LIFE reference no:
Date form completed:
Against which State(s):
Who is completing this questionnaire on behalf of the victim:
Ⅰ. Identity:
Family name: Latin:

First name: Latin:

Sex: Male Female
Birth date or year at least:
Place of violation:
Nationality / Nationalities:
Identity document(if any):
Issued by:
On date:
No. :
Profession and/or activity:(if believed to be relevant to the arrest/detention)
Address of usual residence:
Family status: Married   Single
Has Children: Yes No
Nationality of spouse:
Nationality of children:
Family address:
Contact details of:
• Family:
• Lawyer/Advocate:
Place of violation:
Ⅱ. Arrest:
Date of arrest:
Where arrested from (city, province etc)?
Identity of force(s) who carried out the arrest or are believed to have carried it out:
Were they in uniform or civilian clothes?
Did they show a warrant or other decision by a public authority? Yes No
Date of the charge:
Nature of charges/ Accusations (or any available details you may have)
Circumstances of arrest (eg mistreatment, beaten)
All places of detention(indicate any transfer and present place of detention):
Dates from:
Was /Is there any incommunicado detention? (this is considered torture) If yes, which dates, where and by whom? Yes No

When did the family last have contact with the detainee?
How frequently/many times have family had contact with detainee? Please provide details:
Current place of detention (if relevant):
Ⅲ. Circumstances surrounding torture
Indication of the forces carrying out the torture:
Description of the form of torture used and injury suffered as a result. (specific details, any particular methods etc)
What was believed to be the purpose of the torture?
Were any person, such as a lawyer, relatives or friends permitted to see the victim during the detention? If so, how long after the arrest? Were other members of the family tortured or mistreated? Yes No

Ⅳ. Confessions under torture:
Any confessions made under torture? Yes No
Was he permitted to read the confession(s)? Yes No
Confessions under torture used in court? Yes No
If relevant, was the Court informed of torture – specify the Court, and if you can when and by whom?
Did the Court take notification of torture into account and/or order and investigation? Yes No
Lawyer Details (if applicable)
Final Sentence:
Date of release:
Ⅴ. Medical
Was the victim examined by a doctor at any point during or after his/her ordeal? Yes No
Was the examination performed by a prison or government doctor?
Was appropriate treatment received for injuries sustained as a result of the torture? Yes No
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? Yes No
Were any medical reports or certificates issued?If so, what did the reports reveal? Yes No

If the victim died in custody, was an autopsy or forensic examination performed and what were the results? Yes No

Ⅵ. Other Legal 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? Yes No

Situation of family members – eg women and children (problems they are facing, eg harassment, health):
Any other details?
Who is completing this questionnaire on behalf of the victim ?
What is their relation to the victim?
Contact details of the person completing the questionnaire:
Would you like LIFE to submit the information about the victim to the United Nations? Yes No
Would you like LIFE to speak about the case in public (for example: press release)? Yes No