Project Logo

Protection of Conscience Project

Service, not Servitude

Victim Worksheet

Persons Report

DO NOT send to Project

(Make as many copies as required)
Complete and retain for counsel.

Surname G1 G2 Age or birthdate
Street Address
City, Town Province/State Postal Code
Work Tel. Work Fax. Home Tel.
Work E-mail Home 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 (Circle):

Co-operative Unco-operative Sympathetic Hostile 


Print Friendly and PDF