| Information About the Perpetrator | |
| Name of the person abusing or stalking you: | |
| Relationship of that person to you (if relevant): | |
| Contact information of that person: | |
| Home address:
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Work address: |
| Phone number(s):
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Email address(es): |
| Online account(s), including screen name & type of online account (Facebook, etc.):
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| Other information about the perpetrator (that might be relevant):
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| Description of the Violence | |
| Date:
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Time: |
| Describe the event:
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| Type of technology involved:
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| Were there any witnesses? What are their names?
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| Documentation | |
| If you were able to document the violence, what type of documentation do you have?
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| Other Information | |
| Did you report it to the police? If so, what is the report number and officer name?
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| Did you go to the hospital/see a doctor? If so, what was the hospital/doctor name?
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©2019 BC Society of Transition Houses, Technology Safety Project.
Adapted from and in cooperation with the Safety Net Technology Project at the National Network to End Domestic Violence, United States