ANNEXURE

FORM MHCA 25

DEPARTMENT OF HEALTH

NOTICE OF ABSCONDMENT TO SOUTH AFRIAN POLICE SERVICE (SAPS) AND REQUEST FOR ASSISTANCE TO LOCATE, APPREHEND AND RETURN USER

(Sections 40(4) or 57(1) of the Act)

Surname of assisted user / involuntary user / state patient / mentally ill prisoner  ................................................

First name(s) of assisted user / involuntary user / state patient / mentally ill prisoner  ..........................................

Date of birth  ...........................or estimated age ....................

Date if admission to health establishment: ..................................

The above assisted user / involuntary user / state patient / mentally ill prisoner absconded from : ....................................................... (name of health establishment)

Address: ...................................................................................................................

.................................................................................................................................

.................................................................................................................................

Date of abscondment: ...................................

Absconder is:  (mark with a cross)

Diagnosis on medical condition:

.........................................................................................................................................

..........................................................................................................................................

..........................................................................................................................................

..........................................................................................................................................

Estimation of likelihood of doing harm to self or others: (mark with a cross)

Circumstances of abscondment:

.......................................................................................................................................

.......................................................................................................................................

.......................................................................................................................................

.......................................................................................................................................

Attach full report (if available)

Your assistance in locating and apprehending the above assisted/involuntary user/state patient/mentally ill prisoner is appreciated

Print initials and surname: .................................................................

Signature: .....................................................

                   (Head of health establishment)

Date: ..........................

Place: ...................................

[In case of an assisted – or involuntary User: copy of this notice to be submitted to head of provincial department]

[In case of a state patient: copy of this notice to be submitted to Registrar or Clerk of the relevant Court official curator ad litem and head of national department]

[In the case of a mentally ill prisoner: copy of this notice to be submitted to head of the prison from where the User was initially transferred and to head of national department]