Full Name:
Gender:
Date of Birth:
Country of Citizenship:
Occupation:
Ethnic, Religious, Social Beliefs (if relevant):
Address:
Other relevant information:
Have the victim(s) given you his/her consent to send this communication on his/her behalf?:
Has the victim(s) been informed that, if the Special Rapporteur decides to take action on her letter concerning what happened to he:
Is the victim(s) aware that, if this communication is taken up, a summary of what happened appear in a public report of the Special:
Would the victim(s) prefer that her full name or merely his/her initials appear in the public report of Special Procedures of the Huma
Detailed Description of the Human Rights Violation:
Date:
Time:
Location / Country:
What Number of Assailants were there?:
Are the assailant(s) known or related to the victim? If so, how?:
Name of nickname of assailant(s):
Does the victim believe he/she was targeted specifically because of her identity, classified by gender, race, religion, or other subgr:
Has the incident been reported to the relevant state/national authorities? If so, which authorities and when?:
Have the authorities taken any action after the incident? If so, which authorities, what action, when?:
If the violation was committed by private individuals or groups (rather than government officials), include any information which mig:
Has the victim seen a doctor after the incident took place? Are there any medical certificates/notes relating to the incident concern
If your submission concerns a law or policy, please summarize it and the effects of its implementation on human rights. Provide co