Women Safety Wing

Reporter Information

Identity Preference

Provide DetailsAnonymous

(You can stay anonymous, but we require contact details to verify the complaint.)

Full Name *

Email Address *

Phone Number *

Relationship to Victim

Address

Victim Information

Victim's Name *

Age *

Gender Identity

Contact Info

Current Location *

Occupation

Marital Status

Incident Details

Type of Issue *

Severity Level

Date of Incident *

Location Type

Exact Location *

Detailed Description *

This is an ongoing issueVictim is in immediate dangerWeapon involvedChildren were present

Frequency

Perpetrator Details

Name of Perpetrator

Relationship to Victim

Approximate Age

Physical Description

Address/Location

Contact Info

Has regular access to victimKnown to carry weaponsSubstance abuse issuesHistory of violence

Witnesses

There were witnesses

Evidence

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Description of Evidence

Impact Assessment

Physical Impact

Psychological Impact

Social Impact

Professional Impact

Financial Impact

Specific Consequences:

Required Medical TreatmentCounseling NeededChanged Routine/BehaviorFears Retaliation

Previous Actions

This abuse has been reported before

Response Received

Support Needed

Immediate Needs

Safety Plan

Additional Information

Legal Warning: False reporting is a serious offense. Information may be shared with authorities for safety.

I declare that the information provided is true and accurate. *I consent to BRAC processing this information for women safety. *I understand this information may be shared with authorities for protection. *

Secure & Confidential Submission

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