Emergency Help

Name of the victim (as on your ID)

First Name

Family Name

Known as (write pseudonyms or other names you have been known as):

Gender
MaleFemale

Date of birth (or approximate age, if date of birth unknown):

Address of usual residence:

Contact Details (if we need to get in touch with you to discuss your case further):

Phone Number:

Email:

Occupation(s) or profession:

What human rights activity you have been/are engaged in (give details of your human rights activities and give details of area/town/district you are usually conducting your human rights work):

Family details (i.e. whether married, how many children and dependants, etc.) – please give dates of birth where possible:

Details of the Incident
1) Date/ time when the threat/incident occur (during the day, night, etc)

2) Exact location of the incident Specify: at home/office/on the road, etc Which Town, District, Province:

3) Details of what exactly happened - Verbal threat: write down the exact words; give phone number if made by phone; give the name of the person threatening you, if known, what language they spoke, did they have any accent? - Threatening letter – please send a copy of the letter - Subjected to physical attack/harassment – please give details about the incident - arrest, beating, armed attack, sexual harassment, domestic violence as punishment for your work, attack on family member because of your work, etc

4) Who made the threat/abuse (please be specific – how many people were the abusers, if vehicle was used any specific marks, number plate of the car, clothes of assailants/uniforms, were they armed, other identification)

5) If you think the abusers were linked to the government or Afghan forces, or specific armed militia group - Why do you think so (give details):

6) Were there any other victims? If so provide details if you know – who they are; what are their relationship with you, what are their occupation, etc

7) Were there any witnesses to the abuse? - Who? What were they doing at the time of the threat/attack?

8) Explain why you think the threat/attack was as result of your work of defending human rights. - Was the incident linked to a particular activity of defence of human rights you have done and why (be specific)

9) Explain if you think the abuse/threat relate to the political, social, religious or cultural context you are working in.

10) Did you report the incident to the authorities (if yes, which one and what was their response; if not, explain why) - provide copy any official complaint documents if available

11) Did you report the incident to any local or international organization or to the media? -If so which one and what was the response?

12) Give details of any previous threats/attacks in connection to you human rights work.

13) What do you require SRMO to do to assist in your situation? - Please give details of your current needs as result of the threat/attack against you because of your human rights work

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