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GABRIELA RODRIGUEZ PIZARRO QUESTIONNAIRE FOR
ALLEGATIONS OF VIOLATIONS OF MIGRANTS' HUMAN RIGHTS
1. The objective of this questionnaire is to have
access to precise information on alleged violations of the human rights of
migrants. The Special Rapporteur may raise her concerns about the incidents
reported and request Governments to make observations and comments on the
matter. 2. Please indicate whether the information provided is
confidential (in the relevant sections). 3. Should the information you wish to provide relate to
conditions/policies/practices or laws (ie more general situations), which
affect the human rights of migrants, please do not use this form. A special form
will be provided at a later date to address the issue of good practice and/or
negative developments with regards to the protection of the human rights of
migrants. Meanwhile you may send that type of information without completing
a form to the contact numbers indicated at the end of the questionnaire. 4. Do not hesitate to attach additional sheets, if the
space provided is not sufficient.
1. GENERAL INFORMATION: (Please mark with an X when
appropriate) o Does the incident involve an individual _______ or a
group______ ? o If it involves a group please state the number of
people involved ____________ and the characteristics of the group: Number of
Men ________ o Number of Women ________ o Number of Minors ________ o Country in which the incident took place
_______________________________________________ o Nationality of the victim(s)
__________________________________________________________ 2. IDENTITY OF THE PERSONS CONCERNED: 1. Family name: ______________________________ 2. First name: ___________________________________ 3. Sex: __ male __ female 4. Birth date or age: ____________________________ 5. Nationality(ies): _____________________________ 6. Civil status (single, married, etc.): _________ 7. Profession and/or activity (e.g. trade union,
political, religious, humanitarian/solidarity/human rights, etc.)
_____________________________________________ 8. Status in the country where the incident took place:
o Undocumented_______________________________ o Transit _______________________________________ o Tourist _______________________________________ o Student _______________________________________ o Work Permit ___________________________________ o Resident ______________________________________ o Refugee _______________________________________ o Asylum seeker _________________________________ o Temporary protection __________________________ o Other (please specify) ________________________ 3. INFORMATION REGARDING THE ALLEGED VIOLATION 0. Date: 1. Place: 2. Time: 3. The nature of the incident: Please describe the
circumstances of the incident: 4. Was any consular official contacted by the alleged
victim or the authorities? (Please explain) 5. Was the alleged victim aware of his/her right to
contact a consular official of his/her country of origin? (Please explain) 4. AGENTS BELIEVED TO BE RESPONSIBLE FOR THE ALLEGED
VIOLATION o State Agents (specify) ________________________ o Non - state Agents (specify) __________________ o If it is unclear whether they were state or non -
state agents please explain why? o If the perpetrators are believed to be State agents,
please specify (military, police, agents of security services, unit to which
they belong, rank and functions, etc.) and indicate why they are believed to
be responsible; be as precise as possible: o If an identification as State agents is not
possible, do you believe that Government authorities, or persons linked to
them, are responsible for the incident, why? 5. STEPS TAKEN BY THE VICTIM, HIS/HER FAMILY OR ANY ONE
ELSE ON HIS/HER BEHALF 6. IDENTITY OF THE PERSON OR INSTITUTION SUBMITTING
THIS FORM o Institution __________ o Individual _______________ o NAME _____________________ o Contact number or address (please indicate country
and area code): ________________ o FAX : ____________________ o TEL: _____________________ o Email: ___________________ o Date you are submitting this form:
_________________________
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