BLOTTER ENTRY NUMBER

TYPE OF INCIDENT

DATE and TIME REPORTED

VAWC
BCPC
TRAFFICKING
OTHERS: (specify)
______________________

REPUBLIC OF THE PHILIPPINES

QUEZON CITY
BARANGAY ____________________________, DISTRICT __

BARANGAY INCIDENT RECORD FORM

DATE AND TIME OF INCIDENT

A. IMPORMASYON NG NAGREREKLAMO

CONTACT NUMBER

ID PRESENTED

(REPORTING PERSON DATA)

LAST NAME (APELYIDO)

MIDDLE NAME (GITNANG PANGALAN)

EXTENSION (Jr., Sr., II, IV, etc.)

NICKNAME (PALAYAW)

AGE

PLACE OF BIRTH

EDUCATIONAL ATTAINMENT

OCCUPATION

CURRENT ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

OTHER ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

CITIZENSHIP

GENDER

GIVEN NAME (PANGALAN)

CIVIL STATUS

DATE OF BIRTH (MM/DD/YYYY)

LAGYAN NG TSEK KUNG MAY DALAWA

B. IMPORMASYON NG SUSPEK
(SUSPECT DATA)
LAST NAME (APELYIDO)

RELASYON SA BIKTIMA

EXTENSION (Jr., Sr., II, IV, etc.)

NICKNAME (PALAYAW)

PLACE OF BIRTH

EDUCATIONAL ATTAINMENT

OCCUPATION

CURRENT ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

OTHER ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

WORK ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

CITIZENSHIP

GENDER

GIVEN NAME (PANGALAN)

CONTACT NUMBER
O HIGIT PANG SUSPEK, GUMAMIT NG
KARAGDAGANG INCIDENT REPORT FORM
PARA SA BAWAT SUSPEK.
MIDDLE NAME (GITNANG PANGALAN)

CIVIL STATUS

DATE OF BIRTH (MM/DD/YYYY)

AGE

IF AFP/PNP PERSONNEL: RANK

UNIT ASSIGNMENT

GROUP AFFILIATION

WITH PREVIOUS CRIMINAL RECORD?

NO
YES, PLEASE SPECIFY:__________________________________

HEIGHT

COLOR OF EYES

DESCRIPTION OF EYES

COLOR OF HAIR

WEIGHT

FOR CHILDREN IN CONFLICT WITH LAW

DESCRIPTION OF HAIR

PANGALAN NG MAGULANG O GUARDIAN

STATUS OF PREVIOUS CASE

UNDER THE INFLUENCE?

NO
ALAK (LIQUOR)
DRUGS
OTHERS ________________________

ADDRESS

(SAGUTIN KUNG ANG SUSPEK AY MAY EDAD 18 PABABA)

DIVERSION MECHANISM

CONTACT NUMBER

OTHER DISTINGUISHING FEATURES (DESCRIBE IN DETAIL CLOTHES, VEHICLE, SUNGLASSES, WEAPON/S, SCARS, AND OTHER DATA OR ACTIVITY OF THE SUSPECT/S WHICH WERE OBSERVED BY THE REPORTING PERSON AND/OR
WITNESS/ES TO IDENTIFY THE SUSPECT/S. THESE ARE IMPORTANT AND MAY BECOME EVIDENCE TO IDENTIFY, AND LINK TO THE CRIME, THE SUSPECT/S. USE ADDITIONAL SHEET/S IF NECESSARY.

-------------------------- CUT HERE AND ISSUE THIS RECEIPT TO THE REPORTING PERSON (PUTULIN DITO AT IBIGAY SA NAGREREKLAMO) -------------------------BLOTTER ENTRY NUMBER

THIS CERTIFIES THAT

BARANGAY INCIDENT REPORT

TRANSACTION RECEIPT
NAME OF REPORTING PERSON

DATE AND TIME OF REPORT

ADDRESS OF REPORTING PERSON

TYPE OF INCIDENT

REPORTED AN INCIDENT
TO BE RECORDED IN THE
BARANGAY BLOTTER
WHICH INVOLVES

VAWC
BCPC
TRAFFICKING
OTHERS: (specify) ______________________
DATE AND TIME OF INCIDENT

PLACE OF INCIDENT

RECORDED BY

SIGNATURE OVER PRINTED NAME

DESIGNATION

 LAGYAN NG TSEK KUNG ANG NAGREREKLAMO (PART A) AY ANG BIKTIMA. SAGUTIN NA LAMANG ANG PART D
LAGYAN NG TSEK KUNG MAY DALAWA O HIGIT PANG BIKTIMA, GUMAMIT NG KARAGDAGANG INCIDENT REPORT FORM PARA SA BAWAT

C. IMPORMASYON NG BIKTIMA
(VICTIM DATA)

BIKTIMA.

LAST NAME (APELYIDO)

MIDDLE NAME (GITNANG PANGALAN)

EXTENSION (Jr., Sr., II, IV, etc.)

NICKNAME (PALAYAW)

AGE

PLACE OF BIRTH

EDUCATIONAL ATTAINMENT

OCCUPATION

CURRENT ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

OTHER ADDRESS (HOUSE NUMBER, STREET, VILLAGE/SITIO)

BARANGAY

TOWN/CITY

PROVINCE

CITIZENSHIP

GENDER

GIVEN NAME (PANGALAN)

CIVIL STATUS

DATE OF BIRTH (MM/DD/YYYY)

BLOTTER ENTRY NUMBER

D. IMPORMASYON SA PANGYAYARI

TYPE OF INCIDENT

VAWC BCPC TRAFFICKING

OTHERS: (specify) __________________

(NARRATIVE OF INCIDENT)
DATE OF INCIDENT

TIME OF INCIDENT

PLACE OF INCIDENT

ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ASWERING THE WHO, WHAT, WHEN, WHERE, WHY AND HOW OF REPORTING. USE ADDITIONAL SHEET IF NECESSARY.

DETAILS OF THIS NARRATIVE SHALL BE THE BASIS IN THE ENTRY OF REOCRD IN THE BARANGAY BLOTTER

AUTHENTICATION:
I HEREBY CERTIFY TO THE CORRECTNESS OF THE
FOREGOING TO THE BEST OF MY KNOWLEDGE AND BELIEF.

SIGNATURE OVER PRINTED NAME OF

REPORTING PERSON (NAGREREKLAMO)

SIGNATURE OVER PRINTED NAME OF RECORDER

DESIGNATION: ____________________________

CASE DISPOSITION / RECOMMENDED ACTION

RECOMMENDED ACTION/S:
Issued BPO
Referred for Medical
Referred to SSDD
Referred to PNP Station _______________
Referred to COURT
Other Services (Ex. Counselling, to Protection Center)

OTHER RECOMMENDED ACTION/S:

RECOMMENDED BY:

APPROVED BY:

SIGNATURE OVER PRINTED NAME OF RECORDER

SIGNATURE OVER PRINTED NAME OF

PUNONG BARANGAY

DESIGNATION: ____________________________

-------------------------- CUT HERE AND ISSUE THIS RECEIPT TO THE REPORTING PERSON (PUTULIN DITO AT IBIGAY SA NAGREREKLAMO) -------------------------KEEP THIS BARANGAYINCIDENT RECORD TRANSACTION RECEIPT. YOU CAN FOLLOW UP ON THE PROGRESS OF THE CASE YOU HAVE REPORTED UPON PRESENTATION OF THIS RECEIPT.

CASE DISPOSITION / RECOMMENDED ACTION

RECOMMENDED ACTION/S:
Issued BPO
Referred for Medical
Referred to SSDD
Referred to PNP Station _______________
Referred to COURT
Other Services (Ex. Counselling, to Protection Center)

OTHER RECOMMENDED ACTION/S:

RECOMMENDED BY:
SIGNATURE OVER PRINTED NAME OF RECORDER
DESIGNATION: ____________________________

APPROVED BY:
SIGNATURE OVER PRINTED NAME OF
PUNONG BARANGAY