Date of this report: __/__/__

D M Y

Incident Report Number: I-________

Preparing Officer(s)__________________________________

__________________________________

Area office__________________________________

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 all available information:

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

2. Identification of the witnesses:

2.1 Surname: First name(s):

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

2.2 Interview Questionnaire Number: Date of Interview:

2.3 Surname: First name(s):

2.4 Interview Questionnaire Number: Date of Interview:

2.5 Surname: First name(s):

2.6 Interview Questionnaire Number: Date of Interview:

(Attach other sheets for further witnesses)

2.7 Reliability of Information:

3. First Victim (if information contained on interview questionnaires, please identify the questionnaire number ____where the information may be found. If there are several victims, please attach supplementary pages 3 - 7)

A. General

3.1 Surname: First name(s):

3.2 Male Female (Please check a box)

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

(Check the box which is most applicable)

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

(Check the box which is most applicable)

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

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 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 What kind of arms were they carrying?

4.11 Were they carrying radios or other means of telecommunication? 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? (for example, 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 is it?

6.5.1 Does the victim require medical treatment?

yes

no

If 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 center (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

If so, what kind?

6.9 Has money been given to the authorities, 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 a witness and/or victim reported the case to a nongovernmental organization or other intergovernmental organization?

yes

no

If 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 U.N. Field Operation to do?

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

7.6 What action has been undertaken by the observer 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:

F. Recommendations

8.1 Action(s) requested of the human rights operation by the victim or next of kin in the case of a deceased or reportedly disappeared victim:

8.2 Recommendations for Follow-up by the Area Office (including further inquiry):

8.2 Recommendations for Action by Local Authorities:

8.3 Recommendations for Follow-up by the Central Office:

8.4 Recommendations for Action by National Authorities:

8.5 Recommendations for Action by other UN Bodies/Offices:

8.6 Other Recommendations:

8.7 Status of case:

9.1 Coordinator:

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

DMY