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A witness statement template and instructions for witnesses in criminal cases. It covers topics such as the criminal procedure rules, witness details, consent for disclosure of medical records, and what happens after giving a statement. Witnesses are informed about their responsibilities, potential consequences for providing false information, and the role of the witness care unit.
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Signature: Signature Witnessed by:
Statement of:
Age if under 18 (if over insert “over 18”): Occupation:
This statement (consisting of …… 1 …... Pages(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 in it, anything which I know to be
false, or do not believe to be true.
Signature: Date:
RESTRICTED (when complete) MG
RESTRICTED (when complete) MG
Witness Details
Home Address: Post Code:
Home Tel No: Work Tel No: Mobile Tel No:
Email Address: Preferred means of contact:
Name of Parent/Guardian Contact Tel No:
Best time to contact: Ethnicity Code (16+1):
Gender Male / Female Date & Place of Birth: Former Name:
Does the Witness have any inconvenient dates for court? Yes/No
If “Yes” provide details
Witness Care (please tick or type in box provided)
a) Is the witness willing to attend court? Yes/No If ‘No’, include reason(s) on form MG
b) What can be done to ensure attendance?
c) Does the witness require a Special Measures Assessment as a vulnerable or intimidated witness? (youth under 18; witness with mental disorder, learning or physical disability; or witness in fear of giving evidence or witness is the complainant in a sexual offence case). If ‘Yes’ submit MG2 with file in anticipated not guilty, contested or indictable only cases.
Yes/No
d) Does the witness have any particular needs? Yes/No
If ‘Yes’ what are they? (Disability, healthcare, childcare, transport, disability, language difficulties, visually impaired, restricted mobility or other concerns?).
Witness Consent - For Witness Completion Yes^ No^ N / A
a) The Victim Personal Statement scheme (victims only) has been explained to me:
b) I have been given the Victim Personal Statement leaflet:
c) I have been given the tear-off leaflet “Giving A Witness Statement to the Police…”
d) I consent to police having access to my medical record(s) in relation to this matter: (obtained in accordance with local practice)
e) I consent to my medical record in relation to this matter being disclosed to the defence:
f) I consent to the statement being disclosed for the purposes of civil, or other proceedings if applicable, e.g. child care proceedings, CICA
Witness Signature: Print Name:
Parent/Guardian/appropriate adult Signature: Print Name:
Address and telephone number if different from above:
Statement Taken By (print name): Station:
Time and Place Statement Taken:
RESTRICTED
MG 11W (08/2011)
Witness Care Unit
Victim Support and Witness Service
The Witness Charter