VAC Form 1

BARANGAY DATA CAPTURE FORM

MONITORING OF INCIDENCE ON VIOLENCE AGAINST CHILDREN (VAC) DURING THE COVID-19 PANDEMIC
For the Month: ______________________

Region:___________________
Province:______________________________________
City/Municipality:_______________________________
Barangay:____________________________________

GENDER TYPES OF VIOLENCE PERPETRATORS ACTIONS TAKEN BY THE BARANGAY/BCPC

(2) (4) (5) (6)
VAC Immediate Referred for Referred for Others
AGE Physical Sexual Psychological/ Other Close Local Law Others Referred to Referred Referred
VICTIM/S Male Female Neglect Family Acquaintance Stranger Medical Legal (ex: Referred to
(3) Abuse Abuse Emotional Abuse Relative Official Enforcer (ex: Guardian) LSWDO to PNP to NBI
(1) (2a) (2b) (4d) Member (5c) (5d) Treatment Assistance NGOs, FBOs)
(4a) (4b) (4c) (5b) (5e) (5f) (5g) (6a) (6b) (6c)
(5a) (6d) (6e) (6f)
✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 pls. specify ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 pls. specify
Child 1

Child 2

Child 3

TOTAL
*If ✔, encode "1" on the applicable fields *Immediate Family Member/s – parents and siblings
*If "Others," please specify *Other Close Relative/s – uncles, aunts, grandparents, cousins, etc.

Submitted by: Name and Signature

Punong Barangay