Please fill out the following form in as much detail as possible.
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
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?
h) Has detainee been in touch with family members?
i)Has detainee been able to access legal assistance?
j)Has detainee been able to access medical care while in custody?
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?
e) Describe treatment for injuries sustained (if any)
h) Did the victim die in custody?
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?
h) Have the relevant authorities investigated the killing?
h)Have the relevant authorities provided compensation to the families of the victim?
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
b) Geographic location of arrest
c)Was a warrant or other public document shown at time of arrest?
d) Authority who issued warrant
e) Forces who carried out the arrest
d) Describe the circumstances of arrest
i) Has detainee been able to access legal assistance?
j) Has detainee been able to access medical care while in custody
a) Date of torture
b) Geographic location of torture
c) Methods of torture
d) Reason for intention, as stated by authorities
f) Injuries sustained
g) Was victim examined by doctor
h) Describe treatment for injuries sustained (if any)
i) Did the victim die in custody
h) Date of death (if applicable)
vi- If Disappearance
b)Geographic location where disappeared person was last seen:
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?
f) Have the relevant authorities investigated the killing?
g) Have the relevant authorities provided compensation to the families of the victim?
Please describe any other information that you feel is pertinent:
Please describe any national or international efforts undertaken in response to the incident:
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