Military Ombud Act, 2012 (Act No. 4 of 2012)RegulationsMilitary Omud Complaints Regulations 2015AnnexuresAnnexure A : Military Ombud Complaint Form : Complaint in terms of Section 6(2) Military Ombud Act 4 of 2012 |
ANNEXURE A
CONFIDENTIAL
MILITARY OMBUD COMPLAINT FORM
COMPLAINT IN TERMS OF SECTION 6(2) MILITARY OMBUD ACT 4 OF 2012
(Regulation 3)
Please Note:
| 1. | Kindly complete the form in a legible manner and complete all relevant sections. Please note that the fields marked with an asterix (*) are compulsory. |
| 2. | Where the contact person is not the complainant, please provide the relevant person’s correct contact details. If the contact person is acting on behalf of the complainant, a Power of Attorney must accompany this form. |
| 3. | If you have previously referred your complaint for investigation, arbitration, conciliation, mediation or negotiation to another competent tribunal, forum or institution, kindly furnish the relevant details and applicable reference number. |
| 4. | Be as comprehensive as possible and provide as much factual details as possible when completing this form. Ensure that you answer the following questions: Who, What, When, How, Where and What happened thereafter. |
| 5. | Attach all supporting documentation and evidence, which may include copies of photographs, copies of documentation, sworn statements of witnesses, copies of official documents given to you by the Department of Defence, or any other information that may assist the Military Ombud in conducting an investigation. |
| 6. | The Declaration and consent section of this form must be completed to authorise the Military Ombud to obtain copies of records and to access any information that relates to this complaint. |
In which province in South Africa did the complaint originate?
| ❑ | Eastern Cape |
| ❑ | Free State |
| ❑ | Gauteng |
| ❑ | Kwazulu Natal |
| ❑ | Limpopo |
| ❑ | Mpumalanga |
| ❑ | North West |
| ❑ | Northern Cape |
| ❑ | Western Cape |
Where did you learn about the Office of the Military Ombud?
| ❑ | Radio |
| ❑ | Attorney |
| ❑ | Newspaper |
| ❑ | Other Ombudsman |
| ❑ | By word of Mouth |
| ❑ | Department of Defence |
| ❑ | Other (please specify) |
PARTICULARS OF COMPLAINANT
Category of Complainant (*):
| ❑ | Current SANDF Member |
| ❑ | Former Member of the SANDF |
| ❑ | Member of the Public |
| ❑ | Third Party (e.g. union rep, lawyer, etc.) |
Please Note:
| • | If you are a member, former member or member of the public complaining, complete section 1 & 4. |
| • | If you are member of the public complaining about the official conduct of a member of the SANDF please also complete section 1 & 4 (note: only need to provide ID/Passport no.) |
| • | If you are complaining on behalf of a member or former member, complete section 2, 3 & 4. |
| • | Section 5, 6 & 7 is to be completed by all. |
| 1. | PERSONAL DETAILS (if you are the member, former member or member of the public lodging the complaint please complete this section only where applicable) |
Please indicate your Gender and Race (*) : (This information is required for statistical purposes)
| ❑ | Male |
| ❑ | Female |
Race: ________________________
Surname (*): ______________________Full Names(*): __________________________
Title (Mr/Mrs/Miss/Ms/Dr/Prof (*): __________Rank : __________________________
ID/Passport Number (*) __________________________Force Number: _____________
Unit: ________________________________Service Division: ______________________
Residential Address (*): _____________________________________________________
Postal Address (*): _________________________________________________________
City: __________________Province: _______________Postal Code: _________________
Telephone (*) Home: _______________Cell: ______________Work: ________________
Email Address: _______________________________________Fax : __________________
Have you submitted your grievance through the Department of Defence's Individual Grievances Regulations?(*):
(To be completed by current members of the SANDF only)
| ❑ | Yes |
| ❑ | No |
If yes:
| • | At which grievance office (Unit)? _______________________________________________ |
| • | What is the Grievance ID Number? ______________________________________________ |
| 2. | DETAILS OF THIRD PARTY |
Surname (*): _______________________Full Names(*): __________________________
Title (Mr/Mrs/Miss/Ms/Dr/Prof (*): __________ Rank : __________________________
ID/Passport Number (*): _______________________ Force Number: _______________
Unit: ___________________________________Service Division: ___________________
Residential Address (*): _____________________________________________________
Postal Address (*): _________________________________________________________
City: __________________Province: _______________Postal Code: _________________
Telephone (*) Home: _______________Cell: ______________Work: ________________
Email Address: _______________________________________Fax : __________________
| 3. | PERSONAL DETAILS OF AFFECTED PARTY |
Please indicate your Gender and Race (*) : (This information is required for statistical purposes)
| ❑ | Male |
| ❑ | Female |
Surname (*): _______________________Full Names(*): __________________________
Title (Mr/Mrs/Miss/Ms/Dr/Prof (*): __________ Rank : __________________________
ID/Passport Number (*): _______________________ Force Number: _______________
Unit: ___________________________________Service Division: ___________________
Residential Address (*): _____________________________________________________
Postal Address (*): _________________________________________________________
City: __________________Province: _______________Postal Code: _________________
Telephone (*) Home: _______________Cell: ______________Work: ________________
Email Address: _______________________________________Fax : __________________
| 4. | DETAILS OF THE MEMBER OR UNIT YOU ARE COMPLAINING ABOUT |
Please indicate the Gender and Race of the person(s) you are complaining against (*) : (This information is required for statistical purposes)
| ❑ | Male |
| ❑ | Female |
Race:
Surname: __________________________Full Names: ____________________________
Rank : _____________________________ ID/Force Number: ______________________
Unit: ___________________________________Service Division: ___________________
| 5. | DETAILS OF THE COMPLAINT |
Kindly complete this Form in a legible manner setting out all the facts which you consider to have a bearing on this complaint, including dates, places and names. Answer the questions Who, What, When, How, Where and What happened thereafter. Attach copies of all relevant documents. If the space is not sufficient, you may add additional pages.
| 6. | DESCRIBE HOW YOU WOULD LIKE THE MILITARY OMBUD TO ASSIST YOU |
| 7. | DECLARATION AND CONSENT: |
The consent granted to the Military Ombud in this paragraph authorises the Military Ombud to obtain copies of any records, to access any information which relates to this complaint and to contact any person or entity for the purposes of obtaining or verifying such information and/or documentation.
I _________________________________ (name, surname, ID/Force number) declare that to the best of my knowledge, the information provided in the complaint form is true and correct in every respect;
I confirm that I am complaining in my personal capacity / representative capacity.
I hereby consent to the release, to the Military Ombud, of copies of all documentation and/or information, including, but not limited to documentation or information, that in any way relates to this arising from the circumstances detailed in the complaint form.
I further consent to and authorise the Military Ombud to contact any person or entity for purposes of obtaining or verifying such information and/or documentation.
_______________________________ |
_________________________________________ |
Complainant Signature |
Person authorised to sign on behalf of the complainant (where applicable) |
____________________________ |
|
Date |