WRAPA Nigeria

1
Date Reported
Date
Day
Month
Year
2
Full Name of Complainant* This field is required.
First Name
Last Name
3
Name* This field is required.
First Name
Last Name
4
Contact Address of Complainant* This field is required.
5
Email Address
example@example.com
6
Date of Birth* This field is required.
Date
Day
Month
Year
7
Age* This field is required.
8
Phone Number* This field is required.
Please enter a valid phone number.
9
Gender* This field is required.
Female
Male
10
Complainant’s Occupation* This field is required.
11
Marital Status* This field is required.
Please Select
Please Select
Single
Married
Separated
Widow
Cohabiting
12
Date of Marriage
Date
Day
Month
Year
13
Home State* This field is required.
Please Select
Please Select
Abia
Adamawa
Akwa Ibom
Anambra
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Ebonyi
Edo
Ekiti
Enugu
FCT
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nasarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
14
Level of Education* This field is required.
Please Select
Please Select
None
Primary
Secondary
Tertiary
15
Religion* This field is required.
Please Select
Please Select
Atheist
Budhism
Christianity
Hinduism
Islam
16
Date of Incident* This field is required.Type NA if You are Not Sure
17
Date of Incident* This field is required.
Date
Day
Month
Year
18
Location Where Incident Occurred* This field is required.Type NA if You are Not Sure
19
Nature of Complaint* This field is required.You Can Make Multiple Choices
Emotional Abuse
Physical Abuse
Verbal Abuse
Sexual Abuse
Harassment at Work
20
Describe the Incident* This field is required.Give a Detailed Account of the Incident(s)
21
Do you Consent for your story to be shared to encourage women to speak out?* This field is required.
Please Select
Please Select
No
Yes
22
List Dependents including Name, Age and Relationship
23
Person(s)/Authority Complained Against* This field is required.
Please Select
Please Select
Spouse
Employer
24
Others (Specify)
25
Name of person /Entity complained against* This field is required.
26
Address of person/Entity complained against:* This field is required.
27
Phone Number of Person Complained Against
Please enter a valid phone number.
28
Age of person complained against
29
Sex of Person Complained Against* This field is required.
Please Select
Please Select
Female
Male
30
Relief Sought* This field is required.
31
Upload Signature Image* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
32
Summary / Comments
Huge
Large
Normal
Small
Ok
Ok
33
Recommendations
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: