Victims of conscience survey

Victim Worksheet

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Purpose of worksheet Instructions for completion of worksheet Confidentiality General Report Part I - Concerns about confidentiality - Direction for disclosure - Complainant name and address General Report Part II (Pg. 1) - Date and location of incident - Nature of activity to which objection taken - Nature of conscientious objection - Position held by complainant General Report Part II (Pg. 2) - Summary of incident General Report Part III - Complainant reaction (grievance, human rights, civil action) - Consequences for complainant - Expenses incurred by complainant - Willingness to testify Persons Report Documents Elsewhere Documents I Have PURPOSE OF WORKSHEET to help conscientious objectors gather material needed for redress that may be available under existing law, and to document the problems encountered by conscientious objectors. In some cases, it may be possible to refer a complainant to legal counsel or other appropriate source of assistance or support. INSTRUCTIONS FOR COMPLETION OF WORKSHEET 1. Only those parts marked "copy to Project" should be mailed to the Protection of Conscience Project (mailing address). The remaining sections should be completed and retained for consultation with legal counsel or a human rights investigator. 2. Before completing the worksheet, determine how many different incidents are involved. Photocopy enough reports and to document all of the incidents. 3. Feel free to add or refer to other documents or additional information that you believe to be relevant. CONFIDENTIALITY Information collected will not be shared except in accordance with your directions. You may be concerned that disclosure of information about your experience may cause problems for you. Alternatively, you may simply feel uncomfortable about disclosing information. A place is provided at the beginning of the survey to express these concerns and give direction about the use of the information provided.

GENERAL REPORT PART I ( Retain original, copy to Project)			Protection of Conscience Project Victim Worksheet

CONCERNS about CONFIDENTIALITY In the space below, please indicate your concerns about completing the survey and give directions for the handling of your survey.
o	I am concerned that disclosure of this information could adversely impact my employment, application for employment or educational programmes, or professional standing.
o	I do NOT believe that disclosure of this information will have adverse consequences for me.
o	Other:




DIRECTION for DISCLOSURE The information in this survey
o	Must not be further disseminated without my permission.
o	may be disclosed only to elected political representatives who have put forward protection of conscience legislation
o	may be disclosed to anyone working to support or advance protection of conscience legislation
The following restrictions apply: (Here state conditions or restrictions you wish to impose)








Your Name:

Your Address:



Your Tel:		Your Fax:


Your Email Address:

GENERAL REPORT PART II (Pg. 1) ( Retain original, copy to Project)		Protection of Conscience Project Victim Worksheet

Incident Date (Specify date, or between dates)


Incident Location (Specify company/institution/organization and address)


Nature of Activity to which Objection Taken (Circle)
Abortion Artificial Reproduction Assisted Suicide	Causing Death Contraceptive Service Eugenic Screening	Human Experimentation Inter-species Breeding Sterilization
Other (Specify)

Counselling or referral for

Dispensing drugs/devices for

Nature of Conscientious Objection (Circle)

Religious	Moral Ethical	Philosophical

Other (Specify)

Were you a student?	No	Yes
If yes, indicate nature of coercion or discrimination below.

Statement by teacher Statement by administrator Selective discourtesy Censorship of student	Assignment of practicums Selection of essay topics Framing of lesson plans Selection of essay topics	Selection of resources Marking of papers Marking of exams Evaluation

Were you an applicant?	No	Yes For.... (Circle)

Certification Education Programme	Employment Hospital Privileges	Prof. Ass. Membership Union Membership

Other (Specify)

If you were an applicant (Circle answers):

1) Were you questioned about your willingness to participate in what you considered to be an objectionable activity? (If yes, please explain.)		Yes	No







2) Did you answer truthfully?		Yes	No

3) Was your application successful?		Yes	No

GENERAL REPORT PART II (Pg. 2) ( Retain original, copy to Project)	Protection of Conscience Project Victim Worksheet

If your application was unsuccessful, what reason was given?






If not an applicant, what was your position?



1) Had you been advised when you accepted your position that participation in the procedure in question was an expectation?	Yes	No

2) Had you previously indicated conscientious objections to the procedure in question?	Yes	No

3) Had you previously been exempted from participation?	Yes	No

4) Had you previously taken part in the procedure in question?	Yes	No

5) Did you participate in the procedure to which you objected? If so, why?	Yes	No

Summary of Incident

GENERAL REPORT PART III ( Retain original, copy to Project)	Protection of Conscience Project Victim Worksheet

Did you file a grievance? If yes, results? If no, why not?	Yes	No





If grievance filed, date concluded:


Did you file a human rights complaint? If yes, results? If no, why not?	Yes	No





If human rights complaint filed, date concluded:


Did you file a civil suit? If yes, results? If no, why not?	Yes	No





If civil suit filed, date concluded:

Employment or Educational Consequences (Use additional pages if necessary.)









Personal Consequences (Emotional, medical, etc. - Use additional pages if necessary.)









Total Expenses Incurred:

Are you willing to testify to your experience at legislative committee hearings?	Yes	No

PERSONS REPORT (Complete and retain for counsel. DO NOT send to Project) (Make as many copies as required)			Protection of Conscience Project Victim Worksheet

Surname G1 G2			Age or birthdate

Street Address


City, Town		Province/State	Postal Code


Work Tel.	Work Fax	Home Tel.	Home Fax


Work E-mail:		Work E-mail:


Re: Role of this person, or information available from this person (i.e. victim, witness, supervisor, co- worker, lawyer, etc.: party to conversation, overheard statements, has documents)









With respect to providing information, this person is likely to be:

Co-operative o	Unco-operative o	Sympathetic o	Hostile o


PERSONS REPORT (Complete and retain for counsel. DO NOT send to Project) (Make as many copies as required)			Protection of Conscience Project Victim worksheet

Surname G1 G2			Age or birthdate

Street Address


City, Town		Province/State	Postal Code


Work Tel.	Work Fax	Home Tel.	Home Fax


Work E-mail:		Work E-mail:


Re: Role of this person, or information available from this person (i.e. victim, witness, supervisor, co- worker, lawyer, etc.: party to conversation, overheard statements, has documents)









With respect to providing information, this person is likely to be:

Co-operative o	Unco-operative o	Sympathetic o	Hostile o

DOCUMENTS ELSEWHERE
Complete and retain for counsel.
DO NOT send to Project)
(Make as many copies as required)

Protection of Conscience Project
Victim Worksheet

I believe that the following documents indicate unjust discrimination for reasons of conscience, and that they can be found in the location(s) indicated:

Letters Re: Employment

oLetter(s) of support

oCaution/warning letters

oLetter(s) of dismissal

oLetter(s) of complaint

oLetter(s) of reprimand

Locations held:

Employer Policy

oManual(s)

oDirective(s)

oMemo(s)

oManual extract(s)

oLetter(s)

oMinutes

oBulletin(s)

oNewsletter(s)

Locations held:

Unions/Associations

oManual(s)

oDirective(s)

oMemo(s)

oManual extract(s)

oLetter(s)

oMinutes

oBulletin(s)

oNewsletter(s)

Locations held:

Legal Documents

oTranscript(s)

o Affidavit(s)

oSettlements

oJudgement(s)

oCourt/Tribunal Order(s)

Locations held:

Audio/visual/electronic materials