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Republic of the Philippines

Province of Cavite
City of Bacoor
Barangay Mambog 4

National Violence Against Women (NVAW) Document System

Barangay Client Card

Handling Organization: _________________________ Date of intake: __/__/____ (mm/dd/yyyy)


Address:_________________________________________________________________________________________
Region :________ Province:____________ City/Mun:________________ 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: O Male O Female Date of Birth: __/__/____ (mm/dd/yyyy) Age: ______

Civil Status: Highest Education Attainment:


O Single O Married O No Formal Education O Elementary Level/Graduated O High School
Level/Graduated
O Live-in O Widowed O Vocational O College Level/Graduated O Post Graduate
O Separated O No Response O Other: ____________________________________
Nationality: _______________________ Passport No. (If non-filipino): _____________________________________
Occupation: ______________________________________________________________________________________
Religion:
O Roman Catholic O Islam O Protestant O Iglesya Ni Kristo O Aglipayan O Others: __________________
Address: ________________________________________________________________________________________
Last Name First Name Middle Name
Region: _________ Province: __________________ City/Mun.: __________________ Barangay: ________________
O With Disability O Without Disability O Permanent Disability O Temporary Disability
Number of Children (if any) _______________ Age of Children _____________________ (from oldest to youngest)

IF VICTIM-SURVIVOR IS ASURVIVOR (below 18 )


Name of Parent/Guardian: __________________________________________________________________________
Last Name First Name Middle Name
Relation of Guardian to Victim-Survivor: ______________________________________________________________
Address of the Guardian:___________________________________________________________________________
Region: _________ Province: _________________ City/Mun.: ___________________ Barangay: ________________
Contact no. of Parent/Guardian: _____________________________
PERPETRATOR INFORMATION
Name______________________________________________________________________ Alllas: _______________
Sex: O Male O Female Date of Birth: __/__/____ (mm/dd/yyyy) Age: ______

Civil Status: Highest Education Attainment:


O Single O Married O No Formal Education O Elementary Level/Graduated O High School
Level/Graduated
O Live-in O Widowed O Vocational O College Level/Graduated O Post Graduate
O Separated O No Response O Other: ___________________________________
Nationality: _______________________ Passport No. (If non-filipino): _____________________________________
Occupation: __________________________________ Identify Remarks: ____________________________________

Religion:
O Roman Catholic O Islam O Protestant O Iglesya Ni Kristo O Aglipayan O Others: __________________
Address: ________________________________________________________________________________________
Region: _________ Province: __________________ City/Mun.: __________________ Barangay: ________________
Relationship of Perpertrator to Victim:
O Current Spouse / Partner O Former spounse / Partner O Current Fiance/Dating Relationship
O Former Fiance / Dating relationship O Employer/Manager/Supervisor O Agent of the Employer
O Teacher / Instractor / Professor O Coach / Trainer O People of Authority/Service
Provider
O Neighbors/Peers/CoWorker/Classmate O Stranger O Immediate Family (e.g. Father,
Mother)
O Other Relatives (e.g. uncle, cousin, ______________________ ) O Other

IF PERPETRATOR IS A CHILD

Name of Parent/Guardian: __________________________________________________________________________


Last Name First Name Middle Name
Relation 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.
O Sexual Abuse O Psychological O Physical O Economic O Other _____________________
O RA 8353: Anti-Rape Law of 1995.
O Rape by sexual intercourse O Rape by sexual Assults
O RA 7877: Anti-Sexual Harassmemt Act.
O Verbal O Physical O Use of objects, pcitures,letters or notes with sexual under-pinnings
O RA 7610: Special Protection of Children Against Child Abuse ,Exportation and Discrimination Act
O Engage, facilitate, promote of attemps to commits child prostitution
O Sexual intercourse or lascivious conduct
O RA 9208: Anti-Trafficking in Person Actof 2003.
O RA 9775: Anti-child Pornography Act.
O RA 9995 Anti-Photo and Video Voyeurism Act 2009.
O Revised Penal Code.
O Art 336; Acts of Lasciviousness O
Other.___________________________________________________

Description of Incident:____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Date of Latest Incident:____/_____/_______(MM/DD/Year)


Geographic Location Incident:
Region______________ Province________________City /Mun.__________________Barangay__________________
Place of Incident:
O Home O Work O School O Commercial
Place
O Religious Institutions O. Places of Medical Treatment O. Trassport & Connecting Sites
O Brothels & Simiral Establishment O Others____________________ O No Response________________________
Witness: (Use additional paper if necessary) (Not to be encoded in the system)
1 _____________________________ __________________________________ ___________________________
Name Address Contact Number

Eye-Witness Account:______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Service Information:
Date:_________________(mm/dd//yyyy)
O Crisis Intervention including rescue O Issuance/ Enforcement of Barangay Protection Order
O Refer to Social Welfare and Development Office: Date,_____/______/________(mm/dd/yyyy)
O Psychosocial Services O Emergency Shelter O Economic Assistance
O Refer to the healthcare Provider: Date.____/____/_____ Name of Healthcare
Provider:______________________
O First Aid O Provision of appropriate medical treatment O Issuance of Medical Certicate
O Medico Legal Exam O Other ______________________________________
O Refer to Law Enforcement ; Date.___/___/____ Type of Service_______________
Agency__________________
O 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:
O Lost of interest to file O Reconciled with the perpetrator (w/o medication)
O Trasfer Residence O Lack of support
O Lack of confidence with service provider
O Other: please specify_____________________________________________________________________________

Case Closed: O No O Yes Date ____/____/_______ (mm/dd/year)

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