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Abuse Case Report
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All information captured is confidential and used only in assisting the relevant victims of violence.
Personal Details
Name
Please enter your name
Email Address
Invalid Email Address
Phone Number
(This eases case follow up)
Your phone is required
Gender
- Select -
Male
Female
Other
Gender is required
Location
(Search by Sub-County or Village)
Nearest Landmark
(e.g School,Police Station, Hill,e.t.c )
Please enter the nearest known physical feature/landmark
Are you reporting for yourself?
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Victim Details
Victim Name
Age
Guardian/Parent Name
Gender
- Select -
Male
Female
Other
Location
(Search by Sub-County or Village)
Nearest Landmark
(e.g School,Police Station, Hill,e.t.c )
Do you know the perpetrator?
(Person causing the issue to the victim)
Yes
No
Please select whether the perpetrator is known or not..
Perpetrator Details
Name
Email Address
Phone Number
Gender
- Select -
Male
Female
Other
Location
Nearest Landmark
(e.g School,Police Station, Hill,e.t.c )
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Case Details
Describe the case
Has the case been reported?
Where has it been reported?
(Include SDREF/CRB/CRR Number if police)
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