Report Of Incident Of Sexual Assault

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					                     Please Send This To Domestic Violence And Sexual Assault Tel:                                                                 Fax:
※Confidential
                     Prevention Center In        County (City)                Email:
Report Of Domestic Violence And Child Protection Incident (Non-Sexual Assault Incident)
Applicable Beginning January 1, 2006
Type Of Case: Marriage/Divorce/Cohabitation Violence Child/Teenager Protection                    Senior Abuse Others

         Organization Hospital Clinic Health Police Social Educational Judicial 113 Prevention Center Others

             Personnel      Medical Police Social Educational Child Care Judicial Others
Report        Name Of                                                                                            Handling Organization Needs To Reply To Reporting
 ed By Organization                                                                                              Organization?: Yes    No
         N a m e                                    Title                                                        T e l

         Received               Year     Month         Day     Hour        Minute               Reported              Year      Month        Day          Hour           Minute
                                                                                                    Year Month
         N a m e                                    S e x □Male□Female Bi rth Da t e                                     Id Number (Or Passport Number)
                                                                                                          Day
                     Non-Indigenous Taiwan National No Nationality Unknown
                     Indigenous Taiwan National (Bunon Paiwan Saisiyat Amis Rukai Atayal Puyuma Yami Tsou Thao Kavalan
         Nationality                              Truku Others                  )
                     China Hk/Macao Foreigner (Thailand □Indonesia Philippines Vietnam Kampuchea Mongolia
                     Others                       )
Person Level Of Education: Preschool Primary Junior High Senior High (Vocational) Junior College University Graduate School And Above Illiterate
 Being                             Self-Study Unknown
Protect Physically-, Mentally-Challenged (Disabled Vision-Impaired Hearing-Impaired Speech-Impaired Mentally-Retarded Mentally-Ill □Multiple
  ed     Disabilities Others          ) Non-Physically, Mentally-Challenged

(Victim Occupation: Student Services Industry Professional Agriculture, Forestry, Fishery, Animal Husbandry □Industrial, Mining □Business
   )                Public Servant, Teacher, Military, Police □Homemaker Retired Unemployed Others                           Unknown
         Permanent Address:              County (City)          Village (Town, City, District)             Cun (Li)   Lin       Road     Section      Lane       Alley      Number

         Floor

         Mailing Address:              County (City)          Village (Town, City, District)              Cun (Li)    Lin       Road     Section      Lane       Alley      Number

         Floor

         Tel:【Home】                                  【Office】                              【Mobile】

         Secure Contact Person:                               Tel:                         Relationship With Person Being Protected (Victim):

                                                              □ M a l e                             Year Month
         N a m e                                    S e x                      Bi rth Da t e                             Id Number (Or Passport Number)
                                                              □ F e m a l e                               Day
                         Non-Indigenous Taiwan National No Nationality Unknown
         National Indigenous Taiwan National (Bunon Paiwan Saisiyat Amis Rukai Atayal Puyuma Yami Tsou Thao Kavalan Truku
 The     i     t     y                                   Others                           )

 Other                   China Hk/Macao Foreigner (Thailand Indonesia Philippines Vietnam Kampuchea Mongolia Others                                                     )

 Party Permanent Address:

         Mailing Address:

         Tel:【Home】                                  【Office】                              【Mobile】

         Other Friends And Relatives That Can Be Contacted:                                      Tel:

         1.        Time:          Year           Month               Day            Hour
         2.        Place:       County (City)          Village (Town, City, District)          Cun (Li)    Lin        Road     Section    Lane       Alley   Number          Floor
         3.        Description Of Incident (Process Of Incident, Assistance Rendered, Result Of Brutalization, Etc.):


 Facts
       Domestic Violence Case (Marriage/Divorce/Cohabitation/Senior/Others)                          Child And Teenager Protection Case
1.      Relationship Between The Two Parties: Married (Living Together          1.   Identity Of The Other Party: Father Mother Foster Father □Foster
        Separated) Divorced Having Or Once Had One Of The Following                Mother Care Provider Institutional Personnel Boyfriend Of Mother
        Relationships: Husband And Wife Parent And Child □Family Member              Or Stepfather Girlfriend Of Father Or Stepmother Relative
        □Lineal Blood Relation □Lineal Relation By Marriage □Collateral Blood          Others
        Relation Within The Fourth Degree □Collateral Relation By Marriage Within 2.   Enrolment Status: Not Enrolled Preschool Enrolled Schooling
        The Fourth Degree (Description Of Relationship:            )                   Discontinued Schooling Suspended Not Seeking Further Education
        Others:(               )                                                      School Enrolled In:
2.      The Victim Needs Subsequent Assistance?: No Yes (Types Of Assistance 3.      Reporting According To: Children And Youth Welfare Act【Read Back Of
        Needed:                                                                        This Page. Please Check】
        Medical Exam And Treatment □Applying For Writ Of Protection                    (1) Article 26-1-2.
        Notifying The Police □Emergency Placement/Protection                           (2) Article 28-1.
        Financial Assistance □Legal Assistance □Psychotherapy And Counseling           (3) Article 30: Section          .
        Employment                                                                     (4) Article 36-1: Section          .
        Schooling □Household Registration □Others           )                          (5) Status After Sustaining Other Injuries:

3.      Willing To Be Looked For By Perpetrator? Yes No
     ═ Read Back of Page for Instructions On Filling Out The Form ═
     Instructions On Filling Out The Form:
1.     According to Articles 41 and 51 of Domestic Violence Prevention Act and Article 34 of Children and Youth Act, when
       performing their duties, all personnel shall immediately notify local authorities by any means when becoming aware of
       incidents of suspected domestic violence or incidents concerning children and youth protection. Meanwhile, they shall fill
       out this form and deliver it to local authorities within 24 hours. Those failing to do so shall be fined NT$6,000-30,000
       according to law.
2.     The reporting organization shall take the initiative to ensure that the handling organization has received the report with a copy
       of it kept at the reporting organization.
3.     When reporting, attention shall be paid to protect the victim’s privacy without revealing or making public their personal
       information.
4.     Reporting according to: Children And Youth Welfare Act
(1) Article 26-1-2:
       Use of narcotics, illegal use of controlled drugs or other substances harmful to physical, mental health
(2) Article 28-1:
       Being a waiter/waitress at a restaurant, coffee/tea shop acting as an intermediary of sexual transactions and places
         offering electronic gaming with excessive violence or adult content and sites involved in gambling, sex and violence.
(3) Article 30: No one can do any of the following to children and teenagers:
       Section 1: Abandoning them
       Section 2: Physically, mentally abusing them
       Section 3: Using them to engage in dangerous or deceptive activities harmful to their health
       Section 4: Showing physically-, mentally-challenged or deformed children to the public for money
       Section 5: Using them to beg
       Section 6: Depriving them of or obstructing their opportunity to receive compulsory education
       Section 7: Forcing them to marry someone not of their choice
       Section 8: Duping, kidnapping, buying or selling, and pledging them or use them as a guarantee
       Section 9: Forcing, luring and housing them to engage in obscene activity or sexual intercourse or assisting them in doing so
         by acting as a pimp
       Section10: Supplying them weapons or other dangerous articles
       Section11: Using them to tape or copy obscene, pornographic or other publications, films, CD-ROMs, websites or other
                    articles harmful to their physical, mental developments
       Section12: Violating rules governing media classification and providing them with or broadcasting publications, films,
                    CD-ROMs, websites or other articles harmful to their physical, mental developments
       Section13: Leading or luring them into places harmful to their physical, mental health
       Section14: Using them to commit other crimes or engage in other illegitimate activities
(4) Article 36-1: Circumstances in which life, body or freedom is in obvious and immediate danger:
       Section 1: Not being properly raised or taken care of
       Section 2: Needing immediate medical attention but is not receiving any
       Section 3: Being abandoned, maltreated, sold, and forced or lured to engage in illegitimate activities or work
       Section 4: Being subjected to other types of oppression and cannot be effectively protected unless immediately placed