VIOLENCE AGAINST WOMEN

INTAKE FORMS

Handling Organization:______________________________ Date of Intake:__________________________

Address:_________________________________________________________________________________
Region:________ Province: __________________City:________________Barangay:___________________
Intake by:___________________________________________________ Position:_____________________
Last Name First Name Middle name
Case Manager:____________________________________________________________________________
Last Name First Name Middle name

VICTIM & SURVIVOR INFORMATION

Case/Blotter No.________ Name: _________________________________________________________
Last Name First Name Middle Name
Sex: _____Male _____Female Date of Birth: _______________________ (mm/dd/yyyy) Age:________________
Civil Status Highest Educational Attainment
____Single ____Married ____No Formal Education ____Elementary Level/Graduated ____Highschool Level/Graduated
____Live-in ____ Widow ____Vocational ____College Level/ Graduated ____Post Graduate
____Separated ____No Responses ____Others_______________________________
Nationality: ____________________________ Passport No. (If Non-Filipino):_________________________________
Occupation: ___________________________
Religion:
____Roman Catholic ____Islam ____Protestant ____Iglesia ni Cristo ____Aglipayan ____Others__________________
Address:___________________________________________________________________________________________
Region: __________ Province: __________________ City/Mun. ___________________ Barangay: _________________
_____With Disability _____Permanent Disability _____Temporary Disability
_____Without Disability
Number of Children (If Any): _________ Ages of Children: _____________ (
IF VICTIM-SURVIVOR IS A CHILD (Below 18 or as defined in RA 7610)
Name of Parent/Guardian: _____________________ _________________________ __________________________
Last Name First Name Middle Name
Relationship of guardian to Victim-Survivor:______________________________________________________________
Address of the Guardian: _____________________________________________________________________________
Region: __________ Province: __________________ City/Mun. ___________________ Barangay: _________________
Contact no. of Parent/Guardian: _____________________________

PERPETRATOR INFORMATION
Name: ____________________________________________________________ Alias: _________________
Last Name First Name Middle Name
Sex: _____Male _____Female Date of Birth: _______________________ (mm/dd/yyyy) Age:________________
Civil Status Highest Educational Attainment
____Single ____Married ____No Formal Education ____Elementary Level/Graduated ____Highschool Level/Graduated
____Live-in ____ Widow ____Vocational ____College Level/ Graduated ____Post Graduate
____Separated ____No Responses ____Others_______________________________
Nationality: ____________________________ Passport No. (If Non-Filipino):________________________________
Occupation: ___________________________ Identifying Marks: __________________________________________
Religion:
____Roman Catholic ____Islam ____Protestant ____Iglesia ni Cristo ____Aglipayan ____Others__________________
Address:___________________________________________________________________________________________
Region: __________ Province: __________________ City/Mun. ___________________ Barangay: _________________

Relationship of Perpetrator to Victim:

__Current spouse/partner __Former spouse/partner __Current fiance/dating relationship
__Former partner/ dating relationship __Employer/Manager/Superior __Agent of the employer
__Teacher/instructor/guidance __Coach/ trainer __People of authority/service provider
__Neighbor/Peer/Co-worker/Team mates __Stranger __Immediate Family (e.g. father/mother): ________
__Other relatives(e.g. uncle, cousin _________) __Others:_________________________
IF PERPETRATOR IS A CHILD (Below 18 or as defined in RA 7610)
Name of Parent/Guardian: _____________________ _________________________ __________________________
Last Name First Name Middle Name
Relationship of guardian to Victim-Survivor: _____________________________________________________________
Address of the Guardian: _____________________________________________________________________________
Region: __________ Province: __________________ City/Mun. ___________________ Barangay: _________________
Contact no. of Parent/Guardian: _____________________________
INCIDENT INFORMATION
o RA 9262: Anti Violence Against Women and Their Children Act
____Sexual Abuse ____Psychological ____Physical ____Economic ____Other:_____________
o RA 8353: Anti-Rape Maw of 1995
____Rape by sexual intercourse ____Rape by sexual assault
o RA 7877: Anti-Sexual Harassment Act
____Verbal ____Physical ____Use of objects, pictures, letters or notes with sexual under-
printings
o RA 7510: Special Protection of Children Against Child Abuse, Exploitation and Discrimination Act
____Engage, facilitate, promote or attempt to commit child prostitution ___Sexual intercourse or
lascivious conduct
o RA 9205: Anti- Trafficking in Persons Act of 2003
o RA 9775: Anti-Child Pornography Act
o RA 9985: Anti-Photo and Video Voyeurism Act of 2009
o Revised Penal Code
____Act 336: Act of Lasciviousness Others:_____________________________________

Description of Incident: ______________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date of Latest incident: ____ / ____ /________ (mm/dd/yyyy)
Geographic Location of Incident:
Region: __________ Province: __________________ City/Mun. ___________________ Barangay: _________________
Place of Incident:
_____Home _____Work _____School _____Commercial Places
_____Religious Institutions _____Places of Medical Treatment _____Transport & Connecting Cites
_____Brothers and Sister Establishments _____Others:__________________ _____No response

Witnesses: (Use additional Sheet if necessary) (Not to be encoded in the system)

1)________________________________________________________________________________________________
Name Address Contact no.
Eye Witness Account:________________________________________________________________________________
__________________________________________________________________________________________________
SERVICES INFORMATION
Date: ____ / ____ /________ (mm/dd/yyyy)
_____Crime Intervention including rescue _____Issuance Enforcement of Barangay Protection Order
_____ Refers to Social Welfare and Development Office? Date: ____ / ____ /________ (mm/dd/yyyy)
____Psychosocial of Services ____Emergency Shelter ____Economic Assistance ____Other:_________________
_____ Refers to Healthcare provider? Date: ____ / ____ /_____ Name of Healthcare Provider:____________________
____First Aid ____Provision of appropriates medical treatment ____Insurance of medical certificate
____Medico-legal Exam ____Others:_______________________
_____ Refers to Law Enforcement? Date: ___ / ____/____ Type of Service: _______________ Agency:_____________
_____ Refers to Other Service Provider? Date: ___ / ____/____ Type of Service: ___________________
Name of Service Provider: _____________________________________
Note to Barangay VAW Desk Office:

If the victim does not went to continue or pursue the case, please indicate here in the reason:

____Lost of Interest to file ____Reconciled with the perpetrator (who mediation)

____Transfer residence ____Lack of support
____Lack of confidence with service provider
____Others: please specify, ___________________________________________________________________________
 REFERRAL FORM

Case No._____________________ Date of Referral_________________________________

To:_______________________________________________________________________________________

Address___________________________________________________________________________________

Contact Person_____________________________________________________________________________

Name of Client_____________________________________________________________________________

Age _________ Sex____________________Address______________________________________________

Name of Family/Guardian_______________________________ Contact No.__________________________

Address___________________________________________________________________________________

Reason/s for Referral________________________________________________________________________

Specific Service/s Requested__________________________________________________________________

Please refer to attached report/intake form/case summary for more information.

Feedback requested and send to Referring Party/Agency:

Address___________________________________________________________________________________

Cell Phone No._____________________________ Land line No._____________________________________

Email address_______________________________ Fax No.______________________________________

Contact Person_____________________________________________________________________________

Referred by:

_____________________________________ _____________________________________
SIGNATURE OVER PRINTED NAME DESIGNATION
 BPO APPLICATION FORM
Republic of the Philippines
Province of Ilocos Norte
City of Batac
Barangay____________________

1. NAME OF APPLICANT:_____________________________DATE OF BIRTH:_______________________

ADDRESS:__________________________________________ CONTACT NO.________________________
RELATIONSHIP TO VICTIM/S:__________________________OCCUPATION__________________________
2. NAME OF VICTIM/S:______________________________ DATE OF BIRTH________________________
OCCUPATION/SOURCE OF INCOME:_________________________________________________________
CIVIL STATUS:____ SINGLE _____MARRIED _____WIDOW _____ SEPARATED ____ LEGALLY SEPARATED
3. NAME/S OF CHILDREN: DATE OF BIRTH SEX
______________________________ __________________ ____________
______________________________ __________________ ____________
______________________________ ___________________ _____________

OTHER CHILDREN UNDER HER CARE: DATE OF BIRTH SEX

______________________________ __________________ _____________
______________________________ __________________ _____________
______________________________ __________________ _____________
4. NAME OF RESPONDENT DATE OF BIRTH SEX
______________________________ _________________ ______________
ADDRESS______________________________________ CONTACT NO._____________________________
CIVIL STATUS:___ SINGLE ___ MARRIED ____ WIDOW/ER ____ SEPARATED ____LEGALLY SEPARATED
5. RELATIONSHIP OF VICTIM TO RESPONDENT:
____ WIFE ____ FORMER WIFE ___LIVE-IN RELATIONSHIP ___DATING RELATIONSHIP
______SEXUAL RELATIONSHIP
6. ACTS COMPLAINED OF: _____ THREATS _____PHYSICAL INJURIES
DESCRIPTION:___________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________.
7. DATE/S OF COMMISSION: ______________________________________________________________
8. PLACE/S OF COMMISSION:______________________________________________________________
9. IF APPLICANT IS NOT THE VICTIM, STATE THE CIRCUMSTANCES OF CONSENT:
____________________________________________________________________________________
____________________________________________________________________________________

______________________________________
APPLICANT SIGNATURE OVER PRINTED NAME
VERIFICATION OF THE PUNONG BARANGAY

I certify that the applicant for BPO who personally appeared before me is a bonafide resident of this
barangay and is the same person who supplied all the above information and attest to the correctness of said
information.

_________________________________________
Punong Barangay
SIGNATURE OVER PRINTED
DATE ISSUED:______________________________
 FEEDBACK FORM

CASE NO. ___________________________________ DATE __________________

Name of Clients: Age: Sex: Address:

Date referred: Referred to:

Service/s Service/s Names of Inclusive dates of Other Client’s

requested provided service provision pertinent satisfaction
provider/s information feedback
and Initial Update such as
designation problem/s (Only for case
encountered managers)