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.