Response

Please take a moment to share with Congresswoman Kelly how gun violence has impacted you or your community.

Prefix

RequiredFirst Name

RequiredLast Name

RequiredAddress Line 1

Address Line 2

RequiredCity

RequiredState

RequiredZip

RequiredEmail

Phone

RequiredWhere do you live?

RequiredWhat is your age?

Under 18
18-25
26-35
36-45
46-55
56-65
66-75
76-85
86+

RequiredHave you been personally affected by an instance of gun violence?

Yes
No
Other (please specify)

RequiredHow have you been impacted by gun violence?

I have been hurt
A family member has been hurt
Someone I know has been hurt
I have seen or heard of instances in my community
I have not been personally impacted by gun violence

RequiredWhen considering gun violence, do you feel safe in your community?

Yes
Most of the time
Sometimes
Rarely
No

RequiredAre you aware of gun violence prevention efforts in your community?

Yes
No
I would like to learn more

RequiredDo you think we need additional federal gun violence prevention legislation?

Yes
No
I'm not sure

If you would like to share a personal story about how gun violence has impacted you, please do so here. Stories will not be shared publicly without your written permission.

If you shared a personal story, may my office contact you to learn more about your experience?

Yes
No

By completing this survey I understand that I am opting to receive future communication from the Office of Congresswoman Robin Kelly.