Alliances for Africa::

Submit Report for Myself

(Please tick the circles and boxes below and fill in appropriately where needed)

I give my consent/assent for my data to be collected, stored and shared with service providers who maybe offering services to me. I understand that this data will help intervene in my case and offer relevant services. It has been explained to me that the purpose of this data collection is for planning and policy development only. I voluntarily consent/assent to use Kpọtụrụm for reporting GBV incidents and understand the rights, responsibilities, and limitations associated with its usage.

1. Name of Survivor: 2. Gender: Male Female Others 3. Marital Status: Single Married Divorced Cohabiting Seperated Others 4. Age: 0-5 6-10 11-17 18-30 31-45 46-60 Above 60 5. Phone Number of Survivor: 6. State of Residence: Senatorial Zone of Residence LGA of Residence 7. Location of Incidence: Others 8. Type of Abuse: Explain the Abuse Or select from abuse category below

Abuse Options

9. Name of Perpetrator(s): 10. Perpetrator's Age(s): 0-5 6-10 11-17 18-30 31-45 46-60 Above 60 11. Perpetrator's Gender: Male Female Others 12. Perpetrator's Phone Number(s): 13. Address of Perpetrator(s): 14. Who is the Perpetrator to you?: Others 15. Date of Occurrence: 16. Has the case been reported to any police station?: Yes No 17. Status of the Victim?: 18. Do you want justice?: Yes, I want Justice No, I do not want Justice Others 19. What is the status of the case?: Justifiably concluded On-going Case closed/ justifiably denied / unjustifiably concluded Settlement among the families Others 20. Upload An Evidence of Abuse If Any?: Upload File * (jpg, jpeg, gif, png, pdf, doc, docx, ppt, pptx, xls, xlsx, zip, rar)

NOTE: The information you provided is confidential and the data will remain anonymous and not linked to you as an Individual. Thank you for taking time to complete this form.

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