VAC Form 1

BARANGAY DATA CAPTURE FORM

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

Region:__ VIII
Province: LEYTE
City/Municipalit ALANGAALANG
Barangay: EKIRAN
ASLUM

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

(2) (4) (5) (6)

Psychological/ Immediate Other Referred for Referred for Others

VAC Physical Sexual Local Law Others Referred to Referred Referred
Male Female AGE Emotional Neglect Family Close Acquaintance Stranger Medical Legal (ex: Referred to
VICTIM/S Abuse Abuse Official Enforcer (ex: Guardian) LSWDO to PNP to NBI
(2a) (2b) (3) Abuse (4d) Member Relative (5c) (5d) Treatment Assistance NGOs, FBOs)
(1) (4a) (4b) (5e) (5f) (5g) (6a) (6b) (6c)
(4c) (5a) (5b) (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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Child 2

Child 3

TOTAL 0
*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:
Punong Barangay