FOR POLICE BLOTTER ENCODER USE ONLY
BLOTTER ENTRY NUMBER
Philippine National Police
TYPE OF INCIDENT INCIDENT RECORD FORM
INSTRUCTIONS: Refer to PNP SOP on ‘Recording of Incidents in the Police Blotter’ in filling up this form. This Incident Record Form (I
DATE AND TIME REPORTED: DATE AND TIME OF INCIDENT:
ITEM “A” - REPORTING PERSON
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION ID CARD PRESENTED EMAIL ADDRESS (If Any)
ITEM “B” - SUSPECT DATA
CHECK HERE IF THERE IS NO SUSPECT INVOLVED AND THEREAFTER PROCEED TO ITEM “C”.
CHECK HERE IF THERE ARE TWO OR MORE SUSPECTS. THEREAFTER, USE ADDITIONAL INCIDENT REPORT FORM SHEETS FOR EACH OF THE SUSPECTS.
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS RELATION TO VICTIM
IF AFP/PNP PERSONNEL: RANK UNIT ASSIGNMENT GROUP AFFILIATION WITH PREVIOUS CRIMINAL RECORD? [ ] Yes [ ] No
(If Yes, Pls. Specify)
HEIGHT WEIGHT COLOR OF EYES DESCRIPTION OF EYES COLOR OF HAIR DESCRIPTION OF HAIR UNDER THE INFLUENCE?
NO DRUGS LIQUOR
OTHERS
FOR CHILDREN IN CONFLICT WITH THE LAW
NAME OF GUARDIAN GUARDIAN ADDRESS HOME PHONE MOBILE PHONE
DIVERSION MECHANISM
OTHER DISTINGUISHING FEATURES (DESCRIBE IN DETAIL CLOTHES, VEHICLE, SUNGLASSES, WEAPON/S, SCARS, AND OTHER DATA OR ACTIVITY OF THE SUSPECT/S WHICH WERE OBSERVED BY THE RE
WITNESS/ES TO IDENTIFY THE SUSPECT/S. THESE ARE IMPORTANT AND MAY BECOME EVIDENCE TO IDENTIFY, AND LINK TO THE CRIME, THE SUSPECT/S. USE ADDITIONAL SHEET/S IF NE
l Police
RD FORM
is Incident Record Form (IRF) may be reproduced, photocopied, and/or downloaded from the DIDM website, www.didm.pnp.gov.ph.
TING PERSON
QUALIFIER NICKNAME
HOME PHONE MOBILE PHONE
TOWN/CITY PROVINCE
TOWN/CITY PROVINCE
EMAIL ADDRESS (If Any)
USPECTS.
QUALIFIER NICKNAME
HOME PHONE MOBILE PHONE
TOWN/CITY PROVINCE
TOWN/CITY PROVINCE
RELATION TO VICTIM EMAIL ADDRESS (If Any)
STATUS OF PREVIOUS CASE
UNDER THE INFLUENCE?
NO DRUGS LIQUOR
OTHERS
AW
MOBILE PHONE
WHICH WERE OBSERVED BY THE REPORTING PERSON AND/OR
T/S. USE ADDITIONAL SHEET/S IF NECESSARY)
CUT HERE. ISSUE THIS RECEIPT TO THE REPORTING PERSON
BLOTTER ENTRY NUMBER
INCIDENT RECORD TRANSACTION RECEIPT
THIS CERTIFIES THAT NAME OF REPORTING PERSON: ADDRESS OF REPORTING PERSON:
REPORTED AN INCIDENT TO BE RECORDED IN THE TYPE OF INCIDENT:
POLICE BLOTTER
WHICH INVOLVES
AND RECORDED BY:
DATE/TIME OF REPORT: DATE/TIME OF INCIDENT: PLACE OF INCIDENT:
SACTION RECEIPT
DRESS OF REPORTING PERSON:
RANK/NAME/SIGNATURE OF DESK OFFICER
ITEM “C” – VICTIM DATA
CHECK HERE IF THE REPORTING PERSON (ITEM “A”) IS THE VICTIM. PROCEED TO ITEM “D”.
CHECK HERE IF THERE ARE TWO OR MORE VICTIMS. USE ADDITIONAL INCIDENT REPORT FORM SHEETS FOR THE DATA OF THE ADDITIONAL VICTIMS.
FAMILY NAME FIRST NAME MIDDLE NAME
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS
ITEM “D” - NARRATIVE OF INCIDENT
BLOTTER ENTRY NUMBER TYPE OF INCIDENT TIME DATE
ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHAT, WHEN, WHERE, WHY AND HOW OF REPORTING. (USE ADDITIONAL SHEET/S IF N
(DETAILS OF THIS NARRATIVE SHALL BE THE BASIS IN THE ENTRY OF RECORD IN THE POLICE BLOTTER)
AUTHENTICATION
I HEREBY CERTIFY TO THE CORRECTNESS OF THE FOREGOING TO THE NAME/SIGNATURE OF REPORTING PERSON NAME/SIGNATURE OF DESK
BEST OF MY KNOWLEDGE AND
BELIEF.
CASE DISPOSITION (For Chief/Head of Office Use Only)
CHIEF Of STATION/OFFICE INSTRUCTIONS NAME OF DESIGNATED INVESTIGATOR-ON-CASE NAME OF CHIEF OF STATION
AL VICTIMS.
QUALIFIER NICKNAME
HOME PHONE MOBILE PHONE
TOWN/CITY PROVINCE
TOWN/CITY PROVINCE
EMAIL ADDRESS (If Any)
PLACE OF INCIDENT
PORTING. (USE ADDITIONAL SHEET/S IF NECESSARY)
BLOTTER)
NAME/SIGNATURE OF DESK OFFICER
Use Only)
NAME OF CHIEF OF STATION/OFFICE
-----------------------------CUT HERE--------------------------------------------------------------------------------------CUT HERE------------------------------------------------------
INSTRUCTIONS TO REPORTING PERSON
Keep this Incident Record Transaction Receipt (IRTR). An update of the progress of the investigation of the crime or incident that you reported
will be given to you upon presentation of this IRTR. For your reference, the data below is the contact details of this police station.
Name of Police Station Telephone
Investigator-on-Case Mobile Phone
Name of Chief/Head of Mobile Phone
Office
