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* CityMun.* Barangay*
Intake by* Position
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 Graduate Post Graduate
Separated No re Others
Nationality Passport no (if non Filipino)
Occupation
Religion
Roman Catholic Islam Protestant Iglesia ni Kristo Aglipayan Other
Address:
Region Province: CityMun. 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 as defined as R.A 7610

Name of Parent/ Guardian: , , , Allias

Last Name First Name Middle Name
Relationship of Guardian to Victim –Survivor:
Relationship of Guardian
Region Province: City/Mun. Barangay:
Contact no. of Parent/Guardian:

PERPETRATOR INFORMATION
Name* Allias:
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 Graduate Post Graduate
Separated No re Others
Nationality Passport no (if non Filipino)
Occupation
Religion
Roman Catholic Islam Protestant Iglesia ni Kristo Aglipayan Other
Address:
Region Province: CityMun. Barangay:
Relationship of Perpetrator to Victims*
Current spouse partner Former spouse/Partner Current descending Relationship
Former descending Relationship Employer/Manager/Supervisor Agent of the employer
Teacher/Instructor/Professor Coach/ Trainer People of authority service provider
Neighbor Stranger Immediate Family (e.g other)
Other relative (e.g uncle. Cousin)

IF PERPETRATOR IS A CHILD (below 18 or as defined as R.A 7610

Name of Parent/ Guardian: , , , Allias

Last Name First Name Middle Name
Relationship of Guardian to Victim –Survivor:
Relationship of Guardian
Region Province: City/Mun. Barangay:
Contact no. of Parent/Guardian:

INCIDENT INFORMATION

R.A 9262 Anti violence Again Women And their Children Act*
Sexual Abuse Psychological Physical Economic Other

R.A 8353 Anti Rape Law of 1995

Rape by Sexual Intercourse Rape by sexual Assault

R.A 7877 Anti Sexual Harassment Act*

Verbal Physical use objects picture letter or notes with sexual under pinning’s
R.A 7610 Special Protection of Children Against Child Abuse, Exploitation and Dissemination Act*
Engage facilitate promote or attempt to commit child prostitution Sexual Intercourse or lascivious conduct
R.A 920B Anti Trafficking in Persons Act of 2003
R.A 9775 Anti Child Pornography Act
R.A 9995 Anti Photo and Video Voyeurism Act 2009
Revised Penal Code
Art 300 acts of lasciviousness Others
Description of Incident:

Date of Latest incident / / (mm/dd/yyyy)

Geographic Location of Incident
Region Province: CityMun. Barangay:
Place of Incident

House Work School Commercial Place

Religious Institutions Places Medical Treatment Transport & Connecting Sites

Brothel and Similar Establishment 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

Date / / (mm/dd/yyyy)
Crisis Intervention include rescue Issuance/Enforcement of Barangay Protect Order

Refer to Social Welfare and Development Officer?* Date / / (mm/dd/yyyy)

Psychiatric/Services Emergency Shelter Economic Assistance Other

Refer to Healthcare Provider?* Date / / Name of Healthcare Provider

First Aid Provision of appropriate medical treatment insurance of medical Certificate

Medical legal Exam Others

Refer to Law Enforcement?* Date / / Type of Service Agency

Refer to other Service Provider Date / / Type of Service
Name of Service Provider

Note to Barangay VAW Desk Officer.

If the victim does not went to continue of pursue the case please indicate herein the reason:

Lost of interest Reconnected with the perpetrator (w/o mediation)

Transfer residence Lack of Support
Lack of confidence with service provider
Other please specify