Intake and Consent Forms

Currently, most organizations collecting GBV information determine individually and independently what data they will be collecting from survivors and how to define that data.  Consequently, the format, content and quality of the resulting GBV data varies greatly from one organization to another.  This makes compiling data from different service providers and then effectively analyzing that data extremely difficult.

The Intake and Initial Assessment Form is an easy-to-use, customizable template to be used by individuals interviewing GBV survivors reporting an incident.  It is designed to collect a standard set of meaningful GBV indicators across all service providers while reducing variation in how data is collected.  The intake form is comprised of six sections, each section containing fields collecting relevant and important information:

• Administrative Information
• Survivor Information
• Details of the Incident
• Alleged Perpetrator Information
• Planned Action/Action Taken
• Assessment Point

The Consent for Release of Information Form is a form requiring survivors to give their authorization for any of their information to be shared with other agencies or organizations.  It is intended to ensure that the rights of the survivors to control their incident data are maintained and protected.

Download consent form [English - pdf | ms word] [Français] [Español] [عربية]

Download standard intake form [English] [Français] [Español] [عربية]

Download basic 2-page intake form [English] [Français] [عربية]

Download health practitioner intake form [English] [Français] [عربية]

Download acute emergencies intake form [English] [عربية]