Economic Human Rights Violation Form

Send supporting evidence or materials to Jamie at jpfleck@yahoo.com or mail them to:

The Coalition to Protect Public Housing

984 N. Hudson St.

Chicago, IL 60610

Name:

Address:

Phone Number:

Race/ Ethnicity:

Age:

Gender:

Date:

Article 10-- Right to Freedom of opinion and expression, and the right to seek, receive and impart information and ideas through any media and regardless of frontiers.

Have you ever been denied housing, employment, government benefits, education, healthcare, etc. because of a communication barrier?

Yes No

Has a communication barrier kept you from accessing information that is relevant to your well-being?

Yes No

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

What is your income?

How many people are dependent on your income?

Have you ever been denied work or laid off from work in the past year?

Yes No

Have you ever gotten sick or injured because of your job?

Yes No

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 welfare (cash, food stamps, medical, or SSI)?

Yes No

Have you ever lived in a house that was in dangerous condition?

Yes No

Have you ever been homeless?

Yes No

Have you ever had your utilities shut off?

Yes No

Has your family ever gone without meals because there wasn't enough money?

Yes No

Have you ever been denied medical treatment?

Yes No

Have you ever had problems obtaining childcare for your children because you could not afford it?

Yes No

Article 26-- Right to Education

Have you ever had to leave school or training because you could not afford to go anymore?

Yes No

Case Summary--Please use the follow space to go into more detail about the economic human rights violations you've experienced.

Economic Human Rights Articles from the Universal Declaration of Human Rights

Address the following rights:

Article 10-- Right to Freedom of opinion and expression, and the right to seek, receive and impart information and ideas through any media and regardless of frontiers.

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

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

Article 26-- Right to Education

Personal History/Case Summary: Please use the space below to summarize the economic human rights violations that you've experienced.

Confidentiality Waiver

I certify that the Poor People's Economic Human Rights Campaign, the Women's Economic Agenda Project, the Kensington Welfare Rights Union and the Coalition to Protect Public Housing have permission to use this story in their efforts to document economic human rights violations in the United States Sign: Date:

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