Section 5. Sample Forms

Report of Visit to Victim (Form: RH2)

To be filled in by the investigating officer at the first interview at home following an incident. It may also be used to record other incidents if they occur subsequently.

Name of tenant or person affected





Household Details

Number of adults and children - with ages of children

Date when incident occurred

Type of Incident: please tick appropriate box(es)

  Racist Graffiti in common areas

  Racist Graffiti on property where household lives

  Written abuse/threats

  Abusive telephone calls

  Verbal Abuse

  Damage to property

  Excessive noise

  Physical Assault

  Other (Please state) _______________________________________________

Details of Incident and the effect on household

e.g. health, education etc

Who else was present at the incident?

Give names and addresses, include any children

Details of Alleged perpetrator(s)

Where known, give names and addresses if the victim wishes to give this information

Have the police been informed?

If yes, give details including: police station and officer handling incident, and date reported

Does the tenant want the police to be informed? Yes/No

Support for the tenant

a) Does the tenant need any additional help? Yes/No

b) If yes, what help does the tenant need?

c) What action would the tenant like to be taken?

Details of other agencies involved: contact person/address

Advice Centre

Law Centre

Social Work



Community or voluntary organization

a) Is a transfer requested?

b) Is temporary re-housing requested?

Any other relevant information

Name of investigating officer

Signature of investigating officer

Date of interview


  1. This report will form the basis of subsequent interviews with the alleged
  2. perpetrator(s) and with witnesses. It is therefore important that as much detail as possible is recorded.
  3. A copy of this report should be kept on the victim/tenant's file.
  4. The victim should be told to report any further incidents promptly to the housing provider. Where further incidents occur, this detailed report can be used to record the details.
  5. A Schedule of Repairs (Form RH4) should be prepared by the investigating officer.
  6. The victim should be given a diary sheet (RH3) to record any further incidents which occur. This is particularly useful if the organisation decides to take action to obtain an interdict or seek eviction of tenants who perpetrate racial harassment.

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