Gender-Based Violence Outcome Report Form
Document the outcomes of gender-based violence response cases with clear, concise details.
Case Reference Number
*
Date of Report
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Type of Incident
*
Please Select
Physical violence
Sexual violence
Emotional/psychological abuse
Economic abuse
Other
Survivor Age Group
*
Please Select
Under 18
18-24
25-34
35-44
45 and above
Prefer not to say
Survivor Gender
*
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Actions Taken
*
Safety planning
Medical support provided
Legal support provided
Counseling/psychosocial support
Referral to shelter
Other
Services Provided
*
Emergency accommodation
Food and basic needs
Transport assistance
Medical care
Legal aid
Other
Outcome Summary
*
Follow-Up Actions or Needs
Staff Name and Role
*
Submit Report
Should be Empty: