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Complaint Form
If you have difficulty filling out this form, please get in touch with the following number:
+62 811-969-224
What incident would you like to report?
*
Your Name
Are you filing a report as a victim, witness, or support person?
*
Victim
Witness
Support person
Contact number we can reach you at
*
Date of Incident
*
Briefly describe the incident
*
Are you comfortable with this information being made public? The victim's name will remain anonymous.
*
`
Select...
`;
Ya
Tidak
Are you interested in pursuing further action on this case? If so, we will pass this report along to the appropriate list of relevant victim advocates.
*
`
Select...
`;
Yes
No
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