Institution Name (Jina la Taasisi) *Gender (Jinsia) *Male (Kiume)Female (kike)Phone Number (Namba ya Simu)Would you like to be contacted (Je, unaruhusu tuwasiliane na wewe?) *Yes(Ndio)No(Hapana)Street Address (Anwani ya Mtaa)City (Mkoa)Type of Abuse (Aina ya Nyanyaso) *Physical touch without consentRape He/She asked for sex bribeOthersDate of the incident (Tarehe ya Tukio) *Day *Month *Year *Environment where the incident happened (Ni mahali gani tukio lilitokea)Home (Nyumbani)School/Uni/College (Shule/Chuo)Public Spaces (Mahali pa wazi)OthersWhat is your relationship with the person you have reported? (Je, una uhusiano na mtu uliyemripoti?) *Share details about the Incident (Elezea Tukio) *Upload evidence if any (Weka Ushahidi wa picha au video kama unao)Choose FileNo file chosenDelete uploaded fileWhat help/support would you need from us (Utahitaji msaada gani kutoka kwetu) *Want to talk to an expert(Unahitaji kuongea na mtaalamu)Tools to help you cope and healLegal advise or assistanceOthersSubmit Report
