The Victim Impact Statement Form printable pdf download

The Victim Impact Statement Form

VICTIM IMPACT STATEMENT

COMMONWEALTH VS:__________________________________________________

Assistant District Attorney:__________________________________________________

Victim/Witness Advocate:___________________________________________________

Name:__________________________________________________________________

If you are not the victim, please state what relationship you have with the victim.

________________________________________________________________________

Physical Impact of the Crime:

1. As a result of this incident, did you suffer any physical injuries? Yes_____ No_____

If yes, please describe your injuries. Include any medical attention received and the

length of time treatment was required.

________________________________________________________________________

2. Did other family members suffer any physical injuries?

Yes_____ No_____

If yes, please describe.

________________________________________________________________________

The Victim Impact Statement Form