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Incidence Date and Witness Details

if the withness is the same as the survivor, just fill the date and move to the next tab

Incidence date
Is reporting witness the same as survivor?	Yes No
Name of the person who contacted police
Phone number of witness
Witness Address Address City State

Survivor Detail

Full name

Alias/Nickname

Relationship to Suspect

Family

Friend

Stranger

Others

Age

0-18

19-36

37-49

50 above

Gender

Male

Female

Others

Marital Status

Single

Married

Separated

Divorced

Widowed

State Of Origin

Address

City

State

Does Survivor has any personal Disability?

Yes

Emergency Contact/Best way to Safely Contact Survivor

Does the Survivor have any physical injuries? If yes, detail in narrative

Yes

Does the Survivor report any physical pain? If yes, describe

Yes

Were weapons used to hurt/injure/threaten? If yes, detail in narrative

Yes

Does Survivor believe he/she may have been drugged with any controlled substance? If yes or unsure, detail in narrative

Yes

Has abuse by suspect been ongoing? If yes, how long

Yes

0-30 days

1-3 months

4-6 months

1 year and above

Full name of Suspect

Aliases/Nickname

Relationship to Survivor?

Family

Friend

Stranger

Others

Phone Number of Suspect

Marital Status

Single

Married

Separated

Divorced

Widowed

Gender

Male

Female

Others

Age

0-18

19-36

37-49

50 above

Address

City

State

Employment Status

Employed

Un-employed

Self-employed

Does Suspect live with Disability?

Yes

Specific markings for identification

Specific Hair Color

Specific Eye Color

Suspect Height

2-4 ft

5-7 ft

7ft and Above

Did the Suspect consume any alcohol or controlled substance 24hrs prior to the incident?

Yes

Location of interaction with Suspect before the incident

Suspect location before the incident

Location of Incident

Location suspect took victim after the incident

Types of Coercion/Fear/Force involved (select all that apply)

Disregarding the survivor’s stated or communicated lack of consent

Verbal pressure/coercion

Position of authority (teacher, parent, employer, guardian)

Restraint/Threat of physical force or violence

Survivor was incapacitated

Presence of weapon

Stalking

Physical force

Threat of Kidnapping

Other (describe)

Type of Assault (select all that apply)

Rape

Attempted

Committed

Not Committed

Defilement

Attempted

Committed

Not Committed

Sodomy

Attempted

Committed

Not Committed

Indecent Assault

Attempted

Committed

Not Committed

Domestic Violence (Physical assault/battery)

Attempted

Committed

Not Committed

Child Sexual Abuse (Grooming)

Attempted

Committed

Not Committed

Other (describe)

Additional Incident to be investigated?

Details of Prior Report (If any)

Has a prior report been made? If yes, detail

Yes

Was this report made by Survivor? If yes, detail

Yes

Did the report involve the same Suspect?

Yes

What was the Case Title?

To what organization?

CSOs

NAPTIP

Social Welfare

NSCDC

NPF

Others

Attachment of Picture Evidence (If any)

Incidence Date and Witness Details

Yes No

Details of Prior Report (If any)

Yes

No