*Marked fields are required

* 1. Complaint Type

Group Complaints: Interposed by two or more persons of a single fact. Individual Complaint: Interposed by a single person.

Personal Information

* 2. Legal First Name

* 3. Legal Last Name

4. Social Name

It is the name that the person uses and is not necessarily legally registered.

* 5. Birth date

* 6. Telephone number

You can enter numbers with parentheses and special characters +, -

* 7. Personal E-mail

* 8. Document type

* 9. Document Number

* 10. Sex according to legal document

* 11. Address

* 12. Area

13. Nationality

* 14. Country of Birth


* 15. Country where violation occurred

* 16. Does Someone know about your HIV diagnosis?

17. If your answer is YES, do you give us authorization to contact them??

18. Name of support person that knows your diagnosis

19. Telephone number of support person that knows your diagnosis

20. Email of support person that knows your diagnosis


* 21. Details of violation

* 22. Where did the violation occur?

* 23. When\ndid the incident occur?

24. Do you Know the name of the person who aggravated you?

25. What is the name of the institution or place where incident occurred?

26. Please provide us the address of the institution or place where incident occurred?

27. Please provide us the area/department or service station of the person´s who aggravates you

28. Have you presented this complaint to another authority?

29. Mention where

30. Mention any other important details