GBV Media Report

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Victim Information

Full Name * This field is required

Gender *

Male

Female

Other

Age *

Phone Number

Media Organization/Workplace *

Position/Role in Media

Perpetrator Relationship to Victim *

Incident Information

Type of Violence *

Date of Incident *

Province *

District *

Sector *

Cell *

Specific Location/Venue *

Duration of the GBV

Detailed Description of Incident *

I would like this case forwarded to the police/RIB

I need support services (counseling, legal aid, etc.)

Were there witnesses to this incident?

Perpetrator Information

Name (if known)

Gender

Male

Female

Age Range

Position/Role

Organization/Affiliation

Additional Information

Any Additional Comments or Information

Evidence File (Optional)

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Accepted formats: JPG, PNG, PDF, MP4, MOV, AVI (Max 5MB)

Report Gender-Based Violence in Media

Reporter Information

Victim Information

Incident Information

Perpetrator Information

Additional Information

Evidence File (Optional)

Report Submitted Successfully!

Report Gender-Based Violence in Media

Reporter Information

Victim Information

Incident Information

Perpetrator Information

Additional Information

Evidence File (Optional)

Witness Information

Add New Witness

Report Submitted Successfully!