GRIP Police Station Victim Friendly Facility- Case summary
To be completed for every survivor.

1 Identifying details:

1. SAPS Case Number -----------------------------------------------------------------------

2. Date of Report -----------------------------------------------------------------------

3. Time of Report -----------------------------------------------------------------------

4. Date of Crime -----------------------------------------------------------------------

5. Charge officer -----------------------------------------------------------------------

6. Station -----------------------------------------------------------------------

7. Name of defuser -----------------------------------------------------------------------

8. Duty date -----------------------------------------------------------------------

9. Name of survivor -----------------------------------------------------------------------

10. Contact cell or work -----------------------------------------------------------------------

11. Friend's contact -----------------------------------------------------------------------

12. Gender of survivor -----------------------------------------------------------------------

13. Address of survivor -----------------------------------------------------------------------

14. Age of survivor -----------------------------------------------------------------------

2. Information regarding the crime:

2.1 Type of crime committed:

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.2 Case number give? Yes / No

2.3 Previously a Victim ( if yes please give details)

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.4 Injuries Yes/No If yes please note injuries:

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.5 Was substance abuse involved in the crime or incident? Yes/ No

Type of drug-----------------------------------------------------------------------------

Explain

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.6 How does the survivor feels: SAD/ ANGRY/UPSET/NORMAL

2.7 Explain the feelings before counseling:

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.8 Comments made by defuser after counseling

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.9 CARE ROOM / Defuser support
(defuser to mention all the things she did in the presence of the survivor for instance offering food, tea, place of shelter etc. )

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2.10 Referral made: Hospital/ GRIP head office/ Court/ Other (specify)

------------------------------------------------------------------------------------------------------------

2.11 How did the defuser that provided support feel regarding the case?

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Signature of Defuser Date--------------------------------------

Signature of Survivor Date--------------------------------------