National Violence Against Women (NVAW) Documentation System
INTAKE FORM
Barangay Client Card
Handling Organization: ______________________________________ Date of Intake: ___/___/________ (mm/dd/yyyy)
Address: ___________________________________________________________________________________________
Region: IV-A Province: Cavite City/Municipality: General Mariano Alvarez 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 Elem. Level / Graduated High Sch 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 Iglesia ni Kristo Aglipayan Others: _________________
Region: IV-A Province: Cavite City/Municipality: General Mariano Alvarez Barangay: _________________
With Disability Permanent Disability Temporary Disability
Without Disability
Number of Children (If Any): ____ Ages of Children: _____________________________ (from eldest to youngest)
IF VICTIM SURVIVOR IS A CHILD (below 18 or as defined in RA 7610) YERFFOJ
Name of Parent / Guardian: ___________________________________________________________________________
Last Name First Name Middle Name
Relationship of Guardian to Victim – Survivor: ____________________________________________________________
Address of Guardian: ________________________________________________________________________________
Region: IV-A Province: Cavite City/Municipality: General Mariano Alvarez Barangay: _________________
Contact No. of Parent or Guardian: _____________________________________________________________________
PERPETRATOR INFORMATION
Name: ____________________________________________________________________ Alias: ___________________
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 Elem. Level / Graduated High Sch 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 Iglesia ni Kristo Aglipayan Others: _________________
Region: _____ Province: ___________ City/Municipality: ____________________ Barangay: _________________
Relationship of Perpetrator to Victim:
Current spouse / partner Former spouse / partner 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
Neighbour/peer/co-worker/classmate Stranger Immediate family (e.g. father,______
Other relatives (e.g. uncle, cousin, ___________________) Others ________________________
IF PERPETRATOR IS A CHILD (below 18 or as defined in RA 7610)
Name of Parent / Guardian: ___________________________________________________________________________
Last Name First Name Middle Name
Relationship of Guardian to Victim-Survivor: ______________________________________________________________
Address of the Guardian: _____________________________________________________________________________
Region: IV-A Province: Cavite City/Municipality: General Mariano Alvarez Barangay: _________________
Contact No. of Parent / Guardian: ______________________________________________________________________
Page 1 of 2 Barangay Client Card
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, letter or notes with sexual under-pinning
RA 7610: Special Protection of Children Against Child Abuse, Exploitation, and Discrimination Act
Engage, facilitate, promote, or attempt to commit child prostitution sex’l intercourse or lascivious conduct
RA 9208: Anti-trafficking in Persons Act of 2003
RA 9775: Anti Child Pornography Law Act
RA 9995: Anti-photo and Video Voyeurism Act of 2009
Revised Penal Code
Art 336: Acts of Lasciviousness Others: ______________________________________________
Description of the Incident:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date of Latest Incident: ____/____/__________ (mm/dd/yyyy)
Geographical Location of Incident:
Region: IV-A Province: Cavite City/Municipality: General Mariano Alvarez Barangay: _________________
Place of Incident:
Home Work School Commercial Places
Religious Institutions Places of Medical Treatment Transport & Connecting Sites
Brother and Similar establishments Others ___________________________________ No response
Witnesses: (Use additional sheet if necessary) (Not to be encoded in the system)
1) _______________________________________________________________________________________________
Name Address Contact No.
Eye Witness Account: ________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SERVICES INFORMATION YERFFOJ
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 Others __________________
Refer to Healthcare Provider Date: __/__/__________ (mm/dd/yyyy) Name of Healthcare Provider: ___________________
First Aid Provision of appropriate medical treatment Issuance of medical certificate
Medico-legal Exam Others ________________________________________________________________
Refer to Law Enforcement: Date: __/__/__________ (mm/dd/yyyy) Type of Service _____________________________
Name of Service Provider: ______________________________________________________________________
Note to Barangay VAW Desk Officers:
If the victim does not want to continue or pursue the case, please indicate herein the reason:
Lost of interest to file Reconciled with the perpetrator (w/o mediation)
Transfer residence Lack of support
Lack of confidence with service provider
Others, please specify ______________________________________________________________________________
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