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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude
Resources

Victim Worksheet

General Report - Part III

You may copy to the Project

Did you file a grievance?

Yes

No

If yes, results? If no, why not?

 
 
 

If grievance filed, date concluded:

 

Did you file a human rights complaint?

Yes

No

If yes, results? If no, why not?

 
 
 

If human rights complaint filed, date concluded:

 

Did you file a civil suit?

Yes

No

If yes, results? If no, why not?

 
 
 

If civil suit filed, date concluded.

 

Employment or Educational Consequences (Use additional pages if necessary.)

 
 
 

Personal Consequences (Emotional, medical, etc. - Use additional pages if necessary.)

 
 
 

Total Expenses Incurred:

 

Are you willing to testify to your experience at legislative committee hearings?

Yes

No

 

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