EmailMeForm
Incident report
Case number / PIR
Organization
*
PERSONAL DATA OF THE BENEFICIARY
Name
Surname
Sex
*
Please select
Female
Male
Nationality
*
Date of birth
*
MM
/
DD
/
YYYY
INFORMATION ABOUT THE CASE
Beneficiary
*
Men
Women
Children
Family
Person with disability
Pregnant woman
Elderly person
Other
Date of contact with the beneficiary/ies
*
MM
/
DD
/
YYYY
Type of incident
Legal assistance
Psychosocial support
Medical referral
Gender based violence
Police brutality
Domestic violence
Hate cimes
Hate speech
Discrimination
Physical violence
Other
Narrative description of case
Type of assistance provided
*
Legal assistance
Psycho-social support
Medical referral
Translation
Other
Brief description of provided assistance
Was your assistance helpful?
Status of case
*
Please select
Open
Closed
Further assistance required
Please select
Yes
No
Type of assistance needed
*
Legal assistance
Psychosocial support
Medical referral
Gender based violence
Referral to other organization
Referred to NHI
Other
PIR
Enter case code if it is action related to some of the previous incident reports referred to you.
Referred to organization
Select only if you want to send the case to an organization within the network for further assistance/consultation.
Institutional repsonse
Whether the case was reported and to whom (police, medical staff, social workers) and how was it processed, which is most crucial for us when it comes to the violation of human rights.
Assistance received
Date
Result
Comment
Action 1
Action 2
Action 3
Action 4
