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  • 7/26/2019 FORM KDRT

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    Jl. Gajah Mada - Meulaboh 23614Telp. (0655) 7551274 Fax. (0655) 7551274

    Ea!l " #eb$!%e "

    1. &oo' a$u$ " ........................................................................................

    2. &oo' e*a Med!$ " ........................................................................................

    3. Je+!$ a$u$ " e*e'a$a+ F!$!*,e*$ual,$!*!$,e+ela+%a'a+4. /a'!,Tl, #a*%u ee'!*$aa+ " .........................................................................................

    5. &oo' " .........................................................................................

    6. &aa ol!$! " .........................................................................................

    7. &aa o*%e' Muda " .........................................................................................

    . &aa o*%e' ee'!*$a " .........................................................................................

    . &aa o*%e' o+$ule+ " .........................................................................................

    I. Identitas Korban

    1. &aa e+*ap " .........................................................................................

    2. Tepa%,Ta+al ah!' " .........................................................................................

    3. Je+!$ ela!+ " .........................................................................................

    4. &oo' T " .........................................................................................

    5. aa " .........................................................................................

    6. u*u a+$a " .........................................................................................

    7. e+d!d!*a+ Te'a*h!' " .........................................................................................

    . e*e'jaa+ " .........................................................................................

    . %a%u$ dala *elua'a " [ ] ua! [ ] +a* *e.......... da'! ...........

    [ ] 8$%'! [ ] la!+-la!+9 $ebu%*a+...............

    10. %a%u$ pe'*a:!a+

    a. J!*a *a:!+9 %ahu+ e+!*ah " .........................................................................................

    b. Julah a+a* " .........................................................................................

    REKAM MEDIS KEKERASAN DALAM RUMAH TANGGA

    ( DOMESTIC IOLENCE )

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    II. Ri!a"at Ke#adian

    1. #a*%u *ejad!a+ (/a'!,Ta+al) " .........................................................................................

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    2. Tepa% *ejad!a+ " .........................................................................................

    3. e+%u* pe'la*ua+ "

    A. Ke$erasan %isi$

    Tanpa senjata

    [ ] d!pu*ul,d!%!+ju [ ] d!!!% [ ] d!%apa'[ ] d!;a*a' [ ] d!do'o+ [ ] d!jaba*

    [ ] d!ba+%!+ [ ] d!%e+da+ [ ] d!!*a%

    Dengan senjata

    [ ] %aja,p!$au [ ] %upul,*a

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    edua $elaa ........................ e+!%

    e%!a $elaa ........................ e+!%

    C. )eneantaran

    ebu%*a+ " .........................................................................................................................

    4. pa*ah *ejad!a+ !+! !%al " T ".........../ &ad! ".......x,e+!% "...........x,e+!%

    uhu "............. ?

    3. epala,lehe' " .....................................................................................................

    4. Tho'ax " .....................................................................................................

    a'u-pa'u " .....................................................................................................

    Ja+%u+ " .....................................................................................................

    5. bdoe+ " .....................................................................................................

    6. Ex%e!%a$ $upe'!o' " .....................................................................................................

    7. Ex%'e!%a$ !+@e'!o' " .....................................................................................................

    . ee'!*$aa+ u*a " .....................................................................................................

    . ee'!*$aa+ %a%u$ lo*al!$ " ...................................................................................................

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    Jl. Gajah Mada - Meulaboh 23614Telp. (0655) 7551274 Fax. (0655) 7551274

    Ea!l " #eb$!%e "

    I. )enataa$sanaan

    1. ee'!*a$aa+ pe+u+ja+ da+ ha$!l pee'!*$aa+ "

    2. Te'ap! "

    3. [ ] a:a% 8+ap [ ] a:a% Jala+

    4. Folo: up

    [ ] o*%e' pe$!al!$ " ..........................................................................................................

    [ ] o*%e' pe$!al!$ Fo'e+$!* " ...........................................................................................

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