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Individual complaint form

1. PETITIONER : (This information, if taken up by the Special Rapporteur, will remain confidential).

(a) Name of person/organization: ...................................................................................................................................................................................
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(b) relationship to victim(s).............................................................................................................................................................................................

(c) Address:
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(d) Fax/tel/e-mail, web-site: ..........................................................................................................................................................................................

(e) Date petition sent:....................................................................................................................................................................................................

(f) Other: .....................................................................................................................................................................................................................

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2. ALLEGED INCIDENT

(i) information about the victim(s):

(a) Name: ...................................................................................................................................................................................................................


(b) Sex: ...................................................................................... (c) Date of Birth or Age:............................................................................................

(d) Nationality:.............................................................................................................................................................................................................

(e) Occupation: ...........................................................................................................................................................................................................

(f) Ethnic / religious / social background, if relevant: ......................................................................................................................................................

(g) Address: ...............................................................................................................................................................................................................
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(h) Other relevant information: (such as passport, identity card number):

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(i) Has the victim(s) given you her consent to send this communication on her behalf? .....................................................................................................

(j) Has the victim(s) been informed that, if the Special Rapporteur decides to take action on her behalf, a letter concerning what happened to her will be sent to the authorities?

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(k) Is the victim(s) aware that, if this communication is taken up, a summary of what happened to her will appear in a public report of the Special Procedures of the Human Rights Council?

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(l) Would the victim(s) prefer that her full name or merely her initials appear in the public report of the Special Procedures of the Human Rights Council? ..............................................

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(Please note that the full names of victims appear in communications with governments unless it is indicated that exposing the victims’ names to the government would place the victims at risk of further harm. In the public report, the names of victims under the age of 18 and victims of sexual violence will not be disclosed, but initials or letters in alphabetical or random order will be used)

(ii) information regarding the incident:

(a) Detailed description of human rights violation:
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(b) Date: ..................................................... (c) Time: .................................................... (d) Location/country: .........................................................

(e) Number of assailants: .........

(f) Are the assailant(s) known or related to the victim? If so, how? ................................................................................................................................

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(g) Name or nickname of assailant(s) (if unknown, description, scars or body marks such as tattoos, clothes/uniform worn, title/status, vehicle used): ................................................................................................................................................................................................................................
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(h) Does the victim believe she was specifically targeted because of her sex?
If yes, why? .............................................................................................................................................................................................................
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(i) Has the incident been reported to the relevant State authorities? ..............................................................................................................................
If so, which authorities? ............................................................................................................................................................................................
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When? ....................................................................................................................................................................................................................

(j) Have the authorities taken any action after the incident? .........................................................................................................................................
If so, which authorities? ...........................................................................................................................................................................................
What action? ...........................................................................................................................................................................................................
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When? ....................................................................................................................................................................................................................

(l) If the violation was committed by private individuals or groups (rather than government officials), include any information which might indicate that the Government failed to exercise due diligence to prevent, investigate, punish, and ensure compensation for the violations.

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(m) Has the victim seen a doctor after the incident took place? Are there any medical certificates/notes relating to the incident concerned?

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(iii) Laws or policies which are or are likely to cause or contribute to violence against women

(a) If your submission concerns a law or policy, please summarize it and the effects of its implementation on women’s human rights. Provide concrete examples, when available.

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Please inform the Special Rapporteur of any further information which becomes available after you have submitted this form, including if your concern has been adequately addressed, or a final outcome has been determined in an investigation or trial, or an action which was planned or threatened has been carried out.

PLEASE RETURN TO
THE SPECIAL RAPPORTEUR ON VIOLENCE AGAINST WOMEN, OFFICE OF THE HIGH COMMISSIONER FOR HUMAN RIGHTS,
OHCHR-UNOG, 1211 GENEVA 10, SWITZERLAND
(Fax: + 41 22 917 9006, e-mail: urgent-action@ohchr.org