A PHP Error was encountered

Severity: Notice

Message: Undefined variable: ub

Filename: libraries/Guest_onlines.php

Line Number: 126

A PHP Error was encountered

Severity: Notice

Message: Undefined variable: ub

Filename: libraries/Guest_onlines.php

Line Number: 138

Form Pengisian Kasus

Form Pengisian Kasus

Selasa, 29 November 2016 12:10:06 ppkskab

 

PEMERINTAH ACEH

PUSAT PELAYANAN TERPADU PEMBERDAYAAN PEREMPUAN DAN ANAK

        Jalan Gajahmada Kompleks Kantor Bupati Aceh Barat

email : kppks.acehbaratkab@gmail.com

 

No Dokumen

 

Tgl Terbit

 

No Revisi

 

Halaman

 

           

 

PENERIMAAAN PENGADUAN

No. Register    :  ............................................................

Hari/Tanggal  :  ............................................................

Konselor          :  ............................................................

Media             :  (  ) Tatap Muka          (  ) Surat         (  ) Telepon

 

  1. I.          FORM IDENTITAS MITRA/KORBAN
    1. Nama                                                :  ....................................................................................
    2. NIK                                        :  ....................................................................................
    3. Tempat/Tanggal Lahir          :  ....................................................................................
    4. No. Handphone                     :  ....................................................................................
    5. Alamat                                  :  ....................................................................................

                                                     Kecamatan      :  ............................................................

                                                     Kab/Kota         :  ............................................................

  1. Pendidikan                            :  (     )  Tidak Sekolah             (     ) SLTA/Sederajat

                                                        (     )  SD                               (     ) D1/D2/D3

                                                        (     )  SLTP/Sederajat                       (     ) S1/S2

                                                        Lainnya ........

  1. Agama                                  :  (     ) Islam                            (     ) Kristen

                                                        (     ) Katolik                          (     ) Hindu

                                                        (     ) Budha                          (     ) Konghucu

                                                        Lainnya ........

  1. Pekerjaan                              :  (     ) Guru                             (     ) Swasta

                                                        (     ) Buruh                           (     ) TNI/Polri

                                                        (     ) Karyawan                     (     ) Pelajar/Mahasiswa

                                                        (     ) Pedagang                     (     ) Tani

                                                        (     ) Wiraswasta                  (     ) Ibu Rumah Tangga

                                                        (     ) PNS

NOT:MOHON DILAMPIRKAN KTP/KK KORBAN/PELAKU

  1. Penghasilan/bln                    :  Rp ....................... Pengeluaran : Rp ........................
  2. Status                                    : (     ) Belum Kawin                (     ) Kawin Tahun ..........

                                                            : (     ) Siri Tahun .........                       (     ) Cerai Tahun ...........

  1. Jumlah Anak                         : ..............................................................................
  2. Ama Ortu/Wali                     : ..............................................................................
  3. Alamat                                  : ..............................................................................

                                                            : Kecamatan                : ..........................................

                                                            : Kab/Kota                   : ..........................................

  1. Pekerjaan                              :

                                                              Bapak                                    : ..........................................

                                                              Ibu                             : ..........................................

  1. Jumlah Saudara                    : ................................  Anak Nomor ......................
  2. Hubungan dengan Pelaku     : ..............................................................................
  3. Rujukan Dari                         : ..............................................................................

 

  1. II.        FORM INFORMASI KASUS
    1. Jenis Kasus / Kekerasan :

(     ) KDRT                                                     (     ) Pelecehan Seksual

(     ) KDP                                                       (     ) Buruh Migrant/TKW

(     ) Perkosaan                                             (     ) Trafficking

(     ) Lainnya ...............

 

  1. Bentuk Kekerasan

 

FISIK

SEKSUAL

PSIKOLOGI

EKONOMI / PENELANTARAN

Bentuk Kekerasan

 

 

 

 

Intensitas Kekerasan (jumlah dan kurun waktu)

 

 

 

 

 

 

 

 

  1. Dampak / Akibat Kekerasan

FISIK

SEKSUAL

PSIKOLOGI

EKONOMI / PENELANTARAN

 

 

 

 

 

 

 

 

 

  1. Tempat dan Waktu Kejadian Kekerasan

NO

BENTUK KEKERASAN

WAKTU

TEMPAT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Saksi dan Alat Bukti :
    1. (     ) Tidak Ada
    2. (     ) Ada

NO

BENTUK KEKERASAN

ALAT BUKTI

SAKSI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Keinginan dan Harapan Korban/Mitra

KEINGINAN

HARAPAN

 

 

 

 

  1. Layanan yang diinginkan korban/Mitra

(     ) Konseling                      (     )  Shelter

(     ) Konsultasi                     (     )  Mediasi

(     ) Bantuan Hukum           (     )  Psikologi/Psikiater

(     ) Medis                           (     )  Support Gr

(     ) Lainnya .........

  1. Alasan Korban/Mitra Melapor : ...................................................................................
  2. Informasi di Peroleh dari : ...........................................................................................
  3. Kedatangan Korban/Mitra ke Kantor :

(   ) Sendiri

(   ) Diantar/Bersama orang lain

No

NAMA

RELASI DENGAN KORBAN

ALAMAT

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Kronologi Singkat :

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

......................................................................................................................................

  1. Khusus Kasus Trafficking
    1. Rute Trafficking :

..............................................................................................................................................................................................................................................................

  1. Alat Transportasi

(     )  Darat        : ..............................................................

(     )  Laut          : ..............................................................

(     )  Udara       : ..............................................................

  1. Cara yang digunakan :

NO

CARA

TAHAP PROSES

 

 

 

 

 

 

 

 

 

 

  1. Bentuk Eksploitasi yang Dialami Korban di Negara/daerah Tujuan :

..........................................................................................................................................................................................

  1. Bentuk Pelanggaran :

..........................................................................................................................................................................................

  1. Bentuk Kriminalisasi (Bila Ada) :

..........................................................................................................................................................................................

 

 

 

 

 

 

 

 

 

  1. III.      FORM IDENTITAS PELAKU
  2. Nama                                      : .......................................................................................
  3. Tempat/Tanggal Lahir            : .......................................................................................
  4. Alamat                                    : .......................................................................................

                                                                          Kecamatan                : ...................................................

                                                                          Kab/Kota                   : ...................................................

 

 

  1. Pendidikan                              : (     ) Tidak Sekolah      (     ) SLTA/Sederajat

                                                            : (     ) SD                        (     ) D1/D2/D3

                                                            : (     ) SLTP/Sederajat    (     ) S1/S2

                                                            : Lainnya ..........

  1. Agama                         : (     ) Islam                    (     ) Kristen

                                                            : (     ) Katolik                  (     ) Hindu

                                                            : (     ) Budha                  (     ) Konghucu

                                                            : (     ) Lainnya

  1. Pekerjaan                                : (     ) Guru                     (     ) Swasta

                                                            : (     ) Buruh                   (     ) TNI/Polri

                                                            : (     ) Karyawan             (     ) Pelajar/Mahasiswa

                                                            : (     ) Pedagang             (     ) Tani

                                                            : (     ) Wiraswasta          (     ) Ibu Rumah Tangga

                                                            : (     ) PNS

  1. Penghasilan                             : Rp ............................ Pengeluaran Rp ...........................
  2. Status                          : (     ) Belum Kawin                (     ) Kawin Tahun ...........

                                                            : (     ) Siri Tahun ........                        (     ) Cerai Tahun .............

  1. Nama Ortu/Wali                     : .......................................................................................

10.Alamat                                    : .......................................................................................

                                                              Kecamatan                : ............................................

                                                              Kab/Kota                   : ............................................

11.Pekerjaan                                :

                                                              Bapak                                    : ...........................................

                                                              Ibu                             : ...........................................

12.Jumlah Saudara                      : ....................... Anak Nomor ..........................

13.Hubungan dengan Pelaku       : .......................................................................................

14.Ciri-ciri Khusus Pelaku            : a.  ..................................................................................

                                                            : b.  ..................................................................................

                                                            : c.  ..................................................................................

  1. NIK                                           :

 

 

 

                                                                                                     Meulaboh,

 

             Pendamping                                                                                                 Mitra

 

 

       (                                )                                                                           (                                       )