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:
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(e) Date petition
sent:....................................................................................................................................................................................................
(f) Other:
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2. ALLEGED INCIDENT
(i) information about the
victim(s):
(a) Name:
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(b)
Sex:
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(c) Date of Birth or
Age:............................................................................................
(d)
Nationality:.............................................................................................................................................................................................................
(e) Occupation:
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(f) Ethnic / religious / social background, if
relevant:
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(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?
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(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 Rapporteur?
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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
Rapporteur?
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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 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:
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(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?
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If
so, which authorities?
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When?
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(j) Have the authorities taken any action after the
incident?
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If
so, which authorities?
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What
action?
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When?
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(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 TOTHE
SPECIAL RAPPORTEUR ON VIOLENCE AGAINST WOMEN, OFFICE OF THE HIGH
COMMISSIONER FOR HUMAN RIGHTS,OHCHR-UNOG, 1211
GENEVA 10, SWITZERLAND(Fax: 00 41 22 917
9006, e-mail:
urgent-action@ohchr.org