— New Orleans Bourbon Street Attack

First Name:

Middle Name:

Last Name:

Date of Birth (mm/dd/yyyy)

Phone Number (no dashes, spaces, or parentheses)

Email Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Country

Were you physically injured as a result of the attack?

Yes
No

If yes, did you seek medical attention as a result of your injury?

Yes
No

If yes, where did you seek medical attention?

Did you speak with the FBI?

Yes
No

Did you speak with any other law enforcement agency?

Yes
No

If yes, which agency and with whom? Please provide a name and contact information if you have it.

Were you an eyewitness in direct proximity to the attack without suffering physical injury?

Yes
No

Were you displaced from your home or business as a result of the attack?

Yes
No

If yes, how long were you displaced from your home?

1 - 5 days
6 - 10 days
More than 10 days

Was your home or business damaged as a result of the attack?

Yes
No

If yes, please give a brief description of the damage.

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Did you lose personal belongs while on Bourbon Street between the crossroads of Canal Street and Conti Street as a result of the attack?

Yes
No

If yes, please give a brief description of the item(s) lost.

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Please provide any additional information you think may be relevant.

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The FBI Victim Services Division will review the information provided in this survey and respond appropriately.

Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/doj-systems-records#doj

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New Orleans Bourbon Street Attack

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