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:


Work address:
Phone number(s):


Email address(es):
Online account(s), including screen name & type of online account (Facebook, etc.):



Other information about the perpetrator (that might be relevant):



Description of the Violence


Describe the event:



Type of technology involved:




Were there any witnesses? What are their names?



If you were able to document the violence, what type of documentation do you have?



Other Information
Did you report it to the police? If so, what is the report number and officer name?


Did you go to the hospital/see a doctor? If so, what was the hospital/doctor name?



©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