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VAW Form 1

BARANGAY DATA CAPTURE FORM


MONITORING OF INCIDENCE ON VIOLENCE AGAINST WOMEN (VAW) DURING THE COVID -19 PANDEMIC
For the period: March 16, 2020 – June 16, 2020
Region: ______________________________
Province: _______________________________________________
City/Municipality: ________________________________________
Barangay: ______________________________________________
TYPES OF VIOLENCE (2) ACTIONS TAKEN BY THE BARANGAY (3)
Referred for Referred for
VAW Physical Psychological/ Economic Issued BPO Referred to Referred to Referred to Medical Legal Referred (ex
VICTIM/S Abuse Sexual Abuse Emotional Abuse Abuse (3a) LSWDO PNP NBI Treatment Assistance to Court N
(1) (2a) (2b) (2c) (2d) (3b) (3c) (3d) (3e) (3f) (3g)

√ =1 √ =1 √ =1 √ =1 √ =1 √ =1 √ =1 √ =1 √ =1 √ =1 √ =1 p
Victim 1

Victim 2

Victim 3

TOTAL

*If √ , encode “1” on the applicable fields


*If “Others,” please specify

Submitted by: ______________________________________


Punong Barangay

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