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Who is reporting?
First Name
Last Name
Contact Number
Email Address
Do you have preference about how and when we should contact you?
(Please write here any time and preferred method of communication)
ٰVictim’s Personal Details
First Name
Last Name
Date of Birth
Victim's Marital Status
Single
Married
Separated
Divorced
Widowed
If married, please write the names of spouse and children
City
Next of kin
(Name, Age, Contact Detail)
Incident Details
Describe what happened to you (Victim) that put you (Victim) in the situation you are in now.
When did it happen?
(Date? Time?)
Who made the arrest? How many agents were involved?
(Please explain)
Where you shown arrest and/or search warrant?
Yes
No
Where did it happen?
(Private home? Workplace? Street? Other?)
Why? Were you informed of the reasons for the arrest?
(Were you shown an arrest and/or search warrant?)
Detention
Number of days held in solitary confinement?
Date officially charged?
Dates & places detained?
Please describe the conditions you were held in?
How was the interrogation process?
Did you suffer any violence or mistreatment in prison?
Date of temporary release?
What were the charges against you?
(Please be as accurate and specific about the wording as possible)
Legal Situation
Date officially charged?
Bail amount?
Do you have a lawyer?
* If yes please write his or her name
Date of the court hearing?
Name of your judge?
What is your case number in the official court documents?
Have you had an appeal hearing? Date? Judge’s name?
Impact
Describe any effects this incident has had on your life (and the lives of your family members).
Impact on your safety?
Impact on income?
Impact on Spiritual life?
Impact on Physical health?
Impact on psychological wellbeing?
Witness/s
Do you have any witnesses who saw or can confirm what happened to you? (Name, age, relationship to you, contact details)
Request for Assistance
What kind of assistance do you require?
Legal or medical assistance?
Trauma counselling?
Discreet advocasy?
Publicity and campaign?
Other...
Any other useful information
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