Complaint Details

CAS/CR No/

lnquest No

Province

Date of incident

Time of incident

Reported to SAPS

[    ]  Yes    [    ]  No

Date reported to SAPS

Incident relates to

[    ]  Death in police custody

[    ]  Death as a result of police action

[    ]  Discharge of firearm by police officer

[    ]  Rape by police officer

       On Duty  [    ]    Off Duty  [    ]

[    ]  Rape of person in police custody

[    ]  Torture / assault by police officer

Complaint Description (Use additional folios if necessary)

Complaint Details

Role in the case

[    ]  Complainant              [    ]  Third party

ID Number

Passport Number

Title

First name

Middle name

Surname

Landline

Mobile

Fax

E-mail

Nationality

Gender

[    ]  Male

[    ]  Female

Disabled status

[    ]  Yes                        [    ]  No

Address (if complainant is willing to disclose this)

Country

City

Suburb

Postal code

Preferred contact method (eg. Email, SMS, Fax)

Police Details (Reporting Station/Unit/MPS)

Policing Unit

Policing Entity (e.g. SAPS, MPS)

Police Station

Investigating Officer First Name

Investigating Officer Middle Name

Investigating Officer Surname

Investigating Officer Rank

ID Parade Held

[]Yes[]No

Title of Person Reporting Incident

First Name of Person Reporting Incident

Middle Name of Person Reporting Incident

Surname of Person Reporting Incident

District Surgeon Notified

[]Yes[]No

District Surgeon First    Name

District Surgeon Middle Name

District Surgeon Surname

District Surgeon Tel

Victim Details

Nationality

ID Number

Passport Number

First Name

Middle Name

Surname

Gender

[]Male..

[]Female

Race

Age

Next of Kin Notified

[]Yes []No

Location of Body

Responsible Person for death/injury

[    ]  Himself/Herself

[    ]  SAPS / MPS Member (s)

[    ]  Inmates

[    ]  Vigilantes / Members of the public

[    ]  Other

Responsible Person (Other)

[    ]  Suicide

[    ]  During Apprehension

[    ]  In-Transit with SAPS vehicle

[    ]  Natural Causes

[    ]  Self-defense

[    ]  During escape

[    ]  Due to motor vehicle accident

[    ]  Unknown

[    ] Other

Classify Deceased

[    ]  Suspect

[    ]  Sentenced

[    ]  Witness Protection

[    ]  Awaiting trial

[    ]  Mental patient

Detainee

[    ] Yes      [    ]  No

Reason for Detention

Place where Death

Occurred

Instrument / Object

Causing Death

Service Member’s Details

Identified

[]Yes []No

Rank

Persal number

ID Number

Initial

First Name

Middle Name

Surname

Gender

[]Male

[]Female

Race

Duty Station

Duty Station Unit

On Duty

[]Yes[]No

Identified

[]Yes[]No

Rank

Persal number

ID Number

Initial

First Name

Middle Name

Surname

Gender

[]Male

[]Female

Race

Duty Station

On Duty

[]Yes[]No

Identified

Rank

Persal number

Initial

First Name

Middle Name

Surname

Gender

[]Male

[]Female

Race

Duty Station

Duty Station Unit

On Duty

[]Yes[]No

Contact Number

Vehicle Registration Number

Description of vehicle

Station Commissioner’s Rand

Station Commissioner’s Full names

Station Commissioner’s Signature