)

Permission to use Victim's Likeness/ Name on Awareness Materials? *

Yes, as the parent/guardian of this child I give my consent for their name/likeness to be used for any education/awareness

No, permission is denied at this time

Would you like to be contact by any media outlet requesting information or interviews? Please leave the best way to contact you below.

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.

Additional Comments

Would you like additional information on any of the following:

Grief Support

Media Relations

Advocacy against the Choking Game

Presenter Training to Educate Adults

Presenter Training to Educate Youth

Contacting other CG families in your area

General Volunteering for DBF

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