Model questionnaire to be completed by persons alleging torture or their representatives
Information on the torture of a person should be transmitted to the Special Rapporteur in written form and sent to:
Special Rapporteur on Torture
c/o Office of the High Commissioner for Human Rights
United Nations Office at Geneva
CH-1211 Geneva 10, Switzerland
Although it is important to provide as much detail as possible, the lack of a comprehensive accounting should not necessarily preclude the submission of reports. However, the Special Rapporteur can only deal with clearly identified individual cases containing the following minimum elements of information:
a. Full name of the victim;
b. Date on which the incident(s) of torture occurred (at least as to the month and year);
c. Place where the person was seized (city, province, etc.) And location at which the torture was carried out (if known);
d. Indication of the forces carrying out the torture;
e. Description of the form of torture used and any injury suffered as a result;
f. Identify of the person or organization submitting the report (name and address, which will be kept confidential).
Additional sheets should be attached where space does not allow for a full rendering of the information requested. Also, copies of any relevant corroborating documents, such as medical or police records should be supplied where it is believed that such information may contribute to a fuller accounting of the incident. Only copies and not originals of such documents should be sent.
I. Identity of the person(s) subjected to torture
A. Family Name
B. First and other names
C. Sex: Male Female
D. Birth date or age
G. Identity card number (if applicable)
F. Activities (trade union, political, religious, humanitarian/ solidarity, press, etc.)
G. Residential and/or work address
II. Circumstances surrounding torture
A. Date and place of arrest and subsequent torture
B. Identity of force(s) carrying out the initial detention and/or torture (police, intelligence services, armed forces, paramilitary, prison officials, other)
C. Were any person, such as a lawyer, relatives or friends, permitted to see the victim during detention? If so, how long after the arrest?
D. Describe the methods of torture used
E. What injuries were sustained as a result of the torture?
F. What was believed to be the purpose of the torture?
G. Was the victim examined by a doctor at any point during or after his/her ordeal? If so, when? Was the examination performed by a prison or government doctor?
H. Was appropriate treatment received for injuries sustained as a result of the torture?
I. Was the medical examination performed in a manner which would enable the doctor to detect evidence of injuries sustained as a result of the torture? Were any medical reports or certificates issued? If so, what did the reports reveal?
J. If the victim died in custody, was an autopsy or forensic examination performed and which were the results?
III. Remedial action
Were any domestic remedies pursued by the victim or his/her family or representatives (complaints with the forces responsible, the judiciary, political organs, etc.)? If so, what was the result?
IV. Information concerning the author of the present report:
A. Family Name
B. First Name
C. Relationship to victim
D. Organization represented, if any
E. Present full address