Annexure 2 (SOP 3)
ICD 3-2 (4/99 Revision 2)

Republic of South Africa
INDEPENDENT COMPLAINTS DIRECTORATE
Complaint Reporting Form
NOTE: If additional space is required to provide information, use a Continuation Sheet and refer to item number which is being supplemented.

Please complete all items to the extent possible to enable the ICD to locate persons who are important to the investigation of this complaint.

 1 Date/Time of Complaint

3 Method of Receipt
o In Person o Third Party
o Telephone o Written
o Mero Motu

2 CCN

4 o SAPS CAS/CR No._______________
5 Complainant’s
Legal Name                      (Surname)                       (First Name)		 6 Name of 3rd Party lodging
Complaint (if any)                   (Surname)              (First Name)
7 Complainant’s
Address		 8 Complainant’s
Telephone Number		 9 Complainant’s ID No.
10 City/Town/Province
                                                                                (Postal Code) 		11 Directions to
Complainant’s Home
12 Victim (If different
from Complainant)               (Surname)                   (First Name)
13 Complainant’s
Occupation		 14 Work Telephone
Number
15 Complainant’s
Work Address		 16 Complainant’s Date
of Birth
17 Name of Closest
Living Relative                    (Surname)                       (First Name)		 18 Relative’s
Telephone Number
19 Relative’s Street
Address		 20 City/Town/Province
                                                                                      (Postal Code)
21 Name of Nearest
Neighbor                            (Surname)                       (First Name)		 22 Neighbor’s
Telephone Number
23 Neighbor’s Street
Address		 24 City/Town/Province
                                                                                     (Postal Code)
25 Date of Incident 26 Time of Incident
                  AM/PM		 27 Specific Location
of Incident		 28 Province
29 Give full details
of incident (Use
Continuation
Sheet if
Necessary)
30 Name(s)of Service
Members(s)
Involved in or
Witnessing
Incident		 1.

2.

3

 31 Rank of Service
Members (s)
Involved in or
Witnessing Incident		 32 Duty Station
33 Description of
Service Member(s)
Involved in or
Witnessing
Incident		 1.

2.

3.

 

 

 
34 Description/Tag
No. of Service
Vehicles (If
any)

 

 

35 Names of Non-                  1.
Service                                  2.
Witnesses to                         3.
Incident                                  4.
36 Witness 1
Street Address		 37 Witness 1
Other Name
38 City/Town/Province 39 Witness 1
Telephone Number
40 Witness 2
Street Address		 41 Witness 2
Other Name
42 City/Town/Province 43 Witness 2
Telephone Number
44 Witness 3
Street Address		 45 Witness 3
Other Name
46 City/Town/Province 47 Witness 3
Telephone Number
48 Witness 4
Street Address		 49 Witness 4
Other Name
50 City/Town/Province 51 Witness 4
Telephone Number

 

COMPLAINT CERTIFICATION

I have been advised that the filing of a false report may be considered Defeating the Ends of Justice which is an offence, and I hereby certify that all of the information contained in this Complaint Reporting Form as well as any supporting Complaint Continuation Sheets is true and correct to the best of my knowledge and belief.

Date                                 Signature/Mark of Complainant

Date                                 Signature of Witness

52 Printed Name
of Report
Taker
 53 Signature
of Report
Taker		 54 Number of Continuation
Sheets Completed and
Attached		  

FOR USE OF ICD PERSONNEL ONLY

55 ICD personnel receiving Complaint
mark one with an "x":

o CWTRA o CENPRA

56 Preliminary Classification:
o Class I o Class IV
o Class II o Class V
o Class III 		57 Insert Code Number from
Incident Description
Code Sheet in space to
Right		  

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TEAR OR CUT ALONG THIS LINE

IMPORTANT - DO NOT LOSE THIS RECEIPT!

This is a receipt for the Complaint you have just filed. It bears a Complaint Number in the lower right hand box which identifies the Complaint. Please make sure that the numbers are the same before you accept this Receipt. Any future communication concerning this matter should refer to the Complaint Number. If you have additional information or questions, you may call the ICD at _______________ during the hours of 0800 to 1630 Hrs. You will be contacted during the processing of this matter and at the time a decision is reached concerning a final disposition. Thank you for your assistance!                                                    The Independent Complaints Directorate
Printed Name of
Report Taker		 Signature of
Report Taker		 Number of Continuation Sheets Completed and Attached

Complaint Number