Section 17, Protection of Women from Domestic…

(I) The aggrieved person or the Protection Officer or the service provider may make a request under section 7 to a person in charge of a medical facility in writing, clearly stating that the application is being made under section 7.

(2) When a Protection Officer makes such a request, it shall be accompanied by a copy of the domestic incident report:

Provided that the medical facility shall not refuse medical assistance to an aggrieved person under the Act, for her not having lodged a domestic incident report, prior to making a request for medical assistance or examination to the medical facility.

(3) If no domestic incident report has been made, the person-in-charge of the medical facility shall fill in Form I and forward the same to the local Protection Officer.

(4) The medical facility shall supply a copy of the medical examination report to the aggrieved person free of cost.

THE GAZETTE OF INDIA: EXTRAORDINARY ART El-SEC. 3(i FORM I [See rule 5(1) and (2) and 17(3)] Domestic Incident Report under sections 9 (b) and 37 (2) (c) of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005) I. Details of the complainant/aggrieved person

(1) Name of the complainant/aggrieved person:

(2) Age:

(3) Address of the shred household:

(4) Present Address:

(5) Phone Number, if any:

2. Details of Respondents:

S.No. Name Relationship with the aggrieved person Address Telephone No. if any.

3. Details of children, if any, of the aggrieved person:

(a) Number of Children:

(b) Details of children:

Name Age Sex With whom at present residing

4. Incidents of domestic violence:

S.No. Date, place and time of violence Person who caused domestic violence Types of violence Remarks P Physical violence Causing hurt of any kind, please specify.

(ii) Sexual violence Please tick mark p i the column applicable. ] 111 Forced sexual intercourse.

E Forced to watch pornography or other obscene material G Forcibly using you to entertain others 17 Any other act of sexual nature, abusing, humiliating, degrading or otherwise violative of your dignity (please specify details in the space provided below):

IiRti : SWOP% 61 [3-117 3(i)] (H)verbal and emotional abuse • 0 Accusation/aspersion on your character or conduct, etc.

0 insult for not brining dowry, etc.

0 Insult for not having a male child.

0 Insult for not • having any child .

0 Demeaning, humiliating or undermining remarks/statement 0 Ridicule 0 Name calling 0 Forcing you to not attend ' school, college Or any other educational institution.

0 Preventing you from taking up a job 0 Preventing you from leaving the House 0 Preventing you from meeting any particular person O Forcing you to get married against your will 0 Preventing you from marrying a person of your choice 0 Forcing you to marry a person of his/their own choice 0 Any other verbal or emotional abuse (please specify in the space provided below)

(iii) Economic violence 0 Not providing money for maintaining you or your children 0 Not providing food, clothes, medicine, etc, for you or your children.

0 Forcing you out of the house you live in.

0 Preventing you from accessing or using any part of the house.

0 Preventing or obstructing you from 62 THE GAZETTE OF INDIA : EXTRAORDINARY [PART 3(i)l carrying on your employment.

❑ Not allowing you to take up an employment.

❑ Non-payment of rent in case of a rented accommodation ❑ Not allowing you to use clothes or articles of general household use.

❑ Selling or pawing your stridhan or any other valuables without informing you and without your consent.

❑ Forcibly taking away your salary, income or wages etc.

❑ Disposing your stridhan ❑ Non payment of other bills such as electricity, etc.

❑ Any other economic violence (please specify in the space provided below)

(iv) Dowry related harassment ❑ Demands for dowry made, please specify:

❑ Any other detail with regard to dowry, please specify.

Whether details of dowry items, stridhan, etc.

attached with the form ❑ Yes ❑ No

(v) any other information regarding acts of domestic violence against you or your children (Signature or thumb impression of the complainant/aggrieved person) 'girl 3(i)3 ‘ITTIT Trirrsr anrirror

5. List of documents attached Name of document Date Any other detail

11.1111111111.

Medico legal certificate Doctor's certificate or any other .rescri.tion M.111111 1111111=1111.111.1.1111 List of Stridhan Any other document

6. Order that you need under the Protection of Women from Domestic Violence Act, 2005 S.No. Orders Yes/No Any other (I) Protection order under section 18

(2) Residence order under section 19

(3) Maintenance order under Section 20

(4) Custody order under section 21'

(5) Compensation order under section 22

(6) Any other order (specify)

7. Assistance that you need S.No. Assistance available Yes/No Nature of assistance (I) (2) (3) (4) (I) Counsellor

(2) Police assistance

(3) Assistance for initiating criminal proceedings

(4) Shelter home

(5) Medical facilities

(6) Legal aid

8. Instruction for the Police officer assisting in registration of a Domestic Incident Report:

Wherever the information provided in this From discloses an offence under the Indian Penal Code or any other law, the police officer shall-

(a) inform the aggrieved person that she can also initiate criminal proceedings by lodging a First Information Report under the Code of Criminal Procedure, 1973 (2 of 1973)

(b) if the aggrieved person does not want to initiate criminal proceedings, then make daily dairy entry as per the information contained in the domestic incident report with a remark that the aggrieved person due to the intimate nature of the THE GAZETTE OF INDIA : EXTRAORDINARY ['PART II—Sac. 301 relationship with the accused wants to pursue the civil remedies for protection against domestic violence and has requested that on the basis of the information received by her, the matter has been kept pending for appropriate enquiry before registration of an FIR.

(c) if any physical injury or pain being reported by the aggrieved person, offer immediate medical assistance and get the aggrieved person medically examined.

Place: (Counter signature of Protection Officer/Service provider) Date: Name:

Address:

(Seal) Copy forwarded to:-

1. Local Police Station

2. Service Provider/Protection Officer

3. Aggrieved person

4. Magistrate FORM II [See rule 6(1)] Application to the Magistrate under section 12 of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005) To The court of Magistrate Application under section of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005) SHOWETH:

1 That the application under section of Protection of Women from Domestic Violence Act, 2005 is being filed alongwith a copy of Domestic Incident Report by the:-

(a) Aggrieved person r-r

(b) Protection Officer lign : SWIM;

(e) Any other peewit on behalf of the aggrieved person (tlek whichever is applicable) It is played hat the Hon'ble Mtn may take cognizance of the eottlplititit/Domestic incident Report and pass all/any of the orders, as deemed liCaftaitry lit the circumstances of the case.

(0) Pass prOteCtiOrt orders under section 18 and /or

(t) Pest reilidelide orders wider motion 19 and for

(e) direct the tetiondent to pay monetary relief under section 20 and for

(d) Pass orders under section 21 of the act and /or

(e) Direct the respondent 10 grant comperttatittri or damages under section 22 and kit

(f) Pass such Interim Orders as the court deems just and proper;

(g) Pass any mhos as clowns tit in the circumstances of the case.

3. Orders required:

krotettlos bider tattier tauten 18 F.! Prohibiting sets Of tkinteigic V1010104 by granting an injunction against the Respondents from repealing arty otthe acts Meath:Med in terms of column 4(a)/(b)/(c)/(d)/(e)/(f)/(g) of the triplication Prohibiting Respetitteht(S) from entering the settoolkollese/workploee Prohibiting from stopping you Nth- going to your place oremployment rl Prohibiting Respondent(s) from entering the SOBUOVeollege/any other place of your children rt Prohibiting from stopping you from going to your school • Prohibiting arty form Of tiOmmunicatitm by the Respondent with you ü Prohibiting alienation Of' toileti by the Respondent Li Prohibiting operation of jOirit batik lockets/accounts by the Respondent and allowing the aggrieved person.to operate the same Li Directing the Respondent to slay away from the dependents/relatives/any other person of the aggrieVed person to prohibit violence against them 1:; Any other order, ple:ise spec*

(ii) Residence Order under section 19 An order restraining Respondent (s) from Dispossessing or throwing ma out from the shared household Entering that portion of the shared household in which I reside i:1 Alienating/disposing/encumbering the shared household O Renouncing his rights In the shared household An order entitling me continued access to my personal effects An order directing Respondent (a) to o Remove himself from the shared household o Secure same level of alternate accommodation or pay rent for the same Any other order, please specify

(iii) Monetary reliefs under section 20 L l Loss of earnings, Amount claimed 32976( ./b —9 65 THE GAZETTE OF INDIA FATRAORDINARY IPART 1I—SEc. 30)1 Medical expenses, Amount claimed Loss due to destruction/damage or removal of property from the control of the aggrieved person, Amount claimed J Any other loss or physical or mental injury as specified in clause 10 (d) Amount claimed Total amount claimed Any other order, please specify

(iv) Monetary reliefs under section 20 0 Directing the Respondent to pay the following expenses as monetary relief:

12 Food, clothes, medications and other basic necessities, Amount L I per month 0 School fees and related expenses Amount gil Household expenses Amount U Any other expenses Amount Total per month per month per month per month Any other order, please specify r-

(y) Custody Order under section 21 Direct thy. Respondent to hand over the custody of the child or children to the- DAggrieved Person 0 Any other person on her behalf, details of such person

(vi) Compensation order under section 22

(vii) Any other order, please specify 4, Details of previous litigation, if any

(a) 0 tinder the Indian Penal Code, Sections.... Pending in the court of 0 Disposed off, details of relief 1 b) 0:inder CrPC, Sections Pending in the court of L1 I ')ispcsed oft details of relief

1):sposed off, details of relief 4d)C) Under the Hindu Adoptions and Iviaintenance Act,1956, Sections Disposed off, details of relief

(e) --,Application for Maintenance, under section under Interim maintenance Rs. I p.m.

Maintenance granted Rs, p m 65 Pending in the court of Pending in the court of Act 1711-1FT 3(1)] 1N1 TRIM! : 37TITIMT

(f) ° Whether Respondent was sent to Judicial Custody 0 For less than a week 0 For less than a month El For more than a month Specify period 1

(g) Any other order 1 prayer;

It is, therefore, most respectfully prayed that this Hon'ble Court be pleased to grant the relief (s) claimed therein and pass such order or orders other order as this Hor'ble Court may deem fit and proper under the given facts and circumstances of the case for protecting the aggrieved person from domestic violence and in the interest of justice.

Place COMPLAINANT/AGGRIEVED PERSON Dated:

THROUGH COUNSEL VERIFICATION:

Verified at --(place) on this day of that the contents of Paras Ito 12 of the above application are true and correct to the best of my knowledge and nothing material has been concealed therefrom.

DEPONENT Countersignature of Protection Officer with date.

Form III (Sen rule 6 (4 ) and 7] AFFIDAVIT UNDER SECTION 23 (2) OF THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 IN THE COURT OF 144, P/S: ..........

IN THE MATTER OFr Ms & Others ,COMPLAINANT VERSUS Mr & Others ...RESPONDENT 68 THE GAZETTE OF INDIA:EXTRAORDINARY ENTII-Sul5(01 AYFIDAVXT 1, W/o Mr. ,R/o D/o Mr. ,R/o .. ....... ... ,.. ,presently residing at do hereby solemnly affirm and declare on oath as under:

1. That I am the Applicant in the accompanying Application for ......... filed for myself and for my daughter/son.

2. That T am the natural guardian of-- —

3. That being conversant with the facts and circumstances of the case I am competent to swear this affidavit.

4. That the Deponent had been living with the Respondent/s at since . to

5. That the details provided in the present Application for the grant of relief under Section(s) have been entered into by me/at my instructions.

6. That the contents of the application have been read over, explained to me in English/Hindi/any other local language (Please specify ).

7. That the contents of the said application may be read as part of this affidavit and are not repeated herein for the sake of brevity.

30)) IMF ITISR4 : Avaritiv4

8. That the applicant apprehends repetition of the acts of domestic violence by the Respondent (s} against which relief accompanying application.

is sought in the

9. That the Respondent has threatened that the . Applicant

18. That the reliefs claimed in the accompanying application are urgent in as much as the applicant would face great financial hardship and would be forced to live under threat of repetition/escalation of acts of domestic violence complained' of in the accompanying application by the Respondent(s) if thp said reliefs are not granted on an ex-parte ad-interim basis.

11. That the facts ment*pned herein are true and correct to the best of my knowledge and belief and nothing material has been concealed there from.

DEPONXNT Y.144!;q4T;P:

Verified at .... on this day of .... 20- That the contents of the aboVe affidavit are correct to the best of my knowledge and belief and no part of it is false and nothing material has been concealed there from.

DEPONENT THE GAZETTE OF INDIA : EXTRAORDINARY [PART I I—Ssr, 3(i)1 Form IV [See rule 8(1) (ii)] Information on rights of aggrieved persons under the Protection of Women from Domestic Violence Act, 2005

1. If you are beaten up, threatened or harassed in your home by a person with whom you reside in the same house, then you are facing domestic violence. The Protection of Women from Domestic Violence Act, 2005, gives you the right to claim protection and assistance against domestic violence.

2. You can receive protection and assistance under the Act, if the person(s }with whom you are/were residing in the same house, commits any of the following acts of violence against you or a child in your care and custody - l. Physical Violence:

For example-

(i) Beating,

(ii)' Slapping,

(iii) Hitting,

(iv) Biting,

(v) Kicking,

(vi) Punching,

(vii) Pushing,

(viii) Shoving or

(ix) Causing bodily pain or injury in any other manner.

2. Sexual Violence:

For example-

(i) Forced sexual intercourse;

(ii) Forces you to look at pornography or any other obscene pictures or material;

(iii) Any act of sexual nature to abuse, humiliate or degrade you, or which is otherwise violative of your dignity or any other unwelcome conduct of sexual nature;

(iv) Child sexual abuse

3. Verbal and Emotional Violence:

For example-

(i) Insults;

(ii) Name-calling;

(iii) Accusations on your character or Conduct etc.;

(iv) Insults for not having a male child,

(v) insults for not bringing dowry etc.;

(vi) Preventing you or a child in your custody from attending school, college or any other educational institution;

II—Tivg Xi)] 1$T Tr4731 : alETTNRuT

(vii) Preventing you from taking up a job;

(viii) Forcing you to leave your job;

(ix) Preventing you or a child in your custody from leaving the house;

(x) Preventing you from meeting any person in the normal course of events;

(xi) Forcing you to get married when you do not want to marry;

(xii) Preventing you from marrying a person of your oven choice;

(xiii) Forcing you to marry a particular person of his/their own choice;

(xiv) Threat to commit suicide;

(xv) Any other verbal or emotional abuse.

4. Economic Violence:

For example-

(i) Not providing you money for maintaining you or your children,

(ii) Not providing food, clothes, medicines etc. for you or your children,

(iii) Stopping you from carrying on your employment or ,

(iv) Disturbing you in carrying on your employment,

(v) Not allowing you to take up an employment or

(vi) Taking away your income from your salary, wages etc. or

(vii) Not allowing you to use your salary, wages etc.,

(viii) Forcing you out of the house you live in,

(ix) Stopping you from accessing or using any part of the house,

(x) Not allowing use of clothes, articles or things of general household use,

(xi) Not paying rent if staying in a rented accommodation, etc.

3. If an act of domestic violence is committed against you by a person/s with whom you are/were residing in the same house, you can get all or any of the following orders against the person(s)-

(a) Under section 18:

(i) To stop committing any further acts- of domestic violence on you or your children;

(ii) To give ybu the possession of your stridhan, jewellery, clothes etc.

(iii) Not to operate the joint bank accounts or lockers without permission of the court

(b) Under section 19:

(i) Not to stop you from residing in the house where you were residing with the person/s;

(ii) Not to disturb or interfere with your peaceful enjoyment of residence,

(iii) Not to dispose off the house in which you are residing.

(iv) If your residence is a rented property then either to ensure payment of rent or secure any other suitable alternative accommodation which offers you the same security and facilities as earlier residence.

(v) Not to give up the rights in the property in which you are residing without the permission of the court.

THE GAZETTE OF INDIA: EXTRAORDINARY [FART 3(i)]

(vi) Not to take any loan against the house/property in which you are residing or mortgage it or create any other financial liability involving the property.

(vii) Any or all of the following orders for your safety requiring the person/s to-

(i) Stop the domestic violence complained/reported

(d) Special Orders:

(i) Remove himself/stay away from your place of residence or workplace;

(ii) Stop making any attempts to meet you,

(iii) Stop calling you over phone or making any attempts to communicate with you by letter, e-mail etc.

(iv) Stop talking to you about marriage or forcing you to meet a particular person of his/their choice for marriage;

(v) Stay away from the school of your child/children, or any other place where you and your children visit';

(vi) Surrender possession of firearms, any other weapon or any other dangerous substance

(vii) Not to acquire possession of firearms, any other weapon or any other dangerous substance and not to be in possession of any similar article,

(viii) Not to consume alcohol or drugs with similar effect which led to domestic violence in the past.

(ix) Any other measure required for ensuring your or your children's safety.

(e) An order for interim monetary relief under sections 20 and 22 including -

(i) Maintenance for you or your children,

(ii) Compensation for physical injury including medical expenses,

(iii) Compensation for mental torture and emotional distress,

(iv) Compensation for loss of earning,

(v) Compensation for loss caused by destruction, damage, removal of any property from your possession or control.

Note. — I. Any of the above relief can be granted on an interim basis, as soon as you make a complaint of domestic violence and present your application for any of the relief before the court.

II. A complaint of domestic violence made in Form I under the Act is called a "Domestic Incident Report")

4. If you are a victim of domestic violence, you have the following rights:

(i) The assistance of a protection officer and service providers to inform you about your rights and the relief which you can get under the Act under section 5.

72 Contact Details Name of Or. anization IIVITII-•"11101r 3(0) Mal 15T U : 4T61%1111T

(ii) The assistance of protection officer, service providers or the officer in charge of the nearest police station to assist you in registering your complaint and filing an application for relief under sections 9 and 10.

(iii) To receive protection for you and your children from acts of domestic violence under section 18.

(iv) You have right to measures and orders protecting you against the particular dangers or insecurities you or your child are facing.

(v) To stay in the house where you suffered domestic violence and to seek restraint on other persons residing in the same house, from interfering with or disturbing peaceful enjoyment of the house and the amenities facilities therein, by you or your children under section 19.

(vi) To regain possession of your stridhan, jewellery, clothes, articles of daily use and other house hold goods under section 18.

(vii) To get medical assistance, shelter, counseling and legal aid under sections 6, 7, 9 and 14 .

(viii) To restrain the person committing domestic violence against you from contacting you or communicating with you in any manner under section 18.

(ix) To get compensation for, any physical or mental injury or any other monetary loss due to domestic violence under section 22.

(x) To file complaint or applications for relief under the Act directly to the court under sections 12, 18, 19, 20, 2.1, 22 and 23.

(xi) To get the copies of the complaint filed by you, applications made by you, reports of any medical or other examination that you or your child undergo.

(xii) To get copies of any statements recorded by any authority in connection with Domestic Violence.

(xiii) The assistance of the Protection Officer or the Police to rescue you from any danger.

5. The person providing the form should ensure that the details of all the registered service providers are entered in the manner and space provided below. The following is the list of service providers in the area Continue the list on a separate sheet, if necessary 3 9 7G1 .06— to Form V [See rule 8(1)(iv)I SAFETY PLAN

1. When a Protection Officer, Police officer or any other service provider is assisting the woman in providing details in this form, then details in columns C and D ore to be filled in by the Protection Officer, Police officer or any other service provider, as the case may be, in consultation with the complainant and with her consent.

2. The aggrieved person in case of approaching the court directly may herself provide details in columns C and D,

3. If the aggrieved person leaves columns C and D blank and approaches the court directly, then details in the said columns are to be provided by the Protection Officer to the court, in consultation with the complainant and with her consent.

A B C D SI.

No.

Violence by the Respondent Consequences of violence mentioned in Column A suffered by the Aggrieved Person T Apprehensions of the Aggrieved Person regarding violence mentioned in Column A Measures required for safety Orders sought from the court

1. Physical violence by the Respondent Complainant's perception that she and her children are at risk of repetition of physical violence

(a) Repetition

(b) Escalation

(d) Any other, specify

2. Any sexual act abusing, humiliating or degrading, otherwise violative of youPdignity

(a) Depression

(b) At risk of repetition of such an act

(a) Repetition

(b) Escalation

3. Attempts at strangulation

(a) Physical injury {b) Mental ill health

(a) Repetition

(b) Any other, specify

4. Beatings to the children (a) Injury to the children

(b) Adverse mental effect of the same on the children

(a) Risk of repetition

(b) Adverse effect of violent behaviour/environment on the child .

5. . Threats to commit suicide by the .

Respondent

(a) Violent environment in the house

(b) Threat to safety .

(a) Actually trying to commit the same

(b) Repetition

6. Attempts to commit suicide by the Respondent

(a) Violent environment in the house

(b) Insecurity, anxiety, depression, mental trauma

(a) Repetition, escalation, aggravation of the same

(b) Mental trauma, pain

7. Psychological & Emotional abuse of the Complainant kit,: insults, ridicule, name calling, insults for not having a male child, false accusations of unchastity, etc

(a) Depression

(b) Mental trauma, pain

(d) Any other, specify

(a) Repetition, escalation, aggravation of the same

(b) Mental trauma, pain

8. Making verbal threats to cause harm to the aggrieved person/her children/parents/relatives

(a) Living in constant fear

(b) Mental trauma, pain

(a) Respondent may carry'out the mentioned threats

(b) Mental trauma, pain

9. Forcing not to attend school/college/any other educational institution

(a) Depression

(b), Mental trauma, pain

(a) Repetition

(b) Mental, trauma, pain

10. Forcing to get married when do not want to/forcing not to marry a person of choice/forcing to marry a particular person of Respondent/s' choice

(a) Depression .

(b) Mental trauma, pain

(d) Any other

(a) Repetition

(b) Mental trauma, pain

11. Threatening to kidnap the child/children

(a) Living in constant fear

(b) Threat to the child/children's safety

(a) Children might be kidnapped

(b) Any other, specify .A B D E

12. Actually causing harm to the agrieved pers Onichildren/relatiVes

(a) Living in constant fear . of further harm ;(b) Any other, specify

(a) Repetition .0).Escoistion . .

(d) Any other, specify

13. Stibstanceabuse (drugs/alcohol) Itt)tiving in constant fear .ofebusive and violent behaviour by tile Respondent dine to ,sUbstance abuse

(b) Deprived of leading a normal life

(a) Physical violence after consuming the same

(b) Abusive behaviourafter consuming the same

(d) Any other, specify

14. History of criminal behaviour '(a) Constant fear-of violence

(b)fear ofrevenge by the Respondent

(a) Respondent has a tendency to violate law and is likely to flout orders passed by the-court against him

(b) Respondent might cause harm to the aggrieved person/children for filing any further. .proceedings

15. Not provided money towards maintenance, food, clothes, medicines, etc.

-(a)Driven towards vagrancy and destitution

(b) Any other, specify

(a) Have to face great hardship to fulfill the needs and requirements of her ,child/children and herself

(b) Any other, specify

16. Stopped, 4isturbed from carrying DR employment , or not. Allowed to take up the same a) Not able to fulfill the basic seeds -for, yourself and your children b) Any other, specify a) Have to face great hardship to fulfill the 'needs and requirements of her child/children and herself b) Any other, specify

17. Forced out of1he house, stopped from accessing or using any part of the .

(a) Having no; lace to stay for yourself aid your children

(a) Safety of her child/children and herself

(b) Have to face great hardship A B C D E house or prevented from leaving the same

(b) Being restricted to a particular area of the house in providing shelterfor her and her children

(c):Any. odic., specify

18. Not allowed use of clothes, articles or things of general household use

(a) Losing possession of the same

(b) Not having resources to replace the same

(a) The same may be disposed off by the Respondent (Er)Any other

19. Non payment of rent in case of a rented accommodation

(a) Being asked to leave the' same by the owneron such non payment (b3 No alternate accommodation to go to

(c), No. income to afferd a rented accommodation

(a) Losing shelter

(4) Facing great hanishike ' (e) Any ciher, specify,• ti !

1 .

20. Sold, pawned stridhan or any other valuables without informing or without consent

(a) Loss et valuatthes or property

(b) Any other, specify , (a) The same may be disposed ; off by the Respondent

(b) Any other, specify

21. Dispossessed of stridhan (a) Deprived of the property in her possessinn

(b) Any others specify

(a) The same may be disposed off by the Respondent

(b) Fear of never receiving the same again

22. Breach of civil/criminal court order, specify order Please specify Please specify Signature Aggrieved Person Signature Service Provider/ Protection Officer/Police Officer THE GAZETTE OF INDIA: :,TRAORDINARY [PART II—SEC. 3(i)1 FORM VI { See rule 11(1; ) Form for registration as service providers under section 10(1) of the Protection of Women from Domestic Violence Act, 2005

1. Name of the applicant.

2.. Address alongwith Phone number, e-mail address, if any.

3. Services being rendered U Shelter E Psychiatric Counselling 7] Family counselling E Vocational Training Centre El Medical Assistance Li Awareness Programme Counselling for a group of people who are victims of domestic violence and family disputes ❑ Any other, specify.

4. Number of persons employed for providing such services:

5. Whether providing the required services in your institution requires certain statutory minimum professional qualification? If yes, please specify and give details.

6. Whether list of names of the persons and the capacity in which they are working and their professional qualification is attached?

I E Yes • ❑ No '78 LaTrrin-,-wrg3(i)) aTRIVRIT 79 services are being rendered:

111111 Period for whidh the ❑ 3 years ❑ 4 years ❑ 5 years ❑ 6 years ❑ More than 6 years ❑ Yes ❑ No Whether registered under any law/regulation If yes, give the registration Number 111111 III Note:- 18 are of the Whether requirements prescribed by any regulatory body or ?aw fulfilled?

_ If yes, the name and address of the regulatory body:

In case of a shelter home, details under column 10 to to be entered by registering authority after inspection shelter home.

10.

111111 Whether there is adequate space in the shelter home ❑ yes ❑ No Measured area of the entire premise

13.

Number of rooms Area of the rooms

14. Details of security arrangements available 111111 Whether a record available for maintaining a functional telephone connection for the use of inmates for the last 3 ears Distance of the nearest dispensary/ clinic/medical facility Whether any arrangement for regular visits by a medical professional has.

been made?

111111 ❑ Yes ❑ No If es, name of the Medical Professional Address L L__ Contact number Qualification [ Specialization

Act	The Protection of Women from Domestic Violence Rules, 2006
Section	17
Marginal note	Medical Facility to the aggrieved person
Jurisdiction	Central
Status	In force as published by the source

Section 17: Medical Facility to the aggrieved person

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