VAW Form 1

BARANGAY DATA CAPTURE FORM

MONITORING OF INCIDENCE ON VIOLENCE AGAINST WOMEN (VAW) DURING THE CO
PANDEMIC
For the period: May 16, 2020 - June 15, 2020

Region:___________________
Province:______________________________________
City/Municipality:_______________________________
Barangay:____________________________________

TYPES OF VIOLENCE (2) ACTIONS TAKEN BY THE BARANGAY (3)

Psychologi
Referred for
VAW Physical Sexual cal/ Economic Referred to Referred to Referred to
Issued BPO Medical
VICTIM/S Abuse Abuse Emotional Abuse LSWDO PNP NBI
(3a) Treatment
(1) (2a) (2b) Abuse (2d) (3b) (3c) (3d)
(3e)
(2c)

✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1

Victim 1

Victim 2

Victim 3

TOTAL

*If ✔, encode "1" on the applicable fields

*If "Others," please specify

Submitted by: Name and Signatu

Punong Barang
M
AW) DURING THE COVID-19

Y THE BARANGAY (3)

Others
Referred for (ex:
Referred to
Legal Referred to
Court
Assistance NGOs,
(3g)
(3f) FBOs)
(3h)

✔=1 ✔=1 pls. specify

Name and Signature

Punong Barangay
VAC Form 1
BARANGAY DATA CAPTUR
MONITORING OF INCIDENCE ON VIOLENCE AGAINST CHILDR
For the period: May 16, 2020- June

Region:___________________
Province:______________________________________
City/Municipality:_______________________________
Barangay:____________________________________

GENDER TYPES OF VIOLENCE PERPETRA

(2) (4) (5)

Psychologi
VAC Immediate
AGE Physical Sexual cal/ Other Close
VICTIM/S Male Female Neglect Family
(3) Abuse Abuse Emotional Relative
(1) (2a) (2b) (4d) Member
(4a) (4b) Abuse (5b)
(5a)
(4c)

✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1

Child 1

Child 2

Child 3

TOTAL
*If ✔, encode "1" on the applicable fields *Immediate Family Member/s – parents and sibling
*If "Others," please specify *Other Close Relative/s – uncles, aunts, grandpare
NGAY DATA CAPTURE FORM
CE AGAINST CHILDREN (VAC) DURING THE COVID-19 PANDEMIC
e period: May 16, 2020- June 15, 2020

PERPETRATORS ACTIONS TAKEN BY THE BARANGAY/BCPC

(5) (6)

Others Referred for Referred for

Acquaintan Local Law Referred to Referred to Referred to
Stranger (ex: Medical Legal
ce Official Enforcer LSWDO PNP NBI
(5d) Guardian) Treatment Assistance
(5c) (5e) (5f) (6a) (6b) (6c)
(5g) (6d) (6e)

✔=1 ✔=1 ✔=1 ✔=1 pls. specify ✔=1 ✔=1 ✔=1 ✔=1 ✔=1

Member/s – parents and siblings

e/s – uncles, aunts, grandparents, cousins, etc.

Submitted by: Name and Signature

Punong Barangay
GAY/BCPC

Others
(ex:
Referred to
NGOs,
FBOs)
(6f)

pls. specify