Barangay VAW Desk Handbook

ANNEX A

NATIONAL VIOLENCE AGAINST WOMEN (NVAW) DOCUMENTATION

SYSTEM (intake Form)
NATIONAL VIOLENCE AGAINST WOMEN (NVAW) DOCUMENTATION 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* Male Female Date of Birth*: ____/_____/___________ (mm/dd/yyyy) Age*:_____

Civil Status*: Highest Educational Attainment*:

Single Married No formal education Elementary Level/ Graduated High School Level/ Graduated.
. Live-in Widowed Vocational College Level/ Graduated Post Graduate
Separated No Responses Others _____________________
Nationality: ___________________________ Passport No. (If non-Filipino): __________________________
Occupation*: _________________________
Religion*:
Roman Catholic Islam Protestant IglesianiKristo 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 defined in R.A. 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: ____________________________________________________________Allas:__________________________
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 High School Level/ Graduated
. Live-in Widowed Vocational College Level/ Graduated Post Graduate
Separated No Response Others _____________________
Nationality: ___________________________ Passport No. (If non-Filipino): __________________________
Occupation*: _________________________
Religion*:
Roman Catholic Islam Protestant IglesianiKristo Aglipayan Others_________________
Address: ____________________________________________________________________________________________
Region: ______ Province: _________ City/Mun.: ________________________ Barangay: ___________________________

Relationship of Perpetrator to Victim*:

Current/ spouse partner Former spousepartner Current fiancé/ dating relationship

Former fiancé dating relationship Employer/ manager/ supervisor Agent of the employer
Teacher/ Instructor/ professor Coach/ trainer People of authority/ service provider
Neighbors, coworkers, classmates Stranger Immediate Inly (e.g. Other, matter _____)
Other relatives (e.g. uncle, ______________) Others ___________________
IF PERPETRATOR IS A CHILD (below 18 or defined in R.A. 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

RA 9262- Anti Violence Against Women and Their Children Act*

Sexual Abuse Psychological Physical Economic Others:________
RA 8353: Anti-Rape Law of 1995*
Rape by sexual intercourse Rape by sexual assault
RA 7877: Anti-Sexual Harassment Act*
Verbal Physical Use of objects, pictures, letters or notes with sexual under-pinnings
RA 7610: 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
RA 9775: Anti-Child Pornography Act
RA 9995: Anti-Photo and Video Voyeurism Act 2009
Revise 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 Sites
Brothels and Similar Establishments Others ______________ No response

Witness/es: (use additional paper if necessary) (Not to be encoded in system)

1) __________________ _____________________________________ __________________________
Name Address Contact Number
Eye-Witness
Account:_________________________________________________________________________________________________
________________________________________________________________________________________________________

SERVICES INFORMATION

Date: ___/___/______ (mm/dd/yyyy)

Crisis intervention including rescue Issuance/ Enforcement of Barangay Protection Order

Refer to Social Welfare and Development Office: Date ___/___/_____ (mm/dd/yyyy)

Psychosocial services Emergency Shelter Economic Assistance

Refer to Healthcare provider: Date ___/___/______ Name of \healthcare provider:______________________

First Aid Provision of appropriate medical treatment Issuance of medical certificate
. Medico-legal Exam] Others ____________________________

Refer to Law Enforcement?* Date: ___/___/______ Type of Service: __________ Agency:_____________

Refer to Other Service Provider?* Date: ___/___/______ Type of Service: ______________________

________________________________________________________________________________________________________
Note to Barangay VAW Desk Officer:
If the victim does not want to continue or pursue the case, indicate here in the reason:

Lost of Interest to file Reconciled with the perpetrator (with mediation)

Transfer residence Lack of support
Lack of confidence with service provider
Other please specify: ___________________________________________________________