Complaint Details

CAS/CR No/

Inquest No

Province

Date of incident

Time of incident

Reported to SAPS?

[    ]  Yes                [    ]  No

Date Reported to SAPS

Name of SAPS station

Protection Order issued

[    ]  Yes               [     ]  No

Protection Order Type

[  ] Interim

[  ] Final

Date issued

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

[    ] Corruption within the police

Complainant Description (use additional folios if necessary)

Complainant Details (includes third party complaints)

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

Address:

Country

City

Suburb

Postal Code

Preferred contact Method (E.g. E-mail, SMS, Post)

Victim Details:

Passport Number

First Name

Middle Name

Surname

Gender

[    ]  Male

[    ]  Female

Race

Age

Service Member’s Details:

Identified

[    ]Yes        [    ]No

Rank

Persal Number

ID Number

Initials

First Name

Middle Name

Surname

Gender

[    ]  Male

[    ]  Female

Race

Duty Station

Duty Station Unit

Identified

[    ]  Yes

[    ]  No

Rank

Persal Number

ID Number

Initials

First Name

Middle Name

Surname

Gender

[    ]  Male

[      ]Female

Race

Duty Station

Duty Station Unit

Identified

[    ]  Yes

[    ]  No

Rank

Persal Number

ID Number

Initials

First Name

Middle Name

Surname

Gender

[    ]  Male

[    ]  Female

Race

Duty Station

Duty Station Unit

Contact Number

On Duty

[    ]  Yes

[    ]  No

Vehicle Registration Number

Details of Witnesses to Incident

Title

First Name

Middle Name

Surname

Landline

Mobile

Title

First Name

Middle Name

Surname

Landline

Mobile

Title

First Name

Middle Name

Surname

Landline

Mobile

Title

First Name

Middle Name

Surname

Landline

Mobile