Safeguarding Referral Form
Data Protection
Personal Data will be held in accordance with the data protection act 1998. Information on this form may be used anonymously for organisational training, clinical improvement and audit purposes. Your permission will be first requested if your identifiable details are to be used for other purposes.
Complete the following sections to submit your Safeguarding referral to our Safeguarding Lead
Once the referral is recieved the details will be reviewed and logged on the company incident report tracker.
Incident Date
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Incident or PCR Number
Police Reference Number
Is the child or adult in immediate risk?
Patients Details
Patients Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Ethnicity
Contact Number
Patients Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location of Incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GP Name
GP Practice
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patients NHS Number
What type of abuse is suspected - Tick all that apply.
Neglect and Acts of Omission
Self Neglect
Domestic Abuse
Emotional/ Phsychological Abuse
Financial - Material Abuse
Sexual Exploitation
Sexual Abuse
Modern Slavery
Discriminatory (including hate crime)
Physical Abuse
Organisational
Environment
Disclosure by Victim/ Other Person
Confidentiality & Consent
Have you discussed raising this concern with the person?
Yes
No
Other
Does the person consent for the safeguarding concern to be reported to Adults' Services?
Yes
No
If the answer to either/both of the above questions is NO please state your reasons for proceeding without consent?
Safeguarding Details
What are the concerns being raised; What are the risks to the person?
Are there any known risks to other people?
If children are involved have Chilrens Services been informed?
Yes
No
N/A
Is this an ongoing concern?
Yes
No
Does the person live alone?
Yes
No
What are the persons primary needs?
Physical Disability Support
Learning Disability Support
Mental Health Support
Substance Abuse Support
Dementia Support
Sensory Impairment Support
Older Person, Frailty, Temporary Illness Support
Terminal Illness Support
Other
What are the persons views and what outcome do they want?
Does the person have mental capacity to be involved in the enquiry and protection plan? (if unsure pressume capacity)
Yes
No
Unknown
Does the person have a diagnosis or present in such a way that indicates that a mental capacity assessment is required?
Yes
No
Has a mental capacity assessment been arranged or taken place?
Yes
No
Unknown
If a person is unable to give their own view is there someone they would like to represent their views? If so, provide name, relationship and contact details:
Details of the person or organisation thought to be the cause of risk (if applicable)
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Relationship to patient?
Is the person or organisation who is thought to be cause of risk aware of this concern being raised
Yes
No
Unknown
Action Taken
What action has already been taken to minimise the risk for the person?
Include any emergency medical treatment povided (ensure PCR form is also completed), evidence preserved and actions taken to prevent further abuse.
Please tick if any other agencies have been alerted
Care Quality Commission (CQC)
Police
Hospital
General Practitioner (GP)
Fire Service
NHS Foundation Trust (ie, SCAS)
NHS Community Trust
Clinical Commissioning Group
Contracts and Commissioning
Other
If 'Hospital' or 'Other' have been selected above, please specify below:
Details of person completing the referral
Your details
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
Organisation
Call Sign
If working for NHS Trusts, if working on a private transfer please specify 'private'
Staff ID Number
Second Member of Staff
Please complete details of your crewmate if working on a DCA
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
Organisation
Staff ID Number
Declaration
Date of submission
-
Month
-
Day
Year
Date
Time of submission
Hour Minutes
AM
PM
AM/PM Option
Signature (Person Completing Form)
Signature (Second Person in Attendance)
Submit
Should be Empty: