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VAW Intake Form 2023
VAW Intake Form 2023
Province of Cavite
City of Bacoor
Barangay Mambog 4
VICTIM-SURVIVOR INFORMATION
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
Description of Incident:____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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:___________________________________________
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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_____________________________________________________________________________