Date of Report: __/__/__

D M Y

Questionnaire; Interview Report Number: Q-________

Officer(s) Preparing Report__________________________________

__________________________________

Area Office_____________________________

Date of Interview: __/__/__

D M Y

Introduction for the Interview

The interviewer(s) should introduce themselves.

The interviewer should explain the purpose of the interview.

The interviewer should explain the importance of the interview in the process of obtaining facts.

The interviewer should obtain the relevant consent for the interview, for example at a minimum, the interviewer should reassure the individual interviewed that all the information provided will be held in confidence, unless there is permission.

Please use supplementary sheets, if there is insufficient space. Also use supplementary sheets for any additional information not included in the questions -- indicating the source of information. This form has been prepared for a single witness or other source of information. If more than one victim is identified, attachments for each victim should be appended.

1. Summary of the case based on the recitation by the witness:

(Note the details, including the places, dates, times, circumstances, etc.)

1.1 Does the victim/source of information/witness agree that the given information may be used for steps with the authorities or may be disclosed in public reports ?

May their name be cited?

yes

no

2. Personal Information about the witness

2.1 Surname: First name(s):

(or use an identifying number and keep the individual's name elsewhere)

2.2 Male Female

2.3 Date of birth: Day____Month_____Year____Approximate age at interview:____

2.4 Place of birth:

(town/city, province/county/state, other indications)

2.5 Present address:

2.6 Do you have a telephone? (Please give number: )

2.6.1 Is it your own telephone or another person? yes no Whose?

2.7 Address where you can be contacted (if other than above):

2.8 Means for the interviewer to stay in contact with the witness:

2.9 Civil/Family Status:

Single Married Divorced Separated Widowed

2.10 Family details (number of children and dependents -- Please give names and ages if possible):

2.11 Occupation or profession (please specify):

Artisan Farmer Government employee Journalist Merchant Military Professional Student Unemployed Other

2.12 Education: Primary School Secondary School University Graduate study

(names of schools and universities attended):

2.13 Identity document: Type: Number:

2.14 Connection with the victim:

Witness is the victim

Witness has direct evidence of the violation

Witness has indirect information

Witness is related to the victim

Other connection (please specify: )

2.15 Do you have particular comments about the source(s) of information?

3. First Victim (if different from witness; if there are several, please attach supplementary pages 3 - 7)

A. General

3.1 Surname: First name(s):

3.2 Male Female

3.3 Date of birth: Day____Month____Year____Approximate age at interview:____

3.4 Place of birth:

(town/city, province/county/state, other indications)

3.5 Present address and telephone (if different from above):

3.6 Address where victim can be contacted (if other than above):

3.7 Civil/Family Status:

Single Married Divorced Separated Widowed

3.8 Family details (number of children and dependents -- Please give names and ages if possible):

3.9 Occupation or profession (please specify):

Artisan Farmer Government employee Journalist Merchant Military Professional Student Unemployed Other

3.10 Education: Primary School Secondary School University Graduate study (Please check the box indicating the highest level of education attained)

(names of schools and universities attended):

3.11 Political affiliation or sympathies of the victim:

3.12 Membership/support of other organizations (please specify):

association of students:

community association:

human rights group:

peasant movement:

political party:

popular movement:

religious community:

trade union:

youth group:

other:

3.13 Other comment/information about the victim:

B. Incident (If there were several incidents, please note here the incident which occurred earliest in time and attach supplementary sheets (pp. 4-7) for other incidents.)

4. What happened to the victim specified above:

4.1 Date and time of violation: day: month: year: time:

4.2 Place (town/city/community, department/province - exact place or address, if possible):

4.3 Circumstances of the incident

Recitation of the facts (for example: in case of an arrest, how did it occur?; in case of a killing, description of the killing; in case of a disappearance, circumstances of the seizure or place where the person was last seen and where was he/she heading to, etc.; if there were threats or extortions, describe them; if it concerns a displaced person, what was the reason for his/her departure?)

4.4 Apparent Violation (please specify briefly the elements of the violation and nature of person responsible)

Arrest:

Perpetrator(s)(use list in 4.7 below and identify as person in 4.7.a., b, etc.:

Other detention:

Perpetrator(s) (use list in 4.7):

Rape:

Perpetrator(s) (use list in 4.7):

Other torture:

Perpetrator(s) (use list in 4.7):

Other ill-treatment:

Perpetrator(s) (use list in 4.7):

Killing:

Perpetrator(s) (use list in 4.7):

Attempted killing:

Perpetrator(s) (use list in 4.7):

Disappearance:

Perpetrator(s) (use list in 4.7):

Violation of freedom of association:

Perpetrator(s) (use list in 4.7):

Violation of freedom of expression:

Perpetrator(s) (use list in 4.7):

Threat:

Perpetrator(s) (use list in 4.7):

Theft of property:

Perpetrator(s) (use list in 4.7):

Other form of persecution:

Perpetrator(s) (use list in 4.7):

Discriminatory conduct:

Perpetrator(s) (use list in 4.7):

Other:

Perpetrator(s) (use list in 4.7):

4.5 How many persons where responsible for the violations during this incident? 1 2 3 4 5 6-10 11-15 more than 16

4.6 Can you identify any of these perpetrators? Why are they believed to be soldiers, police officers, or otherwise associated with the Government?

4.7 Name/Surname (or other Connection with Government, e.g., identification) army unit, police, etc.)

a.____________________________ ____________________________________

b.____________________________ ____________________________________

c.____________________________ ____________________________________

d.____________________________ ____________________________________

e.____________________________ ____________________________________

4.8 How were the perpetrators dressed?

Uniform Civilian dress

If uniform, colour of uniform: khaki olive green blue black

Boots: yes no Helmet: yes no Mask: yes no

Other identifying clothing or insignia :

4.9 How did the perpetrators reach the place of the incident?

on foot

characteristics (type (e.g., jeep), make, colour, insignia, license no.) on motorcycle :

in police vehicle :

in army vehicle :

in another official vehicle :

in taxi :

in private vehicle :

4.10 Were they carrying weapon(s)?

yes

no

If so, what?

4.11 Were they carrying radios or other telecommunication device?

yes

no

4.12 Did they speak among themselves? If so, did they use any names or other identifications?

4.13 Who was giving the orders?

4.14 How many people were victims of the same violations during this incident? 1 2 3 4 5 6-10 11-15 more than 16

4.15 Can you identify any of these other victims?

Name/Surname (or other identification) Means of contacting (address, etc.)

a.___________________________________ _________________________________

b.___________________________________ _________________________________

c.___________________________________ _________________________________

d.___________________________________ _________________________________

e.___________________________________ _________________________________

4.16 Were there other witnesses (other than victims)? Is it possible to contact them? Please attach their version of the events on another questionnaire.)

4.17 Name/Surname (or other identification) Means of contacting (address, etc.)

a._____________________________________ _________________________________

b._____________________________________ _________________________________

c._____________________________________ _________________________________

d._____________________________________ _________________________________

e._____________________________________ ________________________________

C. Arrest

5. If an arrest has been carried out: Was there an arrest warrant? yes no What kind of an arrest warrant?

5.1 Reasons given by the authorities for the arrest/what are the charges brought against the detainee? Specify the acts of which the detainee has been accused? When?

5.2 Has the victim been formally charged? , give specific details of charges brought against him/her? Has the victim been sentenced? (give dates)?

5.3 Has the victim seen an attorney since the arrest? yes no If so, give his/her name and address:

5.4 Name and apparent location of detention centre:

5.5 Other detainees who could be identified:

Name (or other identification) Means of contacting family (address, etc.)

a.____________________________ ____________________________________

b.____________________________ ____________________________________

c.____________________________ ____________________________________

d.____________________________ ____________________________________

e.____________________________ ____________________________________

5.6 Date of release: Day____ Month____ Year____

D. Torture/ill-treatment

6. At what moment did the torture/ill-treatment take place?

at the moment of arrest

during transport

while in detention

during the interrogation

other (specify:)

6.1 Describe precisely the nature, duration, and frequency of torture

Try to give details as to the type of torture, for example:

Beating to the head, feet, hands, other :

Using fist, club, gun, other:

Restriction on movements:

Suspension:

Asphyxiation:

Electrical shocks:

Sexual assault or other form of sexual violence :

Threats to family:

Mock execution:

Isolation (period, location):

Excessive noise, light, or smell:

Other (specify):

6.2 Was there any purpose for the torture given?

yes

no

If so, what was it?

6.3 Were you questioned during torture?

yes

no

6.4 Personnel who participated (how many ____; security , military , please give names if possible; who did what? Same as in question 4.9 above)

6.5 Is there any physical or psychological consequence of torture evident on date (d: m: y: ) when the victim was viewed?

yes

no

If so, what was it?

6.5.1 Does the victim require medical treatment?

yes

no

Iif so, what kind?

6.6 In the opinion of the source of information, what were the authorities' reasons for the violation, and which activities of the victim have really motivated the authorities to this violation?

6.7 Prison conditions in detention centre (for example, solitary confinement, right to visits and correspondence, quantity and quality of food, access to fresh air and exercise, number of prisoners per cell)

6.8 Have the victim or his/her family, previously been subjected to other violations? yes no What kind of violations?

6.9 Has money been given to the authorities?

yes

no

Or have the authorities requested money to stop or to prevent a violation or to improve the condition of the victim?

yes

no

How much money was given?

or requested?

6.10 Were injuries suffered?

yes

no

If so, please specify:

6.11 What is the actual situation of the victim?

6.12 Actual situation of his/her family and close relations -- have they been threatened/prosecuted/harassed? yes no Or have they been subject to other violations?

yes

no

if so, please specify:

E. Various information

7. Has the witness (yes no ), the victim (yes no), and/or someone else (yes no) reported the case to the authorities?

7.1 If yes, to which authorities?

authorities responsible for the violation (please specify):

police:

judicial authorities:

prosecutor:

investigating judge:

court:

ombudsman:

other:

7.2 Has the witness and/or victim reported the case to a nongovernmental organization or other intergovernmental organization?

yes

no

Iif so, please specify:

7.3 Did the above organization(s) take action?

yes

no

If so, please specify:

7.4 What does the source of information/the victim/witness want the human rights officer or the UN human rights operation to do?

7.5 What action has been undertaken by the human rights officer with the

authorities responsible for the violation (please specify):

verification of information received (please specify):

police:

judicial authorities:

prosecutor:

investigating judge:

court:

ombudsman:

other:

7.7 Response given by the authorities

a) authorities responsible for the violation:

b) police:

b) judicial authorities:

c) other authorities (please specify):

7.8 Are documents annexed to this report? yes no , if so, please specify:

7.9 Other comments:

7.10 Date of interview: __/__/__

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7.11 Date of this report: __/__/__

D M Y

7.12 Preparer(s) of this report:

After the interview is done and this questionnaire form is completed, if the witness/victim is still accessible or can return to the office, the interviewer may, to the extent possible and consistent with security, read everything which has been written on this questionnaire and ask whether the information is accurate or whether corrections should be made. If the witness/victim agrees with the information written on this questionnaire, the interviewer may ask if the witness/victim wishes to sign the document or place his/her thumb print below:

This form is an accurate account of my statement.

___________________________ Dated __/__/__

(Signature or thumb print) D M Y

7.13 Coordinator:

7.14 Date the report was forwarded to the central office: __/__/__

D M Y