Victim Survey

The information contained on this survey is forwarded directly to the National Victim Services Manager of MADD Canada.

Are you a victim of impaired driving?

Yes No

Is this the first time that you are visiting our web page?

Yes No

Is there anything that you would like to see on our website
that would be helpful to you?

Yes No

If Yes, please explain:

Would you like to receive information relating to Victim
Issues from MADD Canada?

Yes No

If Yes, please provide the following information:

First Name:
Last Name:
Postal Code:

Thank you for taking the time to complete our survey. If ever we can be of assistance do not hesitate to contact Gloria Appleby at 1-800-665-6233; email



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