• When you submitted your complaint:.............................................. ............................................................................................... • What was the outcome (if any):..................................................... ............................................................................................... Important: Enclose copies of relevant documentation (e.g., your submission, the final outcome). DO NOT SEND ORIGINALS. VII. Request for interim measures (optional) You must indicate expressly if you wish the Committee to request interim measures from the State concerned to prevent irreparable damage to the victim of the alleged violation. In that case: – Describe the victim’s personal risk; – Identify the possible irreparable damage; – If possible, indicate the measure(s) that could be taken by the State concerned to avoid possible irreparable damage. VIII. Date and signature Date/place: ................................................................................... Signature of author(s) and/or victim(s): ................................................ IX. List of documents attached (do not send originals, only copies) .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... Author(s) of a communication are required to make sure, before sending the form, that all the above-mentioned elements are included. This will allow for a smoother consideration of the case. 41