The form asks for your name, if you are a citizen, are you at least 18, zip code, phone number (although it will accept "yes" in answer to the question "Would you mind sharing your phone number, in case we need to get in touch?"), and email before it starts to talk about what happened to you on social media.
You grant the U.S. Government (including, but not limited to the Executive Office of the President) a license to any “Content” (including but not limited to the photographs, information, text, or otherwise) you post or submit on this site.
This permission grants the U.S. Government a license to use, edit, display, publish, broadcast, transmit, post, or otherwise distribute all or part of the Content (including edited, composite, or derivative works made therefrom).
The license you grant is irrevocable and valid in perpetuity, throughout the world, and in all forms of media.
You waive any right to inspect or approve any Content or edited, composite or derivative works made from Content (including those which may contain your Information) before use. You are not entitled to any prior notice before the U.S. Government uses Content or Information. You are not entitled to any compensation for Content.
Notwithstanding any of the above:
You solely bear all responsibility for all Content.
............ This message may or may not be governed by the terms of http://www.noticebored.com/html/cisspforumfaq.html#Friday or https://blogs.securiteam.com/index.php/archives/1468