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)Address (Anwani ya Mtaa na Wilaya))City (Mkoa)Date of the incident (Tarehe ya Tukio)DayMonthYearEnvironment 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) *What help/support would you need from us (Utahitaji msaada gani kutoka kwetu) *Want to talk to an expert(Unahitaji kuongea na mtaalamu)Legal advise or assistance(Nahitaji-msaada-wa-kisheria)Tools & Resources - Self Therapy (Zana na Rasilimali - Tiba ya Kujitegemea)Others (Nyingineyo)Submit Report