Today's date (required)
Your Email Address(*)
Name of Informant
Give a reason if you are requesting anonymity. (However you are encouraged to provide your name and full details.)
Informant contacts. (Give your phone number/s and email address as informant)
Relationship of Informant and Victim. (If report is made by victim – indicate SELF) (*)
Name of the Victim (*)
Contacts of the Victim. (where victim and informant are different)
Date of offence/incident (*)
Where did the offence/incident occur? (*)
Type of Complaint. (e.g threat to life, sexual harassment) (*)
Provide a description of the perpetrator(s). (Include name, occupation/position if possible) (*)
Provide a background/circumstances leading to the offence/incident (*)
Was initial report made to the police? (If not yet, informant/victim is encouraged to report to the Police ASAP) (*) Yes, it was reported to the police.
The date it was reported.
OB number of the case reported.
List exhibits collected from the scene. (These include photographs, sound recordings, physical exhibits etc) (*)
List medical/intervention exhibits if there are any. (These include medical reports, prescriptions etc.)
Number of witnesses. (Witness details and statements provided are sealed and in strict confidence with us.) (*)
As the informant/victim I herein do hereby consent to attend to court and to investigative agencies to shed more light on the information contained herein, subject to witness protection mechanisms where necessary) (*) Yes I consent to this
Your Full Name. (*)
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