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Serious Incident Diary

 
Please note: Using the translator tool available on this website forms  can be translated into other languages to assist, but they must be completed in English to be submitted to Evolve Housing. 
 
To be completed by a person who is experiencing serious ongoing or persistent problem with an Evolve Housing tenant.
For information or assistance with this form, phone your Housing Manager on 1300 692 245 or 02 8862 1500.

Please provide as much information as possible.If you need more room to answer any questions, please include details on a separate page and attach it to this form.

Your details

Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name  
Address  
Postcode                               Contact no                                Mobile                     
Email Address  

Incident 1

1. Name and address of person(s) involved in the incident

Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name  
Address  
Postcode                               Contact no                                Mobile                     
Email Address  
2. Where did the incident occur?                                                                                                       
3. What happened?
                                                            
 
 
 
  Yes No
4. Did anyone else witness the incident?                                                

If Yes, please give witness details below.

Witness details
First Name   Last Name  
Address  
Postcode                               Contact no                                Mobile                     
  Yes No
5. Did you report the incident to the police?                                  
       

If Yes, please give details

Report details
Date                               Time                               
Police Station   Event Number  
Name of Police Officer  
 
Yes
No
6. Did police attend to the incident?                                
     
 
7. Did the police advise they were taking any action? (If Yes, give details below)
 
 
 
 
8. Did you make a statement to the Police? (If Yes, attach details)
   

NOTE: If there is another incident continue to Incident 2, if not go to Consent and Declaration Section.

Incident 2

1. Name and address of person(s) involved in the incident

Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name:  
Address  
Postcode                               Contact no:                                Mobile:                     
Email Address  
2. Where did the incident occur?                                                                                                       
3. What happened?                                                              
 
 
 
  Yes No
4. Did anyone else witness the incident?                                                

If Yes, please give witness details

Witness details
First Name   Last Name  
Address  
Postcode                               Contact no                                Mobile                     
  Yes No
5. Did you report the incident to the police?                                          

If Yes, please give details

Report details
Date                               Time                               
Police Station   Event Number  
Name of Police Officer  
  Yes No
6. Did police attend to the incident?                                        
7. Did the police advise they were taking any action? (If Yes, give details below)    
 
 
8. Did you make a statement to the Police? (If Yes, attach details)    

NOTE: If there is another incident continue to Incident 3, if not go to Consent and Declaration Section.

Incident 3

1. Name and address of person(s) involved in the incident

Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name:  
Address  
Postcode                               Contact no:                                Mobile:                     
Email Address  
2. Where did the incident occur?                                                                                                       
3. What happened?                                                             
 
 
 
  Yes No
4. Did anyone else witness the incident?                                                

If Yes, please give witness details

Witness details
Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name:  
Address  
Postcode                               Contact no:                                Mobile:                     
  Yes No
5. Did you report the incident to the police?                                          

If Yes, please give details

Report details
Date                               Time                               
Police Station   Event Number  
Name of Police Officer  
  Yes No
6. Did police attend to the incident?                                        
7. Did the police advise they were taking any action? (If Yes, give details below)    
 
 
8. Did you make a statement to the Police? (If Yes, attach details)    

NOTE: If there is another incident continue to Incident 4, if not go to Consent and Declaration Section.

Incident 4

1. Name and address of person(s) involved in the incident

Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name:  
Address  
Postcode                               Contact no:                                Mobile:                     
Email Address  
2. Where did the incident occur?                                                                                                       
3. What happened?                                                             
 
 
 
  Yes No
4. Did anyone else witness the incident?                                                

If Yes, please give witness details

Witness details
Title (Mr, Mrs, Ms, Miss)  
First Name   Last Name:  
Address  
Postcode                               Contact no:                                Mobile:                     
  Yes No
5. Did you report the incident to the police?                                          

If Yes, please give details

Report details
Date                               Time                               
Police Station   Event Number  
Name of Police Officer  
  Yes No
6. Did police attend to the incident?                                        
7. Did the police advise they were taking any action? (If Yes, give details below)    
 
 
8. Did you make a statement to the Police? (If Yes, attach details)    

NOTE: If there is another incident please include details on a separate page and attach it to this form, if not go to Consent and Declaration Section.

Consent and Declaration

Under the Housing Act 2001, the Privacy and Personal Information Act 1998 and the Health Records and Information Privacy Act 2002, your consent is needed before Evolve Housing can exchange your personal information (including health information) with another party unless required or authorises by law to do so.
If you are prepared to give evidence to the NSW Civil and Administrative Tribunal (NCAT) please read and sign the notice below. If you are not prepared to give evidence this may limit Evolve Housing’s ability to successfully take action against a tenancy at the NCAT.

Consent and Authority

  • I am prepared to give evidence to the NSW Civil and Administrative Tribunal (NCAT)
  • I also authorise Evolve Housing to confirm information provided by me with any third party and/or any such third party to provide Evolve Housing with any relevant documentation or information sought by Evolve Hosuing when determining or supporting this statement.
Full name (please print)  
Signature                                                                                       Date                    

Declaration

  • To the best of my knowledge, the information provided in this form is correct.
  • I understand there are penalties for giving false or misleading information.
Full name (please print)  
Signature                                                                                       Date                

Declaration from person assisting witness/complainant

  Yes No
Is there another person helping you to fill out this form?         

If Yes, that person should read and sign the declaration below.

  • I filled in this form on the basis of the information the complainant/witness gave me.
  • I have read out the form and the answers to the complainant/witness who seemed to understand them.
  • I understand there are penalties for giving false or misleading information.
Full name (please print)   Contact phone number                    
Signature                                                         Date              

Form Information

Document no: HS112.2.0