Type of copy: [specify whether master copy, working copy, lawyer’s copy, or other]
Type of electronic record: [specify whether videotape, DVD, or other]
Reference number of electronic record:
File number (if applicable):
Name of person interviewed:
Date of birth of person interviewed:
Name of guardian(s) (if person interviewed is under 18 years or mentally impaired):
Designation/level of position of interviewer:
Name and designation of all other persons present:
Reasons for interview: [type of incident or offence]
Time interview commenced:
Time interview concluded:
Number of tapes/DVDs used for this interview:
Number of breaks in interview:
Reasons for breaks, eg, to speak to another person, for refreshments, or toilet breaks (if applicable):
Reasons for premature conclusion of interview (if applicable):
Cross-reference(s) to other tape/DVD records of person interviewed:
I certify that the contents of this certificate are correct.
[Signature of interviewer or
Schedule form: amended, on 1 October 2008, pursuant to section 116(a)(i) of the Policing Act 2008 (2008 No 72).
Schedule form: amended, on 1 October 2008, by section 130(3) of the Policing Act 2008 (2008 No 72).