ANNEXURE

FORM MHCA 26

DEPARTMENT OF HEALTH

NOTICE OF THE RETURN OF AN ABSCONDED ASSISTED USER / INVOLUNTARY USER / STATE PATIENT / MENTALLY ILL PRISONER

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

(to be completed by the head of Health Establishment)

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: ..............................................................................................

Date of return: .........................................................................................................

Returned by (e.g. SAPS, self, relative):

Print Initials and Surname: .......................................................................................

Force Number if applicable: .....................................................................................

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

State physical / mental condition:

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

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

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

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

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

                                                         (head of health establishment)

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

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

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

[In case of an assisted or involuntary mental health care user: copy of this notice to be submitted to the Review Board and head of provincial department]

[In case of 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 case of a mentally ill prisoner: copy of this notice to be submitted to the Magistrate,

head of the prison from where the User was initially transferred and to head of national department]