Survey

COULD ANY CHANGES BE OBSERVED IN THE CLIENT AFTER THE INCIDENT

Which of the following ...: Tick all areas that apply

Alleged Offender's Details

Offender #1

AGE

RACE

SEX

SEXUAL ORIENTATION

NATIONALITY

LANGUAGE

RELIGIOUS AFFILIATION

IDENTITY

Offender #2

AGE

RACE

SEX

SEXUAL ORIENTATION

NATIONALITY

LANGUAGE

RELIGIOUS AFFILIATION

IDENTITY

Offender #3

AGE

RACE

SEX

SEXUAL ORIENTATION

NATIONALITY

LANGUAGE

RELIGIOUS AFFILIATION

IDENTITY

Offender #4

AGE

RACE

SEX

SEXUAL ORIENTATION

NATIONALITY

LANGUAGE

RELIGIOUS AFFILIATION

IDENTITY

Police (SAPS)

CASE NUMBER

NAME OF POLICE STATION

NAME OF INVESTIGATING OFFICER

WHAT WAS DONE BY THE POLICE REGARDING THE INCIDENT

WHAT STILL NEEDS TO BE DONE

Legal Assistance and Support

WHAT WAS DONE IN TERMS OF LEGAL ASSISTANCE AND SUPPORT

HAS THIS MATTER BEEN BROUGHT BEFORE A COURT

Medical (Healthcare) Assistance and Support

DID THE CLIENT SEEK OR NEED MEDICAL / HEALTHCARE ASSISTANCE *

WHAT WAS DONE IN TERMS OF MEDICAL ASSISTANCE AND SUPPORT

WHAT STILL NEEDS TO BE DONE

Psycho-Social Assistance and Support

WHAT WAS DONE IN TERMS OF PSYCO-SOCIAL ASSISTANCE AND SUPPORT

WHAT STILL NEEDS TO BE DONE

DESCRIBE THE IMPACT OF THE INCIDENT ON THE INDIVIDUAL (Client)

DESCRIBE THE IMPACT OF THE INCIDENT ON THE INDIVIDUAL'S LOVED ONES

DESCRIBE THE IMPACT OF THE INCIDENT ON THE INDIVIDUAL'S COMMUNITY

Previous Incident Details

WHAT WERE THEY RELATED TO

DESCRIBE THE PREVIOUS INCIDENT

understand that I have the right to confidentiality, and the above specific information will be treated as such. No infomation will be disclosed without my informed consent *

don't be shy

Mail Us On
info@ac2.org.za

Call Us On
+27 10 100 3177

REPORT INCIDENT /
HUMAN RIGHTS VIOLATIONS

Personal Details

Inquiry

Alleged Offender's Details

Offender #1

Offender #2

Offender #3

Offender #4

Police (SAPS)

Legal Assistance and Support

Medical (Healthcare) Assistance and Support

Psycho-Social Assistance and Support

Previous Incident Details

don't be shy

Mail Us Oninfo@ac2.org.za

Call Us On+27 10 100 3177

REPORT INCIDENT / HUMAN RIGHTS VIOLATIONS

Personal Details

Inquiry

Alleged Offender's Details

Offender #1

Offender #2

Offender #3

Offender #4

Police (SAPS)

Legal Assistance and Support

Medical (Healthcare) Assistance and Support

Psycho-Social Assistance and Support

Previous Incident Details

Mail Us On
info@ac2.org.za

Call Us On
+27 10 100 3177

REPORT INCIDENT /
HUMAN RIGHTS VIOLATIONS