PSEA Complaints Referral Form

IMPORTANT: All information must be held securely and handled strictly in line with applicable reporting and investigation procedures.

Fields marked with * are required.

Complainant Information

Name *

Ethnic Origin/Nationality

Address/Contact Details

Identity No

Age

Sex

Is the victim different from the complainant? *

Name(s) and Address of Parents (if under 18)

Has the Victim given consent to the completion of this form? *

Date of Incident(s) *

Time of Incident(s)

Location of Incident(s) *

Physical & Emotional State of Victim (Describe any cuts, bruises, lacerations, behaviour, and mood)

Witnesses' Names and Contact Information

Brief Description of Incident(s) *

Name of Accused Person(s)

Job Title of Accused Person(s)

Organization Accused Person(s) Works For

Address of Accused Person(s) (if known)

Age

Sex

Physical Description of Accused Person(s)

Attach any supporting documents or evidence (optional).

Add files: