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Serious Incident Report Form

 
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  

Details of peron (s) you are complaining about

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

Details of incident

1. Where were you when the incident occured? (e.g. at my house accross the road) 
 
2. What were you doing when the incident occurred?
 
  Yes     No    
3. Did anyone else witnessed the incident? (If yes, provide details)    
 
4. What did you see? (Be specific. Do not provide details of history, only what you saw)
 
5. Where was the alleged offending person(s)?
 
6. What was the alleged offending person(s) doing?
 
7. How did this affect you?
 
8. Were the police called?
 
 
9. Who called the police?
 
10. Police event number
     
11. Is there a police statement?
 
 

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

Form Information

Document no: HS113.2.0