Page 40 - Main Second Asbo Book1

·witness contact details
Home address:
............................................................................................... ....................... .................................... Postcode:
Home telephone number ...................................................... Work telephone number
Mobile/pager number ...................................................... Email address:
Preferred means of contact:
Male / Female (delete as applicable) Date and place of birth:
Former name: Ethnicity Code (16+ ]): . .... ............. ... Religion/belief:
Dates of witness non-ava.iJability

Witness care
a) ls the witness willing and likely to attend court? Yes / No. If 'No', include reason(s) on MG6.
b) What can be done to ensure attendance?

c) Does the witness require a Special Measures Assessment as a vulnerable or intimidated witness?
Yes / No. If 'Yes' submit MG2 with file.
d) Does the witness have any specific care needs? Yes / No. If 'Yes' what are they? (Disability, healthcar<:, childcare. transport, . language
difficuhies. visually impaired. res1ricted mobiliry or other concerns?)

Witness Consent (for witness completion)
a) The criminal justice process and Victim Personal Statement scheme (victims only) has Yes No
been explained to me □ □
□ □
I have been given the Victim Personal Statement leaflet Yes No
□ □
I have been given the leaflet 'Giving a witness taternent to police - what happens next?' Yes No

I consent to police having access to my medical record(s) in relation to this matter: Yes No
(obtained in accordance with local practice) □ □ I. □
I consent to my medical record in relation to this matter being disclosed to the defence: Yes No
□ □
I consent to the statement being disclosed for the purposes of civil proceedings e.g. child Yes No
care proceedings, CICA □ □
The information recorded above will be disclosed 10 the Witness Service so they can offer
help and support, unless you ask them nor to. Tick this box to decline their services: □
ignature of witness: Print name:
Signature of parent/guardian/appropriate adult: Print name:
Address and tele hone number if different from above:

Statement taken by (print name): PC 752YE 206372 Steve ELSMORE ......... ... Station: YE ................................................ .. .

Time and place tatement taken :

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