Regulations > General Regulations > Annexures 1-46

ANNEXURE

FORM MHCA 02

DEPARTMENT OF HEALTH

REPORT TO EXPLOITATION, PHYSICAL OR OTHER ABUSE, NEGLECT OR DEGRADING TREATMENT OF A MENTAL HEALTH CARE USER

(Section 11(2) of the Act)

(All the information contained in this Form will be held strictly confidential).

I ......................................................................................................................................

(name/s)

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

(address)

hereby declare that I have witnessed exploitation, physical or other abuse, neglect or degrading treatment of the following mental health care user:

hereby declare that I have been through exploitation, physical or other abuse, neglect or degrading treatment

A. Details of User (where known)

First Name and Surname of User .................................................................................................

Date of birth ................................or estimated age ...................

Gender:

Male

Female

Occupation

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

Marital status:

Residential address:

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

B. Name of health establishment or other place where the alleged incident occurred

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

Address:

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

C. Date of incident .....................................................................................

D. Brief description of the User:

E. Description of the alleged incident:

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

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

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

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

Contact number: ........................................................................................

Signature under oath: ................................................................................

(person who witnessed alleged incident)

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

OATH/AFFIRMATION

I certify that:

i.	The deponent acknowledged to me that:

a.	He/she knows and understands the contents of this declaration;

b.	He/she has no objection to taking the prescribed oath;

c.	He/she considers the prescribed oath to be binding on his/her conscience;

ii.	The deponent signed this declaration in my presence at .............................................on this................. day of............................... 20............

________________________________________

Signature: Commissioner of Oath: Ex-Officio

Name: ................................................................................................

Rank / Designation: ............................................................................

[Original to be submitted to the relevant Mental Health Review Board]

Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 02