PEACE CORPS/UKRAINE

REPORT OF CRIME OR INCIDENT

Person Reporting the Crime:

Contact Phone Number/Address

Victim's Full Name:

Address in Ukraine:

Crime Category:
Robbery Assault Harassment Sex offense
Theft Vandalism Burglary Loss _________
Other ______ (If other, specify) __________________________________________________

Date/time of the Crime:

Location of Crime:

Description of the Crime:

PCV’s perception: annoyed □ uncomfortable □ scared □ intimidated_□

Description of Stolen Items:

Description of Injuries:

Witnesses to the Crime 1. __________________________________________________________________

(Addresses & Phones): 2.
3.

Offender(s) : 1.___________________________________________________________________
2.
Weapon(s) use: yes □ no □ (if yes, specify)

Reported to Militia/Authorities: yes □ no □ Date: ________ Time: __________________

Place ______________________________ Police Reg.# _______________ Tel # ________________
PCV’s intention to prosecute: yes □ no □ undecided □

Volunteer’s/Trainee’s Signature: Date:

Follow Up:
Staff Signature: Date: