Crisis Intervention Centres(CICs) Performa

Telephone No.- +91-11-2337 9181

Delhi Commission For Women
Government of National Capital Territory of Delhi
C-Block, 2nd Floor, Vikas Bhawan,
New Delhi-110 002

Report From Non-Governemental Organization

Crisis Intervention Centre for Rape

1. Victims 

  • Case File No.:
  • Date of Reporting:
  • FIR No. & Sections of IPC:
  • Police Station:
  • Referred by:
  • Name of the Investigation Officer:
  • Date of Visit:

2. Victim’s Details:

  • Name:
  • Daughter of:
  • Date of Birth & Age:
  • Religion:
  • Caste:
  • Communication Address:
  • Permanent Address:
  • Telephone No.:
  • Educational Status:
  • Means of Livelihood:

3. Family Background:

Name Relation with Victim Age Education Occupation Income
           

4. Location of the House:

  • Urban Locality/Urban Village/Slum:
  • Own/Rented/Any other:
  • Number of rooms in the house

5. Details of the Accused:

  • Name of the Accused:
  • Age:
  • Address:

6. Family Background:

Name Relation with Victim Age Education Occupation Income
           
  • Means of Livelihood:
  • Was he accused before:
  • If known :
  • Nature of the rape:
  • Place of Rape:
  • Any other detail:

7. Status of the Case:

  • Is the Accused Arrested:
  • Medical done:
  • Details of the evidence collected :

8. Observation of the CIC Team:

9. Need Assessment of the Victim:

  • Intervention required in the area of :
  • Health :
  • Education :
  • Legal :
  • Vocational Training :
  • Support Services i.e. Shelter/Marriage/Financial Assistance) :
  • Counseling Services, CICs Team, -(Individual/Family):

Date:                                                           Signature:
 

10. Follow up by Delhi Commission for Women:

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