Akha Culture

CONFIDENTIAL

VIOLENCE AGAINST WOMEN

INFORMATION FORM

INFORMER: the name and address of the person/organization submitting the information will remain confidential. Please also mention whether we can contact you for additional information, and if so by what means.

Name of person/organization: ..........................................................

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Address:

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Fax/tel/e-mail: ..............................................................................

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VICTIM(S): information about the victim(s) including full name, age, sex, residence, professional and/or other activities related to the alleged violation, and any other information helpful in identifying a person (such as passport or identity card number). Please mention whether the victim is willing for the case to be transmitted to the Government concerned.

Name: .........................................................................................

Address: ......................................................................................

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Date of birth: ...............................................................................

Nationality: .................................................................................

Sex: ..........................................................................................

Occupation: ................................................................................

Ethnic background, religious, social group (if relevant): .......................

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THE INCIDENT: including dates, place, and the harm suffered or to be prevented. If your submission concerns a law or policy rather than a specific incident, summarize the law or policy and the effects of its implementation on women’s human rights. Include information about the alleged perpetrators: their names (if known), any relationship they may have to the victims and/or to the Government, and an explanation of the reasons why you believe they are the perpetrators. If you submit information about violations 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. Include information about the steps taken by the victims or their families to obtain remedies including complaints filed with the police, other officials or independent national human rights institutions. If no complaints have been filed, explain why not. Include information about steps taken by officials to investigate the alleged violation (or threatened violation) and to prevent similar acts in the future. If a complaint has been filed, include information about the action taken by the authorities, the status of the investigation at the time the communication is submitted, and/or how the results of the investigation are inadequate.

Date: ................ Time: ............. Location/country: ..........................

Number of assailants: ......... Are the assailant(s) known to the victim? ...........

Name of assailant(s): ......................................................................

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Does the victim have a relationship with the assailant(s)? If so what is the nature of the

relationship? ..................................................................................

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Description of the assailant(s) (include any identifying features):

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DESCRIPTION OF THE INCIDENT:

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Does the victim believe she was specifically targeted because of gender? .....

If yes, why? .................................................................................

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Has the incident been reported to the relevant State authorities? ..........

If so, which authorities and when? ....................................................

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Have the authorities taken any action after the incident? .....................

If so, which authorities? ................................................................

What action? ...............................................................................

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When? ........................................................................................

WITNESSES: Were there any witnesses? .........................................

Name/age/relationship/contact address:

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Please bring to the attention of the Special Rapporteur any information which becomes available after you have submitted this form. For example, please inform the Special Rapporteur if your human rights 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

OHCHR-UNOG, 1211 GENEVA 10, SWITZERLAND

(Fax: 00 41 22 917 9006, e-mail: csaunders.hchr@unog.ch)