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Full name as it appears on the passport or the residency permit in English*
Full name in Arabic*
Personal number also known as CPR:*
A copy of the residency permit or the smart card*
Address and place of residency*
Date and place of the arrest*
Reason for the arrest/did authorities state the reason*
Officers in plain/civilian clothing (i.e. no uniform, no insignia present)
Officers from the Ministry of Interior (including riot police and security police forces, and Criminal Investigations Directorate officers)
Officers from the National Security Agency*
Was an arrest warrant or any other official document presented at the time of the arrest?
Who issued the warrant?
Was the victim disappeared during his detention (if so, please provide a brief explanation, including the dates and times during which he/she was disappeared)
The charges and the number of cases (cases issued by both the civil court and the military court):
Date of Appeal and outcome (upheld or overturned):
Court of Cassation and outcome (upheld or overturned):
Name of the lawyer:
Was the victim denied access to his attorney:
Did the victim have adequate time and facilities to prepare for trial:
Was the victim able to present evidence and challenge evidence
presented against him/her:
Was the victim brought promptly before a judge (i.e.: within 48 hours
after an arrest):
When was the victim first able to contact their family?
How long was the individual interrogated, and was their lawyer
permitted to attend?
Was the victim transferred between multiple locations during this time? If so please provide the locations and dates:
What are the violations he witnessed during the investigation (torture,
mistreatment, etc...)?In what prison is he?
We need the case file:
The entity that initiated torture:
When did the torture happen:
Place of torture
Was anyone allowed to meet him during detention
Methods of torture
Injuries resulting from torture
The treatment he received
The reason for torture according to you
Did the victim confess after torture
Was this confession used in the trial against him
Did the victim ask for a doctor?
Was the victim examined?
Is there a medical record? Yes/no (if yes please attach):
Doctor’s contact information (please attach if available):
Did you file any complaints to any governmental organization or human rights organization, and what was is about? (detention or torture or irreverence in medical care) (If available please state dates and numbers of complaints):
Ministry of Interior, Ombudsman: Y/N ; date of complaint ; any follow-up from the organization
National Institute for Human Rights: Y/N ; date of complaint ; any follow-up from the organization
sex/gender, language, political or other opinion, national or social origin, property, or for any other reason (if so, please provide an explanation)?:
Do you agree to empower the organization to represent the detainee or his family before international bodies, before the ombudsman, and also before the National Human Rights Institution (if yes, we will send you the application form to sign)?
Other useful information:
Your Email (required)
Username or email address *
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