Step 1 of 7
Survivor Information
Section 1: Survivor Information
Fields marked with
*
are required.
Preferred Name or Case Code
(optional)
Age Range
*
— Select —
Below 18
18–24
25–35
36–45
Above 45
Prefer not to say
Gender
*
Woman
Man
Self-describe
Prefer not to say
Is there any aspect of your identity you'd like us to be aware of to better support you?
(optional)
Disability Status
(optional)
None
Physical disability
Visual impairment
Hearing impairment
Psychosocial disability
Intellectual disability
Chronic illness
Other
Prefer not to say
Are you a Human Rights Defender?
(optional)
Yes
No
Prefer not to say
District
*
— Select —
Kampala
Wakiso
Mukono
Buikwe
Buvuma
Gomba
Kalangala
Kalungu
Kyankwanzi
Luweero
Lwengo
Lyantonde
Masaka
Mityana
Mpigi
Mubende
Nakaseke
Nakasongola
Rakai
Sembabule
Butebo
Jinja
Bugiri
Bugweri
Busia
Buyende
Iganga
Kaliro
Kamuli
Kapchorwa
Katakwi
Kibuku
Kumi
Luuka
Manafwa
Mayuge
Mbale
Namayingo
Namisindwa
Namutumba
Ngora
Pallisa
Serere
Sironko
Soroti
Tororo
Abim
Adjumani
Agago
Alebtong
Amolatar
Amudat
Amuria
Amuru
Apac
Arua
Dokolo
Gulu
Kaabong
Kitgum
Koboko
Kole
Kotido
Kwania
Lamwo
Lira
Madi-Okollo
Maracha
Moroto
Moyo
Napak
Nebbi
Nwoya
Obongi
Omoro
Otuke
Oyam
Pader
Pakwach
Terego
Yumbe
Zombo
Buliisa
Bundibugyo
Bushenyi
Buhweju
Bunyangabu
FortPortal
Hoima
Ibanda
Isingiro
Kabale
Kabarole
Kagadi
Kakumiro
Kamwenge
Kanungu
Kasese
Kibaale
Kiruhura
Kiryandongo
Kisoro
Kyegegwa
Kyenjojo
Masindi
Mbarara
Mitooma
Ntoroko
Ntungamo
Rubanda
Rubirizi
Rukiga
Rukungiri
Sheema
Region
*
Village / Parish / Exact Location
*
Occupation / Source of Livelihood
*
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