Form MG 11-Page No: 1Of3

Appendix 7

Form MG 11-Page No: 1of3

Name:

WITNESS STATEMENT

(CJ Act 1967, s.9;MC Act 1980, ss.5A(3) (a) and 5B; MC Rules 1981, r.70)

Statement of:(Your Name)

Age if under 18:(Age/Over 18 - if over 18 insert ‘over18’)Occupation: (Job Title)

This statement (consisting of page(s) each signed by me) is true to the best of my knowledge and belief and I make it knowing that, if it is tendered in evidence, I shall be liable to prosecution if I have wilfully stated anything which I know to be false, or do not believe to be true.

Signature:Date:(TODAYS DATE)

I am the above named person and I live at an address known to Police. I am currently employed by NTW TRUST as a (GIVE YOUR POSITION) on (NAME WARD/UNIT.) I have held this position for (~~) years(IF APPLICABLE GIVE FURTHER DETAIL OF YOUR EXPERIENCE AND KNOWLEDGE). (NAME WARD/UNIT.) is a Hospital Ward within the Northumberland Tyne and WearNHS Trust dealing with (Give a brief description of the ward/unit type and the type and number of service users/whether it is a secure ward & ANY OTHER RELEVANT DETAILS.)

On (DATE OF INCIDENT) I was (GIVE A BRIEF OUTLINE OF WHAT YOU WERE DOING JUST PRIOR TO THE INCIDENT OCCURING) at (TIME INCIDENT OCCURRED) a patient on the ward known to me as (NAME PATIENT AND D.O.B.) was (DESCRIBE THE CIRCUMSTANCES IN THE FIRST PERSON. DESCRIBE EXACTLY WHERE IT HAPPENED AND EXACTLY WHAT HAPPENED IN CHRONOLOGICAL ORDER FROM START TO FINISH. DESCRIBE NOT ONLY WHAT HAPPENED, BUT EXACTLY HOW IT HAPPENED E.G. “HE PUNCHED WITH HIS CLOSED RIGHT FIST OF HIS LEFT HAND AND MADE CONTACT WITH THE LEFT SIDE OF MY HEAD”. “HE PICKED UP A CHAIR WITH BOTH HANDS AND THREW IT OVERHEAD WITH A GREAT DEAL OF FORCE AT THE WINDOW.”

DESCRIBE EVERYTHING SPOKEN IN DIRECT SPEECH E.G. HE SHOUTED AT ME “IM GOING TO PUNCH YOUR LIGHTS OUT IN A MINUTE.” I SAID TO HIM “PLEASE CALM DOWN.”

DESCRIBE THE LEVEL OF ASSAULT / DAMAGE E.G. IF YOU ARE THE VICTIM SAY HOW THIS MADE YOU FEEL E.G. “THIS CAUSED ME IMMEDIATE PAIN AND I LATER DISCOVERED I HAD A CUT TO MY HEAD / THE WINDOW WAS COMPLETELY SMASHED AND THE FRAME WAS BENT MEANING THAT IT COULD NOT BE OPENED OR CLOSED. I ESTIMATE THE DAMAGE TO BE £ ####”

I can state that (NAME OFF OFFENDER) did not have any permission to assault me / cause damage to Trust property.

The entire incident lasted (ESTIMATE TIME) I witnessed the entire incident (IF NOT DESCRIBE HOW MUCH YOU SAW) from a distance of approximately (DISTANCE) The visibility was excellent. (IF NOT STATE WHY) There were no obstructions to my view. (IF THERE WERE SAY WHAT/WHY) I know this patient well and have known him/her personally for ## years (IF YOU DO NOT KNOW THE SUSPECT SAY WHETHER YOU WOULD RECOGNISE THEM AGAIN)

(**VICTIMS ONLY**)

The Victim Personal Statement has been explained to me and I wish to add the following / do not wish to add anything at this time.

(IF COMPLETING A PERSONAL STATEMENT YOU SHOULD TAKE THE OPPORTUNITY DESCRIBE/EXPLAIN EXACTLY HOW THE INCIDENT HAS AFFECTED YOU AND MADE YOU FEEL IN AS HONEST AND FRANK A WAY AS POSSIBLE. A VICTIM PERSONAL STATEMENT IS YOUR OPORTUNITY TO DESCRIBE TO A COURT HOW YOU PERSONALLY WERE AFFECTED AND IS VERY EFFECTIVE.)

(To complete this pro-forma statement please delete the guidance notes in bold and brackets and re-write using your own words IN STANDARD TEXT, NON-BOLD.)

PLEASE PUT SURNAMES IN CAPITAL LETTERS

PLEASE PUT DIRECT SPEECH IN “SPEECHMARKS AND CAPITAL LETTERS”

REFER TO ANY PERSON (SUSPECT OR WITNESS) BY FULL NAME OR SURNAME

THIS IS YOUR VERSION OF EVENTS DO NOT INCLUDE HOW YOU PERCIEVE OTHERS TO HAVE FELT OR OTHER INDIVIDUALS VIEWS

Signature:………………………………….………Signature witnessed by:…………………………………