Page 67 - Main Second Asbo Book1

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W itne s con t11ct dctnils
Home address: Enfield Police Station ................................................................................... ......................................................... .
....................... . ........ .... ....................... .............................. .... ....... ......... ....................................... ..... Postcode: EN1 ...................... .
Home telephone number Work telephone number 0208 345 1123 ......... ........................ ..
Mobile/pager number Email address:
Preferred means of contact:
Ma-le-/ Female (dclc1e as applicable) Date and place of birth:
Former name: ..................... .......................... Ethnicity Code ( 16+ I): ..................... Religion/belief:
Dates of witness non-:ivailability 23/12/14 - 02/01/2015

Witness care
a) Is the witness willing and likely to attend court? Yes. If ' No', include reason(s) on M GG.
b) What can be done to eusure attendance?

c) Does the witness require a Special Measures Assessment as a vulnerable or intimidated witness?
No. If ' Yes' submi t MG2 with file.

d) Does the witness have any specific care needs? No. If 'Yes' what are they? (Disabili1y. hcnl1hcarc. childelln:. 1ra11spor1 •. la111:uagc diflicul1i~
vi~,mlly i1npain:d. n:s1ricted 111obili1y or other conecn,s?)

Witness Consent (for witness completion)
a) The criminaJ justice process and Victim Personal Statement scheme (victims only) has Yes No
been explained io me □ □
□ □
l have been given the Victim Persona l Statement leaflet Yes No
□ □
I have been given the le110e1 ' Giving a witness statement to police - what happens next?' Yes No
□ □
I consent to police having access to my medical record(s) in relation to this matter: Ye ' No NIA □
(ob1.1ined in nccord:mcc wilh toc..11 11racticc)
□ □
I consent to my medical record in relacion to this matter being disclosed to the defence: Yes No NIA □
I consent lo the slalemelll being disclosed for the purposes of civil proceedings e.g. child Ye$ No
care proceed ings, CICA □ □
The infomiation recorded above will be disclosed to the W itness Service so they can offer
help and support, unless you ask them not to. T ick th is box to decline their services: □

Signature of witness: Print name: ······················································
Signal lire of pa.rent/guardian/appropriate adult: Print name: ············· ·········································
Address and tele hone number if different from above:

Statement taken by (print na me): PC Sophie THEODOU LOU ........................... Station: ENFIELD .......................................... .
Time and place statement taken: . _1_3.1 o ... J:µ.rs. ..... 9-t .... En p aJd. .... Pw.C2.. ...... ~ o..h.0,................. . . . . . . . . ............. .

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