|
The United Nations Human Rights Treaties |
Complaint Form to the Committee on the Rights of Persons with Disabilities1. Information concerning the author(s) of the communication
Family name ..............
First name(s) ......
Date and place of birth ..
Nationality/citizenship ......
Sex .
Other relevant personal identification data (if any of the above details are not available) . ..
Present address . . . ..
Mailing address for confidential correspondence (if other than present address) . . .
Telephone or mobile number (if any) ...
E-mail address (if any) .
Fax number (if any) .
If you are submitting the communication on behalf of the alleged victim(s), please provide evidence showing the consent of the victim(s), or reasons that justify submitting the communication without such consent ..
2. Information concerning the alleged victim(s)
Family name ..............
First name(s) ......
Date and place of birth ..
Nationality/citizenship ......
Sex .
If you consider it appropriate, please indicate whether the alleged
victim(s) has a disability and, if so, the nature of their disability
Other relevant personal identification data (if any of the above details are not available) . ..
Present address . . . ..
Mailing address for confidential correspondence (if other than present address) . . .
Telephone or mobile number (if any) ...
E-mail address (if any) .
Fax number (if any) .
If the communication concerns a group of individuals claiming to be victims, please provide basic information about each individual, in line with the above list
3. Information on the State party concerned
Name of the State party (country)
4. Subject matter of the communication
... .... ... ...
5. Nature of the alleged violation(s)
Please provide detailed information to substantiate your claim, including:
Description of the alleged violation(s), specifying the acts or omissions that prompted the communication ............................................... ................................................................................................... ...... .................................................................................................................
Details of the perpetrators of the alleged violation(s) ..................... .....................................................................................................
Date(s) ........ .
Place(s) ...... ..
Insofar as possible, please indicate which provisions of the Convention were allegedly violated. If the communication refers to more than one provision, describe each issue separately .............................. . .................................... ............................................................................
6. Steps taken to exhaust domestic remedies
Describe the action taken to exhaust domestic remedies in the State party in which the alleged violation(s) of rights protected under the Convention occurred, such as attempts to obtain legal or administrative redress. Any complaint submitted to the Committee must first have been submitted to the national courts and authorities for consideration.
In particular, please indicate:
Type(s) of action taken by the alleged victim(s) to exhaust domestic remedies, such as decisions of domestic courts
Authority or body addressed
Name of the court hearing the case (if any)
Date(s)
Place(s)
Who initiated the action or sought a solution
Key points of the final decision of the authority, body or court addressed
If domestic remedies have not been exhausted, please explain why:
Note: Please enclose copies of all relevant documentation, including copies of legal or administrative decisions or domestic legislation related to the case or summaries of such decisions or legislation in one of the working languages of the Secretariat (English, French, Spanish or Russian).
7. Other international procedures
Has the same matter already been examined or is it being examined under another procedure of international investigation or settlement?
If yes, explain:
Type of procedure(s)
Body or bodies addressed
Date(s)
Place(s)
Results (if any)
Note: Please enclose copies of all relevant documentation.
8. Specific requests/remedies
Please detail the specific requests or remedies that are being submitted to the Committee for consideration.
9. Date, place and signature
Date of communication:
Place of signature of communication:
Signature of author(s) and/or alleged victim(s):
10. List of documents attached
Note: Do not send originals, only copies.
11. Address for submission of the communication
Please send your communication to:
Petitions Team
Office of the United Nations High Commissioner United Nations Office at Geneva 1211 Geneva 10, Switzerland E-mail: tb-petitions@ohchr.org Fax: +41 22 917 90 22
|