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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude
Resources

Victim Worksheet

General Report - Part II

You may copy to the Project

Incident Date (Specify date, or between dates)

 
 

Incident Location (Specify company/institution/organization and address)

Company/institution/oranization name
Address
 
 
 

Nature of Activity to which Objection Taken (Circle)

Abortion

Artificial Reproduction

Assisted Suicide

Causing Death

Contraceptive Service

Eugenic Screening

Human Experimentation

Inter-species Breeding

Sterilization

Other (Specify)

Counselling or referral for (Specify)

Dispensing drugs/devices for (Specify)

 

Nature of Conscientious Objection (Circle)

Religious Moral  Ethical Philosophical
Other (Specify)
 
 

Were you a student? (Circle)       Yes     No

 

If yes, indicate nature of coercion or discrimination below.

  Statement by teacher   Assignment of practicums   Selection of resources
  Statement by administrator   Selection of essay topics   Marking of papers
  Selective discourtesy   Framing of lesson plans   Marking of exams
  Censorship of student   Selection of essay topics   Evaluation
 

Were you an applicant? (Circle)   No       Yes - - - For - -

Certification   Employment   Professional Ass. Membership
  Education Programme   Hospital Privileges   Union Membership
Other (specify):
 
 

If you were an applicant (Circle ):

1) Were you questioned about your willingness to participate in what you considered to be an objectionable activity? (If yes, please explain.)

Yes 

No

 
 
 

2) Did you answer truthfully?

Yes 

No

3) Was your application successful?

Yes

No

 

If your application was unsuccessful, what reason was given?

 
 
 

If not an applicant, what was your position?

 

1) Were you advised when you accepted your position that participation in the procedure in question was an expectation?

Yes 

No

2) Had you previously indicated conscientious objections to the procedure in question?

Yes 

No

3) Had you previously been exempted from participation?

Yes 

No

4) Had you previously taken part in the procedure in question?

Yes 

No

) Did you participate in the procedure to which you objected? If so, why?

Yes 

No

 

Summary of Incident

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Use additional pages if necessary.

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