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Name * First Last
26) How did you travel to D.C. and who accompanied you?
27) What time did you arrive at the Capitol grounds?
28) Where did you enter the Capitol grounds? (Provide location details)
29) Did you attend any prior events or speeches before arriving? (Yes/No)
Yes No
30) Did you interact with law enforcement before entering the grounds? (Yes/No)
Yes No
a) If yes, describe the interaction.
31) Did you witness or experience any use of force by law enforcement? (Yes/No)
Yes No
a) If yes, provide details.
32) What route did you take through the Capitol? (List all locations visited)
33) Did you enter any restricted areas? (Yes/No)
Yes No
34) Did you know you were entering any restricted areas? (Yes/No)
Yes No
a) If no, explain why.
35) Did you enter the Capitol Building?
Yes No
a) What time did you leave the Capitol building? HH : MM : SS AM/PM
36) Did you enter private offices or chambers?
Yes No
37) Did you participate in chanting, singing, or making public statements?
Yes No
a) If yes, describe what was said or done.
38) Did you take photos or videos inside or outside the Capitol? (Yes/No)
Yes No
A) If yes, provide details and upload any available media.
Attach a File
URL
URL
b) Did you attempt to de-escalate any conflicts? (Yes/No) If yes, describe your actions.
Yes No
Describe your actions
c) Did you assist anyone who was injured or in distress? (Yes/No)
Yes No
d) Did you interact with media or journalists at the event? (Yes/No)
Yes No
39) Did you get involved with any violence?
Yes No
40) Did you strike anyone or were you accused of striking anyone?
Yes No
a) Please provide an explanation.
41) Were you struck by anyone (or by a projectile/pepper spray/CS gas)?
Yes No
a) Please provide an explanation.
b) Were you injured?
Yes No
42) How did you exit the Capitol grounds?
43) Did you make any statements to law enforcement after leaving? (Yes/No)
Yes No
44) Did you return home immediately after the event, or did you stay in D.C
45) Please explain anything further which you want to explain.
Do Not Fill This Out

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