Model
questionnaire to be completed by persons alleging
torture or
their representatives
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Information on
the torture of a person should be transmitted to the Special Rapporteur in
written form and sent c/o Office of the High Commissioner for Human Rights,
United Nations Office at Geneva, CH-1211 Geneva 10, Switzerland; E-mail: urgent-action@ohchr.org. Although it is important to provide as
much detail as possible, the lack of a comprehensive accounting should not
necessarily preclude the submission of reports. However, the Special Rapporteur
can only deal with clearly identified individual cases containing the following
minimum elements of information:
a. Full name of
the victim;
b. Date on which
the incident(s) of torture occurred (at least as to the month and year);
c. Place where
the person was seized (city, province, etc.) And location at which the torture
was carried out (if known);
d. Indication of
the forces carrying out the torture;
e. Description of
the form of torture used and any injury suffered as a result;
f. Identify of
the person or organization submitting the report (name and address, which will
be kept confidential).
Additional sheets
should be attached where space does not allow for a full rendering of the
information requested. Also, copies of any relevant corroborating documents,
such as medical or police records should be supplied where it is believed that
such information may contribute to a fuller accounting of the incident. Only
copies and not originals of such documents should be sent.
I. Identity of
the person(s) subjected to torture
A. Family Name
B. First and
other names
C. Sex: Male
Female
D. Birth date or
age
E. Nationality
F. Occupation
G. Identity card
number (if applicable)
F. Activities
(trade union, political, religious, humanitarian/ solidarity, press, etc.)
G. Residential
and/or work address
II.
Circumstances surrounding torture
A. Date and place
of arrest and subsequent torture
B. Identity of
force(s) carrying out the initial detention and/or torture (police,
intelligence services, armed forces, paramilitary, prison officials, other)
C. Were any
person, such as a lawyer, relatives or friends, permitted to see the victim
during detention? If so, how long after the arrest?
D. Describe the
methods of torture used
E. What injuries
were sustained as a result of the torture?
F. What was
believed to be the purpose of the torture?
G. Was the victim
examined by a doctor at any point during or after his/her ordeal? If so, when?
Was the examination performed by a prison or government doctor?
H. Was
appropriate treatment received for injuries sustained as a result of the
torture?
I. Was the
medical examination performed in a manner which would enable the doctor to
detect evidence of injuries sustained as a result of the torture? Were any
medical reports or certificates issued? If so, what did the reports reveal?
J. If the victim died
in custody, was an autopsy or forensic examination performed and which were the
results?
III. Remedial
action
Were any domestic
remedies pursued by the victim or his/her family or representatives (complaints
with the forces responsible, the judiciary, political organs, etc.)? If so,
what was the result?
IV.
Information concerning the author of the present report:
A. Family Name
B. First Name
C. Relationship
to victim
D. Organization
represented, if any
E. Present full
address