USCIRF Victims List Intake Form

Victim of (check all that apply)

Imprisonment

Detention

House Arrest

Disappearance

Torture

Forced Renunciation of Faith

Other

Please elaborate in the Summary of Circumstances section.

Date of Abuse

Perpetrator (name of country or entity*)

Only governments and entities that USCIRF recommends as “countries of particular concern” (CPCs), "special watch list" (SWLs), or “entities of particular concern” (EPCs) qualify.

Victimized based on (check all that apply)

Religious beliefs

Religious activity

Religious freedom advocacy

Expression about religion

Non-belief

Religious identity

Should this case be kept confidential?

Yes

Submitter Information (for internal use only)

Your Organization Name (if applicable)

Your Name

Your Email

Date

Phone

Victim Information

Full Name

Gender

Religion/Belief

Occupation (Mention if Religious Leader)

Location of Victimization (Village/Town, District, Province/State)

Detention Location (If Applicable and/or Known)

Official Charges and Dates of Charges (If Applicable)

Photo

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png.

Dates of Arrest/Detention/Disappearance/Event

Has case gone to trial?

Yes

Trial Date(s) (If Applicable)

Conviction Date (If Applicable)

Sentencing Date (If Applicable)

Sentence (If Applicable)

Was Victim Denied Legal Representation at Any Time

Yes

Summary of Circumstances

Please include specific information on the religious nature of the persecution experienced, including details about any instances of imprisonment, detention, forced disappearances, house arrest, torture, or forced renunciations of faith.

Potential Controversies (use or advocacy of violence, scandals, etc)

Links to sources of information

International recognition and support (if any)

Other Considerations (if any)

E.g. does victim has a spouse, children, or other dependents, health concerns, time urgency.

If you have a large number of submissions and would like to avoid filling out individual forms for each victim, please download this spreadsheet and fill in as much information for each victim as you can. The required sections are denoted in green. Once done, you may send it to [email protected]

Legal documents or additional information

One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

USCIRF Victims List Intake Form

Submitter Information (for internal use only)

Victim Information

FoRB Victims List intake spreadsheet