ANNEXURE

FORM MHCA 28

DEPARTMENT OF HEALTH

CANCELLATION OF LEAVE OF ABSENCE OF A STATE PATIENT OR AN ASSISTED OR INVOLUNTARY MENTAL HEALTH CARE USER

(Sections 45(3), 66(1)(j) of the Act)

I hereby cancel the leave of absence of .............................................................

(name of state patient, assisted or involuntary mental health care user)

File No. ................................

You are not complying with the terms and conditions applicable to the leave of absence and/or have/has relapsed to the extent of requiring hospitalization.

Reasons for cancellation of leave of absence:

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

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

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

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

You must return to ..........................................................................................

                                     (name of detention centre)

by ............................................................................... (date) or you will be reported to the South African Police Services as absconded.

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

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

(head of health establishment)

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

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

(Copy to custodian)