|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:|
|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?
|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