Gender-Based Violence Incident Report Form
Report an incident of gender-based violence. Please provide as much detail as possible while avoiding personal identifiers.
Type of incident
*
Physical violence
Sexual violence
Emotional/psychological abuse
Economic abuse
Other
Date of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of incident (if known)
Hour Minutes
AM
PM
AM/PM Option
Location of incident (general area, do not enter specific address)
*
Relationship of perpetrator to victim
*
Intimate partner/spouse
Family member
Friend/acquaintance
Stranger
Other
Gender of the victim
*
Female
Male
Non-binary
Prefer not to say
Other
Gender of the perpetrator (if known)
Female
Male
Non-binary
Unknown
Brief description of the incident (do not include names or identifying details)
*
Was medical attention sought?
Yes
No
Prefer not to say
Was law enforcement contacted?
Yes
No
Prefer not to say
Submit Report
Should be Empty: