Internews Pakistan - Media Violations Monitoring Form

FORM FOR REPORTING MEDIA FREEDOM VIOLATIONS

Internews Pakistan's Media Legal Resource Center is gathering data on the media freedom violations. Below is a simple form for reporting such incidents. In case of any difficulty, reports can be submitted through telephone or fax, Our telephone numbers are : 009251 2877984 and Fax: 00 9251 2870969. The summary of the report will also be published online. Meanwhile the data submitted and follow ups will contribute to our detailed report on media freedom violations. If there are any suggestions or comments on this format, please share your feedback with us in order to enrich this process further.

Victim's Details:
Name of Victim: *
Age (Years):
Organization:
Designation:
Address Line 1: *
Address Line 2:
City:
Province: *
Telephone No:
Mobile number: *
Email address:
Any association/ membership:
Incident Details:
Nature of the incident: *
Nature of incident (Other):
Date of Occurence: *
Time of Occurence:
Place of Occurence:
Property damage incurred (if any):
Name of witnesses (if any):
Motive behind action:
Whether reported to authorities:
Whether FIR registered:
Identity of perpetrator(s): (with name and position)
Any other follow up:
Followup (Other):
Response of authorities:
Contact phone/fax/email of authorities to whom appeal has to be made:
Appeal To:
Appeal To (Other):
Contact details of the authority to whom appeal has to be made:
Any other details
Any other update
Source of information:
Submitter Details:
Form submitted by: *
Telephone/ Mobile No.: *
Fax No.:
Email Address:

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