FOR POLICE BLOTTER USE ONLY

BLOTTER ENTRY NUMBER

Philippine National Police

TYPES OF INCIDENT
INCIDENT RECORD FORM
INSTRUCTIONS: Refer to PNP SOP on recording of incidents of the police blotter in filling up this form. This incident record form (IRF) may be reproductive , photocopied, and/or
downloaded on the DNDM Website, www.dndm.pnp.gov.ph.
DATE AND TIME REPORTED DATE AND TIME OF INCIDENT
ITEM “A “ – REPORTING PERSON
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE

CURRENT ADDRESS (HOUSE NUMBER/ STREET) VILLAGE/ SITIO BARANGAY TOWN/CITY PROVINCE

OTHER ADDRESS (HOUSE NUMBER/ STREET) VILLAGE/ SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OOCUPATION ID CARD PRESENTED EMAIL ADDRESS(If Any)

ITEM “B “ – SUSPECT DATA

CHECK HERE IF THERE IS NO SUSPECT ENVOLVED AND THEREAFTER PROCEED TO ITEM “C”.
CHECK HERE IF THERE ARE TWO OR MORE SUSPECTS THEREAFTER, USE ADDITIONAL INCIDENT REPORT FORMSHEETS FOR EACH OF THE SUSPECTS.
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE

CURRENT ADDRESS (HOUSE NUMBER/ STREET) VILLAGE/ SITIO BARANGAY TOWN/CITY PROVINCE

OTHER ADDRESS (HOUSE NUMBER/ STREET) VILLAGE/ SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OOCUPATION WORK ADDRESS RELATION TO VICTIM EMAIL ADDRESS(If Any)

IF AFP/ PNP PERSONNEL RANK UNIT ASSESSMENT GROUP APPLICATION WITH PREVIOUS CRIMINAL RECORD [ ] YES [ ] NO STATUS OF PREVIOUS CASE
(If Yes, Pls. Specify)

HIEGHT WIEGHT COLOR OF EYES DESCRIPTION OF EYES COLOR HAIR DESCRIPTION OF HAIR UNDER THE INFLUNCE
NO DRUGS LIQOUR
OTHERS ____________________________

FOR CHILDREN IN CONFLICT WITH THE LAW

NAME OF GUARDIAN GUARDIAN ADDRESS HOME PHONE MOBILE PHONE

DIVERSION MECHANISM

--------------------------------------CUT HERE. ISSUE THIS RECEIPT TO THE REPORTING PERSON-----------------------------------

BLOTTER ENTRY NUMBER
INCIDENT RECORD TRANSACTION RECEIPT
THIS CERTIFIES THAT NAME OF THE REPORTING PERSON ADDRESS OF REPORTING PERSON

REPORTED AN INCIDENT TO BE RECORDED IN TYPES OF INCIDENT

THE POLICE BLOTTER WHICH INCLUDES
AND
DATE/TIME OF REPORT: DATE/TIME OF INCIDENT: PLACE OF INCIDENT: RECORDED BY:
RANK/NAME/SIGNATURE OF POLICE 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 QUALIFIER NICKNAME

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE

CURRENT ADDRESS (HOUSE NUMBER/ STREET) VILLAGE/ SITIO BARANGAY TOWN/CITY PROVINCE

OTHER ADDRESS (HOUSE NUMBER/ STREET) VILLAGE/ SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OOCUPATION WORK ADDRESS EMAIL ADDRESS(If Any)

ITEM “D “ – NARRATIVE OF INCIDENT

BLOTTER ENTRY NAME TYPE OF INCIDENT TIME DATE PLACE OF INCIDENT

ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHEN, WHERE, WHY AND HOW OF REPORTING. (USE ADDITIONAL SHEET/S IF NECESSARY)

(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 NAME/SIGNATURE OF REPORTING PERSON NAME/SIGNATURE OF DESK OFFICER
FOREGOING TO THE BEST OF MY KNOWLEDGE AND
BELIEF.

CASE DISPOSITION (For Chief/Head of Office Use Only)

CHIEF OF STATION/OFFICE INSTRUCTIONS NAME OF DESIGNATED INVESTIGATION-ON-CASE NAME OF CHIEF STATION/OFFICE

---------------------------------------------------------------------------CUT HERE-------------------------------------------------------------------CUT HERE---------------------------------------------------------------------------

INSTRUCTIONS TO REPORTING PERSON
Keep this incident Record 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

Investigation-on-Case Mobile Phone

Name of Chief/Head of Office Mobile Phone