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SEXUAL VIOLENCE AND DISCRIMINATION REPORTING

Incident Status Details

Incident Reference Number

LABEL DESCRIPTION NEEDS TO BE SHOWN HERE

Request Immediate Assistance
Contact Number*

Description*

Complainant Details
Remain Anonymous? Yes
Were you targeted in this incident? : Yes
Were there any other persons targeted? : Yes
Were you targeted in this incident? : Yes
First Name
Last Name
Email Address
Cell Number
External Reference
Gender *
Complainant Status*

Incident Details
What type of incident would you like to report? *
Where did the incident take place? *

When did the incident occur? *

Day	Month *	Year *
Hour	Minute

Perpetrator Details
Remain Anonymous? Yes
First Name Last Name Email Address Cell Number External Reference
What is the Perpetrator Known As?
Perpetrator Gender *
What is the Perpetrator relationship to the survivor(s)?
Perpetrator Status*

Survivor Details
Remain Anonymous? Yes
First Name Last Name Email Address Cell Number External Reference What is the Survivor Known As?
Survivor Gender *
Survivor Status *

Witness Details
Were there any other persons targeted? : Yes
Remain Anonymous? Yes
First Name Last Name Email Address Cell Number External Reference What is the Witness Known As?
Witness Gender *
Witness Status *

Complainant Statement
Please provide a detailed description of the incident * Please select any extra relevant information

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Confirm and Submit Details

Thank You For Reporting
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