VAWC Form # 5

VAWC Form # 5
Brgy. Form No. ______
Control No. ______
Republic of the PHILIPPINES
Province of LAGUNA
Municipality of CALAUAN
Barangay MABACAN

VIOLENCE AGAINST WOMEN AND THEIR CHILDREN INCIDENT REPORT

I. PERSONAL CIRCUMSTANCES
(A) Name of Complainant/ victims Age Address
_______ ________________________________
_______ ________________________________
_______ ________________________________

(B) Civil Status (C) Relationship to Perpetrator

Married Wife Girlfriend
Separated Ex-wife Dating relationship
Widow

(C) Occupation / Profession: Complainant Perpetrator

______________________ _______________________

II. INCIDENT DEATAILS

(A) Date/s of Violence committed
Date Reported ____________________
(B) Nature of Violence Inflicted by Perpetrator
Physical _______________________________________________________________________
Sexual ________________________________________________________________________
Psychological ___________________________________________________________________
Economic Abuse ________________________________________________________________

III. ASSISTANCE EXTENDED / PROVIDED TO VICTIM/S

Specific
Service Provided Provided by: Remarks
Medical
Counseling
Referral to
Shelter
Issued BPO Date

Prepared by:

Date Accomplished (Signature Over Printed Name)

OFFICIAL ACCOMPLISHING THIS FORM

Note: Please bring copy of this form to referred agency.

 National Violence Against Women (NVAW) Documentation System
(Barangay Form)

Handling Organization: ________________________Date of Intake __/__/____ (MM/DD/Year)

Address: _________________________________________________________
Region ____ Province __________________ City / Mun _____________ Barangay ___________
Interview By: _____________________________________________Position: _____________
Last Name First Name Middle Name

Victim Survivor Information

Brgy. Case #: ___________ Name: _____________________________________________________
Last Name First Name Middle Name
With Disability Permanent Disability Temporary Disability
Without Disability
Sex: Male Date of Birth: ___/___/_______ (MM/DD/Year) Age: ___
Female
Civil Status: Highest Education Attainment:
Single Married No formal education Elementary Level / Graduate High School Level
Graduate
Live-in Widowed Vocational College Level / Graduate Post Graduate
Separated No Response Others_____________________________
Nationality: _______________________ Passport No (if non-filipino): ______________________
Occupation: ______________________
Religion:
Roman Catholic Islam Protestant Iglesiani Cristo Aglipayan Others
Address: ___________________________________________________________________
Region ______ Province ______________ City / Mun. ___________________ Barangay _____________
Contact No. of Parent / Guardian: ___________________________

Perpetrator information:

Name: _________________________________________________ Alias: _____________________

Last Name First Name Middle Name
Sex: Male Date of Birth: ___/___/_______ (MM/DD/Year) Age: ___
Female
Civil Status: Highest Education Attainment:
Single Married No formal education Elementary Level / Graduate High School Level
Graduate
Live-in Widowed Vocational College Level / Graduate Post Graduate
Separated No Response Others_____________________________
Nationality: _______________________ Passport No (if non-filipino): ______________________
Occupation: ______________________ Identifying Marks: ______________________________
Religion:
Roman Catholic Islam Protestant Iglesiani Cristo Aglipayan Others
Address: ___________________________________________________________________
Region ______ Province ______________ City / Mun. ___________________ Barangay _____________

Relationship of Perpetrator to Victim:

Current spouse / partner Former spouse / partner Current fiancé / dating relationship
Former fiancé / dating relationship Employer / manager / supervisor Agent of the employer
Teacher / instructor / professor Coach / trainer Immediate family
Other relatives People of authority / service provider
Neighbors/peers/coworkers/classmate
Stranger
If Perpetrator is a Child:
Name of Parent / Guardian: ____________________________________________________
Last Name First Name Middle Name
Relationship of Guardian: ___________________________
Address: ____________________________________________________________________
Region ______ Province ______________ City / Mun. ___________________ Barangay _____________
Contact No. of Parent / Guardian: ___________________________
Incident Information:
RA 9262: Anti Violence against Women and their Children Act.
Sexual Abuse Psychological Physical Economic Others
____________________
RA 8353: Anti-Rape law of 1995.
Rape by sexual intercourse Rape by sexual assault
Art 336 of the Revised Penal Code
Acts of lasciviousness
RA 7877: Anti-Sexual Harassment Act.
Verbal Physical Use objects, pictures, letters or notes with sexual under-
pinnings
RA 7610: Special Protection of Children Against Child Abuse, Exploitation and
Discrimination Act.
Engage, facilitate, promote of attempt to commit child prostitution
Sexual intercourse or lascivious conduct
RA 9775: Anti-Child Pornography Act.
Description of Incident :

Date of Latest Incident: __/__/_____ (MM/DD/Year) Incomplete Date

Geographic Location Incident:
Region _____ Province ______________ City / Mun. _________________ Barangay_________________
Place of Incident:
Home Work School Commercial Places Religious Institutions
Place of Medical Treatment Transport & Connecting Sites Brothels and Similar
Establishment
Others No response
Witness: (Use additional paper if necessary) (Not to be encoded in system
1) ______________________ ______________________________ _____________
Name Address Contact Number
Eye-Witness Account:

Service Information:
Date: ___/___/________
Crisis intervention including rescue Issuance / Enforcement of Barangay Protection
Order
Refer to Social Welfare and Development Office: Date ___/___/____-
Psychosocial services Emergency Shelter Economic Assistance
Refer to Healthcare provider: Date __/__/____ Name of Healthcare Provider: ______________
Provision of appropriate medical treatment Issuance of medical certificate Medico Legal Exam
Refer to Law Enforcement: Date __/__/____ Agency: ________________________
Receipt and recording of Complaints Rescue Operation for VAW Cases
Forensic Interview and Investigation Enforcement of Protection Order
Refer to Other Service provider: Date __/__/____ Type of Service: ________________
Name of Service Provider: ___________________________________________
Note to Barangay VAW Desk Officer:
If the victim does not want to continue or pursue the case, please indicate herein the reason:
Lost of interest to file Reconciled with the perpetrator (w/o medication)
Transfer residence Lack of support
Lack of confidence with service provider
Others: please specify ___________________
Case Closed : No Yes
Date __/__/______ (MM/DD/Year)