Economic Human Rights Violation Report Form

Attach any available evidence and supporting materials to each form.

Name: __________________________________________________
Address: ________________________________________________
Phone Number: ____________________________
Race/Ethnicity:__________________  Age: ______ Gender: ________
Date: ____________    Location at which filled out: _________________

Article 23 - Right to a job with just and favorable conditions of work and a living wage, and the right to form and join trade unions.

What is your income?
How many people are dependent on your income?
Have you been denied work or laid off from work in the past year?
Have you ever gotten sick or injured because of your job?

Article 25 - Right to well being of a person and their family (food, housing, clothing,medical care, other social services)

Have you ever been denied or cut off of welfare (cash, food stamps, medical or SSI)?
Have you ever lived in a house that was in dangerous condition?
Have you ever been homeless?
Have you ever had your utilities shut off?
Has your family ever gone without meals because there wasn’t enough money for food?
Have you ever been denied medical treatment?
Have you ever had problems obtaining childcare for your children because you
could not afford it?

Article 26 - Right to Education

Have you ever had to leave school or training because you couldn’t afford to go
anymore?

Case Summary - Please use the space on the back of this form to go into more detail about the economic human rights violations you’ve experienced.

Confidentiality Waiver
I certify that the Economic Human Rights Campaign and Poor Voices United has permission touse this story in their efforts to document economic human rights violations in the United States.
X____________________

Name of individual who assisted with documentation of this story: __________________________
Organizational Affiliation: _____________________ Phone Number: ________________
Address: _________________________________________________________________

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