Subject accompanied by (name/position): …………………………………………………... Persons present during exam (name/position):……………………………………………… Subject restrained during exam: yes/no; If “yes”, how/why?............................................. Medical report transferred to (name/position/ID No.):………………………………………. Transfer date:……………………………. Transfer time:……………………………………. Medical evaluation/investigation conducted without restriction (for subjects in custody): yes/no Provide details of any restrictions…………………………………………………………….... II. Clinician’s qualifications (for judicial testimony) 1. Medical education and clinical training 2. Psychological/psychiatric training 3. Experience in documenting evidence of torture and ill-treatment 4. Regional human rights expertise relevant to the investigation 5. Relevant publications, presentations, and training courses 6. Curriculum vitae III. Statement regarding veracity of testimony (for judicial testimony) For example: “I personally know the facts stated below, except those stated on information and belief, which I believe to be true. I would be prepared to testify to the above statements based on my personal knowledge and belief.” IV. Background information 1. General information (age, occupation, education, family composition, etc.) 2. Past medical history 3. Review of prior medical evaluations of torture and ill-treatment 4. Psychosocial history pre-arrest. 27