Blank Form (#3)VIOLATIONS REPORT FORMPRIVILEGED & CONFIDENTIALDate of incident (dd/mm/yyyy):State of incident- Select -AbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraAbuja (Federal Capital Territory)Who is filling this form? Survivor?- Select -SurvivorThird partyL.G.A. of incident:- Select -Aba NorthAba SouthArochukwuBendeIkwuanoIsiala Ngwa NorthIsiala Ngwa SouthIsuikwuatoObi NgwaOhafiaOsisioma NgwaUgwunagboUkwa EastUkwa WestUmuahia NorthUmuahia SouthUmu NneochiDemsaFufureGanyeGuyukGireiGombiHongJadaLamurdeMadagaliMaihaMayo BelwaMichikaMubi NorthMubi SouthNumanShellengSongToungoYola NorthYola SouthAbakEastern OboloEketEsit EketEssien UdimEtim EkpoEtinanIbenoIbesikpo AsutanIbiono-IbomIkaIkonoIkot Abasi (village)Ikot EkpeneIniItuMboMkpat-EninNsit-AtaiNsit-IbomNsit-UbiumObot AkaraOkobo, NigeriaOnnaOronOruk AnamUdung-UkoUkanafunUruanUrue-Offong/OrukoUyoAguataAnambra EastAnambra WestAnaochaAwka NorthAwka SouthAyamelumDunukofiaEkwusigoIdemili NorthIdemili SouthIhialaNjikokaNnewi NorthNnewi SouthOgbaruOnitsha NorthOnitsha SouthOrumba NorthOrumba SouthOyiAlkaleriBauchiBogoroDambanDarazoDassGamawaGanjuwaGiadeItas/GadauJama'areKatagumKirfiMisauNingiShiraTafawa BalewaToroWarjiZakiBrassEkeremorKolokuma/OpokumaNembeOgbiaSagbamaSouthern IjawYenagoaAdoAgatuApaBurukuGbokoGumaGwer EastGwer WestKatsina-AlaKonshishaKwandeLogoMakurdiObiOgbadiboOhiminiOjuOkpokwuOturkpoTarkaUkumUshongoVandeikyaAbadamAskira/UbaBamaBayoBiuChibokDamboaDikwaGubioGuzamalaGwozaHawulJereKagaKala/BalgeKondugaKukawaKwaya KusarMafaMagumeriMaiduguriMarteMobbarMongunoNgalaNganzaiShaniAbiAkamkpaAkpabuyoBakassiBekwarraBiaseBokiCalabar MunicipalCalabar SouthEtungIkomObanlikuObubraObuduOdukpaniOgojaYakurrYalaAniocha NorthAniocha SouthBomadiBurutuEthiope EastEthiope WestIka North EastIka SouthIsoko NorthIsoko SouthNdokwa EastNdokwa WestOkpeOshimili NorthOshimili SouthPataniSapeleUduUghelli NorthUghelli SouthUkwuaniUvwieWarri NorthWarri SouthWarri South WestAbakalikiAfikpoEddaEbonyiEzza NorthEzza SouthIkwoIshieluIvoIzziOhaozaraOhaukwuOnichaAkoko-EdoEgorEsan CentralEsan North-EastEsan South-EastEsan WestEtsako CentralEtsako EastEtsako WestIguebenIkpoba OkhaOrhionmwonOredoOvia North-EastOvia South-WestOwan EastOwan WestUhunmwondeAdo EkitiEfonEkiti EastEkiti South-WestEkiti WestEmureGbonyinIdo OsiIjeroIkereIkoleIlejemejeIrepodun/IfelodunIse/OrunMobaOyeAninriAwguEnugu EastEnugu NorthEnugu SouthEzeaguIgbo EtitiIgbo Eze NorthIgbo Eze SouthIsi UzoNkanu EastNkanu WestNsukkaOji RiverUdenuUdiUzo-UwaniAkkoBalangaBilliriDukkuFunakayeGombeKaltungoKwamiNafadaShongomYamaltu/DebaAboh MbaiseAhiazu MbaiseEhime MbanoEzinihitteIdeato NorthIdeato SouthIhitte/UbomaIkeduruIsiala MbanoIsuMbaitoliNgor OkpalaNjabaNkwerreNwangeleObowoOgutaOhaji/EgbemaOkigweOrluOrsuOru EastOru WestOwerri MunicipalOwerri NorthOwerri WestOnuimoAuyoBaburaBirniwaBirnin KuduBujiDutseGagarawaGarkiGumelGuriGwaramGwiwaHadejiaJahunKafin HausaKaugamaKazaureKiri KasamaKiyawaMaigatariMalam MadoriMigaRingimRoniSule TankarkarTauraYankwashiBirnin GwariChikunGiwaIgabiIkaraJabaJema'aKachiaKaduna NorthKaduna SouthKagarkoKajuruKauraKauruKubauKudanLereMakarfiSabon GariSangaSobaZangon KatafZariaAjingiAlbasuBagwaiBebejiBichiBunkureDalaDambattaDawakin KuduDawakin TofaDoguwaFaggeGabasawaGarkoGarun MallamGayaGezawaGwaleGwarzoKaboKano MunicipalKarayeKibiyaKiruKumbotsoGhariKuraMadobiMakodaMinjibirNasarawaRanoRimin GadoRogoShanonoSumailaTakaiTarauniTofaTsanyawaTudun WadaUngogoWarawaWudilBakoriBatagarawaBatsariBaureBindawaCharanchiDandumeDanjaDan MusaDauraDutsiDutsin MaFaskariFuntuaIngawaJibiaKafurKaitaKankaraKankiaKatsinaKurfiKusadaMai'AduaMalumfashiManiMashiMatazuMusawaRimiSabuwaSafanaSandamuZangoAleiroArewa-DandiArgunguAugieBagudoBirnin KebbiBunzaDandiFakaiGwanduJegaKalgoKoko/BesseMaiyamaNgaskiSakabaShangaSuruWasagu/DankoYauriZuruAdaviAjaokutaAnkpaBassaDekinaIbajiIdahIgalamela-OdoluKabba/BunuMopa-MuroIjumuYagba WestYagba EastOfuOkeneOkehiLokojaOgori/MagongoOlamaboroOmalaKogiEkitiIfelodunIlorin EastIlorin WestIrepodunIsinKaiamaMoroOffaOke EroOyunPategiBarutenAsaEduIlorin SouthAgegeAjeromi-IfelodunAlimoshoAmuwo-OdofinApapaBadagryEpeEti OsaIbeju-LekkiIfako-IjaiyeIkejaIkoroduKosofeLagos IslandLagos MainlandMushinOjoOshodi-IsoloShomoluSurulereAkwangaAweDomaKaruLafiakeanaObiKokonaKeffiNasarawaNasarawa EggonWambaTotoAgaieAgwaraBidaBorguBossoChanchagaEdatiGbakoGuraraKatchaKontagoraLapaiLavunMagamaMarigaMasheguMokwaMunyaPaikoroRafiRijauShiroroSulejaTafaWushishiAbeokuta NorthAbeokuta SouthAdo-Odo/OtaEwekoroIfoIjebu NorthIjebu North EastIjebu OdeIjebu EastIlishan-RemoIkenneImeko AfonIpokiaObafemi OwodeOdedaOdogboluOgun WatersideRemo NorthShagamuYewa NorthYewa SouthIsaraAkoko North-EastAkoko North-WestAkoko South-EastAkoko South-WestAkure NorthAkure SouthEse OdoIfedoreIdanreIlajeIle-Oluji/OkeigboIreleOdigboOkitipupaOndo WestOndo EastOseOwoAiyedaadeAiyedireAtakunmosa EastAtakunmosa WestBoluwaduroBoripeEde NorthEde SouthEgbedoreEjigboIfe CentralIfe EastIfe NorthIfe SouthIfedayoIfelodunIsokanObokunIrewoleOla-OluwaOlorundaIlesa WestIlesa EastOdo-OtinIlaOriadeOroluIrepodunIwoOsogboAfijioAkinyeleIbadan NorthIbadan North-EastIbadan North-WestIbadan South-EastIbadan South-WestIbarapa CentralIbarapa EastIbarapa NorthIdoIrepoIwajowaIseyinItesiwajuOgbomosho NorthOgbomosho SouthOgo OluwaOlorunsogoOluyoleOna AraOrelopeOrireAtisboSaki WestSaki EastEgbedaLageluAtibaOyo EastOyo WestBarkin LadiBassaBokkosJos EastJos NorthJos SouthKanamKankeLangtang NorthLangtang SouthManguMikangPankshinQua'an-PanRiyomShendamWaseAbua-OdualAhoada EastAhoada WestAkuku ToruAndoniAsari ToruBonnyDegemaElemeEmohuaEtcheGokanaIkwerreKhanaObio-AkporOgba-Egbema-NdoniOgu-BoloOkirikaOmumaOpobo-NkoroOyigboPort HarcourtTaiBinjiBodingaDange ShuniGadaSokoto SouthSokoto NorthGwadabawaWamakkoTangazaBodingaSabon BIsahRabahSilameWurnoGoronyoIllelaGuduTuretaTambuwalKwareArdo KolaBaliDongaGashakaGassolIbiJalingoKarim LamidoKurmiLauSardaunaTakumUssaWukariYorroZingBadeBursariDamaturuFikaFuneGeidamGujbaGulaniJakuskoKarasuwaMachinaNangereNguruPotiskumTarmuwaYunusariYusufariAnkaBakukaBirnin Magaji/KiyawBukkuyumBunguduTsafeGummiGusauKaura-NamodaMaradunMaruShinkafiTalata-MafaraZurmiAbajiAbuja Municipal Area CouncilKwaliKujeBwariGwagwaladaSURVIVOR’S DETAILS:First NameLast NameAddressCityPhone NumberEmailNationalitySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweAgeOccupationSexual Orientation- Select -HeterosexualGayLesbianBisexualAsexualPansexualQueerOthers (specify)Gender Identity- Select -Trans-WomanTrans-ManCis-WomanCis-ManNon-BinaryOthers (specify)VIOLATION DETAILS:Nature of Violation- Select -Lawful ArrestAssaultForceful evictionKitoSexual harassmentUnlawful arrestTheftWrongful dismissalRapeBlackmailUnlawful detentionInvasion of privacyDiscriminationExtortionKidnappingCyberbullyingOthers (specify)Address where the violation occurredDescription of violationIs the incident still ongoing or already in the past?- Select -OngoingAlready in the pastHave you reported this violation to any other organization - Select -YesNoWould you like to take legal action or use this as a way to advocate for the rights of women, people living with HIV and/or LGBTQI+ individuals?- Select -Yes I want to legal actionNo, I want to use this as a way to advocate for the rights of women, people living with HIV and/or LGBTQI+ individuals Ubi jus, ibi remedium Where there is a right, there is a remedy. 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