VAWC Form # 3

VAWC Form # 3 CTRL No. ___________

REPUBLIC OF THE PHILIPPINES
PROVINCE OF ________________
CITY/MUNICIPALITY OF _________________

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT:_________________________________ AGE:______________________

ADDRESS:___________________________________________ TEL #:_____________________
RELATIONSHIP TO VICTIM:_____________________________ OCCUPATION:______________
2. NAME OF VICTIM:____________________________________ DATE OF BIRTH:_____________
ADDRESS:___________________________________________ TEL #:_____________________
CIVIL STATUS: Single Married Widow Separated

3. OCCUPATION/SOURCE OF INCOME:____________________ __________________________________

4. NAME OF CHILDREN: DATE OF BIRTH SEX

___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
4.a. Other Children under her care

NAME DATE OF BIRTH SEX

___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
___________________________ ____________ ____
5. NAME OF RESPONDENT:_____________________________ AGE:_____________________
OCCUPATION/SOURCE OF INCOME:______________________________________________
ADDRESS:____________________________________________ TEL:___________________
CIVIL STATUS: Single Married Widow Separated
6. RELATIONSHIP OF COMPLAINANT TO RESPONDENT:
Wife Former Wife Common Law/Live in Relationship
Dating Relationship Sexual Relationship
7. ACTS COMPLAINED OF (Pls. Check)
Threats Physical Injuries
8. DATE OF COMMISION OF THE OFFENSE:________________________________________________
9. PLACE WHERE THE OFFENSE WAS COMMITED:___________________________________________
10. IF THIS APPLICANT IS NOT A VICTIM, STATE THE CIRCUMTANCE OF REFUSSAL TO GIVE CONSENT OF THE
VICTIM.
__________________________________
Signature of Applicant Over Printed Name

___________________
__________________________________________________________________Date_______________
VERIFICATION OF PUNONG BARANGAY

I certify that the applicant of BPO who personally appeared before me is bonafide resident of
this barangay and is the same person who supplied all the above information and attest the
corrections of said information.

__________________________
Punong Barangay
Signature over printed name
 VAWC Form # 4
VAWC Form # 4 CTRL No. _______________

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: ______________________________________

ADDRESS: __________________________________________________

ORDER

_____________________________Applied for a BPO on __________________under oath stating that:

____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________________________

After having heard the application and the witnesses and evidence, the undersigned hereby
issued this BPO ordering you to immediately cease and desist from causing and threatening to cause
physical harm to _____________________________________________________________________
And /or her child/children;

______________________________________ _____________________________________
______________________________________ _____________________________________
______________________________________ _____________________________________

This BPO is effective for 15 days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW:

____________________________
Punong Barangay
Signature over printed name

Date Issued: _____________________

Copy received by: ____________________________
Signature over printed name
Date received: _______________________________
Served by: __________________________________
Signature over printed name

ATTESTATION
(In case the Punong Barangay is unavailable)

I hereby attest that Punong Barangay ______________________________ was unavailable act

on Application for Barangay Protection Order No. _____________ filed by _______________________
On _____________________________ at _____________________ am/pm and issue such order.

____________________________
Punong Barangay
Signature over printed name
 VAWC Form # 5
VAWC Form # 5
Brgy. Form No. ______
Control No. ______
Republic of the Philippines
Province _______________
City/Municipality ________
Barangay ______________

VIOLENCE AGAINST WOMEN AND THEIR CHILDREN INCIDENT REPORT

I. PERSONAL CIRCUMSTANCES
(A) Name of Complainant/ victims Age Address
____________________________ _______ ________________________________
____________________________ _______ ________________________________
____________________________ _______ ________________________________

(B) Civil Status (C) Relationship to Perpetrator

Married Wife Girlfriend
Separated Ex-wife Dating relationship
Widow

(C) Occupation / Profession: Complainant Perpetrator

______________________ _______________________

II. INCIDENT DEATAILS

(A) Date/s of Violence committed
Date Reported ____________________
(B) Nature of Violence Inflicted by Perpetrator
Physical _______________________________________________________________________
Sexual ________________________________________________________________________
Psychological ___________________________________________________________________
Economic Abuse ________________________________________________________________

III. ASSISTANCE EXTENDED / PROVIDED TO VICTIM/S

Specific
Service Provided Provided by: Remarks
Medical _____________________ ______________ _______________
Counseling _____________________ ______________ _______________
Referral to _____________________ ______________ _______________
Shelter _____________________ ______________ _______________
Issued BPO Date _________________ ______________ _______________

Prepared by:

____________________ _______________________________
Date Accomplished (Signature Over Printed Name)
OFFICIAL ACCOMPLISHING THIS FORM

Note: Please bring copy of this form to referred agency.

 National Violence Against Women (NVAW) Documentation System
(Barangay Form)

Handling Organization: ________________________Date of Intake __/__/____ (MM/DD/Year)

Address: _________________________________________________________
Region ____ Province __________________ City / Mun _____________ Barangay ___________
Interview By: _____________________________________________Position: _____________
Last Name First Name Middle Name

Victim Survivor Information

Brgy. Case #: ___________ Name: _____________________________________________________

Last Name First Name Middle Name
With Disability Permanent Disability Temporary Disability
Without Disability
Sex: Male Date of Birth: ___/___/_______ (MM/DD/Year) Age: ___
Female
Civil Status: Highest Education Attainment:
Single Married No formal education Elementary Level / Graduate High School Level Graduate
Live-in Widowed Vocational College Level / Graduate Post Graduate
Separated No Response Others_____________________________
Nationality: _______________________ Passport No (if non-filipino): ______________________
Occupation: ______________________
Religion:
Roman Catholic Islam Protestant Iglesia ni Cristo Aglipayan Others
Address: ___________________________________________________________________
Region ______ Province ______________ City / Mun. ___________________ Barangay _____________
Contact No. of Parent / Guardian: ___________________________

Perpetrator information:

Name: _________________________________________________ Alias: _____________________

Last Name First Name Middle Name
Sex: Male Date of Birth: ___/___/_______ (MM/DD/Year) Age: ___
Female
Civil Status: Highest Education Attainment:
Single Married No formal education Elementary Level / Graduate High School Level Graduate
Live-in Widowed Vocational College Level / Graduate Post Graduate
Separated No Response Others_____________________________
Nationality: _______________________ Passport No (if non-filipino): ______________________
Occupation: ______________________ Identifying Marks: ______________________________
Religion:
Roman Catholic Islam Protestant Iglesia ni Cristo Aglipayan Others
Address: ___________________________________________________________________
Region ______ Province ______________ City / Mun. ___________________ Barangay _____________

Relationship of Perpetrator to Victim:

Current spouse / partner
Former fiancé / dating relationship
Teacher / instructor / professor
Other relatives
Stranger
Former spouse / partner Current fiancé / dating relationship
Employer / manager / supervisor Agent of the employer
Coach / trainer Immediate family
People of authority / service provider Neighbors/peers/coworkers/classmate
If Perpetrator is a Child:

Name of Parent / Guardian: ____________________________________________________

Last Name First Name Middle Name
Relationship of Guardian: ___________________________
Address: ____________________________________________________________________
Region ______ Province ______________ City / Mun. ___________________ Barangay _____________
Contact No. of Parent / Guardian: ___________________________
Incident Information:
RA 9262: Anti Violence against Women and their Children Act.
Sexual Abuse Psychological Physical Economic Others ____________________
RA 8353: Anti-Rape law of 1995.
Rape by sexual intercourse Rape by sexual assault
Art 336 of the Revised Penal Code
Acts of lasciviousness
RA 7877: Anti-Sexual Harassment Act.
Verbal Physical Use objects, pictures, letters or notes with sexual under-pinnings
RA 7610: Special Protection of Children Against Child Abuse, Exploitation and Discrimination Act.
Engage, facilitate, promote of attempt to commit child prostitution
Sexual intercourse or lascivious conduct
RA 9775: Anti-Child Pornography Act.
Description of Incident : ________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of Latest Incident: __/__/_____ (MM/DD/Year) Incomplete Date
Geographic Location Incident:
Region _____ Province ______________ City / Mun. _________________ Barangay_________________
Place of Incident:
Home Work School Commercial Places Religious Institutions
Place of Medical Treatment Transport & Connecting Sites Brothels and Similar Establishment
Others No response
Witness: (Use additional paper if necessary) (Not to be encoded in system
1) ______________________ ______________________________ _____________
Name Address Contact Number
Eye-Witness Account: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Service Information:
Date: ___/___/________
Crisis intervention including rescue Issuance / Enforcement of Barangay Protection Order
Refer to Social Welfare and Development Office: Date ___/___/____-
Psychosocial services Emergency Shelter Economic Assistance
Refer to Healthcare provider: Date __/__/____ Name of Healthcare Provider: ________________
Provision of appropriate medical treatment Issuance of medical certificate Medico Legal Exam
Refer to Law Enforcement: Date __/__/____ Agency: ________________________
Receipt and recording of Complaints Rescue Operation for VAW Cases
Forensic Interview and Investigation Enforcement of Protection Order
Refer to Other Service provider: Date __/__/____ Type of Service: ________________
Name of Service Provider: ___________________________________________
Note to Barangay VAW Desk Officer:
If the victim does not want to continue or pursue the case, please indicate herein the reason:

Lost of interest to file Reconciled with the perpetrator (w/o medication)

Transfer residence Lack of support
Lack of confidence with service provider
Others: please specify ___________________

Case Closed : No Yes

Date __/__/______ (MM/DD/Year)
 REFERRAL FORM

Case No. __________________ Bate of referral __________________

To: _________________________________________________________________________________
Address: _____________________________________________________________________________
Contact Person: _______________________________________________________________________
Name of Client: _______________________________________________________________________
Age: ____ Sex: ______ Address: __________________________________________________________
Name of Family / Guardian: _____________________________________ Contact No. ______________
Address: _____________________________________________________________________________
Reason/s for Referral: __________________________________________________________________
Specific Service/s Requested: ____________________________________________________________

Please refer to the attached report/intake form/case summary for more information.

Feedback requested and send to Referring Party/Agency:

____________________________________________________________________________________
Address: _____________________________________________________________________________
Cellphone No: _______________________ Landline No. ________________________
Email Address: ______________________________ Fax No. __________________________
Contact Person: _____________________________________________
Referred by:

_________________________________ ____________________________
Signature over Printed Name Designation
 FEEDBACK FORM
Case No. _____________________ Date: ____________________

Name of Client: Age: Sex: Address:

Date Referred Referred to:
Other
Names of pertinent
Service/s Service/s service Inclusive dates of provision information Client’s
requested provided provided/s such as satisfaction
and problem/s feedback
designation encountered
Initial Update (Only for case
managers)