Name of Complainant*:

Ethnic origin/Nationality*:

Address/Contact details*:

Identity or Passport #*:

Age*:

Gender*:

Name of Victim (if different from Complainant):

Ethnic origin/Nationality:

Address/Contact details:

Identity or Passport #:

Age:

Gender:

Name(s) and address of Parents, if under 18:

Father:

Mother:

Has the Victim given consent to the completion of this form?
YesNo

Date of Incident(s)*:

Time of Incident(s)*:

Location of Incident(s)*:

Describe any evidence of physical, emotional or mental trauma. (cuts, bruises, lacerations, behaviours, or moods):*:

Witnesses’ Names and Contact Information*:

Brief Description of Incident(s) (Attach extra pages if necessary)*:

Name of Accused person(s)*:

Job Title of Accused person(s)*:

Organization Accused person(s) Works For*:

Address of Accused person(s) (if known)*:

Age*:

Gender*:

Physical Description of Accused person(s)*:

Have the police been contacted by the victim?*
YesNo

If yes, what happened?

If no, does the victim want police assistance? If not, state reason.

Has the victim been informed about available medical treatment?
YesNo

If Yes, has the victim sought Medical Treatment for the incident?
YesNo

If Yes, who provided treatment? What is the diagnosis and prognosis?

What immediate security measures have been undertaken for victim?

Who is responsible for ensuring safety plan (Name, Title, and Organization):

Any other pertinent information provided in interview (including contact made with other Organizations, if any):

Details of referrals and advice given to victim regarding resources for health, psycho-social, or legal needs of victim made by person completing report:

Report completed by:
Name*:

Email*:

Position/Organization*:

Date/Time/Location*:

Has the Complainant and/or victim been informed about the Organization's procedures for dealing with complaints?
YesNo

Does the Victim consent for data to be shared with appropriate GAiN Leadership and other relevant officials of the Organization where the Accused person works:
YesNo

ALL INFORMATION MUST BE HELD SECURELY AND HANDLED STRICTLY IN LINE WITH APPLICABLE REPORTING AND INVESTIGATION PROCEDURES