Impact Statement

Name of Offender in this case, (or type and location of crime,if you don't know name of offender)

Your Name

Your Email

Your Phone

Your Role

Describe Your Participation

Physical , Financial Impact - Please describe any physical harm, property damage, or financial loss you incurred as a direct result of this incident:

Emotional Impact - Please describe your feelings about this incident, including feelings of anger, fear, stress, sadness anxiety, etc:

Life Changes - Please describe any life changes you've made, including avoiding certain places or activities, etc:

Treatment or Repairs - Please describe any medical or psychological treatment, property repairs/replacement, or other actions you've taken to resolve physical damage:

Community Impact - Please describe the impact this incident has had on family members, friends, school or the general community:

Your Ideas for Resolution - Please describe your ideas to resolve the harm caused by this incident, such as specific recommendations for community service, restitution or other ideas:

Any Other Statement - If there is anything else you would like the Peer Jury to consider, please describe here: