SAMPLE REFUGEE QUESTIONNAIRE

Interviewer's Name:________________________
Location of Interview:________________________
Date of report:________________________

BACKGROUND INFO IN KOSOVO

Name (surname first):________________________
Father's name:________________________
Sex: F( ) M( )
DOB:
Ethnicity: Kosovar Albanian ( ) Serb ( ) Roma ( ) Other ( ) (specify)
Religion:________________________

Permanent Address:________________________
Last Place of Residence Before Displacement:________________________
Date of Displacement:________________________

Current Address:________________________
(Relationship with the owner):________________________
Point of contact/telephone number:________________________

1. Describe the situation in the last place of residence:

a) Circumstances of departure/reasons for flight:________________________________________________________________________________________________________________________
b) Were you a direct witness of the incident/event? Were there any casualties?________________________________________________________________________________________________________________________
c) Names of witnesses to contact:________________________________________________
Route taken to exit Kosovo and mode of travel:________________________________________________

2. Freedom of Movement Problems

Is free movement a problem? Yes( ) No( )
If yes:
Lack of IDs? ( )
Fear in general ( )
Harassment at checkpoints? (Specify Fixed/Mobile/KLA/Police):_______________________
Other reasons?_____________________________________________________

3. Security Problems -- Physical Security

Were there acts of violence against you or any members of the family? Yes( ) No( )
When?________________________________________________
By whom?________________________________________________
If yes, relationship to the victim:________________________________________________
Location:________________________________________________
Describe the circumstances:________________________________________________________________________________________________________________
Were you a direct witness?________________________
Type of violence:________________________________________________
Threats (verbal/physical):________________________________________________________________________
Other (specify):________________________________________________

4. Arrest/Detention

Were you or any members of your family ever arrested Yes( ) No( )
If yes, where?________________________________________________
When?________________________________________________
By whom? MUP( ) VJ( ) KLA( ) Others (specify):

5. Enforced Disappearance/Abduction/Missing

Are there any family members missing/disappeared/abducted? Yes( ) No( )
If yes, who?________________________________________________
When?________________________________________________
Where?
Perpetrators:________________________________________________
Probable cause of disappearance:________________________________________________

6. Documentation Problems

Are you in possession of valid documents? Yes( ) No( )
If you answered no, type missing:
Licna Karta ( ) Passport ( ) Citizenship ( ) Birth Certificate ( ) Others (specify):________________________
Why is the documentation missing? Lost ( ) Destroyed ( ) Confiscated ( ) Other:________________________
When?________________________
Where?________________________________________________
By whom?________________________________________________
Unable to renew (specifiy):________________________
Refusal by authorities (specify):________________________
No access to place of origin (specify):________________________

7. Violations

Were you the victim or witness to any incidents prior to your departure from Kosovo? Yes ( ) No ( )
If yes, please describe:________________________________________________________________________________________________________________________________________________________________________________________________

8. Future Plans for Tribunal Contact

Return to Kosovo. Where?________________________________________________
Remain in F.Y.R.O.M. Where?________________________________________________
Going abroad. Where?________________________________________________
Other:

9. Would you be willing to give a more detailed statement to the International Criminal Tribunal for the former Yugoslavia Yes( ) No( )

10. Other comments:________________________________________________________________________________________________________________________