ANNEXURE

FORM MHCA 22

DEPARTMENT OF HEALTH

HANDING OVER CUSTODY BY THE SOUTH AFRICAN POLICE SERVICES (SAPS) OF A PERSON SUSPECTED OF BEING MENTALLY ILL AND LIKELY

TO INFLICT SERIOUS HARM TO HIM / HERSELF OR OTHERS

(Section 40(1) of the Act)

A. I .......................................................................................................hereby inform

      (print rank, initials and surname of member of SAPS)

or

that ..........................................................................................................................

.................................................................................................................................

.................................................................................................................................

..................................................................................................................................

(User's name or description if no name is available)

is suffering from a mental illness and is likely to inflict serious harm to him / herself or others.

I have apprehended the person and have brought him / her to .................................

.................................................................................................................................

      (name of health establishment)

for assessment by a mental health care practitioner.

Name and address of next of kin (where possible)

................................................................................................................................

................................................................................................................................

................................................................................................................................

I hereby hand over custody of the said person to the head of the health establishment or his / her designate.

Signature: .................................................Force No. ..............................................

                    (Member of SAPS)

Date: .......................................

Time: ......................

Place: .....................................

B. I .......................................................................................................................

      (Name of head of health establishment or designated person)

accept custody of  ................................................................................................

      (Name of User of description if no name is available)

at the ...................................................................................................................

       (Name of health establishment)

The User's physical condition is as follows (describe any bruises, lacerations etc):

...........................................................................................................................

...........................................................................................................................

...........................................................................................................................

The mental status of the person will be assessed and an application will be made in terms of section 33 if applicable

Signature: ..............................................................

                    (Head of health establishment or designated person)

Date: ........................................

Time: ................

Place: ...........................................

[Copy to be sent to SAPS to confirm in writing the physical condition as stated above during handing over of custody]

C. The SAPS hereby confirms that the physical condition as stated above was present during t he handing over the User in terms of section 40(1) of the Act.

Print initials and surname: ........................................

Signature: ...................................................................

(Member of SAPS who handed over custody)

Date: .............................

Place: .................................

[Copy to Review Board]