Instructions	Form to be completed by fully trained and designated staff. This document may only be completed by a staff member who has signed the confidentiality agreement.
Note	This form is an interview guide. Staff must be properly trained in interviewing survivors.

INCIDENT TYPE:
Case number:	Camp/Address (for urban and returnee caseload):	Date and time of interview:
Previous incident numbers for this client (if any)

Victim/Survivor Information
Name:	Age:	Yr. of birth:		Sex:
Address:	Tribe/Ethnic background:		Marital status:	Occupation:
No. of children:	Ages:		Head of family (self-OR name, relationship to survivor):
UNHCR "vulnerable" designation (if any):			UNHCR Ration card No. or ID card No.:
If victim/ survivor is a child:
Name of caregiver:			relation:

The incident
Location	Date	Time of day:

Description of incident (summarize circumstances, what exactly occurred, what happened afterward):

Perpetrator information
Name:	No of perpetrators	Sex:
Address:	Nationality:	Age:	Tribe/Ethnic background:
Relationship to Victim/ Survivor:	Marital Status:		Occupation:
If perpetrator unknown, describe him/her, including any identifying marks:
Current location of perpetrator, if known: Is the perpetrator a continuing threat?
If perpetrator is a child:
Name of caregiver:		Relation:

Witness

Describe presence of any witness (including children):

Names and addresses:

Action taken - any action already taken as of the date this form is completed
Reported to	Date reported	Action taken
MOHA Name:
UNHCR Name:
Local Leaders Name:
Health care See page 3 of this form for name/ information Name:
Police Name:
Other Name/Details:

Name:

More Action Needed and Planned Action as of the date this form is completed
Physical security needs assessment and immediate safety plan:
Has the victim/survivor received any kind of counseling-if yes, which kind?	Yes	No
Is victim/survivor going to report the incident to the police?	Yes	No
Is she/he seeking action by elders' tribunal/traditional court?	Yes	No
What follow up will be done by community development/SGBV workers?
What further action is needed by others?
Any other comments:

Form Completed by (print name)

Signature Date:

To the staff member or volunteer completing this form: Read the entire form to the client, explaining that she/he can choose any (or none) of the items listed. Obtain signature or thumb print with witness signature.

Give my permission for the following organizations to share information about the incident I have reported in this form, and about my current needs. I understand this permission is needed so that I can receive the best possible care and assistance. I understand that the Information will be treated with confidentiality and respect, and shared only as needed to provide the assistance I need and request.