Appendix A - Example Diary Sheet
All parts must be fully completed. Two sections have been completed as an example.
Personal details | Please complete: |
---|---|
Your Name | |
Your Address | |
Your Contact Telephone | |
Your Email Address | |
Address complained of: | |
Name of Occupier (if known) | |
Have you spoken to the person causing the problem about this issue? | |
If yes, please give details | |
Have you written to them? | |
If yes, please give details |
|
Was either approach helpful, even if only for a short time? | |
If yes, please give details |
|
Formal intervention by us may ultimately end in Court action. Are you prepared to attend Court and give supporting evidence if required? | Yes/No |
(If we are unable to consider Court action, if appropriate, because you are not prepared to give evidence, this limits what we can do to help you). |
Date | Time | Description | How it affected you | |
---|---|---|---|---|
Example | 14:00hrs | 15.30hrs | Smoky bonfire | Smoke throughout the house, had to close windows on hot day |
Example | 23.30hrs | 02.30hrs | Loud music and shouting | Woke me from sleep, difficult to get back to sleep |
This statement consisting of ........ page(s) signed by me is true to the best of my knowledge and belief and I make 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.