By submitting this form, I certify that I consent to provide the information included in this document OR that I received the consent of all information sources who provided the information included in this document.

Information of the Preparer of this Document

Name of individual

Email: "Optional"

Nationality

Profession

Employer

Address

Relationship to victim (if applicable)

Information about the Incident

Date of incident

Geographic location of incident

Type of incident

Name of individual

Who/What has been affected by the incident?

Health StructureMedical PersonnelPatient(s)Other, Please Specify

If Health Structure(s) Affected or Attacked

Type of health structure

HospitalMedical vehicle(s)Underground ClinicMobile ClinicOther, Please specify

Geographic location of health structure

Location of closest military objective

Medical Personnel Affected or Attacked

Number of medical personnel

Name(s)

Specialization

i- If Arrest

a) Date of arrest

b) Was a warrant or other public document shown at time of arrest?

YESNO

c) Authority who issued warrant

d) Forces who carried out the arrest

e) Describe the circumstances of arrest

ii- If Detention

a) Date of beginning of detention

b) Date of end of detention (if applicable)

c) Forces holding detainee in custody

d) Geographic location of detention (please indicate dates of transfers, if any):

e) Authorities that ordered detention

f) Reason for intention, as stated by authorities

g) Has the detainee been subjected to a travel ban?

YESNO

h) Has detainee been in touch with family members?

YESNO

i)Has detainee been able to access legal assistance?

YESNO

j)Has detainee been able to access medical care while in custody?

YESNO

iii- If Torture

e) Forces carrying out torture

e) Date of torture

e) Geographic location of torture

e) Methods of torture

e) Description of specific abuses and techniques employed

e) Injuries sustained

h) Was victim examined by doctor?

YESNO

e) Describe treatment for injuries sustained (if any)

h) Did the victim die in custody?

YESNO

e) Date of death (if applicable)

iv- If Disappearance

a) Date of disappearance

b) Geographic location where disappeared person was last seen:

c) Force(s) believed to have carried out the disappearance:

v- If killing

a) Date of killing

b) Place of killing

c) Number of medics killed

d)Force(s) believe to have undertaken the killing:

h)Did the killing occur during arrest or while in custody?

YESNO

h) Have the relevant authorities investigated the killing?

YESNO

h)Have the relevant authorities provided compensation to the families of the victim?

YESNO

4.Please describe any other information that you feel is pertinent.

5.Please describe any national or international efforts undertaken in response to the incident:

If Patient(s) Affected or Attacked

1. Number of patient(s)

1. Name(s)

i- If Arrest Occurred during Hospitalization

a) Date of arrest

b) Geographic location of arrest

c)Was a warrant or other public document shown at time of arrest?

YESNO

d) Authority who issued warrant

e) Forces who carried out the arrest

d) Describe the circumstances of arrest

ii- If Detention

a) Date of beginning of detention

b) Date of end of detention (if applicable)

c) Forces holding detainee in custody

d) Geographic location of detention (please indicate dates of transfers, if any):

e) Authorities that ordered detention

f) Reason for intention, as stated by authorities

g) Has the detainee been subjected to a travel ban?

YESNO

h) Has detainee been in touch with family members?

YESNO

i) Has detainee been able to access legal assistance?

YESNO

j) Has detainee been able to access medical care while in custody

YESNO

iii- If Torture

a) Date of torture

b) Geographic location of torture

c) Methods of torture

d) Reason for intention, as stated by authorities

e) Description of specific abuses and techniques employed

f) Injuries sustained

g) Was victim examined by doctor

YESNO

h) Describe treatment for injuries sustained (if any)

i) Did the victim die in custody

YESNO

h) Date of death (if applicable)

vi- If Disappearance

a) Date of disappearance

b)Geographic location where disappeared person was last seen:

c) Force(s) believed to have carried out the disappearance:

iv- If killing

a) Date of killing :

b) Place of killing :

c) Number of patient(s) killed :

d) Forces believe to have undertaken the killing:

e) Did the killing occur while in custody?

YESNO

f) Have the relevant authorities investigated the killing?

YESNO

g) Have the relevant authorities provided compensation to the families of the victim?

YESNO

Please describe any other information that you feel is pertinent:

Please describe any national or international efforts undertaken in response to the incident: