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ESCAPE
34 Democracy crescent, Gaduwa Estate
hello@dnf.org.ng
24/7 +2347013333307
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Home
Who we are
ABOUT US
OUR TEAM
Get involved
CAMPAIGNS
DONATE
CAREERS
Resources
OUR PROJECTS
PUBLICATIONS
PRESS RELEASE
BLOG
REPORT ABUSE
Contact Us
DONATE
INCIDENCE REPORT FORM
This is a Confidential form for Survivors to Report cases of Sexual and Gender-Based Violence. Your information will be kept private and only shared with relevant support services based on your consent.
DO YOU GIVE CONSENT FOR YOUR INFORMATION TO BE USED FOR THE SOLE PURPOSE OF ASSITING YOU
Yes
No
Fullname
AGE
GENDER
MALE
FEMALE
Prefer not to say
Email
PHONE NUMBER
DATE OF INCIDENT
LOCATION OF INCIDENT
TYPE OF VIOLENCE EXPERIENCED(TICK ALL THAT APPLIES)
RAPE
DOMESTIC VIOLENCE
SEXUAL ASSAULT/ SEXUAL HARRASMENT
EMOTIONAL/ECONOMIC/PSYCHOLOGICAL ABUSE
CYBERBULLYING
OTHERS
OTHERS FOR TYPE OF VIOLENCE EXPERIENCED
BRIEF DETAILS OF INCIDENT
URGENCY OF THE CASE
URGENT
VERY URGENT
AT RISK
NOT URGENT
SUPPORT NEEDED
MEDICAL ASSISTANCE
FINANCIAL
THERAPY
LEGAL SUPPORT
HOW DO YOU PREFER TO BE CONTACTED
PHONE CALL
EMAIL
TEXT
WHATSAPP MESSAGE
Submit
