CHILD'S VICTIM IMPACT STATEMENT

CHILD’S VICTIM IMPACT STATEMENTTo the parents: If your child is too young to read, you need to help him/her fill out thevictim impact statement. When helping your child you should: read the directions aloud;talk about what feelings are (happy, sad, mad, scared, or any other feelings you think areappropriate); and discuss with your child what he/she might want to think about whendrawing or writing on the statement. Please do not tell your child what to draw or write.This is your child’s chance to tell the judge how he/she feels about what happened. Ifyour child would rather draw a picture of a bird, a boat or write a story aboutbumblebees, this is okay as well. Should your child become uncomfortable in any waywhile completing the victim impact statement, reassure him/her that filling out the form isvoluntary, and the decision to do so or not is completely up to him/her.What is your name?___________________________________________________________(It’s okay if your parents help you write your name)How old are you?____________________________________________________________If you go to school, what grade are you in? __________________________How do you feel about what happened to you (you may circle as many asyou like).(Turn Page)Revised 9/12/02

If you were the judge, what would you do to _______________________?(Circle as many as you like)A. Send to jailB. Pay some moneyC. Go to a doctor to get helpD. NothingE. Stay away from kidsF. What else? Put you own idea here._________________________________________________________________________________________________________________________If you would like, you may use this page to draw a picture, write a poem, tella story, or anything else you would like to do to tell the judge about how youfeel about what has happened to you. If you don’t want to write or drawanything, that’s okay too. You can use the back of this page or add morepaper if you run out of room.Revised 9/12/02

VICTIM IMPACT STATEMENT FOR THE SCHOOL-AGED CHILDWhat is you name? ____________________________________________How old are you? ____________________________What grade are you in? _______________________Please write or draw anything you would like the judge to know about howyou feel because of what has happened to you. You may want to write aboutanything that has changed in your life or in your family. You can even tell astory or write a poem. You can add more paper if you run out of room.Revised 9/12/02

Please write or draw anything you want the judge to know that may bedifferent at school, in your neighborhood or with your friends because ofwhat has happened to you. You may add more paper if you run out of room.Now that you have told the Judge about your feelings, what would you liketo see happen to this person so you will be safe?Revised 9/12/02