We need your details so that we can address your complaint effectively.

• Your Name *
• Email *
• Phone *
• Address *
• Preferred Form of Contact *
  Email Post

• Programme Title *
• Date of Broadcast *
• Time of Broadcast *
• Channel/Station *
  TVNZ 1 (TVNZ) TVNZ 2 (TVNZ) Three (MediaWorks) Bravo (MediaWorks) Prime (SKY) Māori TV SKY TV Radio NZ National (Radio NZ) RadioLive (RadioWorks) ZM (New Zealand Media and Entertainment) The Hits (New Zealand Media and Entertainment) Radio Sport (New Zealand Media and Entertainment) Newstalk ZB (New Zealand Media and Entertainment) Other (please specify below)
• Other – please specify

• Date of my original complaint to the Broadcaster *
• Broadcasting Code my original complaint was laid under *
  Radio Free-to-Air Television Pay Television
• Standards identified in my original complaint *
  Standard 1: Good Taste and Decency

  Standard 2: Programme Information

  Standard 3: Children's Interests

  Standard 4: Violence

  Standard 5: Law and Order

  Standard 6: Discrimination and Denigration

  Standard 7: Alcohol

  Standard 8: Balance

  Standard 9: Accuracy

  Standard 10: Privacy

  Standard 11: Fairness
• Please attach your original complaint to the Broadcaster here, or email it to us at complaints@bsa.govt.nz

• Date of Broadcaster's Decision (if you have not received a decision from the broadcaster, enter today's date) *
• Please attach the Broadcaster’s decision on your original complaint here, or email it to us at complaints@bsa.govt.nz

• Please identify the standards you wish to complain about to the BSA, and the reasons you are dissatisfied with the Broadcaster’s decision. It is helpful if you can make your reasons specific to the standards you wish to be addressed, for example by using subheadings for each standard. (Note: the BSA can only consider points and standards that you have already raised in your original complaint to the broadcaster.) *

• If you would like to attach further information or evidence in support of your complaint, please attach it here, or email it to us at complaints@bsa.govt.nz (make sure files are clearly labelled and dated)

• Verification code *