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Herefordshire Alert Form Draft FG 08 06 11 v7 2 by 5IQG64GM


									                                HEREFORDSHIRE SAFEGUARDING ADULTS BOARD

                                SAFEGUARDING ADULT ALERT FORM – (AP1)

                               Forms can be emailed or faxed to:
                              Single Point of Access – Safeguarding:
                                       Fax: 01432 261 943
                                 Vulnerable Adult Officer – Police:
                                       Fax: 01432 364 652

                          * MANDATORY SECTIONS ARE CLEARLY STATED*

**This form should be used for raising a concern that a vulnerable adult may have been, is,
                             or might be a victim of abuse**

Date Form Completed:

OIS ref no: (Police only)

NHS No. / Frameworki No. (if

1. Details of Vulnerable Adult
Please tell us about the Person you feel needs Safeguarding

Title:                      Full Name
Home Address:                                                  Any other
                                                               names used

Post Code:

Tel:                                                             Date of Birth:

Primary User               Learning                       Physical & Sensory
Group                      Disability
                           Mental Health                  Other Vulnerable People
Tick one box only
* Mandatory*               Misuse

Ethnic Origin              White British                  White Irish             Other White

Tick one box only          White Traveller                White
                           of Irish Heritage              Gypsy/Roma
*Mandatory*                Black Caribbean                Black African           Other Black

  Review Date: 1 March 2012
                        Indian                     Pakistani               Bangladeshi
                        Chinese                    Other Asian             Mixed White
                                                                           and Black Caribbean
                        Mixed White                Mixed White             Any other mixed
                        and Black                  and Asian               background
                        Refused                    Information not
                                                   yet obtained

Does the person have any communication needs?
   Yes       No

If yes, Please state what would assist:

GP Name and
Contact Details

2. Mental Capacity – *Completion of this section is mandatory*
In relation to the submission of this alert only
Is the person aware of this alert:                             Yes         No

Have they agreed to this alert being raised:                     Yes       No

If not, why not?

Do you have any reason to doubt the person’s capacity to agree to this alert being raised?

    Yes         No

If yes, why?

3a. Current Situation and Details of the Incident/Concern(s) being raised

Does the person continue to be at risk of harm?                      Yes    No

Are there other people who may be at risk of harm?                   Yes        No   Not Known

If the answer to either of the above is yes, please describe the risk that remains and the
names of any others potentially at risk:
(please only refer to identified risk that relates directly to the concern)

 Review Date: 1 March 2012
3b. Details of the concern(s) being raised

Type of Abuse          Physical                         Sexual
                       Psychological/ Emotional         Neglect / Act of Omission
*Mandatory*            Financial                        Discriminatory/Hate Crime
(More than one
box may be

Source of Alert        Domiciliary care staff           Residential/nursing care staff
                       Day care staff                   Social worker/care manager
*Mandatory*            Self-directed care staff         Other social care staff
                       Primary/community health staff   Secondary health staff
(More than one
box may be             Mental health staff              Self-referral
ticked)                Family member                    Friend/neighbour
                       Other service user               Care Quality Commission
                       Housing                          Education/training/workplace
                       Police                           Other

Abuse Setting          Own Home                         Supported Housing
                       Care Home (permanent)            Care Home with Nursing
*Mandatory*                                             (permanent)
                       Care Home (temporary)            Care Home with Nursing
(More than one                                          (temporary)
box may be             Alleged perpetrator’s home       Mental health inpatient setting
                       Acute hospital                   Community hospital
                       Other health setting             Day centre/service
                       Education/training/workplace     Supported Accommodation
                       Public Place                     Not known
                       Other (please give details)

Date(s) of alleged, suspected or
witnessed abuse

Time(s) of alleged, suspected or
witnessed abuse

 Review Date: 1 March 2012
Brief factual details of the incident:

This should include a clear factual outline of the concern being raised with details of people
and places where appropriate.

If injuries are present please give a brief/accurate description:

Details of any medical attention sought in relation to this alert:

Has a Doctor been informed?         Yes       No

Name of Doctor informed:
Date and time of information given:

Actions taken to date to safeguard the individual:

 Review Date: 1 March 2012
Are any other professionals aware of this alert? If so please state job title and organisation

4. Is this person a carer for another Adult/Child
* A separate alert to Safeguarding and Vulnerable Children should be made if you suspect a child is at risk of
abuse (*see guidance for details)
Details of Adults or Children
cared for

(Please list ages of children if
Has a separate notification
been raised for any
child/children that may be at
risk of abuse

Are arrangements in place to
look after any
adults/children involved

(Please give brief details)

5. Details of main carer (if applicable)
* The main carer should only be informed where appropriate to do so
Is the Carer aware of this Yes                No
                              If not why not?
Contact Address:

Telephone No:
Mobile No:

6. Details of alleged perpetrator(s) involved if abuse is suspected
 (please complete as much of this as is known)


Address (if known):

Do they live with the                   Yes         No
vulnerable adult?

  Review Date: 1 March 2012
Is the alleged        Partner                                      Other family member
perpetrator           Health care worker                           Volunteer/befriender
                      Domiciliary care staff                       Residential care staff
*Mandatory*           Day care staff                               Social worker/care manager
                      Self-directed care staff                     Other social care staff
                      Other Vulnerable Adults                      Other Professional
                      Friend/neighbour                             Stranger
                      Other                                        Not known
                      Institutional Abuse

Is this person known/related to the individual who is the subject of this alert? – If so please
describe relationship

Are they aware that an alert has been raised?             Yes         No

7. Please provide details of the person raising this alert.

Telephone No.
Email Address:
Organisation employed
by if applicable. (Please
give address and
contact number)
Relationship if any to the
person this alert is about
Can your details be shared with third parties? We cannot guarantee your anonymity but will try
at all times to keep your details confidential if you prefer. (*Professionals making an alert should be
aware that anonymity cannot be granted)

I would prefer to remain anonymous:              Yes          No

Please give your reasons for remaining anonymous:


Collar Number
(police use only)

**If you have heard nothing back from the Safeguarding Adults Team within 48
hours of your making this alert please contact the Safeguarding Customer
Service Officer on 01432 260 715 who will advise you further.**

  Review Date: 1 March 2012

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