Hospital

Gender Based Violence Register

_______ _________________ ______________ ___________ __________
Region Sub-city/Woreda Health Facility Name Begin Date End Date
 Instruction for Gender Based Violence (GBV) Register
Information filled at front page of register
Region Write region name where the facility is located
Zone/Sub city /Woreda Write Zone/Sub-City /Woreda name where the facility is located.
Facility Name Write the name of the health facility where the service was provided
Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)
Register end date Write the date of the last entry in the register, written as (EC) Day / Month /Year (DD/MM/YY)

Description of the patients’ information filled on main part of register

Col. No Datum Description
Enter sequentially number starting from 1 until the budget year end and start again from 1 at the first day of new
(1) S/No
budget year
(2) Date Write the date of the GBV survivor visited the health facility, written as (EC) Day / Month / Year (DD/MM/YY)
(3) MRN Write unique individual identifier Medical Record Number used on medical information folder, for HC and hospital.
(4) Survivor’s fill Name Write the full name (Given, middle and last) of the GBV survivor
Write age of patient (if it is under 1 month enter in days, if it is under 5 year, enter in month and enter in year if it is
(5) Age
above 5 year old)
(6) Sex Write sex of patient as M for Male and F for Female
(7) Woreda Write the name of the woreda where the survivor comes from
(8) Kebele Write the name of the kebele where the survivor comes from
(9) Telephone Write the telephone number (10 digit) of the survivor or close family
Write the marital status of the GBV survivor as the code given at the bottom of the page. Use code 1. for single, 2 for
(10) Marital status
married, 3 for divorced and 4 for widowed
Write the educational levels of the GBV survivor as the code given the bottom of the page. Use code 1. for Illiterate, 2
(11) Education level
for Elementary, 3 for secondary/high school and 4 for College/University
Identify the GBV survivor’s classification according to the key population category and write the code. Code 1 for CSW
(12) Key Population (Commercial sex Workers), 2 for prisoners, 3 for OVC (Orphan and Vulnerable children), 4 for IDP (Internally displaced
people), 5 for people with disability and 6 for others including the general population
Write the perpetrator based on the category stated at the bottom of the page. Accordingly write 1 if the perpetrator is a
(13) The perpetrator
family member, 2 if intimate partner and 3
Type of Violence (Sexual, Physical, Write the type of the violence as categorized at the bottom of the page. Use code 1 if the violence is sexual, 2 if it is
(14)
Psychological, Mixed) physical, 3 if psychological and 4 if mixed (a mix of any of the three).
(15) # of days after incident Write the number of day in number, example 8, since the incident
Write 1 if there is past history which happened by the same person, 2 if there is past history which happened by a
(16) Past GBV history
different person and 3 if there is no past history of GBV
Write yes if the survivor has any fresh tear, bruise or any other evidence of damage (Vaginal, anal etc) and write No if
(17) Fresh tear/ Bruise etc
there is none.
If the violence was rape, the write the type of rape as coded in the bottom of the page. Write 1 if it is attempted rape, 2
(18) Types of Rape code (If Rape)
if Acquaintance Rape, 3 if Forced Rape and 4 if other
Write ‘Positive’ if the pregnancy test is positive, ‘Negative’ if the test is negative and ‘Not done’ if pregnancy test is not
(19) Pregnancy Test
done.
(20) VDRL Write ‘Positive’ if the VDRL test is positive, ‘Negative’ if the test is negative and ‘Not done’ if VDRL test is not done.
(21) HIV Test Write ‘Positive’ if the HIV test is positive, ‘Negative’ if the test is negative and ‘Not done’ if the HIV test is not done.
Write ‘Positive’ if the Serum for HBs Ag test is positive, ‘Negative’ if the test is negative and ‘Not done’ if Serum for HBs
(22) Serum For HBs Ag
Ag is not done.
Write ‘YES’ if standard treatment is given for injuries is given, ‘No’ if standard treatment is given for injuries is not given
(23) Standard Treatment of injuries
and ‘NA’ if injury treatment was not applicable to the survivor
(24) First- line Support given (yes, No) Write ‘YES’ if first line support is given and ‘No’ if not given
Write ‘YES’ if emergency contraceptive is given, ‘No’ if not given and ‘NA’ if emergency contraceptive provision was not
(25) Emergency Contraceptive
applicable to the survivor
Write ‘YES’ if post exposure prophylaxis (PEP) is given, ‘No’ if not given and ‘NA’ if post exposure prophylaxis (PEP)
(26) PEP
provision was not applicable to the survivor
(27) STI Write ‘YES’ if STI test is done, ‘No’ if not done and ‘NA’ if STI test is not applicable to the survivor
(28) HB Vaccine Write ‘YES’ if HB vaccine is given, ‘No’ if not given and ‘NA’ if HB vaccine provision is not applicable to the survivor
Write the referral service status according to the list at the bottom of the table. Write code 1 if survivor is referred for
(29) Referral to other services legal service, 2 if referred for psychological support, 3 if ART (Chronic care), 4 if survivor was referred for other services
and 5 if referral service was not required.
(30) Remark Write if there is any remark
 Gender Based Violence Registration Book
Region ________________ Woreda ______________________ Name of Health Facility _______________________
If Sexual (History, Physical exam and

Emergency Contraceptive
Contact Adress

Referral to other services

HB Vaccine (Yes, No, NA)
First- line Support given
Standard Treatment of
laboratory tests)

injuries (Yes, No, NA)

PEP (Yes,No, NA)

STI (Yes,No, NA)

Type of Vio-

(Pos, Neg, Not done)

Pregnancy Test (Pos,

VDRL (Pos, Neg, Not

Types of Rape code

HIV Test (Pos, Neg,

(Yes,No, NA)
etc (Code=Yes,No)

Serum For HBs Ag

Fresh tear/ Bruise

Neg, Not done)

(yes, No)
Date Marital Edu- Key * The lence (Sexual, # of days
Sex- Past GBV

Not done)
S.N (DD/MM/ MRN Survivor’s Full Name Age status cation popula- Perpe- Physical, after Remark

(If Rape)
(M/F) history *

done)
YY) Woreda Kebele Telephone * Level* tion? trator* Psychological, incident
Mixed)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30)

10

11

Count
Marital status Code Education (Col. 11) * KP = Key Population (Col. 12) The Perpetrator (Col. 13) Past history of GBV (Col. 16) Types of Rape code (Col. 18) Referral to other services code (Col. 29)
(Col. 10) 1. Illiterate 1. CSW (Commercial sex Workers) [Link] member 1. By same person Sexual Violence 1. Attempted Rape 1. Legal
1. single 2. Elementery 2. Prisoners 2. Intimate partners 2. By differnet person Physical Violence 2. Acquaintance Rape 2. Psychosocial support
2. Married 3. secondary/high 3. OVC 3. Stranger 3. No past history Psychological 3. Forced Rape 3. ART( Chronic care)
3. Divorced school 4. IDP Violence 4. Other 4. Other
4. windowed 4. college/ university 5. People wit disability Mixed 5. No referral was needed
6. Others