Republic of the Philippines

Province of Bataan
Municipality of Orani
BARANGAY CENTRO I
Office of the Sangguniang Barangay

REFERRAL FORM
BARANGAY VIOLENCE AGAINST WOMAN (VAW) DESK
Annex B

Case No . ______ Date of Referral: __________________

To : ____________________________________________
Address : ____________________________________________
Contact Person : ______________________________________
Name of Client : ______________________________________
Age : ________ Sex :______ Address : __________________________________
Name of Family/Guardian : ____________________________ Contact # :_______________
Address : ______________________________________
Reason/s for Referral : ____________________________________________________________
Specific Service/s Requested : ____________________________________________________
Please refer to attached report/ intake form/ case summary for more information.

Feedback requested and send to Referring Party/ Agency:

__________________________________________________________________________________

Address : _________________________________________________
Cellphone # : _________________________ Landline # :_______________________________
Email Address : __________________________________ Fax No. : ________________________
Contact Person : __________________________________________

Referred by :

_________________________
Kag. Carolina G. Samson
VAW Chairman

VAWC FORM NO. 4 CONTROL

NO.
_______
BARANGAY
PROTECTION ORDER
(Alinsunod sa Republic Act 9262
o Anti VAWC Act)
PANGALAN NG RESPONDENT:
______________________________
____
TIRAHAN:
______________________________
____________________
KAUTUSAN
Si
______________________________
__ ay humiling ng BARANGAY
PROTECTION ORDER,
sa ilalim ng sinumpaang salaysay na
nagsasaad:
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
______________________________
______________________________
________________
_____________.
Matapos na masuri ang aplikasyon,
mga pahayag at katunayan, ako, sa
pamamagitan
nito ay ngayo’y nag-iisyu ng
BARANGAY PROTECTION
ORDER na pumapabor sa Biktima
na
si
____________________________.
At dahil dito, ang respondent/
inirereklamo na si
______________________________
_ ay PINAG-UUTUSAN na
tumalima sa mga sumusunod:
1. PAGBABAWAL ng anumang
akto, personal mang isinasagawa o sa
pamamagitan ng ibang
tao, na nagdudulot ng aktwal na
pananakit o pagbababanta ng
pananakit laban sa biktima
at sa kaniyang mga anak;
2. PAGBABAWAL sa anumang
akto ng panggigipit o pangligalig,
pang-iinis o
pangyayamot,
pakikipagkomunikasyon sa
telepono o anumang uri ng
komunikasyon sa biktima, sa
direktang pamamaraan man o
hindi.
Ang KAUTUSANG ito ay may bisa
sa loob ng labinlimang araw (15
days) na bibilangin
mula sa pagkakatanggap nito