This form is for victims of detention, abduction, or enforced disappearance, please answer all the questions. Questions with a ‘*’ are mandatory, so we are able to take steps to document and follow, which will allow more consideration of the case.

*Do you have an authorization by the victim’s family to directly submit the form on their behalf?
YesNo

*Will you be able to follow and transfer information between the family and SNHR team in case any further explanations were needed?
YesNo

Victim’s Information:

*First Name:

*Last Name:

*Father’s Name:

Mother’s Full Name:

Birth Date:

Birth location:

*Gender:
MaleFemale

Job / Profession (before the violation):

*Was the victim under 18 years of age at the time of the violation?
YesNo

Nationality:

Place of Residence:

Social Status:
SingleMarriedWidowed

Information Regarding the Incident:

*Date of arrest / abduction / enforced disappearance
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*(location of detention, abduction, enforced disappearance) be as specific as possible.

*(last date the victim was seen)
2011201220132014201520162017201820192020 0123456789101112012345678910111213141516171819202122232425262728293031

*(last date the victim was seen)

*(please, give a full description as to how the detention/abduction transpired)

*Party responsible for the detention / abduction, please explain why you think this party is the responsible one

*If there were any witnesses to the incident, please give their names, relation to the victim. If they wish to keep their identity confidential please clarify, if they are relatives, pass-byers, or else. If there is an evidence, please point it out.

*If there were any witnesses to the incident, please give their names, relation to the victim. If they wish to keep their identity confidential please clarify, if they are relatives, pass-byers, or else. If there is an evidence, please point it out.

*Attach an image of the victim or any related documents

Information about the Information Recorder:

*Name:

Relation to Victim:

*Provider number or email:

The information and its source are confidential and unavailable to share unless for the sake of documentation or in the service of any related human rights report.