VAC Form 1

BARANGAY DATA CAPTURE FORM

MONITORING OF INCIDENCE ON VIOLENCE AGAINST CHILDREN (VAC) DURING THE COVID-19 PANDEMIC
For the Period: ____________________________

Region: ____________________________
Province: __________________________
City/ Municipality: ________________________________
Barangay: _______________________________

VAC
VICTIMS GENDER (2) TYPES OF VIOLENCE (4) PERPETRATORS (5) ACTIONS TAKEN BY THE BARANGAY/ BCPC (6)
(1)

AGE (3) Psycholog Referred Others

Immediat Close Others Referred Referred Referred Referred
Physical Sexual ical/ Local Law to (ex.
Female Neglect Others e Family Acquainta Stranger (ex. for Legal
Total No. Male (2a) (2b)
Abuse Abuse Emotional
(4d) (4e) Member
Relative
nce (5c) (5d)
Official Enforcer
Guardian)
to LSWDO to PNP to NBI Medical
Assistanc
Referred
of VAC (4a) (4b) Abuse (5b) (5e) (5f) (6a) (6b) (6c) Treatmen to NGOs,
(5a) (5g) e (6e)
Victims (4c) t (6d) FBOs (6f)

pls. pls.
a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 a= 1 specify a= 1 a= 1 a= 1 a= 1 a= 1 specify
Child 1

Child 2

Child 3

Total
*If a, encode "1" on the applicable fields *Immediate Family Members - parents and siblings
*If "Others", please specify *Other Close Relative/s - uncles, aunts, grandparents, cousins, etc.

Submitted by: _______________________________________

Punong Barangay