39 MODUL 3 : INSTRUMEN DAN MEKANISME HAM III. Negara Pihak Pelanggar/pasal yang dilanggar/upaya-upaya domestik Nama negara pihak yang melanggar ................................................................................................................................................................................. Konvensi dan pasal-pasal yang telah dilanggar ................................................................................................................................................................................. Langkah-langkah domestik yang telah diambil ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. Apabila upaya domestik belum tuntas, jelaskan alasan-alasannya7 ................................................................................................................................................................................. ................................................................................................................................................................................. IV. Prosedur Internasional lain .......................................................................................................................................................................................... .......................................................................................................................................................................................... V. Uraian fakta pelanggaran .......................................................................................................................................................................................... .......................................................................................................................................................................................... Nama dan tanda tangan penulis ............................................................................. *1) Tergantung Konvensi apa yang dilanggar/ yang diadukan. • HRC untuk ICCPR • CAT untuk CAT • CERD untuk CERD • CEDAW untuk CEDAW *2) Pihak ketiga yang tidak mempunyai hubungan dengan korban tidak dapat mengajukan pengaduan. M O D U L P E G A N G A N PA RT I S I PA N : P E L AT I H A N DA S A R H AM - K O M N A S H A M 2 0 1 5