Questionnaire

If you have been unable to find the person you are seeking, please complete the questionnaire below (each questionnaire should refer to one person) which forms the basis for entering data in the “Index of the Victims of [Soviet] Repression” data base. All information relating to Poles and to pre-war Polish citizens who suffered repression in the former USSR during the period 1939-1956 is collected on this data base. The biogram of the person you have reported will be included on the web-site of the “Index of the Victims of Soviet Repression” (ICIR), once it has been verified against other sources and confirmed as an instance of repression.

Personal data of victim of repression:

Surname
Family name
First name
Second name
Father’s first name
Mother’s first name
Date of birth
Place of birth
Sex F/M
Nationality
Place of permanent abode in 1939 (place, district, province)

Code names (or surnames and first names) used for underground activities (in camps, in places of exile etc.)

Description of fate of person subject to repression: (When giving details of nature of repression, please give dates, places, surnames which you remember etc.)

Notes (Additional information relating to the victim of repression, or his/her parents, e.g.: personal data used in clandestine activities, religion, trade/profession, membership of a party or organisation, military service, service in the police force, written memoirs, photographs, documents, retained mementoes...)

Informer’s details:

Surname and first name
Address
Telephone
e-mail
My relationship to the reported person is (degree of relationship) (son, brother etc.):