Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressLGASexTelephone NumbersAlternative NumberNature of IncidentPlace Of OccurrenceDate of OccurrenceDD/MM/YYName of Abuser (if known)Relationship with the AbuserAddress of the Abuser (if known)Telephone Number of Abuser:KINDLY TICK AS APPROPRIATEEnglishIgboYorubaHausaPidginothers (please specifyEmployment Status (Client)EmployedUnemployedSelf-EmployedStudentMarital StatusMarriedCohabitingSingleSeparatedDivorcedWidowedAre you a person with disability? YesNoVisual ImpairmentSpeech ImpairmentPhysical DisabilityADHDothers (please specify Reported to any police station?YesNoIf yes, where?Received medical attention? YesNoIf yes, where? Others (please specify) How did you hear about the SGBVRD?Have you visited a Pharmacy?YesNoPLEASE ACKNOWLEDGEWe will like to ask some questions in order to understand your current situation. If it is okay with you, we will be recording our conversation. The purpose of this is so that we can get all the details but at the same time be able to carry on an attentive conversation with you. We ensure you that all your comments will remain confidential. We will likely need to share information in our notes with other organizations, especially the relevant Government Agencies and Approved Sexual Assault Reference Centers, Health Facilities and the police so they can support you. PLEASE TAKE NOTE You can tell us if you would like to keep anything that you tell us confidential from anyone else and you can stop the interview or take a break at any time. Anybody who tries to prevent this case from being charged to court will be charged to court as an accomplice and may be sentenced to prison for up to two (2) years. Should you understand and agree with the above declaration, please append your signature below.SignatureEmail *Submit
