This form was prepared by the "World Organization to Investigate the Persecution of Falun Gong". Please return the forms via mail, fax, or email, or call our toll-free number in North America. All information gathered will be maintained in strict confidentiality.

Part 1: For everyone (Please circle or check the appropriate answers. If you answer yes to any, please also fill out Part 6.)

Have you ever received any anti-Falun Gong materials distributed by your local Chinese Embassies or Consulates?
Yes or No

If Yes, please indicate the type: printed material_____, CD_____, Videotapes_____, or other __________________________________________________________________________

Language of the material: Chinese_____, English_____, Other________________________

Have you heard inflammatory comments directed towards Falun Gong from Chinese Embassy / Consulate officials in public or while doing business?
Yes or No

Have you ever been pressured[1] to view displays defaming Falun Gong in Chinese Embassies or Consulates?
Yes or No

Have you or your family members ever been harassed by the Chinese Embassy / Consulate officials or people hired by the Embassies or Consulates, for example followed, taped, had your picture taken, threatened, beaten, had your vehicle damaged, your assets stolen, your computer attacked?
Yes or No

Have you or your family members ever had the Chinese Embassy / Consulate cancel a passport, deny a passport extension, refuse to issue documents, refuse or cancel a visa?
Yes or No

Have you or your family members been blacklisted by the Chinese Embassy / Consulate?
Yes or No

Others (please specify): _______________________________________________________________________________

Please answer (optional): I am _____ a Falun Gong practitioner; _____ a family member of a Falun Gong practitioner; _____ neither

Part 2: Government Officials and NGOs (Please circle or check the appropriate answers. If you answer yes to any, please also fill out Part 6.)

Have you ever been pressured by Chinese Embassy / Consulate officials to withdraw proclamations issued for Falun Gong? Yes or No

Have you ever been pressured or threatened (financially or politically) by the Chinese Embassies / Consulates because you support Falun Gong?
Yes or No

Have you ever been asked by the Chinese Embassy / Consulate to hinder Falun Gong from participating in or organize local events?
Yes or No

Have your business or personal trips ever been cancelled by the Chinese Embassies / Consulates because of your support for Falun Gong? Yes or No

Have your business activities ever been cancelled or threatened to be cancelled because of your support for Falun Gong?
Yes or No

Others (Please specify):
______________________________________________________________________________________________

Please answer (optional): I am a _____MP; _____MPP; _____City Council Member; _____other officials; _____NGO; _____Business

Part 3: Media (Please circle or check the appropriate answers. If you answer yes to any, please also fill out Part 6.)

Have you ever been threatened or forced to stop your publication by the Chinese Embassy / Consulate because you have reported favorably on Falun Gong? Yes or No

Have you ever been threatened by the Chinese Embassies / Consulates to publish derogatory articles about Falun Gong?
Yes or No

Have you ever been invited to attend press conferences targeting Falun Gong, either inside the Chinese Embassies / Consulates or outside?
Yes or No

Have you ever been asked to write anti-Falun Gong articles?
Yes or No

Others (Please specify): _______________________________________________________________________________

Please answer (optional): I work for a _____ newspaper; _____TV Station; _____ Radio Station; _____ other; Language: ________________________________________________

Part 4: Overseas Chinese (Please circle or check the appropriate answers. If you answer yes to any, please also fill out Part 6.)

Has the staff of Chinese Embassies / Consulates ever tried to instigate hatred by you or your group members towards Falun Gong?
Yes or No

Has the staff of the Chinese Embassies / Consulates ever pressured you or your group to discriminate against Falun Gong?
Yes or No

Have you ever been asked to stop people who practice Falun Gong from participating in activities held by your group?
Yes or No

Have you ever been invited to attend meetings or exhibitions organized by the Chinese Embassies / Consulates targeting Falun Gong?
Yes or No

Are you afraid to openly express your support for Falun Gong out of fear of being attacked, personally or financially?
Yes or No

Others (Please specify): ______________________________________________________________________________________________

Please answer (optional): I am a member of a _____ Chinese Community group; _____ Chinese Overseas Students Association; _____ professional group[2]; _____ I am a Chinese immigrant

Part 5: This only applies to the staff of Chinese Embassies / Consulates

Have you ever participated or are you participating in the persecution of Falun Gong practitioners? Yes or No

If Yes, please specify. Did you do so voluntarily or were you pressured to do so? If you were pressured to do so, please indicate details such as the source of the pressure, etc.

Do you have any other insights on the persecution that you wish to add? (The information you provide will not be used as the basis for a lawsuit against the relevant personnel. The organization will set up a separate investigation and will keep highly confidential all the information provided).

Part 6: Testimony

Location: _________________________________________________________________________________________

Date/Time: ______________________________________

People Involved: ___________________________________________________________________________________

Synopsis: ________________________________________________________________________________________

________________________________________________________________________________________________

Evidence gathered/submitted:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

(Please attach additional sheets of paper if necessary)

Part 7: Personal Information

Name: ______________________________________________________________

Form filled out in: (city) ____________________ (country) ______________________

Form received on: ___________________________ (D/M/Y)

Contact info: Telephone: _______________________ Fax: ______________________

E-mail: ______________________________________________________________

Toll-free number in North America: 1-866-RECTIFY (732-8439)
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[1] An example of being pressured would be the Chinese Embassy / Consulate displaying pictures or playing videotapes defaming Falun Gong that you had to observe while you were in line to enter or to be received at a function.

[2] Such as lawyers, doctors, professors, engineers, etc.