Community Safety Initiative Advisory Committee Interest Form

Please complete the following form to express interest in serving on the Prince William County Community Safety Initiative Advisory Committee.

The Prince William County Community Safety Initiative (CSAC) is an Advisory Committee dedicated to enhancing safety and security in the community. The committee accomplishes this by developing recommendations that consider the safety needs and perspectives of Prince William County residents.

This interest form should be completed by members of the Prince William County community who are interested in serving on the CSAC. Committee members will meet monthly until the end of September 2024 on issues of relevance to safety in the County. The Committee will also conduct listening sessions throughout the spring and summer with communities throughout the County. Members will be tasked with drafting recommendations to be used by the Office of Community Safety to guide policy and strategy related to safety initiatives.

1. First Name *This question is required.

2. Last Name *This question is required.

3. Address *This question is required.

4. Email *This question is required. This question requires a valid email address.

5. Phone Number *This question is required.

6. In which district do you reside in Prince William County? Please use the following link to determine your district: https://gisweb.pwcva.gov/webapps/CountyMapper/. *This question is required.

7. Age range *This question is required.

8. Ethnicity: Are you Hispanic/Latino? People who identify their origin as Hispanic, Latino, or Spanish may be of any race. *This question is required.

9. Please identify your race. Choose all that apply. *This question is required.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the Black racial groups of Africa.
Native American or Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White: person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Do not wish to disclose
Other

10. What is your gender identity? *This question is required.

11. Education *This question is required.

12. How long have you lived in Prince William County? *This question is required.

13. On a scale of 0-10, with "0" being "not very safe" and "10" being "very safe", how safe do you feel in your community? *This question is required.

0	1	2	3	4	5	6	7	8	9	10
0	1	2	3	4	5	6	7	8	9	10

14. Please explain why you chose that number. *This question is required.

15. The CSAC will be accountable for ideating solutions to address safety concerns and developing intervention strategies for PWC. What are some of your ideas around prevention and intervention measures related to safety and how might you contribute to potential initiatives? *This question is required.

16. What motivates your interest in serving on the CSAC committee? *This question is required.

17. Are you a Prince William County employee? *This question is required.

18. If you are a Prince William County employee, what office do you work in? *This question is required.

18. Current employer *This question is required.

18. Work Experience and Industry: Please describe your work experience and industry. *This question is required.

19. Please indicate any relevant experience you have concerning community safety. Community safety refers to the ecosystem of systems, organizations, and process that create safe and secure communities -- this may include justice-related and public health-related organizations or processes. *This question is required.

20. Years of experience in issues involving community safety. *This question is required.

21. Do you or someone close to you have lived experience with the criminal justice system? Lived experience refers to being the victim of a crime or party to actions resulting in interaction with the criminal justice system. *This question is required.

22. If yes, please tell us how this lived experience would contribute to your work on the CSAC. *This question is required.

22. Are you currently affiliated with any programs or organizations that focus on community violence, homelessness, panhandling, social support and poverty alleviation, substance abuse/misuse, etc.? *This question is required.

23. If yes, please tell us more about your work in the above-mentioned areas. *This question is required.

23. Please describe any additional experience you have working with different communities within Prince William County.

24. If there is anything else that would like to tell the selection committee, please include it below.