Model form: To the High Commissioner of Human Rights

downloaded from http://www2.ohchr.org/english/bodies/docs/annex1.pdf June 2011

Model Complaint Form

For communications under:

• Optional Protocol to the International Covenant on Civil and Political Rights
• Convention against Torture, or
• International Convention on the Elimination of Racial Discrimination

Please indicate which of the above procedures you are invoking: ………
Date: ………….

I. Information on the complainant:

Name: ……… First name(s): ………….
Nationality: ……… Date and place of birth: ………….
Address for correspondence on this complaint: ………..
Submitting the communication:
on the author’s own behalf: ………..
on behalf of another person: ………..
[ If the complaint is being submitted on behalf of another person:]
Please provide the following personal details of that other person
Name: ……… First name(s): ………..
Nationality: ……… Date and place of birth: ………..
Address or current whereabouts: ……….
If you are acting with the knowledge and consent of that person, please provide that person’s authorization
for you to bring this complaint …………
Or
If you are not so authorized, please explain the nature of your relationship with that person: ………………
and detail why you consider it appropriate to bring this complaint on his or her behalf: …………..

II. State concerned/Articles violated

Name of the State that is either a party to the Optional Protocol (in the case of a complaint to the Human
Rights Committee) or has made the relevant declaration (in the case of complaints to the Committee against
Torture or the Committee on the Elimination of Racial Discrimination):
…………
Articles of the Covenant or Convention alleged to have been violated:
…………
III. Exhaustion of domestic remedies/Application to other international procedures

Steps taken by or on behalf of the alleged victims to obtain redress within the State concerned for the
alleged violation – detail which procedures have been pursued, including recourse to the courts and other
public authorities, which claims you have made, at which times, and with which outcomes:
…………………..
If you have not exhausted these remedies on the basis that their application would be unduly
prolonged, that they would not be effective, that they are not available to you, or for any other
reason, please explain your reasons in detail: …………………………
Have you submitted the same matter for examination under another procedure of international investigation
or settlement (e.g. the Inter-American Commission on Human Rights, the European Court of Human
Rights, or the African Commission on Human and Peoples’ Rights)? ……………
If so, detail which procedure(s) have been, or are being, pursued, which claims you have made, at
which times, and with which outcomes: …………………………

IV. Facts of the complaint

Detail, in chronological order, the facts and circumstances of the alleged violations. Include all matters
which may be relevant to the assessment and consideration of your particular case. Please explain how you
consider that the facts and circumstances described violate your rights.
………………………….
………………………….
………………………….
Author’s signature: …………
[The blanks under the various sections of this model communication simply indicate where your responses
are required. You should take as much space as you need to set out your responses.]

V. Checklist of supporting documentation (copies, not originals, to be enclosed with your
complaint):

– Written authorization to act (if you are bringing the complaint on behalf of another person and are
not otherwise justifying the absence of specific authorization): ……..
– Decisions of domestic courts and authorities on your claim (a copy of the relevant national
legislation is also helpful): ……..
– Complaints to and decisions by any other procedure of international investigation or settlement:
……..
– Any documentation or other corroborating evidence you possess that substantiates your
description in Part IV of the facts of your claim and/or your argument that the facts described amount to a
violation of your rights: …..…

If you do not enclose this information and it needs to be sought specifically from you, or if accompanying
documentation is not provided in the working languages of the Secretariat, the consideration of your
complaint may be delayed.